Clinical Practice and the Architecture of the Mind

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This book provides an excellent introduction to the theory and technique of communicative psychoanalysis and links it with the growing field of evolutionary psychoanalysis. It provides a clear and stimulating account of some of the most recent developments of lang's highly original and contraversial work, which many practitioners continue to find deepy unsettling.

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1. The fundamentals of psychotherapy

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There is, I believe, a measure of dissatisfaction and a wish for more effective forms of psychotherapy lurking in the mind of every mental health practitioner. There have been many definitions of the unsolved mysteries and the ills that have befallen the psychotherapeutic realm and many prescriptions for their cure. Yet the plethora of diagnoses and amelioratives speaks more as symptoms of the disease rather than their solutions.

Virtually every book written about the theory and practice of dynamic psychotherapy and psychoanalysis (in this book, I do not distinguish between the two) carries with it the implied message: ‘These are the unresolved problems besetting our field, and here are some proposed solutions.” With so many volumes written each year, is it possible to develop an overarching viewpoint that would bring order and sensibility to this maze of confusion and uncertainty? The belief that this quest can be fulfilled is the backbone of this book.

There seems little to be gained by trying to resolve this predicament by turning to one or another of the many current versions of psychoanalytic theory and invoking the seeming clinical insights it would offer. No single theory has gained primacy over its competitors or proven itself as a generally acceptable guide to clinical practice. My own efforts to use the communicative approach to psychotherapy to clarify the treatment experience have met with considerable success, yet they stand without the full support of the therapeutic community (Langs, 1982, 1988, 1992a, 1993a). Another kind of strategy is called for, and it appears to lie in one direction alone—turning at long last to basics, the heretofore undefined fundamentals of psychotherapy.

 

2. Some basic tenets

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Ms Allen is a young woman in once-weekly psychotherapy with Dr Barton, a clinical psychologist. She entered therapy mainly because she was repeatedly attracted to very hurtful and destructive men and had not been able to forge a satisfying and lasting relationship with any of them. *

In the tenth month of her treatment, the patient began a session with a dream in which her father’s brother, Martin, forces her to get into his car and drives her to a secluded place where he forces himself on her sexually. She went on to recall that Martin was an erratic man. At times he was kind and helpful, but he had a violent temper and could be assaultive both verbally and physically to anyone in range of his wrath. Ms Allen remembered an incident in which he appeared unexpectedly at her home when she was a teenager. No one else was there at the time, and he made obscene remarks and seductive overtures towards her. Although quite frightened, she was able to get him to leave by pushing him out the door before anything more untoward occurred.

 

3. Issues of adaptation for patients and therapists

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There are many settings within which we might profitably observe human nature in general and the human mind in particular. Among his many achievements, Freud invented a unique and remarkable setting within which the operations of the emotion-processing mind could be exquisitely investigated. Indeed, as far as I know, there is no better situation for the exploration of the adaptive capacities of the emotion-processing mind than that of dynamic forms of psychotherapy.

The psychological forces that are mobilized by a healer, and by the setting and rules within which he or she works with a patient, create a highly definable and compelling framework for the detailed scrutiny of adaptive interactions and the mental processes that underlie them. While each of the many variants on classical psychoanalysis has its own particular set of ground rules and boundary conditions—factors that affect what may be studied and how the studies are carried out— these situations also share a set of universal properties that, in addition to accounting for aspects of their curative powers, render them as ideal for clinical investigations.

 

4. The classical models of the mind

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We have established two different settings for studying the architecture of the mind. We now need to define how we will attend to and formulate the communications from patients and therapists within these settings. Here, too, we must be selective. Trying to observe everything will only cause us to see nothing; on the other hand, however, what we do decide to study must be nondefensively chosen and fundamental, vital, and sufficiently critical to the therapeutic process and to its curative powers to reveal the structures, processes, and dynamics we seek to understand.

MANIFEST OBSERVABLES

In light of our psychoanalytic approach, we wish to observe both surface phenomena and indications of nonsurface, unconscious transactions and communications. On the surface, there are the manifest contents of the patient’s (and therapist’s) spoken communications as they reflect the subjective state of the patient—and far more. Of special interest are the vicissitudes of the patient’s emotional life and adaptive functioning— dysfunctions in these areas are the targets for therapeutic cure.

 

5. The communicative-adaptational model of the mind

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To this point, we have generated a variety of formulations of the material from our clinical vignette. Each line of thought stressed the intrapsychic operations of the human mind as observed within a globally conceptualized therapeutic interaction. We found that these formulations suggested a rather broad view of the design of the mind as being three interconnected systems—originally, UCS, PCS, and CS; later on, id, ego, and superego.

Something unexpected and almost magical occurs when we shift our way of observing and formulating into a mode that centres on immediate adaptive responsiveness in lieu of the vague and general (weak) adaptational approach characteristic of the standard viewpoints on psychotherapy. A major transformation takes place in our thinking and in our model of the mind. Let us see how this dramatic change comes about.

SOME FATEFUL OMISSIONS

The description of the transactions of Ms Allen’s therapy— the clinical material or observables I presented earlier—and the previously discussed formulations of her free-associations would satisfy most present-day therapists. There would be some debate over the most important implications of the patient’s material, but the clinical data would not be found wanting.

 

6. Some features of the emotion-processing mind

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Our first foray into the design of the mind suggests that there are two rather distinctive systems of the emotion-processing mind—one that is linked to awareness, and another that operates entirely without access to conscious experience. Since this initial impression will be borne out as we proceed, we may now name these two systems of the mind. The first is called the conscious system and the second the deep unconscious system.

Let us turn now to another clinical situation for some further material through which we may begin to generate a well-defined map of the mind and further appreciate what this blueprint tells us about the therapeutic interaction and its techniques.

Gary Nelson, a young man of 17, was in once-weekly psychotherapy with Dr Adams, a woman psychiatrist. He sought therapy because he was doing poorly in school despite his high IQ. Gary was an only child whose parents had a stormy marriage.

The referral came from a school psychologist and the frame was secured, except for the fact that the parents paid for the sessions. Gary made the initial contact with Dr Adams himself, and the therapist did not see the parents.

 

7. The conscious system of the mind

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Our study of Gary’s session suggested a number of aspects of the architecture and functioning of the emotion-processing mind. We had a glimpse of how the conscious system is designed and operates or adapts, and had a chance to compare some of its processing capabilities with those of the deep unconscious system. We want now to concentrate on the conscious system of the mind and to spell out its main structural and functional features. Excerpts from two additional therapy situations will help us in this task.

AN INADVERTENT FRAME DEVIATION

Mrs Chase was in once-weekly empowered psychotherapy with Mr Hall, a social worker; she was severely depressed. Early in the treatment, Mr Hall came into the waiting-room to escort his patient into his consultation room and, as he did so, inadvertently brushed against her arm.

Once the session began, Mrs Chase reported a dream in which she was at a farm with a college girlfriend, Peggy, They are sitting on some hay in the barn and they are recalling and laughing about a hayride they had taken with their boyfriends when they were in college.

 

8. Probing the deep unconscious system of the mind

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In Freud’s (1923) structural model of the mind, there are unconscious aspects to each of the main structures—id, ego, and superego. In this model, “conscious” and “unconscious” become descriptive terms that have been downgraded to qualities of human mentation and experience; there are, as well, both conscious and unconscious structures and functions for each of the three components of the mind. Conscious and unconscious are no longer features that define or distinguish the systems of the mind. Thus, an id wish, an ego function, or a superego attitude could be within or outside awareness. The beacon light of psychoanalysis—unconscious mentation, experience, and communication—has lost its most of its power. Current formulations of clinical material make use of a vague and global concept of an unconscious function, idea, or affect, and the term “unconscious” is used in a manner that is similar to the early uses of the terms “protoplasm” and “atmosphere”. Both entities exist but were so ill-defined as to be virtually meaningless. Rather than serve science, these concepts retarded its advancement. So, too, with the current waste-basket employment of the term “unconscious” in psychoanalytic thinking—it interferes with the growth of psychoanalytic theory and supports poor and harmful clinical techniques.

 

9. Essential features of the deep unconscious system

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We are now ready to collect our impressions of the deep unconscious system of the emotion-processing mind in order to create a composite picture of this system of the mind. In so doing, it is well to realize that we will be not only characterizing the structural and functional designs of this system, but also developing a picture of unconscious experience—the world as seen through unconscious perception (mainly auditory and visual). As we have already observed, this is a very different world from that seen through conscious eyes and ears. It may be difficult to become accustomed to the idea, but we actually live our lives on two distinct plains that share little in common and have only a few connecting links. This suggests, too, that when it comes to psychotherapy, there are two levels on which it is experienced and two very different constellations of techniques and modes of cure, depending on which world a therapist addresses (Langs, 1981, 1985) (see also chapter 10).

SOME KEY FEATURES

 

10. Techniques of therapy and the design of the mind

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While it may seem surprising that developing a model of the mind can have a profound influence on the technique of psychotherapy, there is a strong precedence for these effects. Freud’s (1900) first model of the mind, which used the criteria of conscious versus unconscious operations to define the systems of the mind, very much affected his ideas about psychoanalytic technique and cure. For example, the goal of therapy was stated as making the unconscious conscious (a goal that we have seen to be more complex than previously thought, in that contents are unconscious in two very different senses of the term, one related to the conscious system and the other to the deep unconscious system). Another goal was to resolve the conflicts between UCS wishes and CS defences and moral condemnations, as was the intention of helping the patient modify the censorship or defences that barred unconscious contents from awareness.

The advent of the structural hypotheses (Freud, 1923) ushered in a new era for psychoanalytic and psychotherapeutic techniques. Treatment was conceptualized in terms of a new aphorism—where id was, ego should be. Therapeutic work with ego dysfunctions, pathological id expressions, dysfunctional object relations, and superego aberrations and its offshoot in self-pathology defines most of today’s structurally oriented therapeutic efforts. The issue of conscious versus unconscious mental contents, meanings, conflicts, and communications—and their modification—has faded into the background. There remains only a vague sense that something that is unconscious within the patient is being made conscious. Enhancing the ego and relatedness, improving on a wide range of superego functions and capacities, developing a healthy sense of self, and taming the id are the most common basic goals of treatment at the present time.

 

11. Syndromes of dysfunctional design

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Historically, each of the major shifts in psychoanalytic thinking not only led to new ways of viewing the world of emotional difficulties and their cure, but also brought with it realizations of new forms of emotional dysfunction—previously unrecognized clinical syndromes. Theory does indeed give fresh eyes for observing, and new ways of looking at the therapeutic interaction inevitably generate fresh perspectives on all aspects of the psychotherapeutic endeavour.

The topographic theory (Freud, 1900) of UCS, PCS, and CS stressed the intrapsychic conflicts that arise between the systems UCS and CS, and the repression of incestuous and aggressive wishes. Psychopathological syndromes were largely defined in terms of inner conflict and the excessive use of repression and censorship. The advent of the structural hypotheses (Freud, 1923) brought with it the recognition of a host of new syndromes—ego dysfunctions: disorders of self-image, self-esteem, and self-regulation; interpersonal disorders and the like.

 

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