How do patients use testing to get better? Let’s look at the specifics of testing.

CMT believes that patients regulate their own treatment. They work in therapy to disconfirm their crippling pathogenic beliefs.  Patients are made miserable by these beliefs and are highly motivated to disconfirm them. Patients think unconsciously about their problems, and make plans for disconfirming these beliefs.

Symptoms such as compulsions or inhibitions can now be understood as efforts to avoid dangers foretold by the pathogenic beliefs. One way that patients work to disconfirm their pathogenic beliefs is by testing them in relation to the therapist. This is a way for patient’s to reevaluate the reality basis for the dangers predicted by the pathogenic beliefs. In testing, a patient acts in accordance with his pathogenic belief. Patients test in order to ascertain if the conditions of safety exist for making their beliefs conscious. For example, if a child believes that his parents were overly worried, he assumes that he must have done something wrong that caused them to worry. To test his belief, he will act worrisome with the therapist. He hopes that the therapist will not be worried. This would help him to disconfirm his pathogenic belief that he caused his parents to worry.

If the patient succeeds by testing the therapist, to disconfirm his pathogenic beliefs, Weiss suggests that he may then feel safer to lift his repressions and denials. This would allow the patient to become much more aware of his pathogenic beliefs and whatever impulses, attitudes, goals, or affective states he has repressed in obedience to these beliefs. Typically patients do not want to face core issues until they are reassured that it will be safe to do so. For example, a patient who was impaired by the belief he deserved to be blamed by his parents may not remember being blamed until he assures himself that the therapist will not blame him in the same manner that his parents did.

Two Kinds of Tests

As I said earlier there are two kinds of main tests, transference tests and tests by turning passive into active. The difference in the kinds of testing has to do with the difference in the relationship between parent to child and child to parent.  I will describe them both.

1-Transferring:

The patient invites the therapist to treat him or her as the traumatizing parent (or significant person) did. In these transference repetitions, a patient reproduces with the therapist those behaviors that he believed provoked his parent’s traumatic reactions. He invites the therapist to react in the same traumatizing way his parents did. For example, a patient who in childhood believed that his parents enjoyed lecturing him, might invite the therapist to worry about him to see if the therapist appears to enjoy lecturing and telling him what to do. If the therapist does worry or lecture, the patient might infer that the therapist likes being the authority and feeling needed. He then fears that he would threaten the therapist when he comfortably pursues his own goals. The patient hopes that he will not affect the therapist in the same way that he fears he had affected his parents. If this appears to be the case, the patient may then move toward disconfirming his beliefs that he caused his parents’ traumatizing reactions.

The child’s wish to stay connected to the parent accounts for the ease of the transference test.  The child wants to be and stay connected to the parent and will try to stay connected and get along.  He brings this into the treatment so that he will be cooperative with the therapist and try to give them what she thinks the therapist wants.  Healthier individuals tend to come into treatment with Transference tests.  They have enough faith in others to wish and hope that someone will be on their side.  But they also want someone to help then and believe that they can, so they make themselves likeable in different ways so the therapist will be on their side and want to help.

People who have had more traumas, feel more damaged and don’t find the world a very accommodating place tend to test more vigorously and come in with tests that are more difficult because they don’t think that the world will help them. Some have not been treated well at all and are concerned that the therapist will treat them the same way, so they come in swinging. They often use the second form of testing.

2- Turning passive-into-active:

Here our patient treats the therapist as the traumatizing parent (or other significant object) treated the patient. This test is often used to cope with a stressful life situation. If the patient enacts drama after drama and presents crisis after crisis, it is likely that he is presenting the therapist with the opportunity to experience and feel firsthand those situations, which were traumatizing to the patient as a child. The pull into action must be experienced as a challenge in order to evoke a role model. In turning passive into active, the patient treats the therapist in the same manner that they had been treated and found traumatic. The patient hopes that the therapist will not be traumatized and instead will be better able to deal with the behavior than the patient was. The patient may then identify with the therapist’s capacity to withstand bad treatment such as indifference, false accusations, blame and attacks.

Passive into Active testing has some similarities to projective identification–

The concept of projective identification is a Kleinian term first introduced by Klein in 1946 and later elaborated by Balint in 1952 and 1968, Rosenfield in 1952, 1954 and 1971, and Bion in 1959 (called “attacks on linking” by Bion). Ogden brought it into the popular American psychoanalytic culture in 1982.

There are three main ways that this concept has been used.

1 – One of the ways the term has been used is the idea that one is getting rid of feelings that are unpleasant.

2 – Another use emphasizes the creation of the feelings in another in such a way that the other experiences the unwanted feelings. Some do not believe that you have to actually receive the feelings for this to be happening which seemed like simple projection to me? Some see it as an aggressive act intended to destroy.

3 – Ogden (and others) also used the term as a form of communication between the therapist and patient. Betty Joseph in 1987 offered the possibility that it can be used (whether or not intended) as a way to understand your patient’s communication.

Weiss used it to refer to an intentional interaction, for the purpose of mastery, (even if unconscious), where a patient wants to show you something that he or she can not find the words to tell you. The purpose is so that you can help them deal with a trauma. This is very different idea than an attempt to get rid of the feelings or destroy an object you are envious of.  Weiss’ theory posits that the patient wants to get better and is trying to do so through a variety of strange actions such as showing you in action what was wrong in their early experiences.

Passive into Active tests are more difficult – the patient takes the role of the adult/abuser/parent and gives the role of herself to the therapist.  So the therapist has the experience of the patient in both action and feelings. This is when it is not so much fun to be a therapist.  You feel as the client does which is often uncomfortable.  Often you are having the experience of how the client was treated as well as the emotions that go along with it.  From these experiences you can extrapolate the pathogenic beliefs, or the treatment or the feelings of constraint.  Our patients are trying to learn from our reaction – if I treat you the way I was treated how will you (the therapist) respond to this stuff.  Can you remain calm and stand firm – can I do what you are doing? You are not complying to what I had to comply to – are there are other ways to respond?

Some examples of passive into active tests:

1. Patient arouses very powerful feelings in the therapist — does not have to be angry but can also be overwhelming, confusing and depressing.
2. Patient makes the therapist feel that no matter what they say or do – it is not correct.
3. Therapist fears that if they do the wrong thing, the patient will leave treatment. The test leaves you walking on eggshells.
4. Patient wildly exaggerates a feeling or thought – displays actions or feelings that are out of keeping with their usual behaviors

Testing by Attitudes”

Weiss and Sampson identified a third type of testing, “testing by attitudes”. The patient may attempt to disconfirm pathogenic beliefs by displaying a persistent attitude towards the therapist. They can be positive or negative personality traits, but the patient uses them to infer the therapist’s stance towards the patient’s goals, pathogenic beliefs and childhood traumas. The therapist’s attitudes can play also a therapeutic role in the interaction with the patient, showing and leading to possible change.

Sometimes patient can use different testing to work through the same pathogenic belief. Or can switch the meaning of a test needing a different outcome.  Sometimes the meaning of the test is not always clear. – Sometimes it is never clear and sometimes it is clear only after the test is completed.

In addition to testing, patients also work in treatment by making use of the therapist’s interpretations to become conscious of the pathogenic beliefs and to realize that they are false and maladaptive. This increases the patient’s control over the effects of their beliefs. They may then become less constrained by the beliefs and less vulnerable to the kinds of trauma to which they were exposed by the beliefs.

Control-Mastery theory emphasizes the cooperative working relationship between therapist and patient to disconfirm his pathogenic beliefs. The patient is highly motivated to disconfirm his crippling beliefs in order to recover the capacity to pursue life goals.