Let’s begin with a case—

 

Ellen, a 45 year old Caucasian woman, suffering with long term anxiety and depression, had been in psychotherapy for only a short time when she told the therapist that she was feeling a lot better and was thinking about stopping. Her therapist, after exploring Ellen’s thoughts about this, responded that she didn’t think it was a good idea at that time.  Ellen readily agreed to continue.

In the next session, Ellen reported that she had remembered when her mother had gotten very angry at her when Ellen, as a 7 year old, had said she didn’t like something she was served at dinner time. She went on to describe how this started a reoccurring conflict that went on for years, between her and her mother about this particular food. Her mother, who had died when Ellen was 22 years old, had continued to regularly serve that dish and Ellen had been forced to eat it. Ellen expressed surprise at remembering this because she hadn’t thought about it in many years and as she talked about it she felt very sad. She remembered feeling angry, sad, and trapped every time her mother served that food because she knew she had only two choices, to eat something that made her gag, or to resist and feel her mother’s wrath.

How might we understand this? How are these two sessions linked? Why did Ellen have this memory after the previous session?

How might Control-mastery explain these events?

                  I was first introduced to the theory while attending Smith College Social Work doctoral program starting in 1992. I was very fortunate to have had Drs. Cynthia Shilkret and Robert Shilkret as professors, both of whom taught courses on different aspects of Control-mastery theory. Up to that point I had studied and practiced using theories that social workers drew from and were exposed to in graduate school. At that time, clinical perspectives most often taught toward attaining the MSW were steeped in psychodynamic approaches drawing on Freudian Psychology, Ego Psychology and Self Psychology. In the doctoral program we dove into those theories and I garnered a much richer and deeper understanding of them. In fact, I had one of those life changing experiences when I realized that up to that point I knew very little about how to conduct psychotherapy. Prior to returning for my doctorate, I could probably have been called somebody with an “eclectic” style, which actually means “I don’t really understand the theories I’m using, although I’m well-intentioned and will do different things that might or might not be helpful, but I’m not really sure how to assess what does and doesn’t work.”

                  In my studies about how to conduct psychotherapy I became increasingly convinced that to be effective, drawing on a theory provided the clinician with:

  •              an overarching road map for how/where the therapy would go — especially during moments when the therapist felt uncertain or confused
  •             a way to explain why the client reacts in certain ways and the stance the therapist should take in response
  •              a way to predict outcome
  •              a way to prevent premature termination

                   What was also apparent to me was how Control-mastery theory was so much more compatible with social work practice values. Here was a theory that—

  1. was based on solid, on-going research — the focus of the work of the San Francisco Psychotherapy Research Group for over 50 years  (www.sfprg.org)
  2. took into consideration the complexity of human beings — no one size fits all
  3. did not pathologize people — instead understood clients’ troubles to stem from adaptations they made earlier in life. It maintained the dignity of the person rather than applying a      diagnosis.
  4. encompassed all the ways human beings make sense of their worlds especially their interpersonal relationships — cognitive, psychodynamic, and relational  
  5.  provided an elegant explanation for the countertransference therapists experience — as well as how to make clinical use of it on behalf of the client
  6. was client-driven — the entire case formulation was determined by the client, which the     therapist could discern from what the client says, how the client behaves, the client’s history         and the therapist’s countertransference.

                  Let’s look at the case example from a Control-mastery perspective. First, why would Ellen agree to continue in therapy when she’d announced she wanted to stop? Other perspectives might posit that the therapist’s suggestion that she stay touched on Ellen’s ambivalence about being in therapy. Or, Ellen could be understood to be engaging in resistance and wanting to flee from the intensity or scariness of the therapy— ie. “flight into health”.

                  However, Control-mastery theory tells us that people don’t engage in resistance, and that there isn’t true ambivalence as the person is always leaning more one way than the other. From the CM perspective, Ellen can be understood to be testing the therapist. People come to therapy with a plan to solve problems that are specific to them. They carry these very painful ideas about themselves, which are usually unconscious, that they want the therapist to help them disprove. Each client is inviting the therapist to create a relationship that echoes a painful one from the past to solve the problem the client was left with as a child.

                  We can gather clues about Ellen’s painful problem because after the first session where she tested the therapist, and in essence invited the therapist to kick her out of therapy, she had a memory central to the problem she had unsuccessfully solved when she was a child.

                  Let’s say you were that child struggling with the person who you expect to love you, and who you viewed as the ultimate authority, over eating something you didn’t like.

What could that child have concluded about herself from this difficult dilemma?

  •            Perhaps the child decided that she was bad for “making” her mother angry.
  •              Perhaps, she felt guilty for feeling angry at her mother.
  •              Maybe she decided that expressing her own preferences was bad, since it made her mother angry.
  •              She could have come to believe that there was something wrong with her for not liking that food.
  •              She certainly would have concluded that what was important to her mother took precedence over what Ellen wanted, at least in the situation she described.

                  So how did the first session help Ellen remember this painful repetitive scenario from her past? How were her suggestion to stop therapy, the therapist’s response and the memory linked together? Control-mastery theory tells us that often when clients test their therapists and the therapist passes the test clients may 1) engage more deeply in the therapy, 2) have a memory surface 3) test the therapist more intently, 4) feel more deeply or something else reflecting progress.

                  In this case, when she said she wanted to stop the therapy, Ellen was testing to see if the therapist could accept or tolerate her or would the therapist take her up on her offer to “kick her out”.  When the therapist invited her to remain, she then remembered a time when her mother clearly couldn’t accept or tolerate Ellen as a child having her own need/preference. The memory itself, could very well represent many experiences where her mother reacted angrily whenever Ellen expressed her own needs or likes. As these events would have been traumatic to a child, she would have formed some painful beliefs about herself—which in the theory are call pathogenic beliefs.

                  It is these beliefs that Ellen wants the therapist to help her disconfirm. Why do I say this? Because it is these beliefs that Ellen introduced into the therapy.

                   So begins our journey into the world of our client’s unconscious. Clients come to us with a plan, albeit mostly unconscious, that we as psychotherapists can understand through how the client sits with us. Our focus will be on understanding how the client’s pathogenic beliefs drive the tests the client poses for us to pass. In the case of Ellen, one of her pathogenic beliefs was that her needs were damaging to others. She tested this by offering to leave so that the therapist didn’t have to deal with her needs. When the therapist passed the test by inviting her to stay, essentially saying ‘your needs are not damaging to me’ Ellen could relax and remember more of her painful past that had contributed to the development of the pathogenic belief in the first place. In this way we can help the client toward her or his goals by passing those tests. We need not even interpret or explain what the client is doing—we need only to be proplan, that is, respond in ways that meet the client’s goals. In this way we can help free the client from painful, constricting ideas they carry and allow them to live a more enjoyable, meaningful life. In the articles to follow I will explore some of the specific ideas from Control-mastery Theory using case material to illustrate. You are invited to follow along as well as join the discussion.