OVERCOMING PATHOGENIC BELIEFS: How do patients work in treatment to overcome these crippling beliefs? – Through Testing, Identification and Insight.

We try to adapt to the world to protect ourselves from danger and take advantage of opportunities. We do so through gaining an understanding of the dangers that surround us.

As Weiss says, “testing is a fundamental activity prominent in everyday life and in therapy.”  It is the manifestation of the individual’s effort to adapt to their interpersonal world.  Through testing they explore the world to determine its dangers and its opportunities so that they may protect themself from the dangers and take advantage of the opportunities.

All testing ultimately has to do with the patient’s wish to disconfirm their pathogenic beliefs. It is an attempt to assess the validity of the potential dangers foretold by their internalized object relations, from which they formed their pathogenic beliefs. A test is an occasion for patients to evaluate reality. Everyone tests everywhere all the time!

During the testing process, patients act in accordance with their pathogenic beliefs. They test in an effort to disconfirm those beliefs.

What they need to test first are that the conditions of safety be met in therapy, in order to infer if it is safe to make their beliefs conscious and work on them. If the therapist succeeds in passing the patient’s initial tests then they are able to begin to work on testing their pathogenic beliefs. If the patient succeeds (through testing the therapist) to disconfirm their pathogenic beliefs, they may then feel safe to lift their repressions and denials. This would allow the patient to become more aware of their pathogenic beliefs and the impulses, attitudes, and goals they repressed based on these beliefs. Patients need to feel safe in therapy before facing important issues.

Freud first used the term passive into active (testing) in 1920 in Beyond the Pleasure Principle (p35). There he introduced the compulsion to repeat unpleasant actions in order to master actively an experience that previously were passively endured. Freud returned to this concept in 1926 in the Addenda to Inhibitions, Symptoms, and Anxiety, (p 167) where he summarized the adaptive sequence of signal anxiety. In this action the ego is warned of a danger, and fears helplessness. This promotes the ego to react actively to avert the feared course of traumatic experience. Freud believed that changing from passively experiencing a traumatic event to actively controlling the action would allow a child “to master their experience psychically.”  This concept has also been linked to the concept of identification with the aggressor. Rangel also used the concept of trial by action in 1968.

It makes a big difference to your technique if you believe that a patient wants to remember (either through thoughts or actions) in order to work through their traumas, as Weiss does, (and Freud did some of the time in some of his writings), and that patients come into treatment planning to do just that. Weiss’s testing concept refers to the process by which our patients learn how to handle traumatic experience, and acquire through identification with the therapist; new ego strengths, which will help them, deal with future trauma. This expectation creates a different type of therapeutic relationship in which resistance has a very different meaning.

According to the CMT, psychotherapy is an occasion for the patient to disconfirm pathogenic beliefs by testing these beliefs in the relationship with the therapist. In CMT the process of testing is explained as a mostly unconscious way for the patient to feel safe in the therapeutic dyad, and to bring up the issues connected to the traumas and beliefs that they want or need to work on. Testing offers the therapist a way to collect important information about problematic experiences of the patient.  The therapist works to understand the affects that are being created and pulled for inside the therapist by the patient’s actions. The patient, through testing, should eventually feel safer and thereby be able to introduce more detail.

Testing is a patient-initiated behavior, which emerges within a particular relational context. A test invites or requires a response from the therapist. It is usually an unconscious process, but the patient may have some degree of conscious awareness of testing the therapist. According to Weiss, repeating a trauma through testing in psychotherapy is not the result of an automatic compulsion, but an adaptive interpersonal strategy, under partly unconscious control. He conceptualised “testing” the therapist as a part of the patient’s process to be ready to remember (Weiss 1990; Sampson, 1991; Foreman, 1996).

CMT addresses the discussion about tests through a case-specific approach. It does not propose new techniques for dealing with particular patients, but rather a model for conceptualizing how a person’s problems develop and the ways the patient will need to test the therapist to disconfirm pathogenic beliefs. Key tests are those that are most critical to the patient because they are central to the predominant pathogenic beliefs that the patient is working on to disconfirm so as to access change (Pole et al., 2002; Silberschatz, 2005).

Let’s define a test: (Marshall Bush)

1 – a test is an unconsciously (sometimes consciously) planned patient behavior that attempts to solicit information about the therapist’s willingness and ability to help the patient carry out his or her plan for therapy. The testing behavior may just provide an opportunity for the therapist to intervene in a helpful way or it may exert a strong demand for the therapist to respond to what the patient is doing or saying.

2 – tests vary in how discrete and noticeable they are. Some are barely distinguishable from the patient’s normal behavior. Some are obvious. Some occur repeatedly or continuously throughout the therapy.

3 – the way a patient tests will be determined by their goals, childhood traumas, pathogenic beliefs and unconscious perceptions of the therapist.

4 – there are two main types of tests (and can co-occur) which Weiss identified as “transferring” and “turning passive-into-active.” In the former, the patients invites the therapist to treat him or her as the traumatizing parent did. In the later, the patient treats the therapist as the traumatizing parent treated the patient. Tests can be passed or failed to varying degrees. There is a third kind of test: Testing/Treatment by Attitude. I’ll talk more about that in a few minutes.

What is the purpose of testing:

Testing is the primary way in which patients attempt to

(1) establish if conditions of safety occur with the therapist,

(2) master their childhood traumas,

(3) disconfirm their pathogenic beliefs,

(4) overcome their pathogenic compliances and identifications,

(5) acquire psychological strengths that they lack, and

(6) solicit their therapist’s help in pursuing their therapeutic goals.