Outline of Carl Whitaker’s The Roots of Psychotherapy

[First published on Nathen’s Miraculous Escape, January 9, 2011.]

I started reading The Roots of Psychotherapy last summer, on the advice of John Miller, one of the heads of my Couples and Family Therapy program. He hadn’t actually read it, but had had it so highly recommended to him by a respected colleague that John wished he had time to read it. It was not an easy read, but interesting to see what looked like Whitaker’s explanation of his transition from psychiatry and psychoanalysis to the experiential family therapy of his later career.

This outline is incredibly sloppy, thanks mostly to Open Office’s awful outlining, but the guts of the book as I understand it are here.

A. Foundation

1. Science as a Creative Method

a) Role of the Unconscious (Intuition): Operationalization is tricky in science in general, and in research into psychotherapy in particular. Whitaker makes the case that scientific advances are the result of intuition and creative insight on the part of researchers.

b) “The Creative Unconscious”: The non-conscious parts of our mind are the source of healthy, creative, productive behavior as well as “pathology.” It is a fallacy that only the conscious/rational is valid, and clinging to this idea limits science. The scientific process includes whole of the scientist and his (Whitaker was writing in the early 1950s) relationship to all of his data. Recognize the importance of the subjective experience of the observer.

2. Research in Psychotherapy

a) Methods of Research in Biological Science: In complex systems like the biological, individual cases become very important to observe, and generalization difficult.

b) Methods of Research in Psychotherapy: At the time of writing, research in this area was making some breakthroughs in areas previously intractable.

c) The Group Approach to Research Problems: It’s important to work in groups on research projects, but there are pitfalls in this area that pokes at the researcher’s deep beliefs and experiences. It requires intimacy, which takes time and commitment.

d)Problems of Communication: Written and even spoken communication is inadequate. Shared experiences are required.

e) Psychiatry and Psychotherapy: Art of Psychotherapy: Therapy is an art and intuitive and thus has a lot to offer to the science of psychiatry.

3. The Biological Basis of Psychotherapy: Whitaker makes a case for psychotherapy being a subset of biological studies, and proposes to adopt biological principles in the study of psychotherapy and the change process, which he calls “growth and adaptation.” [This reminds me of Wilber’s “differentiation and reintegration” process of development in Integral Psychology.]

a) Growth = orderly change with a direction as a fundamental process of organic systems. [Wilber calls this “development.”] Phases are “incubation and maturation.”

b) Energetics = The availability of energy depends on the development of the organism and “the tolerance of the system within which the organism functions.” [Italics mine.] He proposes that it is this interaction which provides the direction of growth.

c) Field Principles = The gestalt principle, “which has meaning only as an expression of homeostasis”: The whole is greater than the sum of its parts, but only when acting together in “sensitive dependence”

4. Adaptation: The “autotherapeutic function” of organisms, an internal change response to external or internal stress. Implies that pathology is a disruption of this growth. I’m disagreeing there, thinking “pathology” in this way is more like adaptive ability being overwhelmed by stresses. Or, as in Wilber, the adaptive ability itself matures, and the “pathology” is a result of developmentally inappropriate stresses, i.e. trauma.

a) The Problem of Repair: Organisms’ inherent self-repair ability can be seen as an immune response resulting in lasting adaptation. Physiological repair has many known limitations, but we are not yet aware of what limitations exist for psychological repair.

5. Catalyzed Repair: It is very important in our attempt to catalyze repair to not interfere with natural repair mechanisms! Remember to do no harm. The best we can do is augment natural healing processes.

6. The Community and Psychotherapy: Cultures have always had therapists, and their effectiveness seems based more on the person of the therapist than the soundness of their theory of change. Effective therapy must be congruent with the culture it exists in/serves.

7. Implicit and Explicit Psychotherapy: Whitaker defines therapy: “An interpersonal operation in which the total orgainismic adaptation of one individual is catalyzed by another individual in such a way that the patient’s level of adaptative capacity is increased.” Also, “Psychotherapy occurs whenever there results an increased actualization of the individual’s adaptative potential, with a corresponding decrease in the difference between what that person actually is and what he has the potential of being.” discusses the problem of defining “cure” in a therapeutic sense. Talks about therapy as partly a process of relegating to the unconscious those processes best handled by the unconscious, allowing the person to be more “natural.” Discusses importance of therapeutic relationship and the “patient’s” formulations of such. “Adequate therapy” much have a clear-cut ending where the client no longer needs the therapist.

a) Implicit psychotherapy is the therapy that happens, as defined above, “accidentally,” both in our everyday interactions and in interactions with therapists that therapists are not conscious of or the value of.

b) Explicit psychotherapy is the therapy that happens with mental health professionals, acting consciously on their body of knowledge/theory.

8. Dynamic Psychiatry and Psychotherapy: Psychiatry deals with the prevention and treatment of pathology. Psychotherapy is interested in the relationship of pathology to growth.

a) Psychoanalysis and Psychotherapy: Whitaker distinguishes the two (remember, this is 1953), giving props to analysis for being our most complete theory of personality, but also saying that analytic theory does not make analysis the necessarily best or only kind of therapy.

b) Psychotherapy and Time: Therapies can have two possible time vectors, the “genetic,” in which, since the past determines the experience of the present, the past is intensively reprocessed, and the “non-genetic,” in which, since present experience determines the future, the client’s relationship to theircurrent experience is altered or dealt with in such a way that ameliorates their relationship to both their past and their future. Whitaker calls this “experiential therapy,” which he calls “ahistorical,” “atemporal,” and says relies largely on how involved the therapist and client become in the moment. [I’m getting the sense by this time that experiential therapists basically think training in psychotherapy is just a way to become a really good “insta-friend.”]

B. Process

1. The Patient as a Person: Everyone is potentially a “patient,” so how do we differentiate between potential patients and actual patients?

a) The Genesis of a Patient: “Patient” defined as “a person who asks for help from the psychotherapist. Two fundamental ways psychotherapy is used are to help patient with a specific set of symptoms, or to “help the socially adequate” become more creative and well-integrated.

b) Barriers to Patient Status: First, fear of change. Second, fear of cultural rejection or retaliation, isolation.

c) The Social Therapist: This is my favorite of Whitaker’s ideas so far: Every person is a potential therapist for the people they interact with, and every interaction is a potential moment of therapeutic growth. People become patients of professional therapists because of a failure of their social-therapeutic community.

d) Culture: the Last Barrier: People have to pretend to be more mature than they are to make it in society. Going into therapy feels dangerous, then—giving up the facade of maturity. Also, the patient’s idea of what a therapist is is basically an amalgam of projections, which bring their own difficulties. All of these elements call up a patient’s protective mechanisms, which = “resistances.” The patient’s “growth impulse” must overcome these problems to come into therapy.

e) Conclusion: What is a “cured patient”? He gives a fairly long answer. “overcoming the inertia in the all-but-static growth process.” The patient experiences somethingdifferent which they take out into the world, questioning where they thought their limits were, more expressive, more capable of deep emotional bonds, “the capacity to demand, obtain, and participate in a new experience.” Reminds me of Johnson’s description of securely attached people—a safe haven encourages exploration.

The Process of Psychotherapy: How is therapy distinct from other social relationships, process-wise? Concludes that therapy has two basic processes, one for each session and one for therapy as a whole. This seems to come from psychoanalysis. He says three “segments” the middle of which is subdivided by 7 “phases.”

a) Outline of the Natural Divisions of the Process of Therapy:

1. Pre-Interview Segment: The events leading up to and before the first interview with the therapist, before the therapeutic relationship is established.

2. Analysis of Interview Segment:

a. The Symbolic and the Real In Therapy: The therapist and patient come together from different “realities” and during the process of the phases of the interview segment, both enter into the “essentially fantastic and symbolic” “therapeutic fantasy.” The patient (ideally) dips more fully, almost completely into the fantasy. Calls this “ the degree of symbolic involvement.” The relationship occurs cut-off from the rest of the world. In a way, the therapist is a guide through this experience, having “greater capacity for symbolic experience and unconscious functioning than the other,” because as far as I can tell thetherapist is more highly differentiated, though that’s not the word he uses.

b. The Loci of the Process: The therapeutic process is an unconscious-to- unconscious communication between the therapist and patient, similar to a mother-infant or lover relationship. It was difficult to understand his point here, but I also think he was really on to something—ahead of his time. Like he’s talking about the way brains change each other, described in A General Theory of Love.

c. Disquilibrium Dynamics: “Thevarious ways in which… transference projections emerge and are altered.” This gets complicated. Each participant in the therapeutic relationship has a “therapist vector” and a “patient vector” which my simplistic understanding is that the patient vector is the parataxic disortions of each person, and the therapist vector is the reality-seeing part. It looks like the general scheme (there are diagrams) is that the therapist’s becomes more and more of a therapist and the patient becomes more and more parataxic until the final state is that the patient’s therapist vector has increased dramatically. All disequilibrium dynamics are motivated (that is, therapy is moved forward by) anxiety.

1. shifts in and out of fantasy

2. alternation between needs of therapist and needs of patient.

3. transference/parataxic relationships are repetitive and are upset/changed by the maturity of participants.

d. Phases in the Interview Segment:This is a long, complex section that I don’t fully understand

1. Pre-symbolic phase—not much symbolic interaction. Still in the “real world.” this stage is an extrication from the real world.

I. Anamnestic—patient is pretending to be an adult for the benefit of now not present society.

II. Casting—patient starts filling symbolic needs by transference/fantasy.

2. Symbolic phase—involves transference, which he calls psychotic involvement or therapeutic psychosis. Reiterates that transference goes both ways. Symbolism → isolation of relationship. Fantasy. High level of communication, low level of anxiety.

III. Competitive—patient coming to see therapist as omnipotent

IV. Regressive—patient feels like baby.

V. Core–”therapist denies all reality.” Relation is “primordial parent” to “child-self.” “the essential therapeutic relationship, which patient uses to “work through” problems.

3. Post-symbolic phase—re-repression by client starts here.

VI. Testing—patient begins to see therapist as adult.

VII. Withdrawal—patient = adult. can be trouble for the still-involved therapist.

3. Endings of Therapy: Very important. Three types—positive, negative (patient leaves aggressively, defiantly), compromised (most common, most unsatisfactory—fatalistic withdrawal —therapist keeps patient dependent). Separation is motivated by:

1. patients denial of patient status

2. new insistance on status as separate person

3. acceptance of new therapeutic role by patient.

a) Post-Interview segment: Patient re-represses properly unconscious processes, defines themselves as unique individual who accepts positive restrictions of culture that do not interfere with vitality.

Anxiety and Psychotherapy

a) Bilaterality of Affect in Psychotherapy: The movement of therapy comes from the emotional participation of both patient and therapist, which vary in intensity proportionally.

b) Anxiety in Psychotherapy: Anxiety is unorganized affect, our infantile affective state. Infants use interaction to organize their affect resulting in an intrapersonal organization of affect (ego, basically, maybe also “personality”) which is the tool to deal with anxiety arising from the failure of a supporting interpersonal relationship. This is also the case with adults, though their intrapersonal organization can be much more mature than an infant’s. Positive anxiety arises from finding oneself in a relationship with the potential for growth (better, more mature organization of affect)–”New and unorganized affect is mobilized for growth.” Negative anxiety is basically a breakdown of defense mechanisms, and stems from “pathology of the intrapersonal organization of affect,” meaning a person’s organization breaks down, is inadequate, in a relationship, and that person loses security. Both kinds are “good” for therapy. Anxiety is the growing pain (or “integration pain”) of therapy. Whitaker relates these concepts to transference, countertranference, and symbolization. The last concept is how one person is able to tolerate the anxiety in a therapeutic relationship; the patient symbolizes the therapist (& vice versa, to a lesser degree, hopefully) which allows them to tolerate the “increased affect previously bound in neurotic mechanisms.

1. Anxiety Alterations in the Process of Psychotherapy: In the isolation of the sessions, patient loses their external controls of anxiety, so their anxiety increases. Patient’s anxiety organizes instead around the symbolic relationship with the therapist, whose “positive anxiety” is a buffer. This is a regression and scary for the patient. Therapist must maintain responsibility.

2. Anxiety and Communication: Nonverbal communication, to the extent that the therapist’s positive anxiety can match/outmatch the patient’s negative anxiety, organizes the free-floating affect (which is to say, negative anxiety, I think) therapeutically.

3. Functions of Anxiety for the Therapist: I didn’t quite get this section. He basically describes the interplay between positive and negative anxiety and how it relates to therapeutic impass, which is basically when both P and T are patients. Unmatched negative anxiety leads to repression and impasse. Look out for being tired at the end of a session. That is a sign of repression.

4. Anxiety and Aggression: A strong enough therapeutic relationship organizes anxiety into aggression, overcoming defense mechanisms. Aggression = an active attempt to get attachment needs met. Infants automatically become aggressive when feeling anxiety. In adults, it depends on the moment-to-moment perception of the therapeutic relationship. If a relationship is perceived as an opportunity to meet attachment needs, the resulting positive anxiety (from seeing the discrepancy between himself and his potential) produces positive aggression, organized therapeutically against the patient’s own repression. If a relationship is perceived as a threat to defenses, the resulting negative anxiety (feeling of threat) produces negative aggression, which is destructive and needs to be stopped. This process is at work in both patient and therapist.

The Therapist as a Person: Distinguishes 4 kinds of people. Nontherapists are administrators and have business functions. Social therapists are usually late-stage patients or early stage therapists, who have had some therapy and are aware of their own patient-needs and “who force growth in those around them.” Professional depth therapists have resolved most of their transference needs in treatment, can accept both therapist and patient vectors in their patients, and so gains therapeutically from each patient, which strengthens each patient’s capacity/maturity. Ideal therapists, usually outcasts (! Wonder if Whitaker was feeling like an outcast while writing?), can function as a professional depth therapist for any patient.

a) Community and the Therapist: The community projects as it will on therapists and they must be careful not to fall solely into that role-play. Must nurture professional, social, and individual self.

b) The Professional Therapist as a Social Self: Therapists need a non-therapist community of people who relate to them as a person and not a therapist.

c) The Development of the Therapist: Patient/nontherapist to Professional depth therapist is a continuum. Four facets of moving along it. 1) Being a patient is a big part of it. Experience as a patient. 2) Personal maturation. 3) Experience as a therapist leads to eventually abandoning training. 4) Professional training—important but dicey. Can stifle the therapeutic intuition. The most important part of training is concurrently receiving therapy. Dydactic training is best delayed until significant patient and therapist experience is accrued and must always be secondary to the therapist’s experience as a patient and therapist.

1. Growth in Treating Patients: The therapist grows from treating patients, like parents grow up by raising children. No therapist has approached the limits of maturity.

2. Continuing Motivations of the Depth Therapist: Partly residual infantile fantasies which at best can help understand patients. Partly areas of “minor transference difficulties” which patients poke at and facilitate therapist’s growth. Also, therapist’s own therapy has left superego (internal parent) unrebuilt, which is done with patients. Ultimately, therapist gets to relate to others and himself (body image) with freedom and maturity. That is the real goal.

3. Body Image: Growing up and therapy fragment the experience of self—the distortions of infantile fantasies are corrected by therapy, but things are not reintegrated without performing therapy. Like parents who grow up by parenting.

Patient-Vectors in the Therapist

a) The Concept of Counter-transference: Everyone has transference—basically infantile feelings. Countertransference has been called that transference of the therapist which buys into his patient’s specific transference, undermining the therapeutic process. Whitaker feels that therapy is largely moved by the therapist’s emotion, so distinguishes between “mature countertransference” and “unconsidered and infantile counter- transference.”

b) Patient-Vectors and Therapist-Vectors: In each moment in therapy, whoever is responding in the most mature way is acting as the therapist. Patient-vectors are child- demands for parental attention. In good therapy, the therapist is usually acting on Therapist-vectors and the patient on Patient-vectors. The occasional switch is good for P to exercise adult-development, but sometimes the switch interferes with therapy—this is when the therapist’s P-vector is accurately called countertransference. P-vectors = intrapsychic growth needs. If T is adequate to a particular relationship, the Patient’s P- vectors will make himself well. (This reminds me of Satir, finally. It’s funny how those two get lumped together.) Therefore, It is the therapist’s job, not the patient’s, to resolve impasse. Do not blame “resistance.” It is super-important that T brings his whole selfincluding his P-vector immaturities to the room. Doing so does not guarantee therapist’s adequacy, but it is the best chance—othewise, P feels rejected: “We believe that the child feels rejected only when he senses a difference between what the parent could be as a person and what he actually is.” p. 164

c) Bilateral Character of Therapy and Patient-Vectors: Therapeutic impasse can often only be resolved by the therapist bringing his P-vectors overtly to the patient. This section has the first mention of “brief therapy”–patients do not seem to need continuity from hour to hour or minute to minute in therapy.

d) Categories of Patient-Vectors: There are categories, as listed below.

e) Avoidance of Therapeutic Relationship as a Category of Patient-Vector:Since the Therapeutic process is symbolic, not “real,” when the therapist engages in P’s “real” rather than symbolic problems it make P feel rejected. Avoiding P’s and T’s symbolic needs by “staying real” or “objectivity” is a rejection of the therapeutic process by the therapist. It becomes clear later, I think, that by symbolic, Whitaker basically means emotional.

f) Transference as a Patient-Vector in the Therapist: Patient can usually handle a therapist projecting inner-siblings and sometimes inner-parent on them, but never primordial parent. Also, a description of the classic “transference cure,” where the therapist projects his inner child on the patient and calls the patient “cured” when the patient acts “correctly” as that child. That child/patient will always remain dependent on the therapist.

g) Non-Transference (Sliver) Patient-Vectors in the Therapist: These are where the therapist’s experience with a different patient, something in the therapist’s life, or overenthusiasm for a certain technique, clouds the therapist’s thinking about the patient. Necessary to some degree for motivation, but can lead to impasse.

h) Resolution of the Impasse: Impasse results from the therapist’s denied patient-vectors causing him to avoid moving towards resolution of the therapeutic relationship, in the unconscious hope of satisfying his own patient-needs with the patient. Impasse is resolved by greater involvement in the relationship, not by withdrawal. Tough impasses need a 3rd person involved—supervision for the therapist, a cotherapist on the case, or therapy for the therapist.

i) Diagrams: Chapter 13 ends with ten somewhat mystifying diagrams grouped under t he following categories: “Therapist satisfies his own patient needs in his relationship with the patient,” “Therapist refuses to recognize the bilateral character of the transference relationship,” and “Therapist refuses to recognize patient’s immaturity, maturity, or his growth.”

Restatement of the Problem of Psychotherapy: Based on three fundamental principles of human behavior: 1) growth capacity can overcome trauma and emotional malnutrition, 2) experiential (Id as opposed to Ego) therapy uses the currenterxperience to modify and integrate the way past experiences are organizing present experiences (reminds me of LF), and 3) psychological homeostasis protects patient from therapist’s technical and maturaty inadequacies. Restates the necessity of a reciprocally but not equally therapeutic relationship. The therapeutic relationship is an externalized “good parent” intra-psychic relationship, allowed by the isolation of therapy from reality, freeing IP from cultural roles. The maturity of the therapist gives space for increased positive anxiety in IP to accelerate growth using the emotional relationship.

Techniques

Some Techniques in Brief Psychotherapy: “A technique is an interpersonal operation deliberately used by the therapist, the function of which is to transpose social, latent affect in both participants into deeper, manifest affect in order to catalyze the affective and symbolic process of psychotherapy.” “A technique is effective if it induces personal and deep feeling in the relationship, producing relatedness which is no longer deliberate and conscious, but spontaneous and integrated.” Techniques are more important for the beginning and ending phases of therapy, as the middle phase tends to take care of itself.

a) Techniques of Administration in Therapy: It is better if the therapist does not do administrative work with the patient, even social work type stuff, as this can impede forming a symbolic relationship.

b) Techniques in the Beginning Phase of Therapy: “The abuse of techniques in therapy stems most fundamentally from using the devoid of personal feeling and real affect, but secondarily stems from their use at an inappropriate time.” Techniques for the beginning phase are to isolate the relationship from reality and facilitate the transition to a symbolic, fantasy relationship (which I’m basically reading as a deeply emotional relationship). He discusses many ways to isolate the relationship, including meeting in the same place (not the patient’s house—somewhere unfamiliar), being very strict about the therapy hour, and refusing to be interrupted by phones etc and refusing to engage reality-based content, history, or questions about the therapists “real” life. He recommends focusing on data from the unconscious such as slips of the tongue and posture, and even more in the therapist than the patient. “The therapist needs only the conviction that everything the patient says after the early stages has symbolic portent for their relationship.” Implicit understanding is more important than explicit, and in fact says to fail to respond to any “real” material” to limit the “patient’s energies to the fantasy area.” Do this with firmness. It is particularly effective to use language from childhood, religion, and body image/somatic events, all symbolically interpreted.

c) Techniques in the Symbolic Phase of Therapy: Techniques in this phase mostly just “contaminate” the therapeutic relationship. Whitaker talks seriously about holding, rocking, feeding, and spanking patients(!). But only if the therapeutic response is inadequate. In the final, “core” stage of the symbolic phase, there are no techniques. T and P relate symbolically to each other as nursing mother and infant.

d) Techniques in Ending: Techniques become important again with ending. Whitaker lists 13 ways to tell that the ending phase is here, basically the patient brings reality back in, with more maturity.

e) Techniques Involved in the Testing Stage: The testing stage is the first part of ending. Basically, start refusing fantasy vectors, introduce reality, talk about ending. Show faith in patient’s new maturity.

f) Techniques and Communication in Therapy: “…all [techniques] function through increasing and clarifying the inter-subjective communication between the participants in psychotherapy.” Emphasizes use of non-verbal communication.

g) Technical Orientations Useful Throughout the Process:

                  1. Transference and Emphasis on the Present Relationship:In Whitaker’s “brief depth therapy,” the therapist’s interpretations of the patient’s transference projections are implicit and based on the present moment and relationship. (Sounds a lot like Yalom.) “He alters the nature of the patient’s response, not by an intellectural or ego correction, but by way of his own emotional and personal participation in the relationship.”
                  2. Insistence on Face-to-Face Relationship: No lying on a couch. Therapist does not relay on “objectivity,” but on own maturity and the adequacy of his own therapy (sounds like Bowen). Encourage direct eye contact.
                  3. The Use of Silence as a Technical Aid: Silence helps deepen patient’s transference at various stages. Also advocates actually sleeping at times during session.
                  4. The Use of Aggression as a Technique in Psychotherapy:Aggression is useful but it is the technique most likely to be abused. “The patient learns emotionally, because of the therapist’s active participation in this relationship with him, that aggression is possible without the loss of the underlying positive feeling which unites the patient and therapist.” p. 224
                  5. The Use of Physical Contact as a Technique: Useful and can be problematic, as above. Suggests holding crying patients and bottle feeding.
                  6. The Joint Fantasy Experience as a Technical Aid in Brief Psychotherapy: If therapist can verbally participate in P’s fantasy, it deepens the relationship.

f) Pitfalls of Psychotherapy:

                  1. Do not diagnose. “The aim of the young therapist in the beginning phase of therapy should be to explicate the patient’s needs, never his pathology.”
                  2. Do not accept acute anxiety as an emergency.
                  3. Never deliberately slow the process of therapy. “The process seeks its own rate and technical intervention on the part of the therapist is usually out of his own pathology and dynamically dangerous.”
                  4. Never compromise your “self,” social, or professional life for a client. Refuse “to see the patient at times that would seriously interfere with the satisfaction of [therapist’s] own living.”
                  5. Never verbalize without affect.
                  6. Do not interpret content. Rather, “relate, as a person, with feeling to each symbol presented by the patient.”
                  7. “Never deny the least fragment of ending in the patient. Verbalize ending cues received. “The earlier the ending, the more effective is psychotherapy. Never transfer a patient to another therapist.

g) Technical Aids in the Resolution of the Impasse: Assume the patient’s readiness to end. Then use silence and/or aggression. If you cannot make progress, let the patient initiate ending therapy, so he ends with strength.

h) Technical Aids in the Post Ending Relationship: If you meet a patient in the community after therapy is complete, as long as you know there are other resources for them to use in the community besides you, “feel free to spontaneously participate on a social level, and deny any symbolic role, thus letting the chips fall where they may. I thus asserting his right to be areal person, [the therapist] simultaneously gives expression to his faith in the patient’s capacity to be a real person.

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