The Conjunctive Model Of Psychotherapy (An Excerpt)

The psychotherapy process requires the deliberate joining of two human beings, mainly orchestrated by one, and requiring heartfelt collaboration by both. Breaches in the relationship are plumbed for the information they provide, the two continually surprised and inspired as they move to new, uncharted views about what the patient needs and how to get there. Indeed there are rules, procedures, and boundaries, but knowing when these guidelines contaminate the therapy's authenticity and sap its power is one of the therapist's most subtle challenges.

Therapists constantly work to identify how their craft differs from the commonsensical stuff of everyday relationships. They are not supposed to hug their patients, attend their weddings, or even have the smallest need for their patients' approval. The therapy process is not to be corrupted by patient and therapist embracing too much of their real relationship, as if the technical, less personal aspects of therapy are the most authentically therapeutic.

As therapists, we do not talk much about wanting the patient to respond to the personal influence we may bring to bear in creating desirable change. Struggling, even suffering, in the service of establishing and maintaining an ever more profound connection to the human being otherwise known as "the patient," may be labeled overinvolvement.

Yet, the pull toward connection, uncomplicated human connection, pervades the therapy experience. Much is known about the ways in which this therapeutic connection can be distorted internally via transference, countertransference; pro-jective identification, and developmental distortions and lags. These complicating developments in therapy represent one source of the impasses I call therapeutic disjunctions (Frankel, 2000), in this case intrapsychically generated. Gender differ-ences, cultural background and real life influences on mood are a few examples of the other category of disjunctions based upon mismatches between people, deriving from their perso-nalities and their actual life circumstances. When any of these disjunctive factors is at work the disconnect between therapist and patient can be profound, without necessarily being obvious from the surface appearances both parties maintain. Their words may be right, as if they agree on key issues, but they may be infected by silent skepticism or tarnished by the tone in which they are uttered. Many of our theories of technique are directed at understanding and healing these interpersonal rifts.

Underrepresented in our theory making, however, are the ways in which therapist and patient actively breathe life into each other, collaboratively facilitating the other's healing when required and encouraging ongoing personal and therapeutic development. These creative forces are as present as the divi-sive ones, making therapy a remarkably complex set of activi-ties that encompasses multiple pulls at every moment. In order to distinguish it from other kinds of therapeutic joinings, I call this coming together between therapeutic partners the conjunc-tive process. In this book much space will be devoted to deli-neating and illustrating the driving force in therapy I call conjunctive, as well as addressing why therapists tend to be uncomfortable about actively encouraging this kind of connection with their patients. I use the term conjunctive sequence to refer to a series of linked interpersonal steps involved in therapeutic unification. Finally, at the heart of the matter, conjunctions are points of joining here the two therapy partners clearly influence each other toward depth of understanding, and are aware that the conditions change are being engaged.

But the actual uniting, that which convinces the patient to comprehend in a deep way what he and the therapist have been struggling for, is actually closer to magic than anything I will be able to describe. This magic consists of a special conglomeration words, intuitions, feelings, emphases, and pauses. The order which pain and disappointment, and elation take place is all-important to the final result. The moment at which comprehension occurs, however, is often surprising, and is not so easily linked to the quest to find psychological meaning.

Even contemporary, relationally informed psychodynamic therapies tend to accord the therapist prerogatives in orchestrating and leading the therapy that give him or her an edge on knowing. In this chapter I begin to develop a point of view that, while recognizing the therapist's responsibility to make sure the therapy progresses, argues forcefully for therapist and patient sharing authority and taking full advantage of each other's wisdom. These conditions are required for the two to move effectively toward bilateral change in the direction of the patient's therapeutic goals, the interpersonal and therapeutic development I call conjunction.

How Equal in Influence are Therapist and Patient?

The notion of therapeutic symmetry pervades this book. The underlying principle is that the therapist and patient are both human beings. They make judgments, cooperate when they feel doing so is reasonable, and yield to each other's influence when they are convinced that the other makes sense, deep interpersonal sense. This picture of interpersonal symmetry does not contradict the notion that, indeed, there is an inherent asymmetry in the therapy situation, with the therapist being responsible for guarding its outcome. Other asymmetries are based on the wisdom that each partner brings to the table at any point. Yet, understanding the conjunctive driving force behind the therapy requires a focus on the sharing and colla-boration that constantly occurs between the two therapy partners.

Shifts in psychodynamic thinking acknowledge the individual and shared subjectivity of the therapy situation, as well as the mutative influence therapist and patient may have on each other and provide a contemporary theoretical backdrop for establishing conjunction as a major activity of therapy. In these views, the balance between therapist's and patient's authority to know and lead in the therapy is shifted toward parity, each having moments of greater knowing. My understanding is that this reciprocity, or sharing of influence, occurs whether it is acknowledged formally or not. The undercurrents coloring the therapy experience are always there, with therapist and patient sending a complex array of signals to each other, embellishing the formal work of therapy. In this picture, the therapist is a human being, as fallible and as open to constructive influence as the patient. This statement captures the essence of my own position, emphasizing the equivalence of the two partners, each with his or her role in making the therapy work, each willing to be the authority when needed, each changing through the other's influence. Therapy is a human experience, the two people involved willing to be interested in knowing the other as fully as is necessary for the patient to discover and achieve his or her most personal goals.