Ch. 7: Willing II

Question 1

METHODS OF AVOIDING DECISION: CLINICAL MANIFESTATIONS

Answer 1

1. One can avoid the sense of renunciation by distorting the alternatives
2. Or can avoid existential anxiety and guilt by arranging for someone or something else to make the decision

Question 2

Trading down

Answer 2

The decision becomes happier if one arranges the situation so that one renounces less.

• Alice had been left by her husband one year ago, but without divorce.
• He would come back home rarely for sexual relations, and Alice kept fantasizing of winning him back although she rationally knew the relationship would never work
• After becoming involved with another man, she got enough strength to divorce her husband and even take him to court for not paying child support
• However, this solution didn’t allow her to face her existential isolation, and a few months later the relationship with his new boyfriend had turned sour and she sought help for making the next decision

Question 3

Devaluation of the Unchosen Alternative

Answer 3

Aka cognitive dissonance

A schizoid affect-stifled patient “decided” not to change and live in isolation

• He viewed affect suppression as “dignity” or “decorum”
• and spontaneity as an “animalistic loss of control” where he would run the risk of being overcome by rage and tears

Another patient decided to stay in a highly unsatisfying marriage because the alternative was to join the singles hode - the “vast, pathetic army of freaks, cast-offs, and misfits”

Clinical relevance: one is open to information that upgrades their choice or downgrades the alternative, and conversely closed to information that downgrades their choice or upgrades the alternative

Question 4

Delegating the decision to someone

Fromm

Answer 4

Decision confronts each of us not only with freedom but also with fundamental isolation.

Fromm has maintained that humans have always had a highly ambivalent attitude towards freedom:
they fight fiercely for freedom, they leap at the opportunity to surrender it to a totalitarian regime that promises to remove the burden of freedom and decision from them

Many patients observe very word and expression of the psychologist as if they were an oracle

Yalom: “Two acquaintances of mine who divorced both believed that the other had made the decision: the woman had announced that she is in love with another man, and the man took it as a de facto signal that they’re over so he initiated the divorce.”

A employee might have performed inadequately to earn a firing

A partner might act cold to force the other to break up with them
- In the beginning of the Freedom section, there was a vignette of a woman who hoped that she would catch her husband in bed with another woman so she could leave him

Question 5

Delegating the Decision to Some Thing

Answer 5

Ancient mode of decision was to consult fate, whether in sheep trails, tea leaves, the I Ching, meteorological changes etc

• A modern version is to be found in Luke Rhinehart’s novel The Dice Man, who leaves all decisions up to chance - the toss of the dice
• Although dice man is presented as an existential hero - and individual who embraces total freedom (that is, randomness) and contingency, he may be also viewed as the opposite - one who has surrendered freedom and responsibility

Question 6

Rules

Answer 6

“Rules” are another handy decision-making agency

The Orthodox Jews follow 513 Judaic laws that spare them many decisions like:

• Whom should I marry?
• Should I divorce?
• What career shall I pursue?
• How shall I spend my free time?
• Whom shall I befriend?

Dean Studdert was a patient of Bugental who denied a student access to campus, because she had failed to follow the rules

• “I am really sorry about it, but if I make an exception for you then the rules would soon become meaningless to every other person who breaks the rules.”
• At first she felt content, because she had finally stuck to her word, but later on she started feeling that something was wrong
• Bugental points out that instead of administering the rules, became administered by the rules
• She embraced and cherished the comforting illusion that there is some absolute external referent, that there is a prescribed right and wrong

Question 7

DECISION: CLINICAL STRATEGY AND TECHNIQUES

Answer 7

No change is possible without effort and decision is the trigger of effort.

Question 8

Therapeutic Approaches to Decision: Conscious Levels

Answer 8

Beatrice was a patient with an abusive italian boyfriend who had supposed to visit for a month but stayed for three months

• To Yalom’s persistent questions she:
• Figured she could talk to the guy more openly and less forcefully about why the situation had been so devastating for her
• She could stay with her sister
• She could enlist some friends who could help her confront him
• She could ask for a moving company to come and store her furniture (cheaper than having it smashed)
• She chose to confront him openly, but with care and the guy actually agreed to leave
• Nevertheless, while having dinner the same night as mature adults they still agreed for him to stay
• At a group session a few days later Beatrice shared the situation, but left out the drinking, threats, financial exploitation etc.
• For Beatrice it was important to avoid the anxiety of cognitive dissonance

Question 9

Important to remember about generating options

Answer 9

It is important for the therapist to remember that the patient - not the therapist - must generate and choose among the options

• It is equally important that one owns one’s decisions
• New therapists often make the mistake and are later angry and disappointed when the client doesn’t commit

It is also important to remember that deciding does not end either with a decision or a failure to make one

• The individual must re-decide over and over
• Failing does not “blow it” and need not carry over to the next decision; instead, much can be learned from such a failure

Question 10

“What-ifs”

Kreplach

Answer 10

Many patients are also paralyzed by the “what-ifs”: what if I leave my job? What if my children are alone and get hurt?
- A logical analysis of each situation is sometimes helpful, i.e. asking the patient to consider the whole scenario: the happening, the ramifications, and the feelings

Yiddish joke about kreplach (meat-filled pastry) aversion:
A boy doesn’t like the kreplach and the mother suggests: “You like flour, and eggs, and meat, correct?” The boy agrees readily. “Well, that settles it because that’s all there is in kreplach.” But at the word “kreplach” the child once again promptly retches.

Question 11

Therapeutic Approaches to Decision: Unconscious Levels

Answer 11

How can the therapist approach the unconscious aspects of decision making - what Farber refers to as the “first realm of will”. Answer: “Indirectly.”

Question 12

The therapist’s task

3 approaches

Answer 12

Will is blocked by obstacles in the path of the child’s development - the therapist’s task is to remove them.

• Once that is done, the individual will naturally develop - just as Horney put it, as an acorn develops into an oak.
• The therapist’s task is not to create will but to disencumber it.

1. Help the patient become aware of the inevitability and the omnipresence of the decision
2. Help the patient “frame” or gain perspective upon a particular decision, and then assist the deeper implications (the “meaning”) of that decision
3. Through the leverage of insight the therapist attempts to awaken the dormant will.

Question 13

The inevitability and the omnipresence of decision

Decisions in therapy

Answer 13

One cannot not decide. If one fully accepts the ubiquity of one’s decisions then one confronts one’s existential situation in authentic fashion.

• Procrastination is a decision - as are failure, drinking, being seduced, exploited, trapped.
• Even staying alive: Nietsche said that only after one has fully considered suicide does one take one’s life seriously.
• Many cancer patients take their cortisone replacement pills automatically each day, others make an aware decision to stay alive with each pill

Some therapists reinforce a patient’s awareness of the omnipresence of deciding by reminding them of decisions that have to be made in therapy

• Kaiser recommends a wholly “no conditions” therapy
• Greenwald asks to make decisions like whether one wants to work on dreams, how many sessions to meet for, etc.

Question 14

Meta-decisions

Beatrice & Italian

The ‘catching-in-bed’ patient

Answer 14

It’s also important to help patients become aware of meta-decisions - i.e. decisions about decisions - for some individuals attempt to deny the importance of decisions by persuading themselves that they have decided not to decide
- Such a decision is actually just deciding not to decide actively; evading is impossible, but one can decide passively - e.g. by letting another person decide

Beatrice wouldn’t decide to kick out her italian boyfriend from the apartment, even though when Yalom asked her how she would feel when the boyfriend finally leaves the country then the answer was “Blissful”

Again, the woman who prayed she would catch her husband in bed with another woman

• Each decided for passivity however they payed a high price: both had severely impaired self-esteem and their avoidance contributed to self-contempt
• “If one is to love oneself, one must behave in ways that one can admire.”

Question 15

Framing a decision

Yalom’s Insomnia

How does therapist reframe?

Answer 15

The therapist may occasionally be able to influence the deeper levels of will by changing the frame of a decision by providing a different perspective.

Yalom had a personal example of a siege of insomnia
- He went to a behavioral therapist, tried desensitization and muscular relaxation tapes neither of which were particularly helpful
- After one of the sessions when Yalom was about to leave for Cleveland (a bad sleeping city for him) the therapist said “Don’t forget to pack a revolver.” “Why?” - “Well, if you can’t sleep you can always shoot yourself.”
Yalom: “That comment clicked ‘deep’ inside and proved of enormous benefit. - How did it work? It is painful to explain precisely, but it reframed the situation and put it into a meaningful existential perspective.”
- In Ch. 2 a patient said that her encounter with death allowed her to “trivialize the trivia in life” and stop doing things she didn’t want to do

But how does the therapist reframe and unveil the tapestry of existence?

• Some appeal to reason: Frankl asked a patient with decision problems to meditate upon his core being and suggested that he simply draw a line around this core and become aware of the fact that these decisions involved concerns in outlying and (in the long run) petty areas of life
• Although often not enough for a major shift
• Confrontation with boundary situations is more effective (techniques in Ch. 5)

Question 16

The meaning of decision

Emma, 66

Answer 16

Every decision has a visible conscious component and a massive submerged unconscious component.

Emma was a 66-year-old widow who had an old luxurious estate 150 miles from where she lived and didn’t know what to do with it, because it was costly to keep up, but selling also required consideration of the market etc.

• Her husband had died a year ago and she kept all his old things in the estate
• The estate was a “hotel” where friends would stay over, and she was afraid of loneliness if she would sell it
• She also didn’t have kids, but since the estate had been in the family for generations she had envisaged that she would pass it on
• Yalom: “Thus, she was actually deciding whether to punctuate the loss of her husband, to confront isolation, and to accept her own finiteness”
• Yalom used the house-selling issue as a springboard to these deeper ones, and once the deeper meanings were worked though she easily made the choice to sell the house

Question 17

“Payoff”

“Own it”

Self-destructive behaviour

Answer 17

Many therapists inquire about the “meaning” of a decision when they explore the “payoff” of a decision - there are conscious and unconscious ones in every decision

• If the patient is unable to stick with a decision, the therapist must assume that they have decided for something else with its own payoffs
• If the patient wishes to change but cannot decide to change then therapist may focus on not the refusal, but on the decision that was in fact made - to stay the same.

A decision will not stick unless one “owns” it

• Thus, when an addict wishes to kick the habit then Greenwald asks “Why?” and explores the payoffs: anxiety relief, euphoria, absolution from responsibility
• One is more likely to “own” a decision if one discovers the limits to each of the opposing payoffs
• Two patients in a therapy group wanted to have a sexual relationship but decided not to because of the “rules”
• Yalom hadn’t made any rules and asked them about the “payoffs”
• They both fully discussed their awareness that the group meant a great deal to them and that their relationship would sabotage the work - and thus the decision became more firmly rooted

When we speak of exploring “meaning”, “payoff,” or “secondary gratification” we are referring to the fact that every decision has benefits for the individual

• Self-destructive behavior may make sense to the individual’s experiential world and that in some personal or symbolic way it is self-preservative
• However, many decisions may be difficult to comprehend because of their deep roots in the unconscious

Question 18

INSIGHT AND DECISION

Answer 18

The precise relationship between the two has always remained elusive. Simply, “insight” refers to self-discovery. But:

• Is it insight about how one behaves with others?
• Insight into the current motivation behind one’s behavior?
• Insight into childhood sources, often erroneously referred to as the genetic “causes” of behavior?
• Freud believed the latter to be true, that successful therapy hinged on the excavation of the earliest layers of life’s memories
• Others believe that effective insight comes from currently active dynamics
• E.g. for Emma it was about the husband, loneliness, finiteness

Question 19

Is insight always necessary?

Answer 19

Is insight always necessary - no! (says Yalom) Every therapist has worked with patients who go through substantial change without insight

• E.g. some patients just say “I learned to count by blessings” or “I decided to live my life rather than to postpone it”
• Some may obtain insight as a result of change - one is often able to perceive truths about oneself only after taking some stand toward change

The literature is relatively silent about how insight effects change

• Making the unconscious conscious?
• Undermining resistance?
• Working through of the past?
• Corrective emotional experience?

Question 20

FACILITATION OF THE PATIENT-THERAPIST RELATIONSHIP

Insight is an epiphenomenon (4)

Answer 20

As a result of the therapist’s concern and unconditional regard, the patient’s self-love and self-regard gradually increase.

Insight is an epiphenomenon - a means to a means to an end: it is a fertilizer of the relationship

• The search of understanding provides a context for the formation of the therapist-patient relationship
• The patient is gratified by having his or her inner world scrutinized so thoroughly
• The therapist is charmed by the intellectual challenge
• All the while, the real agent, the relationship, is silently germinating

Question 21

LEVERAGE-PRODUCING INSIGHTS:

“Only I can change the world I have created.”

Answer 21

Responsibility is continuous: one does not create one’s situation in life once and for all; one is continuously creating oneself.

Next, the therapist helps the patient realize that one is responsible for what one is, thus also for changing what one is.

• “If I have created my world then only I can change it.”
• Change is an active process; no one else can change for us.

This insight is at once simplistic and profound - though easily stated, the implications run deep.

Question 22

LEVERAGE-PRODUCING INSIGHTS:

“There is no danger in change.”

Answer 22

Many patients cannot decide to change, because they (often unconsciously) believe that some calamity would befall them

• One fears being engulfed if they’d engage with another
• Another fears rejection or humiliation if one were to be more spontaneous
• Another fears catastrophic retribution as a result of self-assertion

The process of identifying and naming the fantasied calamity can already be helpful

Another approach can be to perform the various aspects of the behavior whose consequences the patient dreads, e.g. deep seated fear of having a dammed-up reservoir of homicidal fury

• Therapist helps such as patient express aggression in carefully calibrated doses
• Pique at being interrupted
• Irritation at the therapists fallibility
• Anger at the therapist for charging money etc.

Question 23

LEVERAGE-PRODUCING INSIGHTS:

“To get what I really want, I must change.”

Answer 23

The patient who seems to be sabotaging his or her own mature needs and goals, is satisfying another set of needs that are often unconscious and incompatible with the first.
- E.g. man might consciously wish for a heterosexual relationship but unconsciously wish to be protected, nursed, let be a part of another

The therapist helps the patient become aware that he or she has conflicting needs and goals, and that each decision (incl no decision) has some “payoff”

• Next the patient helps to realize that the patient has to choose
• Once the patient realizes that their behavior has been designed to fulfill opposing growth-retarding needs, they conclude: “to get what I really want, I must change”

Question 24

LEVERAGE-PRODUCING INSIGHTS:

“I have the power to change.”

Answer 24

Many individuals experience themselves as victims rather than the masters of their conduct - this state doesn’t allow for constructive action.

Explanation is a potent enemy of the powerlessness that emanates from ignorance.
- Explanation, identifying, labeling are all part of the natural sequence of the development of mastery or a sense of mastery

Explanation of a phenomenon is the first step towards the control of it

• If natives live in terror of a volcano eruption they might interpret it as a displeased volcano god
• Importantly, this makes available a course of action (i.e. mastery): if the volcano explodes because the god is displeased then there must be methods to please and thus control the god

Question 25

Jerome Frank - secondary anxiety

Answer 25

Jerome Frank in a study demonstrated that secondary anxiety stemming from the uncertainty towards a disease often creates more havoc than the primary disease itself (in this case schistosomiasis)

• Same thing with psychiatric ones: fear and anxiety about the source of their disorder often clouds the core problem to an extent that effective exploration becomes difficult
• Through explanation the therapist can permit the patient to feel “I am potent, I have a power to change”

Question 26

Exclusive rights

Explanatory power

Answer 26

No explanatory system has hegemony or exclusive rights, no system is the correct, the fundamental, or the “deeper” and therefore better one.

• In one study Yalom and colleagues found that in encounter groups positive outcome was correlated with insight
• The successful group leaders were those who provided some type of cognitive framework for their members
• The type of insight that the successful members had had little to do with the outcome: the important feature was not what they had learned but that they had learned

No matter the school of thought, each might beget a sense of potency

• The superego, the id, the ego; the archetypes, the idealized and the actual selves, the pride system; the self system and the dissociated system, the masculine protest; parent, child and adult ego states – none of these really exist
• They are all fictions that justify their existence only by virtue of their explanatory power

This doesn’t mean that interpretation has no place for psychologist, they should just recognize the purpose and function of an interpretation: superiority does not come from “depth” but from explanatory power

Question 27

Effectiveness of interpretations

Astrology

Answer 27

Interpretations to be truly effective, must be tailored to the recipient:

• More effective if they make sense
• If they are logically consistent and with sound arguments
• If they are bolstered by empirical evidence
• If they are consonant with the patient’s frame of reference: if they “feel” right and can be applied to analogous situations

“Does this mean that an astrological explanation is also valid in psychotherapy?”

• Yalom: “In spite of my own intellectual reservations, I have to respond affirmatively - if an astrological, shamanistic or magical explanation enhances one’s sense of mastery and leads to inner, personal change, then it is valid”
• There is evidence from cross-cultural research that in most primitive cultures only the magical or religious explanation is acceptable and hence valid and effective

Question 28

Time is needed

Answer 28

Even the most elegant interpretation has no benefit if a patient does not hear it. It might take time for the same interpretation to click on a day in the future. Why?

• Nisbett and Wilson have demonstrated that individuals who make decisions are often inaccurate in their descriptions of the antecedents of that decision
• Yalom: “I have found that dramatic breakthroughs are by no means sudden”
• By the time patients have sought therapy, many individuals have already done initial work and the decision to seek therapy is the manifestation not the cause of change

Question 29

Timing

Answer 29

Decisions to change generally require considerable time and must be timed well

Example of patient who wanted to end marriage but was afraid of isolation

• Yalom: “Only if you are willing to give up the marriage can you save it”
• This interpretation was deeply meaningful to the patient, “struck like thunderbolt” and subsequently catalyzed considerable change
• Interestingly, she was in a therapy group with which Yalom always wrote a summary after each session
• The patient kept the summaries and logged them, she was one of the more avid readers of the summaries
• Yalom himself of course had the summaries as well, and one time looked through them to consider the change in the same patient: he discovered that he had said the exact same thing to the same patient one year earlier
• “Though the wording was identical and the interpretation had been underscored and heavily emphasized, she had not heard it previously, because she was not ready to hear it.”

Question 30

The Past versus the Future in Psychotherapy

Origonology

Answer 30

It is of no small significance that the word “will” has a double meaning: it suggests resolution and determination, and it also denotes the future tense - “I will do it - not at this moment, but in the future.”

Psychotherapy is successful if it allows to change the future but the literature is dominated by the past - confusion between explanation and “originology”
- Therapists often believe that in order to explain something - to provide insight - one must lay bare the origins of the past or at least relate the present to the past

Question 31

Modes of explanations that do not rely on the past

Answer 31

Yet there are many modes of explanations that do not rely on the past

• The future (or the idea of it) is no less a powerful determinant of behavior
• Sense of purpose, an idealized self, series goals, an awareness of destiny and of ultimate death

Question 32

Archeological excavation and psychotherapy

Answer 32

Still, so much is focused on the past

• Freud said that archeological excavation and psychotherapy are the same, only that the analyst works under better conditions and has more material to assist him
• Freud went on to say that “construction” is more appropriate than “interpretation” to describe the therapist’s work
• “Instead of recollecting what has been repressed, we produce in him or her an assured conviction of the truth of the construction which achieves the same therapeutic results as a recaptured memory.”
• Yalom: “It is not the content but the process of interpretation or explanation that is important.”

Question 33

Treacherous position of explaining based on external phenomena

10 Freudians & 10 Existentialists

Answer 33

Any system that explains behavior and mental experience on the basis of phenomena outside of the individual responsibility leads to a treacherous position for the therapist.

• Rank: “… frees the patient from responsibility and guilt”
• Of course, freeing oneself from guilt about past events and actions is often important, that “given the circumstances, you could have not acted differently”
• However it leaves the problem of how deal with past in one frame (absolution) and future in another (invoke responsibility)

Gatch and Temerlin studies 10 Freudians and 10 existential analysts to determine how they deal with this paradox

• Existentials made more comments that underscored the patients freedom and responsibility
• However, all of them never spoke of patients of current victims of circumstances beyond control
• When a patient spoke of his or her infancy in childhood, all therapists “circumstances were beyond the control of the patient as the child”
• Existentials focus less on persuasions, and more on the future tense, on the decisions and on the goals
• When dealing with guilt, existentials don’t focus on the past bad choice but for the refusal to make new ones

Question 34

Forgiving for the present and future

Psychological reality & historical reality

Answer 34

One must learn to first forgive oneself for the present and the future

• But even when the working with the past it is important that the individual does not assume disproportionate responsibility: many individuals assume excessive responsibility and guilt for others’ actions and feelings
• Therapist must locate the boundaries of responsibility

The psychological reality is not identical with historical reality

• Even in a lengthy anamnesis, one recalls only a minute fraction of one’s past experience and may selectively recall and synthesize the past so as to achieve consistency with one’s present view
• Change in therapy may lead to long-forgotten positive experiences with parents, leading to humanizing rather than experiencing them as figures of service, one may begin to understand them as well-intentioned individuals struggling with the same overwhelming facts of life

Mark Twain: “When I was 17 I was convinced my father was a damn fool. When I was 21 I was astounded by how much the old man had learned in four years.”

Question 35

Hermeneutic approach

The value of the past

Answer 35

Hermeneutic approach of the relationship between understanding and background:

• grasping understanding requires a certain background, but the new understanding alters the perception of the background.
• A human being’s past is neither fixed or finite; it is constituted by the present and in its ever-changing symbolic immanence, influences the present.

In addition to providing a shared venture for the patient and therapist, the past facilitates the relationship in another important manner:

• the explicit understanding of the early development of a particular interpersonal stance enhances the possibility of engagement
• E.g. a woman with a regal air conveying hauteur and condescension may suddenly seem understandable when the therapist learns of her immigrant parents and her desperate struggle to transcend the degradation of her slum childhood

Question 36

Charles Rycroft

Answer 36

It makes better sense to say that the analyst makes excursions into historical research in order to understand something which is interfering with his present communication with the patient (in the same way that a translator might turn to history to elucidate an obscure text) than to say the he makes contact with the patient in order to gain access to biographical data.