The Dialectics of Psychotherapy

Don Ross, MD
Medical Director, The Retreat at Sheppard Pratt
Clinical Associate Professor of Psychiatry, University of Maryland
Supervising and Training Analyst, Washington Psychoanalytic Institute

“May you live in interesting times.” So goes the famous Chinese “blessing”, which has embedded within it the dialectal tension of crisis and opportunity. We live in interesting times as psychiatrists practicing psychotherapy. For example, we must be responsive to the pressures of the current social and economic environment and thus provide psychotherapy that is short-term, focused, evidence based, and cost effective. And we must respect the clinical needs of many of our patients to go at a pace the patient can tolerate, allow the emergence of difficult material, and provide a holding environment that allows an adequate depth. Otherwise these patients will get no benefit out of psychotherapy. One result of this dialectic is that we often do our most difficult and most interesting work while making the least amount of money.

Dialectics is the process of holding seemingly incompatible truths (thesis and antithesis) in tension with each other so that a new synthesis can emerge. The dialectical process was formulated by the philosopher, Georg Wilhelm Friedrich Hegel, and made popular in psychotherapy through Marsha Linehan’s development of Dialectical Behavior Therapy (DBT) for borderline patients. By engaging a series of dialectics with the help of cognitive behavior therapy (CBT) and Zen, Linehan created a framework for effectively working with chronically suicidal patients. She found that these vulnerable patients need to change, but also need to be validated. They are “the best they can possibly be at this moment” and simultaneously “need to change to have a life worth living.” Endorsing both positions is necessary for effective work to proceed.

Psychiatrists who understand dialectical thinking and apply it to their work may have more success in negotiating the tensions inherent in contemporary psychotherapy. Psychiatric residents learning psychotherapy today have the opportunity to learn the fundamentals within the tension of necessary opposites. In both cases, those who embrace this approach develop flexibility and range as psychotherapists.

What are some of these “necessary opposites”? As psychiatrists, the one we face every day is the tension between treating within a biomedical model vs. treating within a psychotherapeutic framework. Is the patient’s depression an expression of disordered neurochemistry or an understandable (if extreme) reaction to a serious loss? Is the treatment of choice drugs or the “talking cure”? We have moved towards a synthesis of these apparent opposites. The patient gets the best care when the psychiatrist understands that both perspectives are right and deserve attention. The art of much of psychiatry today is in combining effective medications with effective psychotherapy.

Within psychotherapy itself, one must appreciate the relationship within the apparent opposites of acceptance vs. change. Acceptance is not a straightforward and obvious concept. The patient may see acceptance as giving up and living with the current suffering. This seems unbearable and leads to despair. But the patient doesn’t see how much he or she avoids the pain, which leads to further layers of suffering. For example, she may relentlessly pursue a search for a magic medication for her somatic anxiety, which only leads to side effects, addiction, and doctor shopping. The first step forward is to change the attitude towards acceptance and stop these well developed avoidance patterns. This allows for a fuller appreciation of the nature of the pain, which, in turn, creates the ground for effective strategies for change. With the example above, the patient may need to spend some time with her anxiety to understand what she is so anxious about before she can change it. In order to help the patient, the psychotherapist must grasp how working on both acceptance and change creates a therapeutic spiral. Acceptance sets the groundwork for effective change and change leads to new opportunities for acceptance and respect for the self.

The road to psychotherapeutic change has its own inherent dialectics. For example, we often argue over whether to approach a case from a psychodynamic perspective vs. a behavioral perspective. Does the patient need help in understanding internal conflicts or in replacing specific behaviors? Most patients benefit from a skillful synthesis of both approaches. A young man with new onset panic attacks in the context of starting graduate school benefits from behaviorally managing the anxiety and being able to stay in class. He also benefits from understanding the source of his anxiety in his inhibited aggression and guilt around surpassing his working class father. This understanding frees him up to be more assertive with his professors, which he then practices in seminars. This sets the stage for a successful passage through his studies. In turn, successful assertiveness (which is rewarded with good grades, etc.) reinforces his newfound freedom from neurotic conflict. Appreciating the full dialectic of understanding vs. behavior change allows a more comprehensive approach and a better outcome.

Similarly, appreciating the dialectic around dependence vs. independence helps the psychotherapist work with a 34 year old woman who is beginning to despair, as she is stuck with caring for her widowed mother. She can’t see a way out, but she does not fully appreciate the nature of her dilemma. On the surface, her mother depends upon her. The patient feels that reaching for an independent life (perhaps with a husband) is “selfish” and ungrateful. Under the surface, what she can’t see is how her own dependent wishes are in play as well. She fears she will separate from her mother and no one will ever care about her. Holding onto her mother protects her from “independence”, which she unconsciously equates with loneliness. But independence and dependence are only incompatible until one understands the developmental progression from dependent merger > separation/individuation > more mature interdependency. The therapist must see the way out of the patient’s stuck position if he or she is going to help her make the necessary moves.

Let me end with another example of the power of a dialectical perspective, this time in helping us appreciate the complexity and therapeutic power of the patient-therapist relationship. By recognizing that both thesis and antithesis are true, that one does not invalidate the other, the therapist can better work effectively to help the patient. These positions are stated from the patient’s point of view:

- Thesis #1: I need to be close in order to feel loved. If I am not close enough, I feel unloved and unlovable.

- Antithesis #1: When I am close, I feel terribly vulnerable to being hurt (e.g.-abandoned, suffocated, scorned.)

- Synthesis #1: Therapy needs to be intense enough to be emotionally meaningful, but with enough distance to make sense of what is going on.

- Thesis #2: I want my therapist to love me in a special way (which may be maternal, paternal, sexual or in some other way.)

- Antithesis #2: I need my therapist to maintain objectivity so she can help me with the problems I came to therapy with.

- Synthesis #2: The therapist must genuinely care deeply about the patient, while using that caring connection to explore the particular meanings and associated fantasies that love has for this patient.

- Thesis #3: My feelings for my therapist are real and deserve to be recognized as such.

- Antithesis #3: My feelings for my therapist are a repetition of past relationships that have not worked well for me in my adult life. I need to understand these patterns and master them.

- Synthesis #3: Both are true. Old feelings have come alive in this present relationship between patient and therapist. They have been resurrected, not just remembered or play-acted. In this living form, where there is true emotional power, these feelings need to be understood. In this way, the patient can gain full ownership and mastery of these feelings and associated fantasies, and make use of them in life outside of therapy.

This article was originally published in The Maryland Psychiatrist, Volume 38, Number 2, Winter, 2012.