Inside Paul Wachtel's Consulting Room
I've only just come across Paul Wachtel, and am slowly trying to work my way through some of his many fascinating books, starting with Inside the Session: What Really Happens in Psychotherapy, about which some thoughts:
Wachtel starts off by noting that it is of course always easier to write about therapy neatly and tidily than describe the actual messy realities on the ground. Like Nina Coltart, whom I have discussed on here in detail, he also notes that a therapist is mostly uncertain most of the time. If you're overly confident you don't know what you're doing he says quite bluntly.
Wachtel is quite open in this book about his repeated desire to learn from and integrate practices from the diverse traditions of CBT, experiential, systems, and psychodynamics. One concrete way he does this is to look closely at the patient's behavior in daily life: feedback loops and vicious cycles. This unites CBT and psychodynamic approaches: the thought-action cycle. Early experiences, which psychodynamic approaches focus on, are often reinforced by daily behavior today.
He begins this attempted integration by focusing on what he regards as the central role across all these traditions of anxiety, which Freud after 1926 revised his project to say was the cornerstone, even more than repression. For Freud discovering and unlocking repression seemed to be key as one who saw himself as an archaeologist.
The typical idea, Wachtel says, that repressed material is not just "forgotten but can be retrieved later," is no longer believed by just about anybody. Rather repressed material can be discovered in disguised forms.
The therapeutic task is not just unmasking repressed fears and anxiety. It must also grapple with the corrective emotional experience? In so doing, Wachtel says, psychotherapy has undergone a shift from merely unmasking fears to helping the patient bear them.
Wachtel recognizes a considerable body of evidence pointing to the central role of exposure in helping with this task. CBT does this all the time, but Wachtel says it happens in different ways in psychodynamic treatment as well. In the former it is not just a matter of treating immediate thoughts and behavior, and regarding that as sufficient; in the latter it is not just a matter of insight into fears and anxieties, and treating insight as sufficient. Integrated therapy needs and must seek after both.
In both cases, what is, he says, not often remarked but nonetheless very powerful, is the role of kindness. Wachtel: "the history of psychoanalysis is replete with comments about the importance of kindness, caring, and the offering of the analyst’s more benign vision of what is possible for the patient as a substitute for the patient’s harsh superego" (p.14). This book challenges directly the idea that a clinician should be neutral, aloof, non-gratifying of patient's desires. Instead, "a warmly supportive stance toward the patient is the best facilitator of his capacity to explore previously warded-off thoughts, feelings, and wishes" (19).
This leads Wachtel to recognize that it is insufficient for an analyst or analytic therapist merely to proffer insight, or to insist of facing fears, without providing that kindness out of which the therapist comes to recognize that resistance is not irrational opposition to the therapist, but instead reflects the fact that the patient is terrified. So therapy must give the pt. space and safety to begin reappropriating cut-off parts of his psyche.
The task of the therapist here is to maintain a necessary balance, that is to "root the therapeutic effort in the dialectic between accepting the patient’s experience of the world and helping him to change those features of his assumptive world that are contributing to his pain." One must proceed with a careful hand here, for, as Wachtel continues, "in good part, change is reached by not trying to change the patient, or, more accurately I think, by both trying and not trying at the same time" (p.18). Only after feeling understood can a pt. begin to think about change.
Though written nearly a decade ago before "resiliency" became the buzzword it increasingly is today, Wachtel insists in this book that successful therapeutic change requires looking at positive cycles too. Patient and therapist need to focus on the patient's strengths as key to therapy--not just focusing on pathology.
Wachtel here very much echoes the great Adam Phillips in arguing that "When successful, psychotherapy helps the patient to retell his life story, to provide a different frame and give a different moral to the story. Hence, it enables him to give different meaning to events and experiences." This is a point that Phillips has often made.
Finally, Wachtel notes that a good therapeutic alliance and working relationship can have positive spillover effects in other areas outside the consulting room.
Wachtel starts off by noting that it is of course always easier to write about therapy neatly and tidily than describe the actual messy realities on the ground. Like Nina Coltart, whom I have discussed on here in detail, he also notes that a therapist is mostly uncertain most of the time. If you're overly confident you don't know what you're doing he says quite bluntly.
Wachtel is quite open in this book about his repeated desire to learn from and integrate practices from the diverse traditions of CBT, experiential, systems, and psychodynamics. One concrete way he does this is to look closely at the patient's behavior in daily life: feedback loops and vicious cycles. This unites CBT and psychodynamic approaches: the thought-action cycle. Early experiences, which psychodynamic approaches focus on, are often reinforced by daily behavior today.
He begins this attempted integration by focusing on what he regards as the central role across all these traditions of anxiety, which Freud after 1926 revised his project to say was the cornerstone, even more than repression. For Freud discovering and unlocking repression seemed to be key as one who saw himself as an archaeologist.
The typical idea, Wachtel says, that repressed material is not just "forgotten but can be retrieved later," is no longer believed by just about anybody. Rather repressed material can be discovered in disguised forms.
The therapeutic task is not just unmasking repressed fears and anxiety. It must also grapple with the corrective emotional experience? In so doing, Wachtel says, psychotherapy has undergone a shift from merely unmasking fears to helping the patient bear them.
Wachtel recognizes a considerable body of evidence pointing to the central role of exposure in helping with this task. CBT does this all the time, but Wachtel says it happens in different ways in psychodynamic treatment as well. In the former it is not just a matter of treating immediate thoughts and behavior, and regarding that as sufficient; in the latter it is not just a matter of insight into fears and anxieties, and treating insight as sufficient. Integrated therapy needs and must seek after both.
In both cases, what is, he says, not often remarked but nonetheless very powerful, is the role of kindness. Wachtel: "the history of psychoanalysis is replete with comments about the importance of kindness, caring, and the offering of the analyst’s more benign vision of what is possible for the patient as a substitute for the patient’s harsh superego" (p.14). This book challenges directly the idea that a clinician should be neutral, aloof, non-gratifying of patient's desires. Instead, "a warmly supportive stance toward the patient is the best facilitator of his capacity to explore previously warded-off thoughts, feelings, and wishes" (19).
This leads Wachtel to recognize that it is insufficient for an analyst or analytic therapist merely to proffer insight, or to insist of facing fears, without providing that kindness out of which the therapist comes to recognize that resistance is not irrational opposition to the therapist, but instead reflects the fact that the patient is terrified. So therapy must give the pt. space and safety to begin reappropriating cut-off parts of his psyche.
The task of the therapist here is to maintain a necessary balance, that is to "root the therapeutic effort in the dialectic between accepting the patient’s experience of the world and helping him to change those features of his assumptive world that are contributing to his pain." One must proceed with a careful hand here, for, as Wachtel continues, "in good part, change is reached by not trying to change the patient, or, more accurately I think, by both trying and not trying at the same time" (p.18). Only after feeling understood can a pt. begin to think about change.
Though written nearly a decade ago before "resiliency" became the buzzword it increasingly is today, Wachtel insists in this book that successful therapeutic change requires looking at positive cycles too. Patient and therapist need to focus on the patient's strengths as key to therapy--not just focusing on pathology.
Wachtel here very much echoes the great Adam Phillips in arguing that "When successful, psychotherapy helps the patient to retell his life story, to provide a different frame and give a different moral to the story. Hence, it enables him to give different meaning to events and experiences." This is a point that Phillips has often made.
Finally, Wachtel notes that a good therapeutic alliance and working relationship can have positive spillover effects in other areas outside the consulting room.
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