Glen Gabbard; Therapeutic Action; Witnessing; Therapeutic Match; Seeing and not seeing.
Glen Gabbard (virtually) Came to Town the Other Night and Clarified
that Psychotherapeutic Action is not what you think it is…
If David Letterman were a psychoanalyst, he would have Glen Gabbard as his first guest on the show “My Next Guest Needs No Introduction.” Dr. Gabbard has written over 300
psychoanalytic articles – many of the co-authored with other leading analysts -
and multiple books, including Psychodynamic
Psychiatry in Clinical Practice, which is a standard text in both
psychoanalytic institutes and psychiatric residencies. He also edited the most recent edition of the
Textbook
of Psychoanalysis.
I have known Glen for about thirty years, since I was a
trainee at the
Menninger Clinic when he was its director.
I never had him as a teacher when I was there, though he was a
consultant on a patient that our treatment team was working with. I came to understand what he does so well a
few years later when he came to present to my state’s psychological association
on borderline and narcissistic personality disorders. As I was walking out of the presentation, I
overheard one psychologist say to another, “I could have given that
presentation.” I thought to myself, “I
don’t think so.”
Dr. Gabbard’s gift (in my mind) is to take incredibly
complex material and make it comprehensible.
In the psychiatric text, he very neatly explained the differences
between Kohut’s version of narcissism and Kernberg’s, a difference that was the
subject of heated debate in psychoanalysis for decades. He clarified that these two men were working
with very different populations and using the same name to describe the
psychological functioning of these two groups.
When understood in this way, it is no longer a question of who is right,
but which theory is applicable to which particular patient. Elegant.
In the state psychological meeting, he presented complicated concepts so
clearly that others thought what he was doing was easy.
I was looking forward to Dr. Gabbard’s presentation on Psychotherapeutic
Action, which is the question of what it is about psychotherapy that helps our
patients. Recently, due to the COVID pandemic, we have not had the usual national meetings that allow me to connect –
even if across the room – with people like Glen whose work I admire and, in his
case, with someone that I know. It was
also good to welcome him to our group – even if, because when he agreed to come,
it was on the stipulation that it would be virtual because the world was not
yet back to our new sense of normal. I
was not prepared; however, for this paragon of analytic doctrine to rock my
world.
Oh, he started out just fine. He noted that when he was a trainee, he
presented a case to Charles Brenner who was, at the time, the paragon of psychoanalytic
thinking. He noted in his case
presentation, that though there were still a few symptoms, he was prepared to
terminate with the patient. Dr. Brenner
chastised him, stating that a treatment is only complete when there are no
remaining symptoms. Dr. Gabbard was
publicly chastened and apologetic, but on the ride home from the presentation
he thought, “That’s crazy. When is anyone symptom free?”
Indeed, I remember a colleague at Menninger talking about
her own analysis and the fact that she was still smoking (cigarettes) at the
end of it. The newest version of the DSM
had just come out that included nicotine dependence as a disorder – and she
stated that if nicotine dependence had been a disorder when she was in
analysis, surely her analyst would have cured her of that as well.
I repeat that little story to clarify that psychoanalysis,
within psychoanalytic circles, has always been idealized in ways that are not reality
based, but those idealizations have had a powerful impact on us – or at least on
me. For instance, the oft repeated ideal
that the well analyzed person never unintentionally alienates another person
was very attractive to me. I hate
alienating others, but do it quite frequently and, apparently, unintentionally. The idea was, when I was well analyzed, I
would have access to all those unconscious desires to harm others and could therefore
avoid acting on them. Well… apparently, I
am not well analyzed enough to have reached that level.
So, I don’t mind (and have often found helpful) a little de-idealization
of analysis. But what Glen did was
different. After tracing the “relational
shift” in analysis – the transition in analytic thinking from the 1940s into
the 1980s – and indeed even into today – that allows us to realize and consider
the ways in which we influence each other, he talked about the influence of
thinking about relationships in general and the psychotherapeutic relationship in particular as central to human functioning on therapeutic action.
Unlike the old ego psychologists like Dr. Brenner, who saw symptom
reduction as the task of analysis, Gabbard says that we have come to realize
that focusing on symptoms is not helpful; in fact, it can cause our patients to
cling to them ever more tightly. We need
to work on helping our patients live within their own skins; to be comfortable making fuller use of themselves. When we are thinking about improved
functioning rather than symptom reduction, we focus on understanding what leads
the patient to get better. This way of thinking about therapeutic action leads us to be more inclusive than simply looking at what
we as analysts/therapists do. Instead, we are thinking from the perspective of patients do to become healthier. In support
of his position, I would add: when we look at the empirical literature, patient
variables account for much more of the outcome in therapy than therapist (or
orientation of therapist) variables do.
So, Gabbard’s position is that we need to understand therapeutic action
from the position of the patient.
He then proposed three conditions that lead to patient
improvement. The first is the match
between the therapist and the patient.
The second is the process of witnessing (or being witnessed, if we focus
on the patient). The third he called “Seeing
and not seeing”.
Patient/therapist match is indicative of psychotherapy being
a more personal than a technical undertaking.
The patient’s transition to living within his or her own skin – with being
able to tolerate and articulate the feelings that have been warded off and therefore relegated to unavailability rather than being available to help guide his or her behavior – happens within the
context of a human relationship – a relationship with another human being, not
a relationship with a "therapist".
As therapists, we can adjust ourselves, within limits, to “match”
the needs of our patients. I work
particularly well with emotionally remote men.
I think they find my relative ease with emotional expression reassuring. Emotionally remote women, on the other hand,
in my experience, do not respond so well to the same emotional expression. I think, though don’t really know (because they
don’t typically stick around long enough for me to find out), that these women experience me as being unpredictable and therefore threatening. That said, there have been surprising fits
(and misfits) over the years - and I can stretch to work with clients that might not initially feel that I would be a good match for them.
As witnesses, we need to listen. Gabbard minimized the role of interpretation
in change, even though this was seen to be the “mutative” element in early
analytic theory about therapeutic action.
He believes patients come to talk, to be heard, and that our interpretations
are primarily useful in so far as they help the patient feel understood. Indeed,
Gabbard sided with Winnicott who believed that what our patients need is,
essentially, a private experience - a sense of being in contact with themselves. They want (and need) to be
alone – somewhat paradoxically - in the presence of the analyst. Our job, then, is to create a space in which
the patient can feel free to be and express themselves; not for the therapist,
but for themselves.
This part of the talk brought to mind for me a description
of an evening that Ralph Waldo Emerson spent in the company of Henry David
Thoreau. As I remember it, Emerson
arrived and Thoreau invited him into his cabin where they sat in front of the
fire for two or three hours. Neither said a word. At the end of the evening,
they thanked each other for having spent a magnificent time together. Of course, this happened in the context of a
friendship that was based on talking as a means of getting to know one another,
but it also indicated an ability to be present to the other without needing to
be in the other’s business – and that the presence of the other allowed one to
more fully occupy oneself. The maxim of the witnessing perspective, then, would be: In the
context of a relationship, I can more fully get to know myself.
Finally came the unsettling aspect of the evening. If the idea of witnessing had a bit of a Zen
koan feel to it, the idea of Seeing and Not Seeing certainly felt like we were
being implored to clap with one hand.
Dr. Gabbard cited research that suggests that much of what we communicate
is non-verbal. Despite the fact that the
analytic posture (lying mostly motionless on a couch with the analyst largely
out of sight) intentionally minimizes non-verbal communication, Gabbard
insisted that most of our communication occurs outside of our awareness. We don’t understand what we hear and, no
matter how well analyzed we are, we don’t really know what we are saying.
This poses a quandary for the analyst – and even more so for
the person trying to teach someone how to do psychoanalytic work. How do we help someone know what they don’t
know? Of course, this is the central dilemma
in the psychoanalytic process. We are
trying to help our patients access the parts of themselves that are unknown.
In the discussion after the talk, I let Glen know that,
though I had appreciated his talk, I found it disturbing. As a person who is responsible for
shepherding our candidates through the curriculum that teaches them how to do
psychoanalysis, a central component of which is to teach them how to follow the
“red thread” that binds the analytic hour together, to have him (of all people –
I might have added – the avatar of psychoanalytic orthodoxy) tell the psychoanalytic
candidates, but also the psychoanalysts and faculty that, when we listen to and
follow what our analysands are saying, we are missing the majority of what they
are trying to communicate – and likely the most important aspects of what they
are trying to communicate, well… that is unsettling to say the least.
Then, that night, I had a dream. I was wandering about and came across a seam
in the landscape – a ripple in a cliff – and I noticed that it went deeply into
the side of the hill and, as I started to follow it into the hill, each time I
thought I came to the end of it, another alley would open up and I could follow
that deeper into the hill. I was really
excited as I was pulled inexorably forward, discovering new depths, until I
realized that I did not know how I would find my way out, and I awoke with both
a feeling of terror but also a sense of guilt that I did not have more faith in
my ability to navigate things in reverse.
The next day, Dr. Gabbard worked with one of our analytic
candidates to better understand a case she presented to a group of us. Glen practiced what he preached. Generally, our speakers do when they engage
in the consultation/workshop the day after a lecture. But this usually means that they are pointing
out the parts of their theory that are being demonstrated in this particular
case.
Glen was doing something different. He was showing us how to match ourselves to,
in this case, not a patient, but someone consulting with him. He was witnessing what he saw going on, and
he was working to be aware both of what he saw and what he didn’t see. When the person consulting finished
presenting a segment of clinical material, he did not opine about what was
going on, but asked her what she thought was going on. He asked her what the material evoked in her –
what she felt on hearing the history. He
did wonder if she felt some of the things that he felt, but this was presented
in the form of a question, apparently out of curiosity, rather than as a
corrective – he was not saying you should feel what I feel, but wondered with
her why he would be feeling something she did not, if she did not, in fact,
feel it.
I was reminded of his presentation to our state
psychological association. His approach
to consulting seemed so simple that I felt I could easily do that. I know from practice that what he was doing
was, in fact, anything but simple. In
fact, I think it is terrifying. I think
it is like following a series of openings deeper and deeper into a cave, not
knowing if one has left behind a red thread that will allow one to find one’s
way back out.
Towards the end of the consultation, I let the group know
that I had had a dream the night before.
Glen reassured me that there was no better place than in a group of analysts to tell one's dream, so I did.
The group immediately grasped the excitement, but also the terror as a
response to the talk the night before.
My experience was that Glen was asking us to join the patient in the terrible
quest of not knowing – of being present to another without trying to control,
mold, or shape them; without knowing where they would go or how they would get
there.
I think that, at least in my own analysis, this became a faith-based
enterprise. I eventually became
convinced that my thoughts, random though they appeared at first, would coalesce
and, when they did, they would make sense.
And more often than not, they did.
And, frequently when they didn’t, my analyst would help me tie them
together.
I think Glen would support our gaining as much knowledge as
we can so that we are as well equipped as possible to manage the terror that is
part and parcel of being immersed in the relatively unstructured mind of
another person – especially as we try to be as open as possible to the
functioning of our own minds. But I think
he trusts that we will do this. Our
techniques, following red threads, etc., and our concepts, imagining the
organizational structure underlying the association we are listening to, are maps
that help orient us to the terrain we are inhabiting. They help us manage the terror.
But I think that he would not have us use those maps to protect us from the terror and the joy the emerges from the immediacy of the human interaction that the analytic space affords. We should be alive to the moment that we are having with this individual and we should be prepared to be surprised by what will emerge in that moment within them and within ourselves. When we are able to inhabit that space more fully and, in so far as our past experience and theoretical knowledge helps us, hover in that space and not flee from it, this will support our being well matched with our patients, witnessing their experience, and it will help us see both what is apparent and what is harder to sense – those aspects of the interaction that lie just outside of our awareness.