Psychotherapy and Applied Psychology

How Patients Coach and Test their Psychotherapists with Dr. David Kealy

• Season 3 • Episode 38

Share episode

This week's guest is Dr. David Kealy, associate Professor in the Department of Psychiatry at the University of British Columbia.

Dan and Dr. Kealy dive into Control Mastery Theory, exploring its principles, particularly the concepts of pathogenic beliefs, testing, and coaching within therapeutic contexts. Dr. Kealy discusses the importance of understanding a patient's internal struggles and how these beliefs can impact their relationships and self-acceptance. The conversation also highlights the significance of the therapist's role in facilitating a safe environment for patients to explore their feelings and beliefs.

Special Guest: Dr. David Kealy

The San Francisco Psychotherapy Research Group

How Psychotherapy Works by Joseph Weiss

Transformative Relationships by George Silberschatz

💬 Click here to text the show!

🎞️ Video version of the show@PsychotherapyAppliedPsychology on YouTube
🛜 Check out the website: Listen to every episode on your podcast player of choice

Connect with Dan
☏ Leave a voice message on Speakpipe
🔗 LinkedIn
📬 TheAppliedPsychologyPodcast@gmail.com

🦋@danielwcox.bsky.social

[Music] Over the next two episodes, we're doing something a little bit different than normal. In today's episode, my guest is going to be talking about Control Mastery Theory. While I generally try to deemphasize theory-specific psychotherapeutic approaches on the podcast, there are multiple aspects of Control Mastery Theory that are trans-theoretical and that I believe bring valuable insights and tools to practitioners across the therapeutic schools. In particular, we're going to be talking about clients coaching their therapists and clients testing their therapists. So in today's episode, we'll be talking about coaching and testing to set us up for our next episode, where my guest and I will be watching and commenting on these processes as they're unfolding in an actual psychotherapy session. But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, Rye Dyev Deep with leading researchers to uncover practical insights, pull back the curtain, and hopefully have a little bit of fun along the way. If you enjoyed the show, do me a huge favor and subscribe when you're a podcast player, or if you're watching on YouTube, hit the like and subscribe button. It's one of the best ways to help us keep these conversations going. This episode starts with my guest responding to my question about how we got into studying control mastery theory. So without further ado, here's my very special guest, Dr. David Keely. Okay, well, I've been reading about the theory a long time. I kind of came upon it just through reading the set. The time I was a clinician in a mental health clinic and a supervisor and I was heavily involved in psychodynamic, psychotherapy, I'd been studying psychodynamic and psychanalytic theory for a while. And I was really coming from an object relations and a self-psychology kind of background. And one of my supervisors, a major supervisor I had had talked when I presented some clinical material. He talked about something like the patient seemed to be testing something. And he had made a lot of sense to me and sort of continued doing my work and doing all these readings. And one day I came upon a paper or I think I guess it was a paper where testing was being talked about and it was actually being explained in terms of this theory, control mastery theory. And I just I was really excited by it. It really linked up with what had with what the supervisor had pointed out early in my training. And it explained a lot of what I had been experiencing in psychotherapy. It seemed very compatible with the theories that I had been working with. And it also seemed to have an explanation for why other therapies worked as well. Because that's something that I could never quite feel comfortable with is that every theoretical orientation has claims to being like the way to do things. But in the real world you hear from patients who've seen their therapist from different orientations. They've had a DBT treatment or they've had CBT, they've had psychoanalysis. And patients talk about doing well. And we know that from the empirical literature that when you compare therapies head to head, they're really minimal, clinically significant differences. So this theory seemed to explain a lot of that. And the more I've read about it, the more I've studied the theory and worked with people who have been developing and studying the theory. Just the more that I keep liking it and appreciating its relevance. So one of the things that was the initiated this conversation was me talking to you and then reading about therapists testing in particular. And the more I've read about control mastery theory, some of the primary premises, I would say in particular these things like testing and coaching. And that I really, the more that I read about them and how they're conceptualized and worked with, the more that I see them as these are very trans theoretical phenomena that even though there are, you know, control mastery theory has some, certainly has some grounding and more dynamic kind of ends of things. But I read it, I'm just sort of like this is just this is everybody. Like this is everybody who's dealing with these things with their clients. Does that hit home for you? Absolutely, absolutely. The main psychodynamic aspect of the theory, if you will, has to do with the notion that the unconscious part of our mind is responsible for a lot of what we do. And it's a bit of a different conceptualization of unconscious functioning from Freud's original model. Hicks up on some of his later theories, but that's really the extent of the grounding in psychoanalytic and psychodynamic theory other than, you know, the idea of relationships being so important to development. This is also foundational in psychodynamic thinking. And that relationship is also an important factor in how people work to get better in psychotherapy, also a kind of hallmarked psychodynamic idea. But these concepts of testing, concepts of pathogenic beliefs, and the concept of the patient having agency in the therapy and wanting to get better and wanting to make the therapy work. We think that that therapists of all persuasions will resonate with those ideas. We know even in reading, there was so much talk about beliefs and the clients' beliefs and then how you deal with those beliefs. In some words, I was reading it and just thinking, this seems more cognitive than it seems dynamic. Or it just because there's so much, and you know, sort of having a lot of training and more cognitive side of things, it felt like it fit well. It wasn't just the use of the term belief. It was just also like how was articulated, communicated, conceptualized. I don't know, I almost curious. It just seems to fit so well with sort of a cognitive framework. What your thoughts were about that? Yeah, I think that it does. I think I think they're a great, great, there's great wisdom in a lot of cognitive theory and cognitive behavioral therapy. And the belief concept is a big part of that. And I think that unfortunately, in our field, we have all these different languages and there's sort of this construct proliferation issues. So, you know, from an attachment theory perspective, we talk about internal working models from an object relations perspective. We talk about internal representations of the self and of others and of self-in relation with others. I think even person-centered therapists, I think Carl Rob just talked about attitudes and sort of changing people's meaning that they have their experiences. I think we're wrestling with similar phenomena here. Each of these approaches has a slightly different take on it. But I think it's more different parts of the elephant rather than describing something fundamentally different. Yeah, and I remember, I don't remember where I read it, but I was reading somewhere, somebody, a theorist sort of saying that over time dynamic models have gotten increasingly cognitive and cognitive models have gotten increasingly dynamic. I don't know. Do you have any thoughts on that? Yeah, I, I mean, my perception is, I think there's some truth to that. I think some of the third wave CBT models, I think, moving in some directions that relational psychodynamic theorists have been, you know, trading for some time. So there's a lot of what's new that's kind of, it's been around for a long time. Yeah, I'm teaching a psychotherapy theories class right now. In some ways, it's, you know, in going through and reading and we're sort of doing deep dive into a bunch of different theories. Oh, you actually helped me figure out a good psychodynamic book to use. That there is the sort of like, are these different, does it even make sense to think of these as different theories? Like, you know, just because when you look at the, when you look at it, it's just like, geez, there's, you know, by and large, there's so much more overlap than there is difference between them. It just sort of hits you in the face a little bit. So you talked about pathogenic beliefs. I wonder if you could take a moment just to say how that's conceptualized. What a pathogenic belief is. So a pathogenic belief, so it has to turn pathogenic, it's a refer to the fact that, what the notion that it's a belief that gets in people's way of pursuing their personal goals. It's a belief that's obstructive. And so, you know, one of the assumptions of control mastery theory is that people are motivated to avoid important developmental, personally relevant goals. And so these beliefs, they're pathogenic because they get in the way of that. They interfere with the individual's progress. So these are in some ways, these are sort of a key to schemas or beliefs. That's what they think. Absolutely. Yeah. Yeah. We can talk about pathogenic schemas. And it may be a more fitting term because these beliefs kind of have affect associated with them. So it's more than simply a belief. They're often entwined with corollary beliefs and affects that create a kind of schema that interrupts the person's optimal development and progression toward their personal goals. So just to give a very basic example, if a person has a goal, and many people have a goal of wanting to be in loving relationships, mutually, you know, caring, loving relationships, if you have a pathogenic belief that there's something wrong with you that would prevent people feeling caring toward you and loving you, that's going to get in the way. It's going to interfere with your pursuit of that goal. Or if you have a belief that getting close to people means that they will eventually find out something bad about you and that they'll want to leave you, well, that's going to interfere. So there can be all kinds of pathogenic beliefs that could interfere with that goal. Often they kind of, you know, this, like I say, there's sort of like a web of these beliefs that we theorize that patients won't help with, and that's why people come to therapy is to try to overcome these pathogenic beliefs so they can restore the pursuit of these healthy adaptive goals. In reading that, I was reading about that in preparation for this, I always think about these things, these sound very much like what I would typically call a quarterly. Sure, yeah. So it's just like it fit really well. It's like, oh yeah, that's what's kind of going on here. I did think that there was in this particular literature, there was an offer that's done a really nice job, sort of helping the clinician conceptualize these pathogenic beliefs as these things that are typically learned from, you know, uncertain places in how they are, these are the things that are inhibiting us living the life that we're going to live. That's right. Yeah. So, you know, one thing that really want to get into is sort of the testing side of things, the more prep for this, we really much better at coaching. And to me, it makes us stop up coaching before talking about testing, what do you think? I think, I don't think it matters if I could say another thing about pathogenic beliefs before we go on. The theory suggests that pathogenic beliefs come from experience, from people's real experiences in the world. And often, adverse experience that people have to adapt to. And so as an adaptation to an adverse or challenging, we refer to it as a traumatic experience. In adaptation to that, a person develops a pathogenic belief. So originally pathogenic beliefs have an adaptive function. And often, these beliefs are formed very early in a person's development in childhood. And often in the context of their relationships with significant family members. And so, let's say, for example, a child is dealing with an environment in which there's some, let's say, emotional neglect that's occurring. The child has to adapt to that. They have to be able to explain it to themselves. They have to be able to explain the painful feeling that the child experiences of having this yearning for caring, for example, that's not being fulfilled. They have to explain that. And it's difficult for a child to explain it for a young child anyway, in terms of, oh, maybe my parent has some kind of emotional problem that's getting in their way of caring for me and giving me the love and support that I need. So a child might explain it instead, because young children tend to be egocentric and to not have a very elaborate theory of how the world works. They might explain it by saying, there must be something wrong with me. I must be bad. That's why I'm not getting the support and caring that I need. So we would see that as a formation of a kind of self-hate-related pathogenic belief. But in that original context, it's adaptive because it helps the child go about their relationships with their family members. And it's actually that particular pathogenic belief in a way is more hopeful and optimistic for the child because the child could figure, well, I can try to work on myself. If I can be better, maybe if I'm perfect, maybe then I'll get the support that I'm craving. So you take a slight variation on that. What did they draw another example and tell me if this also works? So you have a daughter who is parent or somewhat neglectful, but she gets attention when she gets some sort of an external success, getting on, getting straight A's, or being the MVP of the soccer team or something like that. And that is when there are those external successes. Those are the only times where she gets her parents attention, log detection, you're doing great, you're like support as a worthwhile human being. And to them, she learns that I am only as valuable as I succeed in these particular sort of ways. So that sort of drives her thinking in the sense of self and value of the human being and their approach of shapes how she needs her energy and how she can put herself in her way from others. Is that also kind of fit? Yeah, that would fit as well. That would fit too. And maybe she sees the parents really focusing on those activities, really being into it, almost at the exclusion of everything else. And so she may also develop beliefs along the lines of, who would hurt her parents if she moved away from that, if she actually pursued something that she loves, then her parents would be disappointed in her. Or they may actually be, she may be somewhat aware of the parents' unhappiness perhaps, right? I mean, generally parents who are involved with their kids and emotionally attuned to them, probably are doing her can life. But if these parents are kind of distant, removed, they may be preoccupied with their own struggles. She may kind of detect some of that. And she may feel like, I better keep this up. I better keep going, being this achiever, focusing on all this stuff. Otherwise, it's going to hurt my family members. So one point in the control mastery theory conceptualization of trauma is that it's important for the child not only to protect themselves and to make sure that the child is safe enough, both physically and psychologically, but because we're humans approach social, we believe that children are also mindful of safety for people that they're close to. The emotional well-being of their family members, for example. So that can also be an area that can produce pathogenic beliefs. So if I do this, it'll help make my family members happier, healthier, they'll feel more looked after. If I let go of that, it might be experienced by my family as an abandonment or as a disappointment. And so that's also kind of fertile ground for developing pathogenic beliefs. I think what's very helpful within this framework is just how it is described as this is something that was picked up. And this was a adaptive at that time. Yeah. It might be useful for the community with clients as well. You have to say, you have to lay out to clients to help them understand their own experience. This is why you did this. This is why you have this experience. And we're here because this is getting in the way of you within the right life you want to live today. But when you're a kid or whenever, right, that you can see like we can talk about and it becomes clear how it was adaptive. Exactly. And that's often where the conversation goes. And in therapy, when you begin talking about pathogenic beliefs, it can be helpful for many clients to talk about where they came from and how they were adapted and how they don't necessarily line up with their current reality. But these beliefs are often difficult to overcome because they are bound up in early attachment relationships, loyalty becomes a component with much of these beliefs. They get reinforced over time. A person like other kinds of contingencies are involved that reinforce and essentially reward the belief. A person who believes, for example, that they have to look after important people. They have to sacrifice their own needs in order to care for others around them. We refer to that as omnipotent responsibility related guilt. That person, like a lot of people around them, may enjoy that and value that about they may end up forming a relationship with a partner who benefits a lot from that. People in their workplace benefit a lot from that. They become known as the person. You can always rely on this person. It comes a little bit tricky for them to dial it back a little bit once they realize that it's not exactly getting them where they want to be. So let's fast forward then in person's development to when they're in the therapy, when they're in the adult. Within this framework, there's a discussion of therapists, clients coaching their therapists. What is coaching? What is coaching? It's a great question. A lot of people think about coaching as something that comes from the therapist. The therapist's coaching the client. It's a healthier coping skills. Be more adaptive and so on. But we think about it as something that comes from the client. Coaching is reflective of the client's agency. Their their wish and their will to overcome their pathogenic beliefs. To feel safe enough to explore. They're in a world. They're emotional life, their relationships. To explore traumatic experiences that have been difficult for them. Person needs to feel a certain level of safety for that. We think that patients need to let the therapist know important information about them so that the therapist can be in the best possible position to be helpful. This concept of coaching refers to the patient informing the therapist about what's likely to be helpful, what may be unhelpful. This is where it relates to testing. It is that they may give the therapist some clues as to how the therapist might pass the patient's test. This is where the theory around unconscious mental functioning comes in. Because it's true that some coaching is explicit. It's occurring at a conscious explicit level of functioning. Patient may come to therapy and they may think before they enter the session. I really want to talk about this issue. I really need to tell the therapist this is my main problem and they'll be very clear and they'll be very explicit about that. But we think in many cases people are coaching without necessarily being aware of the full extent of what they're communicating to the therapist. But there's a coaching quality embedded in their communication oriented around priming the therapist and helping the therapist be as helpful as possible to the patient. So coaching isn't necessarily conscious for overt on the part of the coaching? Correct. It could be but there are times when it's not. Where it gets complicated is that sometimes something that appears to be coaching could be testing. Okay, so what it makes sense now to say what is testing? What is testing? Sure. So testing is what we do in the world to inform ourselves. We all test our reality, for example. We test our beliefs and we think that patients do this too. They test their beliefs in therapy. We think people are testing their beliefs in their relationships with others as well. But a test is like a trial, it could be a trial behavior that the patient tries out with the therapist to see. Will the belief that's being tested will it hold up or is it something that I can maybe question and undermine a little bit? So we think that patients are highly motivated to test their pathogenic beliefs because these beliefs are getting in their way. And the patient doesn't want the belief to be true. You have a patient who believes that they're unlovable. That's an extremely painful way to live. And we think that the patient's highly motivated to overcome that belief. So they're going to test that in the relationship with the therapist. Will the therapist treat me in the way that my belief predicts I should be treated? Will the therapist treat me with scorn or derision or be rejecting or will the therapist want to be interested in me and show some acceptance and warmth? Often what gets carried into a test is some behavior or attitude that's reminiscent of the traumatic circumstances that gave rise to the belief in the first place. So and testing can happen in different ways. So a testing could take the form of the patient telling a story. It comes across in a narrative description of the patient in the world with significant others. And then basically scanning the therapist to see how the therapist is responding to that material. Will the therapist pick up on what's being tested in the material and do something with it that could help the patient disconfirm their pathogenic belief? A test could be in the form of some kind of a question or demand that's posed of the therapist or the patient could engage in some kind of behavioral kind of enactment with the therapist to see what the therapist does, how the therapist handles it. And this is all thought to be for the purpose of helping the patient disconfirm or overcome their pathogenic beliefs. Pathogenic beliefs are very constricting. They're very endangering. No one wants to really believe that these beliefs ought to be adhered to, that they are fundamentally true that they should hold on to these beliefs. So sometimes the patient will pose a very dramatic kind of test as a sort of robust way to work on finding some exception to the belief and undermining it and seeing that it could be different. Basically, a test is kind of like the patient asking the question of, can it be different than what my pathogenic beliefs predict? So can you give us, who would be a useful belief, pathogenically to work with in terms of, so you find some examples of testing? Well, so I mean, you could work with any pathogenic belief and think about how it could be tested. So if we were to say like, if we were to use the I'm unlogable, yeah, that would be an example of testing that to become like that look. Well, the person could describe themselves in a bad way. They could really build a case against themselves in the narrative that they present to the therapist or even in the way they present physically and behaviorally to the therapist. They might even make themselves seem insufferable to the therapist, to see if the therapist will be able to recognize that there's still something good about this, about the patient, that the therapist can see through that kind of bluff, if you will. And we would theorize that the patient is behaving in a way that's in compliance with the pathogenic belief when they do that. So if I believe that I'm bad in some way, I'm defective, I'm unlovable, they could present themselves as having, I don't know, a patient could talk about how terrible they are or they could talk about how disturbed they are or they could present themselves in a way that's that makes the therapist really wondering, can I work with this patient? But we would hypothesize that this might be a test of the pathogenic belief, this kind of self-hate-related pathogenic belief by compliance with the belief. There are also times where patients will act the opposite of the belief, you see if the therapist supports it. That's right. So what would might that look like with the similar? Yeah, so we call that a test by non-compliance with the pathogenic belief. Maybe this patient who has a lot of self-hate-related pathogenic beliefs would present something really positive, present something that they did that they might tentatively think is worth celebrating, they might sort of present that to the therapist. They want to see if the therapist will elaborate on that and support them in this positive view of themselves. So maybe like in this case, like literally saying, I don't like not talking, like telling a story of somebody being mean to them or rejecting them or something like that and then the patient said, I don't deserve to be treated like that. Like I'm a person too, like and then seeing that. Yeah, if they say that, they hope the therapist is going to chime in and agree. Yeah. Yeah. So one of the things with both testing and with coaching is, I think one of the challenges, how do you figure out the signal versus the noise in that? Yeah. Yeah. That's a great question. I'll get to that in a moment if I can. There's also another kind of testing to talk about. It's called turning passive into active. It's a bit of a confusing term, but it has to do with the nature of the relationships surrounding the trauma from which the pathogenic belief came to be. And the nature of the relationship that's now being explored in the therapy relationship. So the kind of test that I was talking about before we refer to as a transference test. So the patient is behaving with the therapist as though the therapist is in a position akin to that of the patient's original attachment figures or caregivers or family members. Okay. So if I grew up in an environment where there was neglect and I felt unloved, I developed self-hate around that. And if I come into therapy and I behave in compliance with that belief or by noncompliance with that with that belief, I'm relating to the therapist as though the therapist is an attachment figure. Will the therapist support my deservedness, for example, to be cared for? But a person can also reverse the roles and put the therapist in the position that the patient was in when they were traumatized. And the patient takes the role of the original attachment figure. So maybe the patient comes in and in compliance with the pathogenic belief treats the therapist the way the patient was once treated. So maybe the patient becomes abusive or neglectful. It rejects everything that the therapist says in the way that the patient's parent might have treated them, for example. You might think, "Well, how does that help the person overcome the pathogenic belief? They're just kind of repeating something that happened to them. What's up with that?" But we think that when patients do that, they're looking to the therapist as a figure that they can identify with. So they can learn a different way of adapting to the trauma. That's something that's an alternative to what the patient was stuck with in childhood. So like, if I'm being mistreated, do I have to believe? Do I have to comply with that treatment and believe that it means I'm a worthless person? So they're hoping that the therapist won't develop pathogenic beliefs when they're subjected to that kind of treatment. So again, this is such a, you know, there's so much, it's very difficult for the therapist to be aware that I think about this in a way, in identifying what's testing versus what's not, what's coaching versus what not. How do you help therapists replicate it out? What is the leap? What is the job? So that comes from formulation. So what the theory, one of the clinical implications, a big clinical implication of the theory is that therapists should try to develop a formulation of the patient's plan. So it's another concept of the theory, which is that the patient has a plan for what they are wanting to work on. Not necessarily a conscious plan. Patient may not reveal all of the aspects of their plan. So there's some inference required on the part of the therapist to determine what is this patient wanting to do? What are they trying to achieve? What are their goals in life and that pathogenic beliefs are getting in the way of? And so we think that therapists have some idea of the plan, then they'll be in a better position to ascertain the meaning of the material, the meaning of the patient's behavior. The therapist will be better placed to figure out, is this testing here? And if so, what might the patient need in terms of the therapist's response to pass that particular test, so to speak? What kind of responses from the therapist would be more likely to disconfirm the patient's pathogenic beliefs, help the patient feel safer, and make therapeutic progress and restore the pursuit of their goals? I think it's an important aspect of the theory, the concept of the plan. Even if you find it hard to accept the notion that the patient has some kind of unconscious plan of how the therapy ought to go for them. I think it could still be helpful thing for therapists to view the plan, even as a kind of construction on the part of the therapist to help orient them to the salient issues in the treatment. And I should say this was one of the areas that I think set control mastery theory apart from other psychoanalytic, psychoanemic approaches back in the day, as the Joe Weiss when he wrote about the concept of the patient's plan was in some ways in conversation with prevailing psychoanalytic ideas at the time, which around clinical practice, which had to do with, you know, you learn a little bit about the patient at the intake, but then it's about like letting the process unfold and trusting that, you know, the information that you need will come out over time. But, you know, Joe Weiss who developed the theory was emphasizing that it's actually a good idea for therapists to try to learn a lot about the patient, try to get a really good sense of the patient's developmental history so that you can develop your influences about what were critical issues in the patient's development that may have contributed to the formation of pathogenic beliefs. And what are the goals that the patients having trouble pursuing? So if we have the plan of the patient in mind, if we formulate that fairly early on, then it will probably be better positioned to recognize tests when they're occurring and to develop the kinds of responses that are likely to help pass those tests. And of course, coaching and listening for the possibility that the patient is coaching us to help, you know, bolster our plan. That's also important going going forward throughout therapy because we could formulate a plan early on. We could think to ourselves, okay, this is the kind of pathogenic belief that the patient's really wanting to work on and we've got to figure it out and it's all we need to do is to stick with that. But sometimes goals change over time or the patients haven't revealed everything that's salient early on. And so if we're not paying attention to the possibility that the patient may be coaching us, we, you know, we could kind of lag behind the patient and, you know, get the therapy off track. I would think that the pathogenically, we've got to know pathogenically, that those are going to be so embedded. So that oftentimes, even though in one way I might come back to be, sort of, I want to therapist to support me in overcoming the belief. At the same time, I would imagine that I'd be pretty resistant to certain pushback against that belief since that's so foundational to how I see myself and how I see the way. Yeah, I mean, I think that gets to the notion of internal conflict. You know, that's been a kind of classic idea in the psychedelic world, internal conflict. I think from a control mastery perspective, we wouldn't see, you know, like Freud's idea originally was a conflict between drive and the, the values of society, the, you know, sort of the, the, the ear and ego, that's kind of the source of interest, psychic conflict and control mastery theory, I think we've put it quite differently. And that is that people experience conflict between their goals and their motives to pursue adaptive developmental goals throughout the lifespan. And the messages, if you will, of their pathogenic beliefs that are often bound up in early important relationships and tied up with loyalty to those important figures in the patient's life and often those relationships are still, you know, sort of in real, in real time, still salient for the patient. So we think of conflict in that way. The conflict really is the struggle between the patient's agentic strivings to toward growth and the implications of these, of these beliefs. Before we hop to the video where we're going to see this stuff, hopefully come the light of it, is there anything else that you feel like we should definitely hit? Yeah, actually one of the, one of the important implications of the theory is that the theory doesn't privilege particular techniques in psychotherapy. So from the perspective of control mastery theory, what is most important is not whether an intervention adheres to a particular kind of apriori structure from a therapeutic protocol. In psychodynamic thinking, there's this, you know, this categorization of interventions as either expressive and interpretive on one end of the spectrum or supportive on the other. So, you know, you can do the kind of uncovering kind of like getting into the unconscious conflict on one end of the spectrum and on the other it's more like not going there and supporting the patient's ego functioning as it is. And from a control mastery perspective, that that distinction is not really important. What's really important is whether an intervention is compatible with the patient's plan. Will the intervention help the patient feel safer? The patient feels safe. We look for signs of safety, you know, if the therapist does something that helps the patient feel safe. And when we talk about safety, we don't mean a kind of generic safety. We mean that safety is kind of individually tailored. People feel that different signals or cues are safe to them based on their own internal reality, their own individual history. So, some things will make some people feel safe and other things will make this different people feel safe or endangered. It has to do with their experiences and their pathogenic beliefs. So, what matters is is an intervention pro-plan, i.e. facilitating safety, disconfirming pathogenic beliefs, supporting the patient's movement toward important goals or is the is the intervention anti-plan is it incompatible with with the patient's plan. That's what matters. And so, you know, a patient may be working on a pathogenic belief and the therapist could employ a CBT intervention and it might really connect, it might really be strongly compatible with the patient's plan and therefore contributing to therapeutic progress. Or the therapist might make a psychodynamic interpretation. Or the therapist might explore some important emotion that's connected to the theme that's surrounding the pathogenic belief and maybe that's enough to help the patient feel safer and to advance their therapeutic work. So, there are no specific techniques that are given special privilege or advantage from a control mastery theory perspective. We think of the theory as not a package or a, it's not something that you can manualize and say this is what you do with all patients. We think instead of it as a meta theory of how change happens, how therapy works. So, do you think the way to happen to video or do you want to do more? Well, so we're going to watch Carl Rogers, right? That works. One thing about Rogers is that, you know, I think he was also not so much a technique person. I think he was, he emphasized a lot of the therapist empathy and the therapist kind of attitude toward the patient. There's a lot about that that resonates with what control mastery theory has to say. In fact, there's a concept in the theory called treatment by attitude. Hal Samson wrote a great paper about that, which is that often patient can do very well in therapy. If the therapist has the kinds of attitudes and expresses those attitudes that are compatible with the patient's plan. So, there are probably a lot of tests that we miss all the time in therapy. There's a lot that we don't get right. But if the therapist has an attitude that contributes to the patient's safety and that is overall disconfirming of the patient's major pathogenic beliefs, that could very well win the day. So, there's this treatment by attitude concept that I think maybe we'd want to watch out for in the video. That's a wrap on the first part of our conversation. As noted at the top of the show, be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time.

People on this episode

Head Shot

Dr. Dan Cox

Host
Head Shot

Dr. David Kealy

Guest