Transformative Relationships: The Control-Mastery Theory of Psychotherapy (Book Review)

Author:  Silberschatz, George
Publisher:  Routledge
Reviewed By:  Mary E. Pharis, Vol. XXVII, No. 4, pp. 45-46

So, tell me: how do you feel about “evidence based therapies (EBTs)?” Assuming that readers of this journal are psychoanalytically inclined, I would guess that EBTs might not be high on readers’ “favorites” list. The newly published British Handbook of Evidence-Based Therapies (Freeman & Power, 2007) lists Cognitive Therapy, Behaviour Therapy, Dialectical Behaviour Therapy, Interpersonal Therapy, and Eye Movement Desensitisation and Reprocessing among other treatment approaches, as “true” evidence-based psychotherapies. And our APA, some states, and the Veteran’s Administration among others are on a mission to define EBTs as the approved psychotherapies. Some in education for the professions have also accepted it as their duty to make training and implementation of EBTs a high priority in psychology, psychiatry, social work and other helping professions. One cannot avoid the suspicion that this movement has burgeoned in large part to placate the health care insurance industry in the United States.

Transformative Relationships: The Control-Mastery Theory of Psychotherapy, edited by George Silberschatz and featuring ten of the leading figures in the development of control-mastery theory might just change your mind about this one particular evidence-based theory and therapy. But I am willing to bet it won’t be eagerly welcomed by the insurance industry as a true EBT. No, that would be too costly.

Based on his conviction that “relationships are inherently transformative and that the psychotherapeutic relationship is one particular type of relationship in which transformation is a primary goal,” editor Silberschatz emphasizes that control-mastery theory offers a “lucid, coherent, and powerful theory of the transformative process” (p. xv). Control-mastery theory is not “just” a theory. Elaborated by means of careful, detailed and responsible research over the last 35 years, its principles have been discovered empirically. It has not sought to validate pre-existing theoretical beliefs, quite the reverse. As Silberschatz notes, “the research is based on therapies in which both therapists and patients were unfamiliar with the control-mastery theory (p.190, italics added).”

Out of that sustained program of research, control-mastery theory has yielded principles that have been scientifically demonstrated and confirmed. The research describes how repression works to render experiences unavailable; how they may again become conscious in therapy relationships; how safety is a prerequisite for emotional regulation; what specific role unconscious guilt plays in psychological disorganization and how it can be addressed in therapy, etc. The principles are not new to psychoanalytically oriented therapists, but their research confirmation moves them out of the category of “beliefs” into the category of empirically demonstrated facts about human behavior.

Perhaps the control-mastery concept that is most familiar to those outside of the San Francisco Psychotherapy Research Group (originally the Mt. Zion Psychotherapy Research Group) is the concept of pathogenic beliefs. Pathogenic beliefs, an individual’s system of beliefs about people and the world, which originated from traumatic childhood experiences, are usually unconscious and yield psychopathology because they are invariably constricting. They show up clinically in the form of acute and chronic emotional distress, and they contain clear expressions of patients’ negative assumptions about themselves, and their fear and guilt about the power they believe they have to do harm to others. Pathogenic beliefs are based on incorrect assumptions (and usually egocentric assumptions in the Piagetian sense) which were the developmentally normal and expectable assumptions a child would have made in the face of the traumas he or she was experiencing.

Patients come to therapy with an unconscious agenda of testing to see if therapists fit the pathogenic belief(s) and will retraumatize them. The goal of therapy is to identify patients’ pathogenic beliefs, clarify their origins, and assist patients to alter dysfunctional beliefs by identifying and passing the tests. Silberschatz writes, “Pathogenic beliefs are not dry, intellectualized, abstract thoughts; they are powerful, emotional-laden, painful belief structures that cause severe emotional distress (p.7).”

I think any well-trained analytically oriented therapist should feel right at home with this concept. We know that traumas are involved in generating the pain that patients bring to us; we know they expect similar pain from us; we know we do not want to “fit” their pathogenic beliefs. We know that we will be tested, and we had better “get it” as quickly as possible. In Psychoanalytic Diagnosis, McWilliams (1994) agrees that such transference tests occur in all therapies, often in the very first session, and the therapist’s ability to understand the meaning of such tests and “pass” the test, i.e., respond in ways that disconfirm one or more pathogenic beliefs from which the patient suffers, is crucial to establishing a working relationship and providing the patient with hope that the therapy process will be beneficial. She writes, “Among the greatest contributions of control-mastery theory to psychoanalytic understanding is its emphasis on pathogenic beliefs (e.g., Weiss, 1992) and on the client’s repeated efforts to test them. In addition to passing these tests . . . .the clinician must help the client become aware of what the tests are, and what they reveal about his or her underlying ideas about the nature of life, human beings, the pursuit of happiness, and so on (pp. 274-75)”.

The research in support of its major principles and the impressive case presentations in this book clearly demonstrate that many of the therapies control-mastery theory clinicians conduct require detailed reviews of extraordinarily complex human behaviors and painful histories, elicited in the context of a developing relationship which demands enormously careful consideration of the moment-to-moment interaction between patient and therapist, and the subtleties as the change process unfolds over time in a successful treatment. Any analytically informed therapist will feel fully at home and admiring of the clinicians, case formulations, and complex therapies presented in the book’s twelve chapters.

I was especially admiring of an astonishingly demanding 9-year treatment process reported by Kathryn Pryor with a patient, “Ruth,” in which, over time, 13 specific pathogenic beliefs were identified and addressed in a highly sensitive manner. This case clearly demonstrated that control-mastery theory is in no way a mechanical process that can be easily taught and employed with patients in a “manualized” manner that would have assured a rapid, linear trajectory to a successful outcome with “Ruth.” No, this therapy demanded extremely high levels of intuition and attunement, not to mention a long time and an extraordinary level of patience and endurance on the part of the therapist; it is extremely hard to imagine that a therapist working from a manual and employing EMDR, CBT or DBT could have obtained the outcome that Pryor did in her sensitive application of the empirically-based principles of control-mastery theory.
And the insurance companies don’t want to hear that

References

Freeman, C & Power, M.(Eds.). (2007). Handbook of evidenced-based psychotherapies. Chichester, England: John Wiley & Sons Ltd.
McWilliams, N. (1994). Psychoanalytic diagnosis. New York: Guilford Press
Weiss, J. (1992). Interpretation and its consequences. Psychoanalytic Inquiry, 12, 296-313.

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