Patients with plans

Psychotherapist Alan Rapport has a website with some useful articles about psychotherapy. (All of which, and so the links to them, are pdf files.)

His articles outline an approach to psychotherapy that makes sense and deals effectively with the issues raised by Masson in his Against Therapy by making the patient’s (conscious or unconscious) plan in seeking psychotherapy the central focus. In Rappoport’s words:

In assisting patients to carry out their plans, the sole function of the therapist is to help them conclude that neither their own nor others’ welfare is served by their maintaining their pathogenic adaptations; that is, that is safe for the patient to relinquish them, and it is safe (and typically beneficial) for others that they do so.

Rappoport is clearly very sensitive to the risks to patients involved in therapy. As he writes in The Patient’s Search for Safety:

Therapy is a risky business for patients, since they are exposing themselves to the possibility that they will be retraumatized in ways which were particularly harmful for them. They are as careful as they can be to maximize the likelihood they will benefit from the treatment, and to minimize the dangers of being harmed by it.

Rappoport is using and extending the Control-Mastery model of therapy which he summarises nicely in a short paper. He elsewhere summarises it as:

Control-Mastery theory holds that the causes of psychopathology are pathogenic beliefs, invalid and dysfunctional concepts of oneself and others acquired during our formative years which interfere with healthy interpersonal functioning.

Rappoport carefully sets out the overlaps with other therapeutic approaches and provides an insightful explanation of how patients can gain benefits from therapists pursuing a wide-range of therapeutic approaches:

A great deal of the therapist’s behavior is not significant to the patient in regard to the testing process. The issues which frighten or reassure the patient are quite specific, and behavior which does not relate to them is irrelevant. This is the reason that therapists of many different theoretical orientations and a wide variety of personal styles may be of help to the same patient. For example, if a patient is concerned about whether she is valued by the therapist, the therapist’s neatness or religious affiliation is unlikely to affect the patient’s sense of safety in this area. If a person is concerned about whether the therapist is competitive, the therapist’s school of thought or degree of interest in the arts will not be of great significance. As long as the patient’s needs are met, the therapist has great latitude to be relaxed and natural and, in fact, should be so, thus providing a convincing demonstration of nondefensiveness.

I am impressed by the clarity of exposition and philosophical insight in his papers. Rappoport’s notion of pathogenic adaptation (a term he prefers to pathogenic belief on the grounds that they are not fully accepted as true by the patient but are rather adaptations under pressure) is a much more concise explanation and characterisation of psychic pain and disfunction than I have read previously.

I originally came across his work because a friend showed me this piece on co-narcissism (adapting to narcissistic parents), a copy of which had been given to her by someone who works as a professional therapist.

Rapport does use the concept of self-esteem which I distrust as a therapeutic goal, strongly preferring self-respect. (That is, judgement based on a morally grounded assessment of oneself, not merely feeling good about oneself.) But he clearly means a damaged (and damaging) sense of self, and that is very much the issue. The piece on co-narcissism is impressive in the calm, knowing way it discusses both the damage the narcissist does and the way the narcissist is also damaged.

So, lots of useful and thought-provoking stuff.