A few weeks back I wrote up part one of what I learned from Patricia Coughlin. She a trainer in a little known model called Intensive Short Term Dynamic Psychotherapy (ISTDP).
In the training she presented two sex therapy cases. I was very impressed.
So here's part 2 of what I've learned from Coughlin.
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8. Sometimes sexuality and connection can reintegrate automatically, but sometimes we also have to help people reintegrate.
One of the things I've heard my Emotionally Focused Therapy (EFT) friends say is, "once you fix the relationship problems, then the sexual problems resolve themselves."
That seems crazy to me.
First, I've not seen that in the literature. The EFT literature on sex therapy I've seen says the opposite. That once you help people communicate, they still have to address the sexual connection.
Second, I've not seen that in practice. When I get clients who've seen other EFT therapists, they still have sexual problems.
If it's not happening, why do clinicians say that it works that way?
In Coughlin's training she clearly showed us how her patient had his aggression fused with his sexuality- he had rape fantasies. Then she showed us how she helped him disentangle the two. This happened fairly early in the therapy, but he was still unable to get an erection with his wife. So Coughlin had to reintegrate his sexuality with the patient's feelings of connection and love.
That makes much more since with what I've seen. I guess sometimes sexuality and connection can reintegrate automatically, but sometimes we also have to help people reintegrate.
9. Rage is retaliatory. The person wants to do to you what was done to them (in the past).
The basic intervention Coughlin used was to challenge patients until they got mad with her. Then she'd push them to tell her the fantasy of how they'd attack her, they'd explore the fantasy and, finally, the patient would discover why this specific fantasy was important.
Yeah, I know. It's a crazy intervention.
Coughlin believes this type of work is important because they ways clients fantasize about attacking her mirrors how they themselves were hurt.
I've long believed "hurt people hurt people," and that "all behavior makes sense in context," but the use of fantasy as a way to draw out specifically how the client was hurt, well I'd never considered that before.
I get the sense that many psychodynamic therapists were trained in fantasy work, but not me. This was all new.
10 "Unless clients can sense that you tolerate it, they keep it to themselves."
Honestly, the things Coughlin talked about with the client were quite graphic. At one point, she said, "unless clients can sense that you can tolerate it, they keep it to themselves."
It's this idea that when we were young we were punished, or ignored by our parents when we expressed certain emotions, so we unconsciously decided it wasn't safe to feel those feelings. Part of the corrective experience of therapy is to allow people to fully feel whatever they feel.
No matter how intense.
If client's get the sense that we can't handle their emotions, they keep those emotions to themselves and stay stuck in their emotional pain.
11. Characterological problems.
One of the cases Coughlin presented was a client who was cheating on his wife and continually rationalized his behavior.
Coughlin's clinical hypothesis was he used his intellect to avoid his feelings about his behavior, but the feelings didn't go away. They just changed into depression and anxiety.
After ten sessions, his depression and anxiety went away, and he stopped taking his medication. But, his "characterological" problems persisted- he still rationalized instead of feeling his feelings. Coughlin felt that if he didn't reengage with his feelings, he'd have a high likelihood of relapse.
I was struck by how straightforward her assessment of him was. He's highly logical and doesn't feel his emotions. Since that's the problem, if he doesn't change that, he'll probably relapse.
12. "It's not about me being perfect, it's about the UTA."
In Coughlin's model, ISTDP, they have this idea that inside each of us is a force which keeps us stuck and a force that wants us to grow.
They call this force for growth the UTA or Unconscious Therapeutic Alliance.
For instance, say a client comes in and sits down.
"What brings you in?" you ask.
"Well, I'm only here because my wife asked me to come." He says.
The client seems resistant, right? Well, Coughlin might say something like:
"Well, you came in today. You didn't have to. So what do you want out of therapy?" She would say that because he actually showed up there is something inside of him which wants change.
The therapists job is to ally with the force for growth. If we can ally with the side wanting change, then we have a chance of something big happening.
This also means we don't have to do therapy perfectly. The client already has a force for growth inside of them. Our job isn't to do therapy perfectly. We're merely prodding the client's own internal force for health.
13. You go to the past only when it gets in the way of the present.
While Coughlin frequently worked with the client's past, she was consistently focused on how this problem which began in the past impacts the present.
I think sometimes therapists, myself included, get stuck in endlessly processing the past, hoping it will influence the present.
Sometimes it does, sometimes it doesn't. So to see someone work in the present with the problem was really refreshing.
14. Connection makes us vulnerable to loss.
A core idea in ISTDP is that most problems stem from avoiding core emotions of guilt and anger.
Coughlin said she doesn't believe that.
She believes there are other core emotions, such as connection, which cause problems. For instance connection makes us vulnerable to loss, so we often create defenses to avoid connecting.
First, I admire her ability to think outside of her model. Most of the people I know are attachment therapists, so everything always goes back to attachment theory. They can be pretty adamant that everything goes back to attachment issues. To see Coughlin disagree with her model was refreshing.
Second, just the idea that connection is inherently vulnerable is a big deal. Whenever we love, we open ourselves to loss.
I had never heard the word "syntonic" before this training.
Syntonic means that a patient believes something is just the way they are, but it's really a defense mechanism against feeling.
For example, when a man responds by saying, "I don't really have feelings," it is syntonic because his lack of emotion is actually a defense against feeling.
Another example could be a client who enjoys drugs. They might say they just enjoy drugs, but the therapist could consider this syntonic since the client is using drugs to avoid feeling their emotions.
In the case Coughlin showed the patient had frequent partners outside his marriage but claimed he was just into open relationships. That's syntonic; he thinks he's just into open relationships, but really, he was using his ability to seduce women to avoid feeling inadequate.
It can get tricky to distinguish between syntonic defenses and actual personality traits. For instance, Carl Hart, a Harvard neuroscientist who studies drug use says drug use is a normal part of the human experience, most people can use drugs safely, and most drug use does not impair performance at work or home. In fact, in his view, the real problem is how we vilify drug users, mostly due to racism.
So, how do you know a client's response is syntonic?
I don't know. All I know is that sometimes a clients response is syntonic. I've got more to learn on this one.
Patricia Coughlin and ISTDP Remind Us To ...
I think Coughlin is on the leading edge of therapeutic interventions. She's one of the masters. She knows the research and her model, and she can clearly work in the unconscious.
The only problem is she made it look too easy.
When doing this sort of work, the danger of a misstep is pretty high. I've heard horror stories of ISTDP therapists traumatizing trainees by misreading unconscious signals and hammering home false interpretations.
Also, this work talks an ungodly amount of therapist self regulation.
For instance, several times Coughlin had clients describe, in vivid detail, their fantasies of raping her. You're never going to get the majority of therapists skilled enough to handle that.
Still, I think her willingness to work with the unconscious is the tip of the spear. And I agree with her. As we've moved away from thinking about the unconscious and defenses we've lost something. I'm glad Coughlin's bring it back.
Jordan (the Counselor)
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If you liked this post, consider reading this next. I think you'll like it ;) It's more about what I learned from Patricia Coughlin.