Ch. 6: Responsibility Flashcards
(44 cards)
Curious examples
A group leader has a “can’t” bell which he rings whenever a patient in his group says “I can’t”. The patient is asked to recant and then to restate the phrase as “I won’t”.
“I cannot decide what to do, I can’t bring myself to end the relationship, but I pray that I could catch him in bed with another woman so that I would be able to leave him.”
Therapist asks clients: “Not ‘I have a mind that skips,” but “when I get hurt and feel like crying, I defend myself by being confused.”
Sexually compulsive man after he didn’t find a woman for the night: “Thank God, now I can read and get a good night’s sleep, which is what I really wanted to do all along.”
The therapist asks the client: “Whose unconscious is it?”
Philosopher vs Clinician
To the philosopher, freedom has broad personal, social, moral and political implications. The debate about freedom and causality hasn’t ceased for 2000 years:
- first, people believed in divine providence;
- later in scientific causality;
- still later in the Hegelian view of history as a meaningful progression or in
- Marx’s or Freud’s determinism.
For the clinician, only two are relevant in everyday practice:
- The individual’s freedom to create his or her own life
- The freedom to desire, to choose, to act, and - most importantly to psychotherapy - to change.
Definition of Responsibility
Sartre
in the mental health field = patient’s capability for rational conduct as well as to the therapist’s moral commitment to the patient.
Sartre: “To be responsible is to be the uncontested author of an event or a thing.”
It’s being aware of creating one’s own self, destiny, life predicament, feelings and, if such be the case, one’s own suffering. For the patient who denies such responsibility, who persists in blaming others, no real therapy is possible.
Yalom snorkeling
Husserl’s noema
At the deepest level, responsibility accounts for existence. Yalom had an experience while snorkeling when he looked at the beautiful fish, the blueness of the water, and felt the coziness of the water. Suddenly he realized that the beautiful fish don’t know they are beautiful, the water doesn’t know it’s blue and cozy - all of these Yalom had created in his own mind.
In Husserl’s terms Yalom’s noema (“meaning”) had exploded and he had become aware of his constitutive function
Sartre & chestnut
Kant
Heidegger’s dasein
Sartre also talks through a protagonist about looking at the root of a chestnut tree in a park and experiencing everything around him - the root, the park gates, the bench, the sparse grass - losing their individuality; their individual appearance vanished into a monstrous mass in disorder. “‘This is a root’ - it didn’t work any more.”
The knowledge of his true “situation” crashes in on him as he discovers his responsibility for the world. The world acquired significance only through the way it is constituted by the human being - in Sartre’s terms “for-itself”.
The individual is not only free, but also doomed to freedom.
Kant: “Space itself is not something objective and real but something subjective and ideal; it is, as it were, a schema issuing by a constant law from the nature of the mind for the coordinating of all outer sensa whatever.”
Heidegger referred to the individual as dasein to emphasize the dual nature of human existence: the individual is “there” (da) but they also constitute what is there (sein). It is an empirical, objective ego; and a transcendental ego which constitutes, i.e. is responsible for, the world.
Yalom and Freedom
Mass starvation
Yalom: “Freedom extends beyond being responsible for the world (imbuing the world with significance): one is also entirely responsible for one’s life, not only for one’s actions but for one’s failures to act.”
Yalom says that whereas there is mass starvation on the other side of the world and he feels he can do little to affect the situation, Sartre would point out that he chooses to keep himself uninformed. IMPORTANT: Sartre does not say that we should be doing something different, but that what we do do is our responsibility.
Constituting is frightening
Sartre on man’s project
To constitute oneself and one’s world is (can be) a deeply frightening insight: there are no rules, no ethical systems, no values; no external referent whatsoever, there is no grand design in the universe. Sartre: “man is the being whose project is to be god”.
Groundlessness
Response to groundlessness
Fromm in Escape of Freedom
Heidegger and Sartre on appearances
Empirical world
This leads us to groundlessness.
- Aka “ur-anxiety”, perceived by some thinkers as the most fundamental anxiety.
- “My death” is the most scary one because with it the meaning giver and spectator of the world dies too, and is truly confronted with nothingness.
- It ties to loneliness as well, not only being socially lonely, but also separate from the world, as one experiences it, as well. “The responsibility of the ‘for-itself’ (the individual consciousness) is overwhelming, since it is thanks to the ‘for-itself’ that it happens there is a world.”
We respond to groundlessness as with anxiety: we seek relief.
- As with death we avoid it, we avoid making decisions, isolation, autonomous action to avoid awareness of fundamental groundlessness
Fromm in Escape of Freedom reminds as that even a tyrant is better than no leader at all
- Thus, children are upset by freedom and demand limit setting; and panicky psychotics do the same.
The most powerful defense might be reality as it is experienced - that is, the appearance of things.
- Heidegger and Sartre suggest that appearances serve denial: we constitute the world in such a way that it appears independent of our constitution. To constitute the world as an empirical world means to constitute something as independent of ourselves.
California culture
Yalom’s friend, an art critic, characterized the new California culture by describing an incident that occured on his first visit to Southern California. He stopped at a fast-food joint and was given a small plastic container of ketchup. Elsewhere these containers have a dotted line and the notation “tear here”. The California one had no dotted lines, only the inscription “tear anywhere”.
The picture of psychopathology has changed accordingly. (PS! California was at that time, and probably still is, the birthplace of new psychotherapeutic methods.)
Today’s patient
What are the words used?
How does this relate to existential facts?
Today’s patient has to cope more with freedom than with suppressed drives. Not about a push from within about what one has to do, or from without about what one ought to do. It’s a struggle about choice: with what he or she wants to do.
The word “cure” is gone, now it’s about “growth” or “progress”.
In some sense we are closer than ever to experiencing the existential facts of life, but we are unprepared: it is too much to bear, anxiety clamors for a release, and both individually and socially we engage in a frenetic search to shield ourselves from freedom.
COMPULSIVITY
Instead of freedom, creating a psychic world in which one exists under the sway of some irresistible ego-alien (“not me”) force. It’s a defense.
The guy Bernarnd who was revealed that he didn’t have to have sex with women that night: “I didn’t know that it was what I really wanted until I felt the wave of relief that came over me when the last woman refused me.”
DISPLACEMENT OF RESPONSIBILITY
Bernard
“Little sex” patient
Paranoid patients
Somatic patients
Bernard also shifted his responsibility to Yalom. Yalom pointed it out that he “dumped” his problems in his laps, after it was clear that Bernard didn’t process his thoughts and his sessions in between sessions (“The sessions would lose spontaneity if I would do that.”)
- Also he drove 50 miles to see Yalom every time, with no problems, but when he had to take 20 minutes a day to an exercise where he reflects on himself, he said he doesn’t have the time.
Another patient complained about little sex with his wife, but didn’t want to accept that he is actually free in his sexual matters. That he could leave his wife, but just the mere consideration of this idea was enough for paroxysms of anxiety.
- He appointed his sexual problems to a number of outer factors: wife’s lack of sexual interest, her disinclination to change, squeaky bedsprings so kids would hear (but he wouldn’t get a new bed either), his own aging, his unresolved problems with his mom (served as an apologia for responsibility avoidance)
Paranoid patients do it too - they project their fears to outer influence.
Somatic patients, even when they recognize the psychological substrate to their somatic distress, employ externalizations by attributing their dysphoria to “bad nerves” or adverse work conditions.
DENIAL OF RESPONSIBILITY: INNOCENT VICTIM
Individuals who deny responsibility by experiencing themselves as innocent victims of events they often themselves unwittingly set into motion.
Clarissa, a 40 year old psychotherapist, joined a therapy group after having stopped with a lengthy analysis. After several months in the group he announced that he had re-entered analysis, yet her analyst, who strongly disapproved of group therapy, interpreted her membership in the therapy group as “acting out”. Clarissa suggested that Yalom talk to the analyst, but the analyst completely refused to converse. Other group members became punitive in their comments, saying that Clarissa is “playing dumb” and Clarissa felt that she was a victim once again, forced to leave the group because of “circumstances beyond her control”.
- Yalom: “She came to therapy because of problems establishing intimate relationships. Problem was that she was never with a person. While next to group members, she was with me. While with me, she was with her analyst. While with analyst, she was with her father (who had in her childhood been brutal, punitive, and rejecting of her).”
DENIAL OF RESPONSIBILITY: LOSING CONTROL
Some patients are temporarily “out of mind”. It is important to note that the “losing control” is by no means disorderly: it is purposeful and offers pay-offs as well as an opportunity to avoid responsibility.
The “Whose unconscious is it?” question was asked by a woman who was brutalized and rejected by an insensitive, sadistic lover, “lost control” and “by going crazy” radically changed the balance of control in the relationship. She followed him around for weeks, broke into and vandalized his apartment, threw dishes while he was dining with friends. Eventually, he panicked, sought protection from the police, and required emergency psychiatric care. Her goal accomplished, she - mirabile dictu - regained control and was rational from thereon.
PS! Some patients want nurturance so much (often from their therapist) that they “lose control” even to the point of requiring hospitalization.
AVOIDANCE OF AUTONOMOUS BEHAVIOR
Some know what they have to do but refuse to take that step. Paul was in NY work for three days for job interviews, but felt lonely each night. He had many friends there, and waited for them to get in touch with him, although he hadn’t let them know he was there. He couldn’t pick up the phone himself, because “no energy, “too humiliated to ask for company”, “they’d feel I only call when I need them.”
Responsibility Assumption and Psychotherapy (The first step)
The first step for the therapist is not a technique, but an attitude: continually operating within the frame of reference that a patient has created his or her own distress.
If one continues to believe that distress is caused by others, by bad luck etc. - why invest energy in personal change?
In the face of such a belief system, the obvious strategy is not therapeutic but activist: to change one’s environment.
IDENTIFICATION AND LABELING
The first task is to identify instances and methods of avoiding responsibility and to make them known.
- Ringing the “can’t bell” and asking to change to “will not”
- “Whose unconscious is it?”
- Saying: “Not ‘he bugs me’ but ‘I let him bug me.’”
Vera Gatch’s and Maurice Temerlin’s examples of confrontative interventions (4)
Vera Gatch and Maurice Temerlin studied audiotapes of therapy sessions and shared examples of confrontative interventions designed to enhance responsibility awareness:
- When one man complained bitterly and passively that his wife doesn’t want to have sex with him, the therapist clarified the implicit choice: “You must like her that way, you’ve been married to her a long time.”
- Housewife: “I cannot manage my child, all he does is sit and watch TV all day.” Therapist: “And you’re too little and helpless to turn off the TV.”
- Obsessional man: “Stop me, I’m afraid I’m going to kill myself!” Therapist: “I should stop you? If you really want to kill yourself - to actually die - no one can stop you - except you.”
- With a man who felt life held nothing for him because he suffered from the unrequited love of an older woman, a therapist began singing “Poor little lamb that has lost its way.”
Quicksand of demonstrating responsibility
Solution
Demonstrating responsibility to a patient can wander into quicksand. “This is all very well, but he - sitting here in his office - doesn’t know what it’s like in the business world/how overwhelming my compulsion is/what an impossible boss I have). This is a limitless resistance, because the patient is not an objective observer of their own life.
Solution: to work with first-hand data, i.e. what happens in the sessions.
Demonstrating responsibility:
Doris
48-year-old woman
Doris provides an illustration.
- Problem: anxiety with men - she had time and time again ended up with abusive men
- Her father was abusive, her first husband, current husband, and a string of employees
- Yalom: “I was inclined to empathize with Doris for having had the bad luck to endlessly be thrown into the clutches of tyrannical bastards.”
- After several months in group therapy, she had an anxiety storm and called for an emergency individual meeting the next day. Yalom reorganized the schedule with difficulty, but 20 minutes before the session, Doris cancelled.
- In the group a few days later, Yalom asked: “Why did you cancel?” Doris: “Since your rule was that you won’t see an individual member outside of the group more than only for one hour during the entire course of therapy.” No other members (7) had heard that rule, but Doris was convinced.
- Yalom describes also her remembering a small negative comment, but never remembering a string of positive comments.
- Yalom: “Doris’s interaction with me in the microcosm of here-and-now was representative of her relationship with men and illuminated her responsibility in her life situation.” She saw all men as authoritarian and uncaring.
- This was crucial to work with as it had far-reaching consequences to her basic problem. Yalom to Doris: “Doris, I believe what just happened between you and me is exceedingly important because it gives us a valuable clue to some of the problems that exist between you and men in your life.”
- Repeat this when patient doesn’t take it at first
Another patient, 48 year old woman who said that her children don’t take her seriously.
- Yalom looked at his own feelings about the woman and noticed that he perceives her as having a whining quality in her voice which tempted me not to take her seriously and to treat her as a child. “Sharing my feelings was enormously useful to her: it helped her become aware of her childlike behavior in many areas.”
- They treated her exactly as she asked to be treated (nonverbally through whining).
What to say when therapist feels heavily burdened?
Responses of the client
A therapist who feels heavily burdened by the patient:
- “I feel you are putting everything on my lap”
- “I don’t have a sense of you actively collaborating with me”
- “Why do you come?”
Often response is feigning helplessness
- “I don’t know”
- “Tell me what I have to do”
Important!: they tell you they don’t know what to do, but they don’t disclose their feelings, they don’t write down their dreams (or do other exercises), they prefer to discuss intellectual issues or engage the therapist in a never-ending discussion of how therapy works.
- It isn’t that they don’t know what to do, instead, all of these are gambits to avoid responsibility
Ruth who didn’t know what to do
Ruth, rejected by men because of her dependency, no female friends, desperately lonely, no success in individual therapy (therapists said that she produced no material to work with).
- Ruth joined a group
- Therapist said Ruth does in the group what she does outside of the group (she was passive and helpless).
- Ruth said she comes there every week and doesn’t get anything out of it
- Therapist: “Of course not, how can something happen until you make it happen?”
- Ruth: “I feel ‘blanked out’, I don’t know what to say”
- Therapist: “It seems important for you never to know what to say or do.”
- Ruth: (crying) “Tell me what you want me to do. If I’d know I’d do it!”
- Therapist: “On the contrary. It seems very frightening for you to do what you can do for yourself.”
- Ruth: “Here I am again, my mind is scrambled eggs, you are irritated with me. I feel worse. I don’t know what to do.”
- Group joined in, some expressed annoyance at her eternal helplessness, others reminded that there had been endless discussions in the group about how members could participate more effectively.
- Another: “you could talk about sadness, fears, being hurt. About what a stern bastard the therapist is. Or about feelings towards other members.” She knew, and everyone else knew these options. “Why do you need to maintain your posture of helplessness and pseudodementia?”
- She eventually managed to speak up more, e.g. she admitted that she didn’t stay for coffee after the meetings because she was afraid that Cynthia, who she perceived as needy, would cling to her and start calling at night. This evoked an intense discussion between the two and by the end of the session she had done more work than in the previous six months.
- It was clear that she wanted help and change to come from the outside.
RESPONSIBILITY ASSUMPTION IN GROUP THERAPY: Microcosm
Therapy is a microcosm.
In individual therapy, the patient can often encounter their conflicted problems surrounding authority or problems relating to and stemming from parental relationships.
In group therapy, so many others are encountered who can activate a number of interpersonal issues: sibling rivalry, heterosexuality, homosexuality, competition with peers, intimacy, self-disclosure, generosity, giving and receiving, etc.
Born simultaneously
All members of group therapy are born simultaneously: each starts out on an equal foot. Each also is then responsible for scooping and shaping a particular life in the group, as they are in real life.
- The group also has many eyes, which can notice how members create their own self-victimization (that is, when the group functions in the here-and-now)
