Talk, Action and Belief

TALK, ACTION AND BELIEF How the intentionality model combines attachment-oriented psychodynamic therapy and cognitive behavioural therapy

Ian Rory Owen PhD

Talk, Action and Belief: How the intentionality model combines attachment-oriented psychodynamic therapy and cognitive behavioural therapy

Ian Rory Owen PhD

iUniverse, Inc.

New York Bloomington

Talk, action and belief How the intentionality model combines attachment-oriented psychodynamic therapy and cognitive behavioural therapy Copyright © 2009 by Ian Rory Owen PhD All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the publisher except in the case of brief quotations embodied in critical articles and reviews. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them. This book is in-part based on my experiences in practice. No individuals are intended for the case mentioned. Steps have been taken to make anonymous the identities of people who were considered for the cases mentioned. Any resemblances between persons mentioned here and real persons are entirely coincidental. iUniverse books may be ordered through booksellers or by contacting: iUniverse 1663 Liberty Drive Bloomington, IN 47403 www.iuniverse.com 1-800-Authors (1-800-288-4677) Because of the dynamic nature of the Internet, any Web addresses or links contained in this book may have changed since publication and may no longer be valid. ISBN: 9781440105388 (pbk) ISBN: 9781440105395 (ebk) Printed in the United States of America iUniverse rev. date: 1/15/2009

This book is dedicated to love: For all those who have loved me and who I have loved, And those who have never been in love and were never loved as children and adolescents, And those who are too frightened to love, And who have problems with love. But those who have love in abundance and are willing to teach and give it away, Will find that the more that they give, they will get something in return. Love is a lesson to learn in our time. Let there be more love in the world.

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Contents List of illustrations and tables ............................................................................ viii Preface

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Part I Overview ..................................................................................................xix 1 - The problems of practising .............................................................................. 1 2 - The intentionality of consciousness ................................................................. 9 3 - The intentionality model ............................................................................... 21 Part II Psychodynamics of providing and receiving care through talk and action. 33 4 - Using attachment theory for understanding relationships .............................. 37 5 - The inter-relation between self and other ..................................................... 57 6 - The basics of talking and relating .................................................................. 75 7 - Working to increase security .......................................................................... 99 8 - Action, choice and motivation..................................................................... 121 Part III Psychopathology, belief and the treatment of belief .............................. 141 9 - The psychological worldview of the intentionality model ............................ 145 10 - The biopsychosocial view of personalities and problems ............................ 171 11 - Hermeneutics and belief ............................................................................ 195 12 - Examples of interpreting belief .................................................................. 219 13 - Meta-representation and the developmental origin of belief ...................... 229 Part IV The practice of talk, action and belief ................................................... 247 14 - Assessment ................................................................................................ 251 15 - Treatment planning ................................................................................... 271 16 - How to formulate and work with belief ..................................................... 283 17 - Intentionality and evidence ....................................................................... 315 18 - Six meaningful worldviews ........................................................................ 329 19 - Interventions concerning talk and relating................................................. 355 20 - Interventions concerning action and meaning ........................................... 381 21 - Some cases showing the role of intentionality ............................................ 397 22 - Conclusion................................................................................................ 413 Bibliography ..................................................................................................... 421 vii

List of illustrations and tables Figure 1 - Edgar Rubin’s vase, introduction. Figure 2 - The map of the world of attachment between two persons, chapter 4. Figure 3 - Client and therapist in a secure optimal relationship, chapter 6. Figure 4 - Initially, the client is anxious and insecure but the therapist persists and creates a secure relationship, chapter 6. Figure 5 - The client attempts to contact the therapist psychologically but the therapist is unable to respond so the client withdraws, chapter 6. Figure 6 - The client attempts to contact the therapist psychologically but the therapist is aloof and dominant and the client withdraws, chapter 6. Figure 7 - The client attempts to contact the therapist psychologically but either the therapist remains dominant and withdraws, or otherwise withdraws, so the client also withdraws, chapter 6. Figure 8 - The client becomes increasingly secure in their attempts to contact the therapist but the therapist is not contactable and becomes preoccupied with irrelevancies, chapter 6. Figure 9 - Whilst the therapist is withdrawn in responding, the client remains secure in asking for help, chapter 6. Figure 10 - The client withdraws throughout the session and the therapist is unable to create a secure relationship, chapter 6. Figure 11 - The client starts the session anxious and insecure and continues to withdraw whilst the therapist is unable to create a secure relationship, chapter 6. Figure 12 - General behavioural formulation, chapter 8. Figure 13 - The relations between intentionality, sense, object and context, chapter 9. Figure 14 - The relation between the biological, social and psychological, chapter 10. Figure 15 - A biopsychosocial interpretation of the relation between an originating context and the current context, chapter 16. Figure 16 - Developmental formulation to explain that the personality and psychological problems are attempts at solutions that have negative consequences as well as positive, chapter 16. Figure 17 - A minimalist, decontextualised interpretation of the relation between an originating context and the current context, chapter 16. Figure 18 - Primary problem formulation 1, chapter 16. Figure 19 - Primary problem formulation 2, chapter 16. Figure 20 - Primary problem formulation 3, chapter 16. Figure 21 - An idiosyncratic behavioural formulation, chapter 16. Figure 22 - A descriptive account of the ego, active and passive processes, chapter 19. Table 1 - Explaining what Helen Stein’s findings mean, chapter 7. Table 2 - The biopsychosocial inter-action overall, chapter 10.

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Preface

What you can get from reading this book This book is written for a wide audience. Those who come from a psychodynamic background to it, and who work mainly with the therapeutic relationship, will gain some new ideas and techniques from a contemporary cognitive behavioural perspective and gain a precise understanding of their key practices. Those who come from a contemporary cognitive behavioural perspective may find that reading it will not alter their practice of technique and formulation except to make them more precise. Cognitive behavioural therapists will increase their awareness of the therapeutic relationship and their ability to work with it by understanding the dynamics of attachment. To any reader, the book provides a broad in-depth theoretical explanation of key psychological processes. The value of reading this work is increasing understanding in order to bring relationship-oriented and technique-oriented practice into one model. If there is only one thing that can be gained from this work, it is having greater clarity about theory that leads to better tailoring of interventions to the needs of clients - and that could make therapists more effective. Whether individual readers can be more effective is an empirical question.

Intentionalities map experience All therapies assume that there are intentionalities and that understanding, influencing and controlling them will turn psychological distress to well-being. Intentionality maps the structure of experience. Intentionalities are mental processes and acts of all kinds like perceiving, imagining, emoting, doing, choosing, reasoning, empathising and many more. Often, the focus on mental processes is implicit. This work serves to address that shortfall. The idea of intentionality is used in its many guises as a way of making sense of the intersubjective – the psychosocial - to promote self-understanding and self-care interventions. The object to be understood is meaning as a social phenomenon, open to all manner of views. Intentionality maps the structure of ix

consciousness as intentionality - sense – object and context in a number of ways. For instance, it is possible to anticipate danger that never happens and look for clues that the danger is imminent. This can became hyper-vigilance. In another case, for instance, it is possible to imagine that others say negative things about self and so avoid them for fear that they might just say it aloud. Another case is that it is possible to remember and fixate on the mistakes self has made and hold such memories in consciousness for hours. All these lived experiences are building blocks that contribute to distress. The map-making metaphor was first introduced to philosophy by Edmund Husserl, someone who had a great deal to state about finding the conditions for understanding. In 1901 he published the Logical Investigations, a ground-breaking work. One conclusion concerning understanding, he phrased in the following way: The analogy of what appears and what is meant... does not lead to a straightforward presentation by way of an image, but to a sign-presentation resting upon the latter. The outline of England drawn as a map may indeed represent the form of the land itself, but the pictorial image of the map which comes up when England is mentioned does not mean England itself in pictorial fashion... as the country on the map. It means England after the manner of a mere sign... our naming intention is fulfilled... by... the original object which the name represents. Husserl, 1901/1970a, Sixth Investigation, §20, pp. 727-8. One way of summarising this conclusion is to state that the map of understanding and belief is not the territory that it is about. This means that great care should be taken in making any conclusions for a theory about how to help people and how to believe and understand what other people believe and understand. What is of concern is what therapists bring to the relationship. The understanding that drives psychological help for vulnerable people is a concern. People who are suicidal or near death need one approach. Those who already have great difficulty in trusting and believing that others have positive intentions towards them need another. Yet other persons doubt that there is any hope for them to be able to change. What theory for practice does is create the maps of belief of the landscape of what people experience in general. This means that the intentionality model of the intentionality of others is a general system of mapping mental processes about the relation of people to their conscious experience.

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Hermeneutics: How to understand understanding The word “hermeneutics” in the context at hand refers to the qualitative study of how people make sense. The brute fact that people do make sense of any experience is born out even in the absence of external stimulation because consciousness can take flights of fancy. Consciousness abhors a vacuum and will make sense of any stimuli even in the case of lying in a floatation tank in total darkness where the salt-water mixture is at body heat. Answers are required for basic questions like: how is it possible to make sense of the psychological life? And, how is it possible to make psychological life make sense to specific clients? The tradition of phenomenology centres on interpreting lived experiences through the centrality of intentionalities that grasp objects that are potentially public and open to the view of other people. All human sciences and the therapies make sense of how people make sense. However, each does so in its own style. This work makes sense of people through intentionality. Intentionality is the common name to the mental processes that create linguistic meaning and non-verbal senses, like those of affect, empathic understanding and self-understanding. The intentionality model helps map the psychological problems and personalities of clients, so that idiosyncratic formulations can be made of how these defensive solutions exist. Once an understanding of how clients understand is discussed and agreed, then it becomes possible to tailor interventions for unique presentations. Many therapists might be doing or aiming at something similar. However, the claim of this work is to provide accurate understanding. Understanding is accurate when it promotes therapeutic goals and enables change. The aim is capturing how clients construe themselves in their social world in order to deliver care and facilitate them in being able to change themselves. If the reader is already focused on how clients have their own understanding, then reading this book will provide another means of doing the same. Hermeneutics is the formal name for the study of how experiences make sense. The topic of hermeneutics will be given a detailed attention in chapter 11 and thereafter. A great deal of life is made sense of through self-talk, the acceptance of the beliefs of people we know and what passes through the media of mass communication. Psychological problems are experiential and intersubjective (they lie between people and one person’s problems affect those around them). Understanding the intentionality of consciousness enables modelling how human awareness creates psychological sense: Making sense takes base perceptions and adds psychological sense to produce the outcomes of how people think, feel, act and believe. Many types of therapy would agree that the ways in which people experience themselves and others are influenced by their interpretation of their bodies and senses about their immediate context. Whilst the experiences that people have are “true,” when xi

people accurately describe what they are experiencing. What they experience is not what they potentially could experience about the same object. It is concluded that problematic and traumatic learning causes distress. Therapy promotes re-learning and new experientially-based understanding of the causes of the difficulties to produce sustained change. In the main, this is by dint of the decision and conscious efforts of clients, who choose to live differently, manage their problems and look after themselves. The approach to meaning that is being proposed in these pages is that intentionalities are a qualitative explanation of all meaningful experiences. Let us take figure 1. It is possible to stare at it, and without moving one’s eyes away, find spontaneous changes in non-verbal meaning. The living experiences produced could be called the immediate non-verbal interpretation of an ambiguous visual object. Figure 1 shows how there can be two senses of one perceptual object. The explanation provided is that consciousness has two previous senses that match the perceptual object and that the ambiguity experienced is the result of changes from one retained sense to the other. Figure 1 is a simple case but serves the purpose of stating the case of how meaning can be variable even when there are few meaningindicators to observe. In much more complex cases similar principles arise in understanding self-esteem, another person in relation with self and more complex psychological processes that exist across the lifespan. If a person is feeling suicidal and worthless one day and feels a worthwhile person with plenty to contribute on another, then what is of interest is not just what they conclude – but rather how they use mental processes to make the conclusions that they do. Aron Gurwitsch (1957/1964, 1966) was correct to emphasise that care is required not to transfer findings from one realm to another when analysing lived experience. For instance, conclusions derived from the experience of reading texts do not apply to understanding what happens when regarding ambiguous visual patterns. There is a genuine phenomenon when beholding shifting, nonverbal meanings about the same ambiguous figure – such as Edgar Rubin’s vase. Specifically, Gurwitsch noted that the Gestalt phenomenon overall is the same in consequence as Edmund’s Husserl’s idea of the donation of meaning (1929/1969, §4, p 25, Owen, 2006c). This concrete example helps in being able to identify the types of intentionality concerned. Figure 1 is an example of an ambiguous visual illusion. Husserl agreed that some objects are ambiguous (1913/1982, §103, p 250). It is provided in order to emphasise the living understanding that is the base of psychological theory. The research questions are to ask qualitatively, how to interpret the phenomena that are experienced in looking at the figure. What are the conditions for their meaningfulness? What does consciousness do in making sense of them?

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Figure 1 - Edgar Rubin’s vase. Figure 1 stands an exemplar of how changes in meaning can occur with respect to people and their intentions, or other more complex situations such as thinking about the self ’s personal history. Husserl’s first book of “Ideas” notes there is a tangible difference between the senses-as-they-present-themselves – as opposed to the object-that-presentsitself through a manifold of different appearances (1913/1982, §143, p 342). The recognisable self-same object appears within a shifting “core” or “nucleus” of key features that are definitive of that object. It is the case that depending on the type of intentionality, or intentionalities involved, the same object appears differently. For instance, the appearance of the same object as remembered – will be different to the same object as written about or drawn by hand. Husserl’s method was to compare such different types of meaning, to find out the nature of the intentionalities that create these meanings. Every client wants positive results from therapy - that is what they pay for. Every practitioner believes that their practice is effective and the theory they use is relevant. In these pages, it is claimed that bad theory leads to bad practice because it fails to relate to client experience. What are required are relevant specified actions, beliefs and behaviours about conscious experience. Without that, theory and practice are unjustified and inaccurate. What makes theory good is that it is capable of being shared with clients and so, it is justifiable with respect to their ability to understand themselves and hence care for themselves. Theory is accurate if it promotes change. What makes practice good is that it helps clients increase their quality of life, even if that improvement is only slight. Making accurate theory is making a map about these forms of psychological reality. The map-making process could be called “concluding on beliefs,” or “interpreting what exists and how it exists,” or “making sense of how others make sense”. (As opposed to judging what does not exist. And what some psychological process, object or context is not). However, there is danger to be avoided. Given that therapists do have an understanding and apply it in giving direction and contribute xiii

to the therapeutic relationships in which they participate, then if their understanding is inaccurate, the influence they provide will take clients away from their ability to change themselves. Accordingly, the type of answer being urged is the creation of a qualitative psychology of practice about the provision and receipt of care, conceived in a broad way.

On uniting aspects of psychodynamic and cognitive behavioural therapy However, in order to understand the whole of psychological life, it is necessary to have concluded on how self and other make sense - and what happens in intimate human relationships across the lifespan. Theory has its role in understanding the conditions of how the psychological life makes sense. This is not a task at first for measurement and the testing of hypotheses, but for understanding the processes of care, love and its disappointments called “attachment theory”. Attachment dynamics are brought together with the understanding of intentionality to make sense of the emotional life and interpret the processes of attachment, beliefs, intentions and the emotions. Therefore, the idea of intentionality integrates attachment-oriented psychodynamic and cognitive behavioural therapy. Bringing the best of the two types together creates a useful whole where selected aspects of both sets of skills mutually complement each other. But, non-specific talking and support is not advocated because it is not connected to any current topic or related to the maintenance of the personality and multiple psychological problems. This work is an application of the position I introduced previously as “hermeneutic pure psychology,” (Owen, 2006a, 2006b, 2006c, 2007a, 2007b). The “intentionality model” of individual practice emphasises the experience of clients who receive help in order to remind therapists of the impact of what they do and say. For this model, it is untrue that brand name therapies are the best and the only forms that can deliver help. On the contrary, any therapy is a form of talking, relating and planning action that shares the same bag of tools, and the same basic experiences of kindness, compassion and empathic understanding, with the everyday life. Psychodynamic treatment as it stands is often only half of what is necessary because it usually focuses on the nature of the therapeutic relationship and has a general way of regarding psychological and personality problems in terms of intentionality. Psychodynamic treatment does not follow through to identifying the nature of solutions and supporting clients in the means of making changes. It is alleged that the therapeutic relationship and the employment of intentionality are formative and most important. The aim is to understand providing and receiving care and so pre-empt, identify and rectify any problems that arise. This is achieved

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by using theoretical conclusions in the form of arguing for an attention to how to help clients understand themselves and their problems in explicit ways. Cognitive behavioural therapy shows its strength in its precision and focus on the here and now maintenance of problems, understood in the light of the development of the individual person. Cognitive behavioural therapy is congratulated for recognising and using intentionality. Conclusions on the intentionality of belief came to it from philosophy but now they rest uneasily with psychological science and its naturalistic attitude because belief is abstract although its end-products are tangible. However, it has to be asked why the cognitive behavioural therapies are so effective. The intentionality model answer is that the qualitative basis of attending to conscious mental objects, and the mental processes that exist towards them, are the reasons for its success. But the problem with cognitive behavioural therapy is that its theory of mind is implicit. Theory of mind deals with self-understanding and empathic understanding. Cognitive behavioural therapy is so far clearly proven to be the most effective treatment modality for single occurrences of “axis I” psychological disorders. This is because it enables changes in the here and now meanings, manners of interpreting experiences and alters the overall complex inter-actions between behaviour, mood and other aspects of conscious experience. Cognitive behavioural treatment as it stands is often only half of what is necessary because it usually focuses on intentionality and analyses the problem, identifying a solution and providing support, but does not focus on the therapeutic relationship.

Introducing Husserlian phenomenology Traditionally, phenomenology has been parallel to what is called a theory of mind perspective. Phenomenology has been influential in a wide number of areas within psychology and therapy and has commented on psychoanalysis, Gestalt psychology and behaviourism (Merleau-Ponty, 1942/1963, 1945/1962). In recent years, there has been little commentary from phenomenology on cognitive behavioural therapy. This work serves to correct that shortfall. Encouraging new action in the practice of cognitive behavioural therapy is recapped as potentially useful. Both cognition and behaviour are intentional in the sense that they are both forms of the intentionality of consciousness. The problem with the word “cognition” though, is that it is too broad and used in an imprecise variety of senses by different writers. Cognition could mean reasoning, imagination or anticipation. Cognition could also mean specific tasks like planning and include forms of memory. For this work, cognition is only what happens in the conceptual intentionality of speech and the internal dialogue of thought, although what can be referred to by language includes all types of non-verbal meaning. Relational, xv

affective, implied and non-verbal communication are also capable of being modelled through understanding intentionality, as will become clear in the pages below. The commonality in understanding how consciousness makes sense is the claim that phenomenology aims to find its concepts through studying experiences themselves (Owen, 2008b). Phenomenology is proposed as a partial solution for uniting the talking and action therapies around belief. Phenomenology is briefly introduced in this thumbnail sketch as a theoretical psychology of intentionality. It is a specific type of philosophical practice that works to understand the links between consciousness, its meanings, relationships and behaviours. The starting point for the version of phenomenology in these pages is to consider experience as always-understood and meaning something, because it has already been grasped in some way (Marbach, 1992). Phenomenology serves as a return to the experiences of providing and receiving psychological help and works to provide answers about how to think through the most fundamental parameters. Many therapies are phenomenological in the broadest sense of the word in that they attend to conscious experiences and interpret them. Phenomenology concerns the interpretation of mental processes that exist in relation to conscious senses and meanings of all kinds (Husserl, 1950/1977a, §§20-22). To improve on the original is to assert a better type of interpreting intentionalities from what is consciously discernible. The intentionality model draws the best from the history of the phenomenological movement during the twentieth century. Phenomenology focuses on the conditions for there being meaning in relation to mental processes. The intentionality model is about mental processes that can be controlled by clients. Working with intentionalities leads to self-care that no one else can do for them. The intentionality model arises from a part of philosophy called “phenomenology” that makes concepts fit conscious experiences. It is not against empiricism. Phenomenology encourages the biopsychosocial perspective though preventing an excessive reliance on natural-material understanding. Psychological theorising and understanding should be about psychological events not just material ones. The intentionality model is a model for social skills to promote choice, action, relationship enhancement and mixtures of interventions through an attention to belief. The point of the model is that it fits how awareness focuses on understandable objects and meanings in different ways. Metaphorically, the role of the model is like learning musical theory so it becomes possible to improvise harmonious music. Believing is chosen as the key to understanding living itself and the help that can be supplied through talk, relating and action-oriented interventions concerning behavioural and relational change. Primarily, therapy is a practical service for the general public that aims to improve the quality of life. It most often does this by helping its clientele help themselves find more satisfying ways of living. However, the ways of promoting xvi

understanding and self-care vary a great deal. From the view of its practitioners, what is required are the skills of understanding before practising any means of speaking, relating, motivating and directing people towards ways of making changes. After 21 years of practice and study I have come to the following conclusions about what is most relevant for the treatment of people with the so-called personality disorders and complex presentations of “co-morbid” concurrent psychological problems. This work is written with the idea that prevention is better than cure. For the longstanding personality disorders, neglect and sexual and physical abuse, people need to be actively self-caring in their own recovery. In order to do this, it is imperative to translate theory and research into easily accessible ways of how to understand the needs and tendencies of self in relation to others - in order to manage lifestyle, mood and self-esteem. Therapy is the calm and rational voice that alleviates distress and increases psychological well-being. Because a lead is being taken in this work, it involves a forthright manner of expression. This is why there is the use of the words “should,” “necessary” and sometimes even “must”. In this work, the term “therapy” refers to individual talking and action therapies. The terms “patient” and “analysand” are included in the term “client”. Similarly, variations in terminology like “doctor,” “counsellor,” “clinical psychologist,” “psychotherapist” and “analyst” are included when using the word “therapist”. The term “psychotherapy” refers to all forms including counselling. The term “psychodynamic” is used to refer to those forms that are derived from Freud such as “psychoanalysis,” “psychoanalytic psychotherapy,” “attachment-oriented therapy” and “psychodynamic counselling”. References in the text are placed in the chronological order of their writing not alphabetical order. References to the translations of Edmund Husserl’s works are specified with the section number and page number to help identification of multiple versions of the passages in different translations and the original German. Ian Rory Owen, Leeds, UK. September 2008. http://www.intentionalitymodel.info

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Part I Overview

PART I Overview

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This work is wholistic. It is argued that practice requires an attention to the relevant parts of the whole in the right order, starting with an overview. The wholism in question concerns how to balance opposing forces. If any one were over-influential, it would lead to an unhelpful imbalance, a dead-end, and an excessive focus on something that by itself does not matter. It is only when the whole is properly displayed does it become possible to grasp how the parts fit together. For instance, human development is both individual and social because of the social habitat. The wholistic view is that human development and its causes are biopsychosocial, comprised of biological, psychological and social causes. The first two chapters of this part serve the purpose of introducing the winding path that lies ahead in arguing for an experiential approach to meaning and relating as central concerns. Therapy is envisaged as a form of practical help whereby its clientele can be encouraged to make here and now changes in their lives, discuss what is relevant and be responded to by a profession that knows how to make its promise to the public come true in the genuine delivery of help. The most basic strategies for integrative practice are sketched in chapter 3. The assessment phase includes both talk and action interventions as the means of delivering care. Practising is not primarily intellectual. It is fundamentally emotional, relational and driven by psychological understanding gained through empathy that is informed by intellectual understanding. One problem of practice is how to justify a complex set of skills when there is no overall consensus. How to justify practice is a problem that could be addressed from different perspectives. There are literally hundreds of forms of justification. That hundreds of justifications exist is not a problem in itself. What the proliferation of perspectives shows is the complexity of the problems of practice and the creativity of the workers involved. Justifying practice focuses on what practice should be and how it should be justified. Rather than making critiques and arguing that some forms of justification are illegitimate, this work provides answers concerning how to practice by recourse to the experiences of providing and receiving help itself. For instance, here are two major questions. What are the needs of clients? And how should their needs be met? One answer is that it is acceptable to provide different types of approach for specific clients with different types of problems and different abilities. Another answer is that it is necessary to have some means of choosing and justifying such decisions. Learning the role of therapist is not like an actor learning a specific script but more like growing comfortable with how to improvise a role. A number of learning experiences are required to get an actor in training to improvise sufficiently well. One answer concerning how to train actors in improvisation would be a list of necessary social skills that lead towards explicit aims. Similarly, the intentionality model begins the training for improvisation of practice with xx

theory. It notes that the psychological world has no one-to-one connection with what is perceptually present in the current instant, nor with any specific appearing sense, be it remembered or anticipated, real or fictional. This makes the relation of theory to practice one where theory exists for the competent practice of getting about in the actual psychological world. Metaphorically, that is like stating that clients have a map of their lives when considering any instance of the whole of life. Theory maps the whole universe of possibilities. A sufficiently accurate map is one that helps people find out where they are and helps them identify where they want to go. Theory-making is map-making that works from a consideration of the real possibilities of the whole human world, in order to supply a map for specific areas. Therapists are map readers and need to be proficient in using theory to identify the relevant features of the whole landscape around clients: and be able to help them get from one place to another. The progress between the four parts of this work is sequential in that the first three parts are successively deeper steps into practice and understanding the role of practice. First is an overview that covers intentionality and integrative practice. The second part concerns the basics of practising talk and action. Third is explaining the role of belief as central for understanding how people act, feel, relate and think as they do. The fourth and final part provides examples of how the new understandings work in practice.

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1 The problems of practising Aim: This chapter provides an overview of the major problems of practice. Rather than immediately defining the psychosocial skills of therapists to help clients become self-caring, it is preferred to sketch out the basics and let readers make sense of their own practice. The aim of this work is to ground practice in experience, so that the reward of trying new behaviour becomes the direct evidence of how practice can be more responsive yet structured and accessible and that clients can make decisions based on the experiential evidence of putting in effort to understand, plan and alter their behaviour and feel the reward that they can give themselves in being clearer and more effective. The manner of argument below draws on various sources. Some argument is by appeal to empirical findings. Some argument is by appeal to the theoretical or philosophical psychology of Edmund Husserl called “phenomenological” or “pure” psychology in the sense of a theoretical or philosophically-oriented approach to conscious experience. Some of the experiential basis is abstraction from my own clinical experience since 1987. The view below is a qualitative analysis best characterised as creative thinking in terms of helping clients with their understanding and motivation, to enable them to over-come problems. 1

Talk, action and belief The view of what therapy is believed to be has to be stated straight away. Practice is art not a science. It concerns semi-structured meetings. Therapy is not pseudo-science, logic, applied philosophy nor is it leaderless, motiveless analysis and conjecture about the sources of problems. What is suggested as the way forward is co-working that involves clients in their own self-care and helps them be responsible for their quality of life in an on-going way. Sessions should have positive influence long-after the meetings have finished. This work is a return to the basics of practice. It is an argument for a vision of therapy as responsive, flexible and welcoming of the community at large. What therapy does is change understandings and increase motivation to self-care so that clients will change themselves and be helped in how to change themselves. This means that how clients decide to work and make changes in their lives is a major topic. Therapy assumes that free will is possible. If there were no free will and the ability to change understanding, then speaking to someone about problems would be pointless, as would be altering one’s behaviour in-line with one’s understandings. The fact that psychological change occurs through the media of talk, action and psychological influence, confirms the existence of free will. This chapter explains specific problems and indicates how they will be over-come. The heart of the issue is how to justify practice. One current type of justification is the empirical investigation of what is effective about a type of practice and what works within any particular form. But this work deals with more fundamental concerns. What is of concern below is the psychological interpretation of what appears. The end point of this chapter is stating the case for practising that is justified by a multi-disciplinary approach not allied to any one school of justification or one that draws on only one area of evidence.

The lack of consensus across schools Practice has many problems. From the perspective of therapists, one problem of therapy is how to justify the provision of care. From the perspective of clients, one problem is how to have their needs identified and met. The first problem of practice is that the field lacks consensus. There is the biopsychosocial perspective, but no details of what this means because two radically different areas of human being are brought together in uniting biological nature and psychosocial nurture. A frequently consulted means of justification is empirical research and this avenue for justification has its limits noted. Specifically, empirical research cannot provide justification for every aspect of practice. One conclusion from empirical research states that behavioural change is central to changes in mood and wellbeing and that finding is fully endorsed in this work (Longmore and Worrell, 2007). Behavioural change really means experiential learning. 2

Ian Rory Owen PhD The lack of consensus across the profession could be called the problem of “school-ism” because an excessive focus on one model is a misguided adherence to one way of thinking and acting that misses the breadth of practice as a whole. On further investigation, it is the contention of this work that the traditional boundaries between the current classifications of practice are untenable. This is because there is no means of confining the influence of an intervention to just one dedicated area. Accordingly, there are no enforceable distinctions between any brand name schools of practice. The brand name schools have more in common with each other and the everyday life than they would care to admit. For instance, cognitive interventions try to re-configure rationalising processes to help improve self-control, for instance, or increase the self-consciousness of how a person makes a choice that had previously been habitual and had not been properly conscious. Cognitive interventions use discussion to address verbal thought processes in internal dialogue that connect to behaviour, emotion and the capacity to relate to others and self. Similarly, the relating therapies target the ability to relate but only use talking and relating to achieve changes. The objection is that all aspects of human nature are inter-related, so any one type of practice applied to one area influences the whole of that person’s experience and functioning. Consequently, what it means to have a lack of consensus is that there are no guidelines to go from identifying a problem to knowing how to act. Clinical reasoning concerns “if ___, then ___” statements and criteria that make links between specific situations and lines of action. But if there is no agreement about basic rules across the many schools of practice, then there is no means of getting outside of particular views to find common knowledge. Nor can scientific psychology answer fundamental qualitative questions or provide certainty. Thus, the brand-name therapy schools are limited and their justifications can be challenged. Perhaps no theoretical model could ever accurately map possibilities that comprise the whole of the psychological life. But the profession accepts this difficulty in offering help to the public. The clinical reality is that there are unique presentations and complex interactions between personality factors and multiple disorders. There is a complex interaction between the personal style of the ego, its social context and the developments between the person and the consequences of their problems, that impact on the sense of self across the lifespan. Therefore, as it stands, there is no empirical base on how to work with complex problems because the amount and degree of complexity defeat the ability of the empirical model. Hence, there is the need for proper assessment, and the judicious use of theory and clinical judgement. And before that can be achieved, there is the need for a basic clinical reasoning: Using clear distinctions about what counts and how to understand the complex lived experiences of avoidance, inability and distress. These need to be understood in relation to cooperation and the attainment of satisfaction. 3

Talk, action and belief This work aims to understand talk and action in a fundamental way: A way that has both theoretical and practical implications, one that meets the instance and the general case. There is a need for clinical reasoning about the options that are available before assessing or treating anyone. Clinical reasoning concerns how talk or action, both or neither, are suitable for a person with a specific set of problems, in a specific current situation, with a personality and personal history of a specific sort. The central problem of therapy addressed below is the justification of clinical reasoning. The first problem of therapy that is addressed in these pages is one of a lack of consensus across the profession, and secondly, the ethical necessity to offer a number of choices including what is likely to be an effective form of help. Even though there is no consensus, it is not wise to demur and avoid the difficulties of making guiding theory. It is courageous to theorise and explain reasons for psychological experience. It is not jumping between foundations to begin understanding psychological events as having psychological meaning. With respect to the lack of understanding about the biopsychosocial whole, some choices are: •

There could be defensive complacency and denial that there are problems in the justification of practice concerning causation and meaningfulness.

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There is a need for honesty and openness of reasoning with clients and society at large.

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Caution and a self-reflexive estimation of the difficulties involved are at stake in offering psychological treatments. Caution is required because of the lack of certainty in a number of areas concerning what is the nature of the personality and psychological problems and hence what psychological treatment should be.

Not justifying practice by empirical research alone Contrary to the belief that empiricism has provided clear guidelines for treatment planning, the view here is that practice and formulation are improvisational art, not science. Specifically, it is supported that idiosyncratic formulations must be made for the purpose of tailoring treatment to each individual. Hypotheses about the cause of a specific set of disorders for any one person are nothing more than reasoned estimations, in the light of uncertainty in knowing the client and knowing the causes of psychopathology. Previous analysis, by five nationally-approved or otherwise renowned evidencebases, has been consulted from the American Psychiatric Association (Gabbard, 4

Ian Rory Owen PhD 1995), Anthony Roth and Peter Fonagy (1996), Peter Nathan and Jack Gorman (1998), the Clinical Psychology Division of the American Psychological Association (Chambless et al, 1998) and the UK Department of Health (2001a). What these five authoritative publications show are the following major differences: Of the 186 papers cited by the five evidence bases, 164 (88.2%) claim efficacy for cognitive, behavioural or cognitive-behavioural therapy. Eight (4.3%) claim efficacy for psychodynamic and six (3.2%) recommend inter-personal therapy. The remaining eight papers suggest relaxation skills, social skills, brief therapy and educational approaches as being effective with specific problems. Some people read findings from research into single disorders and conclude that cognitive behavioural therapy is the most effective brand of therapy simply because it is the most researched type of practice. One conclusion that can be drawn from the five authoritative publications above is that human existence includes free will and inter-actions between individuals and others, in such a way that the unique situation is not properly represented by the pseudo-scientific usage of statistics to average out findings and give a general picture of what works. But the problem is that single psychological disorders are rare. Because the quality of the research itself is not standardised, when that combines with research that is not representative of the clinical picture of differing personality styles and multiple disorders, then the findings are not a guide for treatment planning. Empirical findings concern situations that can never have all the variables controlled and the cross-section of the population included in double-blind trials are never representative of the population at large (Richters, 1997). Therefore, such a form of reasoning is misleading. Clinical reality is that individuals can have two to fifteen or more “axis I” disorders concurrently and may be capable of qualifying for a personality disorder in addition. There is no research on unique complexity. It is generally-agreed that the actual flexibility of practitioners is incapable of being made into a manual that covers every human possibility. To an extent this is true. Therapy as it is practised is flexible and responsive to specific clients. And because of that, it is incapable of being standardised and studied like the brand name practices that produce manualised treatment approaches. However, for the intentionality model, practice is another form of meeting. Human inter-actions are incapable of being standardised, replicated and are irreducible. But that does not mean that anything goes and nothing can be concluded about how it makes sense and what helps.

Ethical and effective practice This section notes the most fundamental practice of ethics in any therapy. Before assessing or treating anyone with psychological therapy (or providing any sort of help in UK law), therapists need to ask clients if they want the assessment or treatment. However, gaining consent means gaining informed consent. Clients 5

Talk, action and belief who give consent for assessment and therapy must have understood what it is that they are consenting to: This means having them understand what will help best, through helping them understand why it is a preferable course of action. To quote from the UK Department of Health advice on consent, clients “need sufficient information before they can decide whether to give their consent”. If they are “not offered as much information as they reasonably need to make their decision, and in a form they can understand, their consent may not be valid”, (Department of Health, 2001b). This judgement also applies in the negative: Knowing when some proposed treatment would hurt clients or cause more pain than gain, even when what is being considered is only assessment. Let us be clear about what the choices are. There is a need for legally defensible practice. Without informed consent there can be no treatment. If there is no explanation, there can be no treatment. The explanation provided must be understandable by each client, in order for him or her to consent. And, if there is no discussion of what is being offered, there can be no action. But the problem of consent reveals a further problem in therapy as a whole. If there is no consensus about understanding, then there can be neither competence nor incompetence in the legal sense, and consequently, there is no safeguard to the public. And to state the same thing in the negative, legally defensible practice does not exist across the profession but only within its limited schools. There is only competence or incompetence within a single school of practice because people from one school are not experts in any other. To get legal redress for incompetence requires some idea of what a reasonable therapist of a specific school would do in a given situation. The negligence issue is proved or disproved in a court of law by asking if another reasonable practitioner of a specified school would have chosen the same action as the one in question. What the question concerns is whether the problematic action should have been seen in advance and recognised as ineffective, unsuitable or harmful. And that a better action should have been carried out altogether. But there is no consensus across the profession.

Against the provision of a narrow set of interventions Fundamentally, therapy concerns itself with the lived experience of self and others. Its psychosocial skills are many and varied. The current claims of the schools of therapy - to have ownership of specific portions of life such as linguistic cognition, relating or unconscious psychological processes – have been argued as being unenforceable. Yet the most pressing problem concerns how to practice itself. The question “how to make sense of people’s lives and their psychological problems?” is related to a number of questions such as “how do therapists believe that psychological problems connect with a person’s abilities and personality?” Practice is an answer to such questions. The meetings are explicitly or implicitly 6

Ian Rory Owen PhD about what to do and why clients should do one thing as opposed to another. But these fundamental questions are often off limits because of the limited views of those whose practice only draws from one school. The resulting position of arguing for a broad scope of practice from different traditions is called integrative therapy. In particular, this work follows the lead of Hans Strupp (1973) and Paul Wachtel (1997) in trying to spot the common processes, weaknesses and strong points between psychodynamics and cognitive behavioural therapy. Thomas French was probably the first person to write in this vein (1933) and he was followed by Franz Alexander (1963). In more recent years, Jeremy Holmes and Anthony Bateman (2002) have provided an overview of some psychodynamic integrative practice in the UK. There are many specific forms of integrative therapy, possibly running to several hundred different types. Acceptance and commitment therapy makes clear distinctions between thought in language, emotion and behaviour and works to over-come the rationalemotional dissociation that can happen when people clearly think one way and feel something else entirely differently (Twohig and Hayes, 2008). The way to do this is to ask clients to commit to what they want and ask them to persist in working towards it with the behaviours that will promote it. This is a development of a neo-Skinnerian approach to behaviour therapy. Contemporary cognitive behavioural therapy is experiential and realises that making a behavioural change promotes a complex set of experiences and different types of learning. In a wide view of therapy, one problem is that there are two main groups of schools of therapy that have little or no connection with each other. There is no connection between the followers of Sigmund Freud and those of Albert Ellis. Generally, the followers of Freud specialise in providing understanding of feelings and relationships. Generally, the followers of Ellis provide techniques but have little or no account of the relationship with clients, thus omitting a serious attention to human relationships and meaning. This is not to say that cognitive behavioural therapists are unskilled or unsuccessful in handling clients. Rather, it is to say that there is a significant omission in theory and practice. The significant omission is having an explicit understanding of what it is to relate and understand how meaning exists for more than one person. The problem of the gap between psychodynamic talking therapy and cognitive behavioural action therapy has several facets. Action therapy lacks a full understanding of what talking and relating achieve. Talking therapy lacks the specificity of what action achieves in being able to pinpoint specific areas and promote change. This work aims to rectify these shortfalls and show how talk and action fit together – and how belief can underpin both.

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Talk, action and belief

Summary In this work, the specific focus is theory that justifies how to approach clients in such a way as to bridge the gap between the talk and action modalities. Because of the need to provide clinical reasoning, it is decided to press ahead with a sketch of how to theorise about observable events, conscious emotions and create a hermeneutics to make psychological explanations. This is not considered hastybut long overdue. The role of theory is to make clear statements about what is believed to count. This introductory chapter presented a number of problems within the broad spectrum of therapy research and practice. There is no overall consensus in the field. Rather there are a number of warring factions. The next chapter explains how intentionality is necessary to explain how psychological existence is distributed across the areas of meaning, perspective, time and context. The way forward is to consider some basic qualitative processes concerning how therapy works, in order to create theory for the purposes of guiding practice and communications within it. What is argued for is the view that the proper background to psychological understanding is the great expanse of the cultural and social world. It is inescapable that therapy is about meaning-change and empathised qualities of inter-action. Talk and action are forms of help that are not aided by an excessive focus on the natural, biological or material aspect of human being. Promoting the psychosocial skills of practice demands a greater focus on the meaningful and the social.

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2 The intentionality of consciousness Aim: After the last chapter revealed some problems about practice, this chapter sketches potential solutions to those problems. This chapter argues the case for understanding intentionality and focusing on how people are aware of any object of attention. This chapter argues that intentional explanation shows phenomena adequately by making explicit differences that are otherwise implicit in experience (Owen, 2002, 2007b, 2008a, 2008b, 2008c). Intentionality is common to the many possible intentional relationships of awareness about what appears. Attention will be brought to what it means to be empathic of another person’s consciousness in chapter 4. Rather than turning to empirical findings about what works in therapy, the means of addressing the basic problem of understanding experience is tackled by using some conclusions from philosophical psychology (Husserl, 1962/1977b, 1968/1997c, 1968/1997d, Marbach, 1982, 1984, 1988, 1992, 1993, 1996, 2000, 2005, 2007). Consciousness is awareness. It points to other people, self in relation to them and social situations. Intentionality is the directedness of consciousness in its many forms. The reason for a philosophically-based answer is that currently there are no empirical conclusions on how changes in mental processes facilitate positive changes in psychological problems and personality-functioning. For 9

Talk, action and belief instance, there are no conclusions on psychologies of belief and desire, internal dialogue and emotion, and changes between types of experiences when moving from distress to positive functioning. The sequence of topics below starts with an overview, then the emphasis is on some basic abilities that are common to understanding and psychological change. This is followed by some conclusions on some basic types of intentionality. Next some more complex but introductory types are mentioned. Finally, there is a summary of the chapter.

Overview Therapy assumes it understands the intentionality of consciousness. Intentionality makes the structure of conscious experience clear. The understanding to be gained is one that is close to home and very general: Intentionalities are the mental processes through which consciousness is aware. Understanding how intentionalities are similar and different enables greater precision in providing care because it enables a precise understanding of problems and hence a precise tailoring of interventions and self-care. Let us make the definition of intentionality more concrete through an example. Dan focuses intensely on the possibility that he may have cancer. This happens throughout his waking day to the extent that he also dreams about illnesses, death and hospitals. Dan finds medical information about cancer and focuses intently on every sensation that his body experiences. Then he realises that he experiences himself as excessively fragile and mortal. The tests that he gets his exasperated doctor to carry out for cancer and other illness prove negative but that provides no reassurance for Dan. Dan tortures himself through his strong visual imagination. He can take a slight headache and produce a ‘film’ of himself dying and see the consequences that would be entailed if he were to die, including the detail of imagining his own funeral. He pictures his death bed scene and feels the anxiety and loss that he believes he would feel. The intentionalities that Dan uses are visual imagination, anticipation and his internal dialogue. These constitute forms of worry that produce anxiety. Dan repeatedly talks through his experiences in his internal dialogue and concludes on them in the same negative way. Dan believes he is weak, unmanly and going mad. This case of health anxiety is only one instance where intentionalities are at play. Indeed, it is an assumption of everyday life and its therapy that people know how intentionalities work. It is often unnecessary to define the difference between imagining and anticipation as everybody implicitly understands already, except they may not have grasped the full detail. Psychological commonsense is shared between client and therapist: Everybody knows what imagination, perception, and emotion are in general terms. But the detail of how they are 10

Ian Rory Owen PhD similar and different is often omitted. Therapists need to go much further in having clearer understanding of experiential differences and how experiences fit together. Although it is impossible to specify every situation that arises in practice, intentionality still applies and is a flexible form of explanation. Despite the impossibility of cataloguing ‘if… then…’ instructions concerning how to practice, intentionality provides a flexible means of pointing to the most significant aspects of two people talking and relating. The understanding that there are different intentionalities is born out because each creates different felt-senses. Many interventions occur through identifying the over-reliance on ineffective intentionalities such as worry, procrastination, and rumination on the same topic for hours, self-critical internal dialogue and other matters associated with activities that bring distress. Formulation and intervention acknowledge that individuals create their emotions and behaviours in their unique ways. For some clients, the link between experiences is of the sort that some feeling dictates how they behave. But for others, what they fearfully imagine is enough to require the avoidance of where the feared possibility might be. In what is stated below, the guiding idea is that proper understanding of how consciousness works shows the phenomena. But poor understanding hides them. Many therapies assume they understand consciousness, empathy of the consciousness of others and what it is like to be connected with other people. Understanding translates into action. Intervention in the details of a specific situation needs to be clearly stated. The plans created with clients must relate to experience in a way that is justifiable and capable of understanding by them because a theory that is capable of justification to clients and colleagues makes what therapists reason and do transparent. Checking the understanding given to clients through involving them in it minimises the possibility of mis-communication. As regards practice, the basic assumption is that understanding the differences in experience enables changes to be made by clients on themselves. What Edmund Husserl did was to make explicit in theory what is implicit in lived experience. The details of his methods will not be entered into, but conclusions will be presented below because the differences between the forms of intentionality are psychological explanations of the ‘end-products’ of problems and personalities. The conclusion is that understanding the intentionalities and how sense and meaning are made can be achieved through comparing all types of lived experience (Husserl, 1913/1982, §§130-132). In more concrete terms, what this means is that concepts, perception, empathy, signs and imagination, for instance, form the structure of consciousness. It is a further major basic assumption of theory that people do things because of their understanding, aims, desires, needs and defences – even if these ‘causes’ of motivating factors are not always well-understood by the people who have them. Psychological problems can be caused, for instance, by believing something that 11

Talk, action and belief is merely imagined or anticipated to happen. Let us say there is a relationship problem of an empathic sort. The descriptions of fears of what will happen use phrases like “projection,” “transference” and “mind reading” to refer to mis-empathy. If there is an excessive reliance on unnecessary defences for decades of the lifespan (for any causative reasons), then that constitutes a “personality disorder”. These higher order constructs are tags that refer to complex interactions of non-verbal sense, affect and relating. The next section covers the topic of intentionalities in relation to the change processes of therapy.

Eight prerequisites of intentionality for change The following abilities are crucial in helping clients make changes. The means of answering the following questions are experiential: Some people can make the links easier than others. Actual answers to the questions are made in the moment and across a number of sessions. Theory for practice explains how there is success and failure to attain the following links between experiences. If there is no comprehensive account of these eight basic abilities to understand psychologically, then there is a fundamental gap in understanding. •

Let us start with the phenomenon that the actions, moods, thoughts, beliefs and emotions of a person may or may not make sense to the one has them. There might be many reasons why a person is not able to understand themselves. Theory should account for these lacks of understanding in order to state how it is possible to over-come them. Let us take the case of negative emotion. One possibility is that negative emotions are automatic and arise without volition and choice. Another is that the ego plays a role in contributing to its emotions but is not aware of its own actions. Therefore, a leading question is how come this specific client cannot understand the links between their behaviour and their emotions? If it is an unexplained mystery how people do not change themselves when they are in distress, then it may not be possible to help them change. Therapy exists to identify specific areas for change and claims to be able to promote it. “What is self-understanding of one’s own emotional life?” is a basic question that demands an account. Generally, formulation is the answer provided by therapy.

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If a person identifies the reason for a psychological problem as due to their choices and preferences, it should be possible for him or her to do something to stop that problem, or be able to manage its negative consequences. But if that person does not change their behaviour and that brings them distress, then commonsense would believe that there is some positive outcome that is 12

Ian Rory Owen PhD also being created, that is not yet mentioned, that means that the behaviour is worth the negative consequences involved. In this case, the leading question is this: How come the person will not choose to make a decision in their own best interests? Either the person keeps the problematic behaviour because overall, it is worth it because of its good consequences. Or, the person decides overall, that the behaviour is not worth its negative consequences and so stops choosing the behaviour. However, it seems some people get stuck with behaviours that are negative overall yet they do not give them up. Why? One answer proffered is that generally, people have no experiential evidence of what new choices could bring them, so they are not motivated to make the choice. •

Another question about employing free will is the following. If a difficult but realistically achievable task is chosen, is it actually achieved if the person had previously stated that he or she would do it? In the case of therapy, are clients sufficiently motivated to take part in their own care and complete a formal homework task? Or otherwise act towards achieving their stated aims? What factors create the sufficient conditions for people to act towards achieving their aims? Generally, one answer is that positive motivation is more influential and effective than negative. Yet the topic of motivation towards owned outcomes is not one that appears in many therapy texts.

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If people believe that what they feel in any one moment is an accurate representation of the whole of another person, or their relationship with that person, then ‘the truth of how I feel about you’ becomes accepted as ‘how you are as a person’. Let me explain. In a dating relationship for instance, when a new lover says something hurtful, the pain caused by what they have said could be accepted as the ‘truth:’ that the lover is completely thoughtless and unworthy of being loved. However, if the ‘thoughtless’ comment is really due to the sensitivity of the listener to such material, then the pain felt is a result of the listener and not the speaker: the ‘cause’ of the pain lies with the sensitivity of the person who heard the comment rather than the one who spoke it. The problem is that a temporary feeling about someone could become accepted as indicating the whole nature of that person. How do these empathic, emotional and intellectual judgements get made? One answer is that understanding the nature of empathy leads to understanding emotions in others, non-verbal communication and the relationship between speech and non-verbal communication - and how these function in creating meaning that is transmitted between people. The attachment literature has been consulted and is re-presented in a format that supports working with the therapeutic relationship and understanding relationship-phenomena.

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Talk, action and belief •

Given that people who live in one culture learn to empathise others accurately, people might be able to anticipate how others might empathise self. But when a person inaccurately empathises how others think, feel and act towards self, then this may generate psychological problems because the person is not reacting to what others actually express. A standard form of mis-empathy is to believe that others are better than self, and think badly of self. One consequence is self-imposed limitations on behaviour to stay within an area of safety. How come the person cannot believe that others might think well of them? This inability to believe direct experience can happen even when others show appreciation and gratitude to the person with low self-esteem. A commentary on the social nature of self is begun in chapter 9.

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Given that belief is causative of experience and behaviour, do people understand that what they believe can begin a problem? And that their beliefs can maintain it? What is the nature of psychological beliefs? The causative role of belief also applies to the so-called personality problems where people spend long portions of their life acting to defend themselves or over-compensating for ‘inadequacies’ that they can see in themselves but are invisible to others. Belief is a topic that belongs to philosophy. It deserves a detailed treatment because what is believed represents what exists. Since Plato and Socrates, there has been a keen debate on the difference between what might be mistakenly thought to be the case; as opposed what is more dependable and capable of being believed. Several chapters are devoted to psychological beliefs below.

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Given that a mood problem is to be stuck emotionally in one place without being able to move between a wider range of satisfying emotional experience and consequently freer actions, do people with inaccurate beliefs realise that their on-going believing is causative of their troubled mood? And does the discomfort of a pervasive poor mood lead them to finding better beliefs by themselves or with help from others? What are the necessary conditions for helping people change their beliefs? In short, the answer is that beliefs and believing are part of a complex whole. The answer proffered is that changing one part of the whole can work towards changing belief.

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Finally, can people anticipate that changing a belief (or an action, a thought, an emotion, etcetera) will change the overall experience of precisely the same situation? This means understanding that changing the certainty in one’s own belief will alter forthcoming desire, speech and action. If it were possible to let go of one belief and its consequent felt-senses, and act towards the achievement of a new belief and felt-sense, at a problematic moment or shortly thereafter, then helpful actions might be chosen rather than destructive or self-limiting 14

Ian Rory Owen PhD ones. The answer concerns the ability to provide new understanding and so raise hope about client’s abilities and the social context in which change could occur. The particular manner of answering the question is to think through the overall conditions of possibility for something to occur. These eight basic questions noted above are important. Therapists assume that they can be answered positively for anyone participating in talking, relating and action interventions. These questions assume it is conscious experiential links, and changes in intentionality and its objects, that lead to new understanding, new action and new feeling. This is one set of reasons why there must be an account of intentionality. The next two sections provide some conclusions to make intentionality more tangible.

Some conclusions about single forms of intentionality The being of the psychological world is entirely different to that of material physicality. It is the case that what exists for consciousness includes many objects that are not perceptually real but are imagined, remembered, anticipated, the subject of conjecture or rumination and the perspective taken towards them. This is why understanding intentionality captures the being of psychological objects. This is why intentionality is needed as a concept, to explain what is not materially real - like belief, intention, understanding and determining how people approach the world. In order to make the abstract terminology more concrete, the following conclusions are made about the types of relationships that understand awareness in this way. The “structure of consciousness” is a qualitative conclusion derived from comparing and contrasting what appears for self about other selves and the meaningful world of common objects of understanding. The terminology is abstract because it applies to many different situations. Eduard Marbach, a past Director of the Husserl Archives in Leuven, Belgium, and a current research professor in philosophy at the University of Berne, Switzerland, concludes that perceiving in the five senses concerns the conscious awareness of sensations about real events in the here and now, including how one’s own body feels, in addition to the super-imposition of other types of sense (Marbach, 1993, pp. 51-2). Vision, audition and kinaesthesia each have their own way of perceiving self and the outside world. Together they form the open space of the current moment into which all other forms of meaning and nonverbal sense appear. Perception needs to be sharply distinguished from all else that appears in the now. Psychologically, people have difficulty in functioning in the present when there are interferences from both the past and anticipations about the future (Bernet, Kern and Marbach, 1993, pp. 116-125).

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Talk, action and belief However, let us compare perception to imagination. The imagination is not tied to reality, although it is loosely based on the perceptual world. Imagining concerns something that might or might not happen or exist, at an unspecified time (past, present or future) without believing it is, was or will be real (Marbach, 1993, p 75). The imagination is driven by the conscious choices of the ego that also express the biopsychosocial whole of the core of the individual who is extended across personal history. Accordingly, the imagination of a child is not the same as a middle aged adult in terms of content. However, the overall process is the same. Imagination is useful in creative thinking and as part of problem-solving. Behaviour is most often purposeful action towards a desired outcome. The English language sense of the word “intentionality” as “purposeful” is not what intentionality means in these pages. Behaviour is classed as a mental act and can be the result of both emotion and rational consideration. Behaviour can vary in its degree of skilfulness. Skilled behaviour improves with practice and sometimes may need on-going practice to maintain good performance. Some forms are fully cognisant whilst others are automatic. And there can be mixtures of deliberate and involuntary skill. The contemporary understanding of changing behaviour sees it as a complex non-verbal change. Changes in practical intentionality are most likely to change mood and that has effects on self-esteem. Affect can be about values but most often represents how a self is relating, or has related, and how others are relating or have related to self. Emotion can be about people, objects, ideas and values. Emotion exists in the here and now and is in-part, a bodily felt-sense that represents the meaning of the relationship that is occurring. Emotion is also socially-learned in addition to the causative factors of self-talk and thinking with others in discussion. On the one hand, emotions are a form of intentionality towards what is believed to exist. On the other hand, moods are states of mind that are longer-lasting and have a “higher” purpose and meaning, in the sense that they are based on the “lowest” sensations of the body, perception and other types of awareness. When self-experience and self-understanding are both immediate, there is “primary emotion” because it is immediate and not connected to the ego and volition (covered in detail chapter 19). When emotion is created through internal dialogue or through discussion, it is “secondary emotion” because it is mediated through language or other forms of intentionality and is tied to choices of the ego. Moods also show a person’s relations to others and themselves, past, present and future. Although similar to the emotions, moods are highly-persistent felt-senses. Conceptual intentionality is the use of language in internal dialogue, discussion, reading and writing (Marbach, 1993, p 3). Concepts have a general manner of reference: They can point to first-hand experiences of self, or the secondhand, empathised experiences of others. Concepts employ an abstract manner of giving their meaning: They make meanings known, often without the object of 16

Ian Rory Owen PhD reference itself coming into consciousness. When reading printed text, words and sentences are the object of conceptual intentionality. Conceptual intentionality points to experience in an empty way unless the writing is particularly vivid and fires the imagination. The relation between speech and reasoning in language to non-verbal meaning - is that conceptualisations are about non-verbal senses or other conceptualisations. But the conceptualisations created may not be accurate portrayals of what they are about. Also, there are many types of meaning. Meaning in language might be accurate or not with respect to non-verbal meaning. In some cases, non-verbal meanings are two-fold (ambivalent or bi-stable) or they could be multiple and ambiguous, or entirely novel, or exceedingly weak in their sense. Writing and reading text enable sense to be transmitted by pointing to shared experiences. Thought can also be internal dialogue, in the way that people talk to themselves or refer to the outside world by using their own voice, but not speaking aloud. The tone of voice of internal dialogue is important in that angry and self-critical tones can add additional pain and tension to what people feel about themselves (Bandler, 1985). Similarly, believing that something is the case can also be expressed in explicit speech with another, or in internal dialogue with self, where self is both speaker and listener. The manner and attitude of speaking creates an impact on the emotions and mood. Empathy is the socially learned appreciation of the perspective of others (Husserl, 1950/1977a, §§50-54, Marbach, 1993, p 91, Owen, 2006c, p 162). Empathy is a complex intentionality involving many parameters and cannot be given a full account here although it is explained in brief in subsequent chapters. For instance, what appears perceptually of the other person is their verbal and nonverbal presence. But the received sense of what is being expressed is actively achieved through empathising. In the case of film, sound and vision point to experiences of real or merely fictional people. The way that film is edited represents the story that is unfolding. Empathy with film enables grasping the views of the actors in the story they are portraying. When the acting is credible, it is possible for the viewer to temporarily forget they are in a cinema or at home and become completely involved in the action. The experience of watching drama is a version of empathy that is slightly different. Watching face to face acting employs conventions of storytelling and the stylised portrayal of character and dialogue. Films and plays have many commonalities with ordinary face to face meetings. Empathy is also close to emotion and close to ethical thinking about social conformity and the expected consequences of social actions in a specific culture. Signs of all kinds are understood to mean one thing or another. For instance, mathematical systems of numbers point to general classes of objects. Musical notation exists to define the pitch and length of notes to be played. But by extension in the psychosocial world, there are many types of sign-making and sign-reading activities that create social life in terms of social skills, the degrees of 17

Talk, action and belief sensitivity towards other people and the ability to negotiate and get mutual needs met. Social experience is called “intersubjective” because it exists between subjects, between people. The consequence is that the connection between meanings and the perspectives of people form a whole that exists between the participating persons. Some further simple types of sense that are created through the intentionalities are as follows: Other types of intentionality include dreaming, hallucinating, delusions and complex forms such as imagining a dream or anticipating what someone will say or feel. Hallucinating is a telling example because it can occur in negative and positive forms. Positive hallucination is where an object is superimposed on perceptual presence in the five senses. Mainly, hallucination exists in audition and vision. Negative hallucination is where a perceptual object disappears from audition or vision, for instance. Some hallucinations can be quickly identified for what they are, whilst they are experienced, and not believed. However, other hallucinations are believed to be real and become a part of the life of the believer. What this shows is how donated sense can obliterate what is perceptually present.

Composite or complex combinations of intentionality The simple examples cited above are an introductory step to promote the understanding of much more complex wholes of thought, affect and behaviour and other complex connections. Altogether there are nested types of intentionality in conjunction with temporality, the many facets of the experience of time, past, present and future. This section makes comments on more complex combinations of sense and intentionality. The simple forms of intentionality noted in the last section are related to the overall complex experience of existing in time: There is a temporal orientation that pervades experiential evidence. For instance, remembering is about what a visual perceiving was. Or remembering could be what was said by another, and what was felt and what was thought by self (Marbach, 1993, p 79). Anticipating is the mirror opposite of remembering as it concerns what will be seen, plus anticipating what will be said, and how self will feel. There can be further complications because these intentionalities could be in relation to an anticipatory empathising of how someone might act. Comparisons between what is expected and what actually happens can be the basis of emotion and mood. For instance, if anticipations are low, then something pleasant happens, the comparison between the two will be surprise and happiness. Similarly, if anticipations are high but are not met in actuality, then disappointment and depression might be forthcoming. Anticipation is frequently central in making meaning. For instance, the effect of anticipating something good can constitute good feelings about that object. If a race is expected as a happy event and as a time possibly to win, or at least 18

Ian Rory Owen PhD enjoy the competition, then any thinking about it will be pleasurable. If the race is anticipated as being a tremendous struggle and that people will think negative thoughts as they watch self come last, then as the race approaches, it becomes a horror to avoid. To anticipate something is feeling how the future might feel before it happens. Anticipation is also linked to planning and problem-solving. It is then linked to other types of thinking such as visualisation, memory, verbal skills, critical-logical thinking and reflection on one’s own experiences to spot key distinctions and differences. Let us take a more complex example still. In order to understand and formulate a problem it is necessary to select the topic of thought and re-experience the memories, thoughts and feelings that occur with it. One such experience might be habitual self-criticism because of some regret from the past. Although the mental re-experiencing is not an action, it is a mental activity directed and controlled by the will of the ego. For instance, a hurtful and deeply regretted experience is chosen time and again, with the only outcome of lowering mood and self-esteem: through choosing self-criticism and the outcome is low self-esteem by rumination for days at a time. A more positive choice can be made. For instance, even if the choice involved is a mental one, a new choice can be acceptance of personal history and current feelings. It is complex combinations of mental processes that are the experience of distress and quality of life. Apart from perception of what exists in the here and now in the five senses, there are many additions of understanding to perception and other types of experience. “Mental processes appertaining to original passivity … are unable to bestow sense”, (Husserl, 1929/1969, §4, p 25): meaning that sense is ‘bestowed,’ ‘donated’ or ‘projected’ from the ego and its rationality. A special case of donating sense is empathising the perspective and intentions of others when hearing and looking at them. One general case is to note the difference between inaccurate senses given to a situation - as opposed to other senses of how the object in question could be experienced. For example, Judy wants a boyfriend but is afraid of going to places where there might be eligible men, telling herself that the places are “seedy”. This raises the curiosity of the therapist who inquires what she will expect to happen. Judy replies that she does not like the atmosphere because there will be people looking at her and “weighing her up”. She feels that she would be scrutinised in her physical appearance by both men and women at a night club, dancing class or adult education class. So she will not visit these places. Generally, how people make sense of situations involves linking several types of sense together. Careful open questioning can find what is implicit and specifically why people avoid feared situations. How people put meanings together is also the key for understanding psychological change. The experiential hypothesis for psychological change is that if there is a wide and full experience of the objects of attention (including self and other 19

Talk, action and belief persons) what is promoted is finding substantive evidential experiences about them that will promote accurate belief and accurate interpretation. For instance, over-coming agoraphobia demands being in town on a busy Saturday morning. It demands experiencing what it is like to visit shops that have been out of bounds. For instance, in dating, the only way to find out if a new partner is suitable is to spend time with them and find out what happens. Or generally, staying in a previously fearful situation until the fear falls, promotes finding out if the same situation can be experienced in a more relaxed way. Similarly, spending time with others promotes co-operative, relaxed and gregarious experiences that are mutually enjoyable and satisfying. What promotes psychological change is employing reasoned choice over the use of the intentionalities. Explicitly choosing the ways in which objects of attention are apprehended will contribute to psychological change.

Summary What is of concern is literally how clients and therapists make sense. The answer is that consciousness functions through intentionality. Intentionality includes talking, behaving and relating. There are composite types such as talking about behaving or talking about relating. Understanding intentionality is a way of helping clients understand themselves and promoting self-care. Therapy is effective because changing meaning in the short-term is a sound means of increasing the quality of life. This can occur for clients who are fully on-board in their self-care. Through understanding intentionality, interventions pinpoint and encourage selfunderstanding and self-change in clients. Experiences represent objects - each in their own way - as emotional, as intellectual, as signified by signs, as recorded on video. To not understand that experiences are representations leads to mistaking a specific portrayal of an object - for the only experience of that object that is possible. When intentionality is understood, it becomes clear that what is perceptible is not psychological. Or to put it another way, what is psychological co-exists with perceptual, remembered, anticipated, imagined and other complex forms of intentionality concerning what has been learned socially. But as a form of meaning, the psychological occurs in connection with what is conscious. Wholes of experiences are complex composite forms of conscious meaning created by intentionalities in conjunction with each other. These are important perspectives for understanding the orientation that clients have towards their psychological worlds. The points raised by this chapter will be returned to in various ways below.

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3 The intentionality model Aim: This chapter discusses the bare bones of practice according to the intentionality model for combining talk and action interventions around belief. The chapter concerns how to deal with unique and novel instances because practice will always provide new combinations of personality style, psychological problem, current circumstance and personal history. A sustained attention to belief is delayed until part three. What discussed below are more general parameters. The type of answer provided is that therapy can learn from pure and applied forms of the theory of mind. Specifically, proper understanding needs to be used properly. ‘It is not what you know, it is how you use it’ that counts. The topic of understanding how people understand is linked to the idea of theory of mind that was originally defined in the following way: An “individual has a theory of mind if he imputes mental states to himself and others”, (Premack and Woodruff, 1978, p 515). Premack and Woodruff are commenting on what is called “empathy” and “apperception” in these pages. The type of answer urged is to make accurate distinctions in lived experience about the specific nature of problems in order to make solutions with clients who are in charge of their own well-being. The type of answer provided is to avoid scientific psychology and understand the structure 21

Talk, action and belief of consciousness, outlined in the last chapter, and facilitate experiential changes. This is done through promoting self-understanding and self-care towards clear, desired and highly specific outcomes in complex situations, where there are large numbers of uncontrollable variables. The sequence of comments below starts with an argument for a turn to tailored intervening on what counts because it is possible to identify the structure of consciousness. Next an emphasis is placed on the commonality of intentionality in talking and action approaches. (The focus on the intentionality of belief is delayed until the basics are in-place). Noting the commonality of intentionality is followed by an overview of ten key points that a theory of therapy should contain. The chapter closes with some introductory comments on criteria for the good practice of talk and action interventions.

Mapping experiential differences The basic commonly used strategies of increasing problem-solving and increasing motivation of clients to achieve their aims are achieved through the fine detail of understanding experiential differences of the following sorts. The direction towards cure and management of problems may often require a suspension of belief in the actual existence, anticipated or imagined associations or learned sense. Or cure may occur through the suspension of an action, if a specific sense is experienced (for instance, fear). What this amounts to are suspensions of limiting beliefs in the person’s own abilities, qualities, ability to express themselves and other experiential evidence. These types of changes are achieved through having a clear understanding of the nature of the problem, its ‘cause,’ in order to help people strive to manage and over-come it, entirely of their own volition, in any context in which it might arise. The intentionality model believes there are some common, basic necessities that enable practice to happen. Three of the most pertinent forms of intentionality might be talk, action and belief, but these are only three out of a complex array of possibilities. There is a whole of experience that pertains to practice as well as psychopathology and its alleviation. Talk and action can both begin, and be media for, explicit changes in a number of experiences including the sense of self, selfcare, functioning and mood, and the meanings of the objects of attention. In order to tailor care to client need, the following remarks are an overview that loosens the ‘school-ism’ of ‘pure’ ‘brand name’ approaches (Omer and London, 1986), and creates a position that can employ talk and action. The uniting role that intentionality has in joining together the talk and action traditions is that it becomes possible to make distinctions about forms of representation and focus on belief (Pylyshyn, 1978, Perner, 1991, Kern and Marbach, 2001). What is meant by representation as a form of theory is detailed 22

Ian Rory Owen PhD in chapter 13 after presenting details of it throughout the preceding chapters. Mentioning what this means in-passing is a way of explaining the function of theory for practice. Theory makes general statements about the consciousness of people in general. These statements in language are allegedly true claims about what and how people are aware. Theoretical statements serve the function of modelling one (of a typical case) out of a very large number of other possibilities. Theoretical statements are comparative with a greater whole. The type of statements of interest to practising therapists are those that compare specific senses or “profiles” of the same object, in the same context, for different people. At base, a psychological account is one that can explain how there can be different experiences of the same object, for different people, or for the same person, before and after successful treatment. The intentionality model makes it clear what therapists are doing when they supply new meanings. The intentionality model puts conscious experience at the centre of its concern. The model works to emphasise experience as singly the most important topic to understand. The role of theory is that it structures psychological interventions and activities in meetings and provides flexibility for understanding psychological problems. Beliefs about self, others and cultural objects in the world are grounded on conscious experiences. Concepts are about these referents. What is being argued is that the subject matter of therapy is conscious experience and how to change it. When it comes to making changes in experience, the following is a truism. The bad news is that good experiences might slip away. But the good news is that bad experiences are not here to stay either. Experiential evidence is not like material being. In the theory of mind view, intentional relations are “informationally plastic” because they “can be radically altered by information”, (Pylyshyn, 1978, p 593). What Zenon Pylyshyn is referring to is implicit in conscious understanding of the psychological: that believing acts are about objectsas-believed. His argument is that the interpretation of behaviour is what makes it meaningful (p 592). For instance, without being able to represent representation itself, it is impossible to make the distinction between an appropriate fear in the face of genuine threat - as opposed to inappropriate fear, in the face of no threat, and to note that the nature of threat changes across the lifespan (Gedo, 1993, pp. 153-160). This is a key distinction in structuring how to provide care because if one were to accept that clients’ experiences were unchangeable, then there would be no point offering therapy or seeking its services. What appears perceptually for all to see and hear is made meaningful, organised, explained and interpreted differently according to each interpreter. In short and in relation to defences, these on-going processes are not about coping with real risk and adversity in a proportionate manner. Defences are overcompensations concerning excessive, and even completely unnecessary, beliefs and 23

Talk, action and belief negative emotions that set the level of security and limitation of action that might incur risk too high. And so defences not only pre-empt risk but even hamper or completely prevent adaptive behaviour and relating. For instance, one case of defending can be to the extent that secure attachment is refused (as well as other, less secure, less satisfying types of relationship). For instance, the consequent unhappiness and sense of absence is preferred to the search for finding a long-term partner. The differences between types of intentionality and the senses gained about the same object are explained in the next example: One problem could be fearful thoughts, producing a feared sense about an object, in feared surroundings, like having a phobia. The therapeutic answer gained through successive meetings will be to experience a neutral or less fearful affect that produces calmer senses about the same object, in surroundings that are uneventful. The intervention employs the potential differences between forms of intentionality. These can easily be explained to the layperson. It is easy to enlist the participation of clients through explaining to them in detail, concerning how to help themselves and try new things. By way of summing up so far, meaning involves the intentionality of consciousness turned towards the sense of an object of meaning, whilst being apprehended in a context of some sort. Psychological change occurs through: • Changes between types of intentionality. • Changes between the senses of an object and the amount of time spent on any sense. • Changes between objects of attention. • Changes between contexts of understanding that can surround any sense of an object. The intentionality - sense - object and context schema shows its worth by highlighting how fuller contact with an object in perception is often easier and less anxiety-provoking than anticipations or imaginings of what might happen. For instance, the change from problem-definition to solution-generation is clear, once these four aspects are highlighted. There can be changes in any aspect of intentionality, sense, object or context that will produce different experiences.

The commonality of intentionality in talk and action Intentionality is a simple, direct way of differentiating between the many types of awareness that can exist between single and composite types of awareness about 24

Ian Rory Owen PhD any object of conscious attention. In connection with the topic of assessment in chapter 14, is understanding that intentionality is a pre-requisite for talk, action and belief interventions and can be used to support interventions that alter the deployment of intentionality, its objects and contexts. The commonalities between talk and action can be captured by intentionality. This is true even though the subject matter of inaccurate anticipations of empathy, and the inhibition of self-disclosure are different from classical conditioning and negative reinforcement. Because talking and relating are common to all everyday life and therapy, they are given a priority in the next part of the book. This is because when clients express emotion they enter a two-way street. When one person expresses, he or she gets a response from the other and the interchange forms a context for more responses between each person. In the main, distress comes from clients towards therapists. Therapists need to be confident and capable of understating their reactions to it. Therapists may also feel strong negative and positive emotions and need to interpret to clients what is happening in the session. It is the duty of therapists to state what good things can be attained and warn of any dangers or pitfalls. The ability to work with emotion through the social skills of talking and relating form a central core to practice in any specific school or brand name style of practice. The means of changing meaning in open discussion is that it can occur through finding relevant evidence. Change might occur through no other mechanism than speech promoting new thoughts and feelings and finding relevant memories. No formal cognitive interventions are required to promote these spontaneous changes in Gestalt: The sense of the whole changes because some matters become foreground whilst others fall into the background. This is not to rule out formal cognitive interventions, such as thought records and other procedures of writing down thoughts and experiences to gather evidence or explore issues. However, through talk alone, it is possible to explore the connections between mood, thought, emotion and behaviour. This can be done by taking notes or the formal procedures of identifying automatic thoughts and discussing inter-relationships. If formal talking procedures are used, these use conceptual intentionality to highlight the evidence to which thought and emotion refer. Conceptual intentionality is involved in the provision and reception of new interpretations concerning bodies of relevant regions of evidence, to conclude on alternative explanation of current experience, and identify the consequences of alternative experiences. Discussion is using the conceptual intentionality of speech to explore highly complex issues such as abuse, neglect, complex loss and personal identity. What it provides is detailed clarification but it has the ‘cost’ of involving the therapist in a relationship that can be mis-read by clients. For instance, if a therapist merely sat back in their chair, it can be read as the therapist being dis-interested, when 25

Talk, action and belief no such intention or experience actually occurred for the therapist. Discussion has a reliance on empathic understanding both ways, in what is often a highly charged emotional atmosphere, where the ability to pass on the understanding that therapists are getting is hampered because clients can get the wrong end of the stick. However, therapists are not immune from mis-understanding. If they do not clarify the senses they are receiving, then interventions are aimed at their own wrong understanding. However, there are cases when no amount of discussion of the same topic leads to change: This is when action therapy has its remit in defining the problem precisely in terms of key moments where decisions (that promote self-harm etcetera) are made. What needs to happen are interventions focused on faulty, outmoded destructive, unsatisfying choices and preferences. The aim is promoting better self-care and care for others. In action therapy, “the proof of the pudding is in the eating”. Both talk and action interventions are capable of making lasting changes.

Ten keys of the intentionality model Previous attempts at integration have looked for common theoretical or processoriented commonalities between systems. Below, ten important theoretical positions are stated that underpin practice. These positions are translated into practice. There are the necessities of handling the relationship, in addition to creating clear parameters for different types of work to be negotiated and agreed. There is still insufficient evidence to believe in the superiority of any one explanatory model (Stiles, Shapiro and Elliott, 1986, Elliott, Stiles and Shapiro, 1993). Accordingly, it is argued that therapists should not impose unproven psychological theory but work within a social learning perspective that assumes that psychological help is part of a learning process that enables changes of meaning in the presenting problem and associated aspects of clients’ lives. Specific causes of inter-actions within the whole are not yet consensually agreed among the many schools of psychology and therapy. Despite the biopsychosocial perspective and the fact of biological traits, it can be concluded that human development is strongly influenced by social learning theory. But what this means is that there is no reason to place all faith on any one model of human nature and its development. There is insufficiently reliable evidence to decide among non-wholistic theories. Therapy is between models and individual practitioners should exercise caution against excessive claims and choose accordingly. In short, there are a number of locked doors to domains of knowledge, when it comes to knowing how to practice. The ten keys below are the beginnings of unlocking human nature as it appears in therapy. 26

Ian Rory Owen PhD Key 1 is the belief that personality theory describes aspects of a multi-factorial biopsychosocial whole. Human nature is biopsychosocial, containing complex inter-actions between three types of cause. Specific problems arise as the result of inherited personality characteristics, early and later adult life experience, personal choice and the influence of others and culture. It is impossible to ignore the range of influences. However, the intentionality model believes that the development, perpetuation and solution of problems concern the social learning of self-care. Key 2 is the belief that social learning is a significant ‘causal’ and maintaining factor in the development of psychological problems. What this means is that social triggers or stressors are frequently a psychosocial partial ‘cause’ of a first occurrence of a psychological problem. Key 3 considers meaningful and chosen psychological factors in the on-going perpetuation of these problems. There is the on-going phenomenon of the maintenance and persistence of a personality style and set of psychological problems that accrue through the inter-relationship of personal choice with the current social situation and biological traits. Formulation of the parameters of maintenance on paper happens through drawing a simple diagram for discussion. Or formulation can be achieved entirely in discussion. The aim is to promote informed consent and collaboration for achieving the goals of clients in a transparent and accountable manner. Key 4 is the belief that the process of therapeutic change includes a permanent means of choosing a lifestyle for positive mental health. What is necessary is understanding the qualitative basics. Directives exist that encourage consideration of evidence-based practice, clinical reasoning, quality assurance and clinical governance in professional networks, professional bodies and employers. Psychological change occurs via changes in belief and experienced-meaning that promote and enforce new understanding in relation to the conceptual intentionality of new beliefs, new speech and other realisations expressed in language. Key 5 is that permissible interventions are any that are relevant and can be explained to clients before they are used. The use of talk, action or both, must take into account the wishes, abilities and lifestyle of clients. This indicates the ranges of interventions that are appropriate according to a critical appraisal of relevant factors. Therapists need to maintain informed consent throughout treatment and be flexible about their recommendations. Key 6 is understanding that there are different amounts of client ability and willingness to participate in what is being offered and that is what constitutes stages in the progression of therapy. It is crucial to relate therapeutic stages to choices of interventions. Twelve stages of talking therapy were identified by Carl Rogers and are worth re-stating as a general rule of thumb (1942, pp. 30-45). For the moment though, in regard to how talk and action interventions differ, it 27

Talk, action and belief should be noted that talking is good for meeting complex needs because it can alter meaning through ‘non-specific’ spontaneous means. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Clients attend and so take responsibility to work on their problems. Clients can work out their own solutions. Therapists are friendly, interested and receptive and promote free expression. Therapists make second-person statements about what they believe clients mean and the conscious experience of clients. After expressing negativity and positivity, comes psychological growth. Clients need to accept themselves, become able to recognise their own patterns and interpret themselves. Through 6, clients gain new personality integration and begin to feel more whole and complete. Clients begin to look to the future of new decisions and actions. Clients initiate their own new behaviours because of their own motivations. Further positive change and self-understanding occur. Clients become more integrated and their anxiety reduces. The ending phase of therapy is agreeing a finishing date and keeping to it no matter what. The ending phase is characterised by clients decreasing their need for help and fully understanding that the meetings will finish.

Despite these 12 phases being related to talking therapy, they are still relevant to action therapy and other forms of work. Key 7 is the awareness that theory and clinical reasoning justify the psychosocial skills of practice in relation to the lived experiences of providing and receiving care. Psychological help requires the assessment of hope, motivation and its encouragement in the face of difficulty. Therapists should be psychologically present in the room with clients and responsive in making a therapeutic relationship with them (Rogers, 1957). This is their professional responsibility. It is an ethical requirement for therapists to set people at ease and enable them to participate in what is offered, to the best of their ability. Key 8 is considering therapeutic aims as needing to be gender-, age- and culture-appropriate because of the embedded nature of human being. Work should be tailored to individuals’ mental states and the specifics of how they are living, as part of their family, religion and culture. Key 9 is the necessity of reviewing meetings at assessment, at the end of each meeting, and particularly during the first few meetings, to monitor clients’ mental states and adjust the approach taken. Finding out the perspectives of clients on what is happening in the meeting is a major part of the ability to tailor the care provided according to abilities, level of readiness and general needs. Therapy ends when either the agreed focus has been achieved or most of the aims of 28

Ian Rory Owen PhD clients are met. In the light of feedback from clients, therapists should change their approach according to discussions and gain informed consent for every intervention, particularly if distress is entailed and there is avoidance to be overcome. Therapists may also suggest that certain issues may need to be looked at, so clients may approach those issues that are difficult for them. Yet tackling them would be helpful. Key 10 is the importance of harnessing and motivating free will to provide self-care and care for others. Belief is seen as the tenth key to over-coming persistently negative estimations of self and other and a sense of threat. Despite the clarity of the hypotheses of classical conditioning and negative reinforcement within behaviourism, the identification of belief is a way of working on parts of the whole of complex problems.

Towards criteria for good practice One way to specify practice would be to define criteria and standards for good practice. Criteria define general tendencies of good care. However, standards would state specific actions that should be achieved with specific client personality styles and configurations of specific problems (or state when there might be exemptions from such rules). However, complexity and unpredictability exist in the human being, its abilities and its social context. Although definitive standards for good practice might be desirable, they are not yet achievable as it would take precise knowledge about what helps about the biopsychosocial understanding of specific individuals. Therefore, what are being worked towards are criteria for practice and theory for practice. The only situations where there are clear responsibilities are when there is the need to investigate risk immediately and the possibility of harm to self and others. The need to investigate crimes and risk should be done according to the local laws and legal guidelines of one’s employer and professional body. So the tendency is to specify practice by stating criteria for good and bad practice according to general conscious outcomes and leave the execution of the detail up to individual therapists who need to assess the capabilities of clients and decide on treatment. With this in mind, the following remarks can be made. Skilled practice means being skilled towards specific aims and outcomes. It means working with the general public. Practice happens through the creation of therapeutic relationships where clients can discuss what they want and receive tactfully-worded comments from therapists that increase their motivation for taking action. The view of competent practice is that it is a seamless whole. Experienced practitioners develop their own style and way of doing things that work for them and expresses their personality. What any skills training course does is break the seamless whole apart to consider the parts. Then the course needs to 29

Talk, action and belief support the new practice, as the trainees put the new pieces back together, to make a new whole. Something similar happens in the chapters below. One problem to be avoided is being badly placed in the therapeutic relationship with respect to clients and their needs. However, being able to place self well with respect to them, demands an answer to the question of knowing how consciousness and relationships fit together. It is argued in these pages that the social skills of relating are a pragmatics where accurate understanding proves itself in providing good psychological outcomes. The work done is creating and maintaining therapeutic relationships. Understanding the problems of clients provides clues on how to influence them explicitly and provide informed consent concerning what should be happening. Indeed, what is being encouraged as good practice are therapists as leaders in providing structure, a means of problem-solving and facilitating motivation towards what clients choose. This does not mean being controlling or demanding but fulfilling the role of leading clients away from problematic situations and towards more satisfying ways of life. Without adequate understanding of the emotional pushes and pulls of the therapeutic relationship, then the decisions that therapists need to make are made much harder. For instance, decision-making in practice needs to know how emotions arise in specific instances.

Summary It is argued that because of a model of intentionality, it is possible to specify experiential differences because what a theory of intentionality provides is a theoretical language about psychological processes and senses. For the intentionality model, the premise that there are distinct brand name therapies is unworkable. On the contrary, there are connections between all areas of human functioning. Thought, emotion, action and relating are all parts of a larger social whole. Practitioners are willing to provide help across these areas of life. Therapists integrate interventions across these areas of living. The preferred way of working is to respond to client need with flexible care and to move ahead at the right pace. The main part of practice is tailoring interventions to meet client needs. If a small range of interventions were offered, they would inevitably not meet the very wide range of client problems. Therefore, what is required is a wide repertoire of interventions to offer the public. What happens in practice is that wholes of meaning appear and need to be understood and worked with. Like in ordinary life, what happens between the two persons in individual therapy is a living tapestry of movement and change. Because all aspects of human nature are inter-related, and any one type of practice applies to the whole of human nature, it follows that interventions operate within the same complex whole. What happens is that therapists take 30

Ian Rory Owen PhD their past experience into sessions and improvise in a semi-structured way with each unique client: The skill is being able to improvise and consult relevant theory and past experience. A certain repetition of events and the speech used occurs in meeting the same situations. They are repeated by therapists and some situations get repeated a number of times. With complex cases, where strong emotion is extent, even the most experienced therapists might become temporarily confused. But when that happens, there is the need to gain clarity about what is happening through a basic theory of relating and understanding. This demands the ability to understand and interpret experiences, their psychological ‘causes’ and meanings. This is how the concept of intentionality opens up the phenomena of how fear is produced in the phobias, for instance, and explains how clients can help themselves in over-coming fear through the application of simple principles. Chapters 4 to 7 discuss relationships in general through understanding attachment-oriented psychodynamics and promoting choice and motivation for action interventions. Despite the fact that the delivery of here and now action interventions co-occur within the dynamics of the therapeutic relationship, what is covered as a priority is the creation of good quality professional relating. Part II focuses on interventions concerning the complex intentionality of attachment.

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Part II Psychodynamics of providing and receiving care through talk and action

PART II Psychodynamics of providing and receiving care through talk and action

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Talk, action and belief Now that the problems of practising and explaining practice have been introduced, the remainder of the book provides more detail, one step at a time. What is going to be argued for is the experiential detail of providing and receiving therapy. The most basic proposition is that attachment phenomena need to be described because there can be multiple senses of the same attachment figure (the same person, in precisely the same situation) according to how that same event is interpreted and believed to exist. The devil is in the detail though and rather than shying away from making recommendations, some will be provided. Change is created through combinations of talk and action. But talking and relating are the means of initiating care and monitoring how well the meetings satisfy the needs of clients. The next five chapters provide a snapshot of the whole of relating and promoting change. More detailed examples are provided in part four of the work. Accordingly, the first four of the next five chapters are devoted to ways of understanding relationship types between the two persons in individual therapy, when there is sensitivity to the attachment dynamic that is occurring. Attachment is a research-oriented approach and a theoretical view arising from research that considers how people in intimate relations provide and receive care. Despite the differences between attachment-oriented psychodynamic and cognitive behavioural therapy, there is such a thing as psychological reality that is adequately described by attachment research between clients and therapists, and between children and their carers. Whilst criticisms of psychodynamics and cognitive behavioural theories could be made, these are omitted in preference for a positive characterisation of meaning, as attended to by the various forms of the intentionality of consciousness. The psychodynamic therapy referred to below is a general attention to the therapeutic relationship that is understood via attachment dynamics. What this means is appreciating that the therapeutic relationship is singly the most important aspect of any modality of therapy. Indeed, interventionist therapies like cognitive behavioural therapy are in danger of being overly focused on in-session activities and setting homework to the degree that they might omit sufficient attention to the therapeutic relationship. As regards the lack of consensus in the field as a whole, a book alone cannot solve the problem of a profession of mavericks. The solution to a lack of consensus is to offer the idea of the intentionality of consciousness as a unifying concept to understand psychological problems, personality development, individual and social life, and for understanding relationships. The good legacy of Sigmund Freud is called on to explain how resistance and mis-empathy (“transference”) occur and how they affect relationships. Mis-empathy exists as varying degrees of mis-understanding of the explicit behaviour and speech of others. It can vary from a simple mis-communication to an inaccurate attribution of intent, from self to the other, that persists even when there is evidence to the contrary and after repeated discussion with the other person. Therefore, the accurate parts of 34

Ian Rory Owen PhD Freud’s legacy are separated from a misleading version of his work that encourages insecurity of attachment and amplifies mis-empathy, in order to relate it back to clients. Chapters 6 to 7 note the skills of talking and relating that follow the basic guidelines laid down by Sigmund Freud. The picture of good mental health is to help clients be neither over-cautious in the absence of harm nor under-cautious in the presence of harm. People should not be excessively defended against catastrophes to the extent that their defences cut off all possibilities for attachment satisfaction, growth and enjoyment. Nor should people be excessively impulsive so that caution is thrown to the wind and clients are active in their own destruction through an addiction to temporary fixes and immediate satisfactions that prevent long-term satisfactions at home, work, rest and play. A lead is made by defining bad and good criteria in the talking and relating backbone of practice. The importance of attending to emotions is introduced. Emotions and longer-lasting moods might appear as non-volitional at first, but it is untrue that emotions operate entirely out of the influence of the ego, reason and choice. Emotions are capable of being influenced in both direct and indirect ways. The final chapter of this part concerns how to encourage clients to change their own behaviour as part of the overall work to be done in achieving positive psychological change in long-standing personality functioning and more transient problems.

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4 - Using attachment theory for understanding relationships

4 Using attachment theory for understanding relationships Aim: This chapter uses intentionality, empathy and findings from attachment research to inform practice (Marris, 1996, Levy and Orlans, 1998, Heard and Lake, 1997, Cassidy and Shaver, 1999, Brisch, 2002, Mikulincer and Shaver, 2007). This chapter makes some introductory comments to set the scene for understanding relationship dynamics preparatory to making contact with the tradition of psychodynamics. Edoardo Weiss originally used the word “psychodynamics” to mean “the science that describes and explains the manifestations and the consequences of the interaction of mental forces within the human being”, (1950, p 1). He referred to experiences that are lived through and conscious as “teleological” (p 2) because they concern purposeful, goal-oriented behaviour. This chapter introduces some basic aspects of the psychodynamics of attachment and describes the phenomena that exist generally in an experiential way. The purpose is to help readers identify these phenomena with the hope of being able to spot them as they happen in the 37

Talk, action and belief moment with another person, so that therapists can employ self-control, understand and create positive encounters and discussions, rather than acting on blind impulse. Attachment theory and research presents itself as the only rigorous approach to studying the dynamics of intimacy and caring across the lifespan. It is sufficientlywell diversified to be applicable to a large range of areas pertinent to therapy, home and work life. Intentionality shows its worth in being a theory for the description and explanation of conscious meanings and purposes. The theory of intentionality as it applies to therapy is revealed across the full length of this work. In attachment research there is a consensus that attachment style is created according to learning due to the style of parenting provided (Fonagy, 1999, p 598). This belief is used to understand human development as largely influenced by the different understandings of the mutual relationship that is experienced on both sides of the same two-person relationship. The provision of care to infants and small children is influential and an important determinant for the quality of future relationships. However, the wholistic view of what it is to relate to another person is central, in order to understand clients and know how to respond to them, to create sufficient harmony and co-operation in the therapeutic relationship. The first section argues for a clinically-usable theory of attachment. Second, an empirical view of attachment is explained as a means of understanding a large range of styles of intimate relationships. There are three sections on empathy and two introduce attachment. The next section explains a dynamic view of attaching. The aim is to capture the hopes and disappointments of the short-term professional relationship that is therapy and compare that to the longer-term intimate relationships that people have in their home lives. The sequence below starts with a brief introduction to the role of understanding, followed by some basic terms for understanding the inter-relationship between self and other, empathy and the interrelation between actions, meanings and emotions called “intersubjectivity”.

The need for an experientially-based theory On the one hand, clients may have had extremely chaotic, traumatic or otherwise problematic childhoods and previous life experience, whilst on the other, meetings need to be structured. But on the other, the mutual roles and tasks of treatment need to be clear and manifest for the promise of help to become actual. Accordingly, the needs of practising are experiential and relational ones that require being able to spot the meaning of what both parties experience, and know in what direction to take the relationship in order to re-establish co-operation, for instance. Or to be able to explain how to bring the sessions to a close in such a way that both persons are amicable about the ending. Several hundred models of psychosocial skills exist for practising the therapeutic relationship. At base, what all forms of individual therapy have in 38

Ian Rory Owen PhD common is that there are two people meeting face-to-face who discuss matters in one of their lives. One person seeks help. The other aims to provide it. The one who seeks help speaks of his or her life, problems and frailties. The one who offers help says nothing about his or her personal life and responds in a skilled way towards specific aims that promote self-care and improvement in the quality of life of the other. Or at least provides no harm. Therefore, how the two people understand the common topic of conversation - and relate to each other – are of prime importance. What the intentionality model enables is a map of the world of attachment within two-person relationships. It provides qualitative reasoning to understand and promote self-care and the provision of care to others. It promotes the psychological understanding of personality in context as part of a pervasive complex whole, where the lived sense of self (ego or personality) is a combining style that crosses many areas that could be held separately as intrapsychic, interpersonal, symptomatic, cognitive, systemic, familial or other aspects. But each area is only a part of the whole, rather than catching the inter-relationship within it. Attachment theory and research use the terms “empathy” and “intersubjectivity” and these will be explained in more detail over the course of the work. Attachment is a composite intentionality because it is comprised of empathy and the practical provision of care, potentially leading to a ‘two-way’ flow of care in ordinary social and loving relationships. Attachment within therapy is a ‘one-way’ provision of caring, from therapists to clients. Attaching is more basic than momentary inter-actions that are perceptually observable between two persons. Gaining rapport does not necessitate postural matching or a close attention to non-verbal communication because attachment can occur in the absence of these factors. The intentionality model view is that more fundamental types of intentionality form composite types of attachment in love, hate, anger and disappointment. However, therapists need to identify what clients are doing in the heat of the moment, during the dance of attachment in a session. Even though clients are care-seekers and therapists are care-givers, this does not mean that care is received in the sense that it was sent. An intersubjective view of the situation is one that takes into account the reciprocal and mutual influences of each person on the other: There is a blurring between a person’s intentions to communicate, how they effect that communication, and how it is empathised by the other. There is a marked difference between what a person might intend to communicate - and how the other empathises their communication. This might even be to the extent where a therapist explicitly mentions that the series of sessions are coming to an end, as a means of preparing the client for the ending, but the client does not attend the next session because he heard and felt he was being “sacked” and that there were no more sessions on offer.

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Talk, action and belief What the intentionality model brings to understanding intimate experience is that it makes explicit conclusions on the ability to be aware, understand and interpret relationship dynamics. It compares insecure versions to what a secure relationship could be. The way of understanding attachment processes between two persons is that these are composite intentionalities of an affective sort where empathy co-exists with perception of the non-verbal state of others plus the conceptual intentionality of speech, involuntary memory and additions of sense and anticipation. These intentionalities co-occur in a complex manner where each part can influence the others. Anticipation can be the product of retained and automatically added senses of past significant others and create the sense of selfin-relationship to the other in the moment. The next section focuses on the sense of the other. What should be born in mind throughout is that the senses of self and other are co-constitutive. In order to understand attachment, personally and professionally, it is necessary to be clear that the senses of self and other are at the heart of changes in dynamics. Understanding the objects of attention, self and other, is a priority.

Defining empathy This section is not going to explain the precise detail of how empathy exists. For a fuller account see Owen (2006c). In overview, the conclusion is that the visual perception of people’s bodies, plus past learning and empathic anticipation about people, and assumptions about the current social context, create public participation in meaning through the passive intentionality of empathy. It is passive because most often the outcome is immediate understanding that seems to have no connection with any rationalising process of the ego. A short definition of empathy is provided and what will be explained are the consequences of this understanding for attachment, everyday life, psychology and practice. In brief, empathy is a complex involuntary process that creates the feltsense of the perspective and experiences of other people. On the one hand, the perspective and experiences of other people never appear as they have them. On the other, intersubjective (social, interpersonal) understanding and the shared life is enabled through gaining the impression (to varying degrees of accuracy) that we do know what other people are talking about and experiencing. This ability to get a grasp of the perspectives of others is learned through ordinary experience beginning in childhood. This learning is on-going throughout life. The experiences of other people only ever appear through empathy. So although the joys and the pains of other people are never available to any other person first-hand; the understanding of what others experience is communicable and becomes shared through empathy and discussion. This definition of empathy overlaps with the position of theory of mind (Premack and Woodruff, 1978). 40

Ian Rory Owen PhD To take this insight a step further is to realise that a person and their view of an idea or a thing cannot be understood through perception by itself. It is argued that psychological meanings are part of an irreducible whole of a specific sort of understanding that is so ubiquitous that it frequently gets over-looked and fails to appear as an explicit topic. The technical term for this type of connection between perception and empathy is presentiation. There are several types of presentiation such as imagining something creatively, anticipating a specific occurrence in the future, remembering something, and looking at a canvas and understanding that the painter is communicating what he or she saw or imagined. When it comes to people, similarly to visual art, the beholder does psychological work in addition to visual perception. Empathy (strictly coempathic presentiation) is the intentionality that creates the lived sense of another person and their perspective, on the publicly available meanings of cultural objects. The word “presentiation” is a term that notes the type of givenness of a sense that is not perceptually appearing but is given as an association, a learned sense. The prefix “co-” could be inserted before “empathy” to emphasise the co-occurrence of sense-making between two or more people. Because people make sense of each other simultaneously, empathy should really be called “co-empathy”. However, that word will not be used in what follows. What is of interest is the total effect of the psychological meanings produced. Indeed, psychological meanings are co-extensive with empathy. It is empathy that provides the ‘hologrammatic’ experiences of what others’ might experience. The social world is comprised of the totality of over-lapping senses of what others’ are empathised to experience. What are provided by empathy are strong or weak senses of what is present for others. Metaphorically, it is the creation of a hologram of their view of the world. Empathy is the creation of holograms of a view of the other’s whole from a small portion of their speech and non-verbal expression. The consequence is that the view of any self is inter-twined with the view of others in such a way that even the tiniest hints and mentions of what others experience, for the most part, make instantaneous sense for listeners. When listening carefully, and attending closely to how people speak, what is understood is far in excess of the manner of speech and the logical content of what is said. Empathy is being momentarily and subtly transported out of oneself - and into the perspective, selfexperiences and view of the world of others.

Husserl’s account of empathy Husserl argued that the end-product of the quasi-experience of the other person’s view occurs through over-lapping of senses of different sorts, to create the general social learning that, it is possible to feel, imagine or guess with some accuracy how other people feel, what they intend to do and how they will behave (1950/1977a, 41

Talk, action and belief §52, p 114). Husserl argued that the first donation of sense is to see the other human being (no matter what their actual age, race, gender or bodiliness) to be another living body: This is claimed to be achieved through an association of one’s own living bodiliness with the look of the other person’s body. This is a pervasive learned occurrence due to previous social experience. What this means is that intentionality and psychological being are temporally and intersubjectively distributed. The ability to understand the meanings of another human being, and their senses of cultural objects, is oriented and distributed across time, space and person: It is the orientation and distribution that makes meaning part of social experience. When there is faulty learning and generalised donation of different senses from the past that do not apply to the present, there is mis-empathy: inaccurate or even highly inaccurate understanding of others. This can happen to the extent that the true intentions of others do not appear, even when that other person explains in detail and in truth what their genuine intentions are. How empathy works is that through previous social leaning, we know what other people mean because we can recall some similar experience ourselves. Or we could also imagine what their experience might feel like. Or we can intellectually think it through. What is publicly available about people is the external look of their body and the sound and meaning of their speech. Other persons non-verbally show interest in the same shared world as self: their body is expressive in sound, physical gesture, breathing and movement. The current expressions of these signs get coupled with the previous store of experiences concerning what it has been like to know other people, from the cradle onwards, to create the overall stock of experiences – knowing other peoples’ perspectives - and the general past experiences of having shared meaning with them. Sometimes empathy is called “intuition” because it is so immediate and its results appear without apparent effort, involuntarily. There are a number of forms of empathy in connection with other intentionalities, for instance, anticipation, imagination and the intellect can work together to enhance the accuracy of understanding made. The end-product of understanding others, and oneself in relation to them, can be expressed through verbal reasoning in internal dialogue or be a response to remembering or other experiences such as watching film or reading text. Let us take the situation that the other person is talking about some experience that they have personally had. The referent of their speech is their experiences with another person, say, if they have been on holiday and had a great time. What appears through empathy is their referent of the great time they had. Even with the best descriptions, it is impossible that the referent has been understood entirely as the other person experienced it. However, the effect of empathy, as a reading of signs and a genre of meaning, is the overall effect concerning what it is like to have the experience that other people describe. 42

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The consequences of empathy Empathy gives the perspectives of others “second-hand”. What exists secondhand is the whole of the possible and impossible contents of the shared world as experienced and discussed with others. Likewise, self-disclosure enables others to empathise self in more detail and accuracy. What is believed and disbelieved is what exists for those, who experience first-hand or second-hand for themselves. Therefore, the consequences of the ability to be empathic (or to fail regularly in empathic accuracy) are enormous. Empathy makes social life happen. If there was no empathy, there would be solipsism and random inter-actions between logically connected but psychologically disconnected persons. It is also possible that mis-empathy occurs when the impressions in thought, feeling, belief and the empathised image of the other and their intentions remain inaccurate even in the face of professed evidence to the contrary. More will be made of this later. Empathy enables the sharing of sense, despite the fact that other people always remain separate other persons. By juxtaposition with one’s own experiences do others become understandable. Consequently, social learning is creating an internal map of the social world. A map of retained experiences of the nonverbal basis of human behaviour exists in connection to how people speak and express themselves. This store of meanings and senses is so profound and allencompassing that it creates a pressure of anticipation about any current other person. The anticipation one has of the immediately next moment, or next thing that persons will say, can have a particular flavour of expecting that a person is likely to do one thing and not another. This is what it means to know another human being: it means knowing how he or she is likely to behave and feel. It would be unusual for persons to move discreetly between two or three styles of relating and expressing themselves, but it is possible. It happens when they were joking, lying or had suddenly begun acting in a specific role. Other possibilities for people not acting include if they were highly incongruous because they were dissociating or masking how they felt in a disorganised way, or that their social learning was such that it was a personal rule for them not to express what they felt. One major consequence of empathy is that it influences how a person relates to the psychological world because empathy creates understanding for action. Prior beliefs and understanding come into play in grasping meaning, found through auditory and visual objects, so creating an empathised sense. But psychological processes have no one-to-one correspondence to what appears visually and auditorially, about the past, present or future. In summary, only clients can tell how well therapists have empathised them (given that clients speak the truth about how they feel when asked). The communication of empathic sense back to clients requires speech and discussion to make sure that others are being understood accurately. 43

Talk, action and belief Empathy provides higher forms of psychological meaning and interpretation also because it is the basis of all teaching, learning and comprehension. For others, the logical content of what another says, their sense of what is being discussed, connects with their sense of ourselves. There are very many contexts of sense that can be supplied to understand speech. Some of the communication is about trying to establish the right frame for understanding the logical content of what is said. The next section briefly defines the tem intersubjectivity that refers to all types of sharing and connection between two or more people.

Intersubjectivity is the social condition for knowledge and understanding What is intersubjective is literally between subjects. Intersubjectivity is synonymous with “social” and “interpersonal” and refers to the shared, mutual and reciprocal aspects of human existence. With this view, it becomes possible to understand attachment phenomena. A detour around empathy and intersubjectivity is required before defining attachment phenomena in relation to personal and professional life. Intersubjectivity is the result of empathically sharing the views of others whether that is in complete co-operation and agreement, or be it in dispute and conflict. Meaning, values and lifestyles are intersubjective. They get shared and passed round. Psychological senses of what it feels like to be happy or sad, young or old, to enjoy friendship or to be weighed down by it, all necessitate the accurate transmission of views between persons. The original meaning of intersubjectivity belongs to the school of philosophy that followed Immanuel Kant (1781/1993) called “transcendental philosophy,” that identifies the conditions for something to be possible. Thinking in this way is identifying the enabling conditions that permit something to happen. Intersubjectivity was pursued by Edmund Husserl as an attempt to name the conditions for knowledge and understanding to be social. Intersubjectivity is literally what lies between subjects in the sense that selves and others are necessary for there to be a shared world of commonsense. Intersubjectivity refers to the constituent parts of verbal and non-verbal social acts of communication, social learning across the lifespan, the accumulation of past traditions of academic disciplines, the means of passing on knowledge, plus the meaning of people and contexts in time and space that are interpreted and empathised. Each part builds the sum total of the achievement of knowledge. Husserl’s contribution was to focus on the way that the motivating similarity between the human bodies of selves and others (1950/1977a, §50, p 111) is one contributory factor in empathising others as being united perceivers and thinkers just like selves (1952/1989, §62, pp. 297-8).

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In passing, the sense of the other is being aware through empathising the perspectives of others and through intersubjectivity: how selves are irreducibly inter-related with others – something that will be explained in progressive stages. The detail of this position will become clearer in chapters 5 to 7. Human relations cannot be neutral. It is impossible to be a blank screen and not contribute to the relationship. Human relations cannot be meaningless. Through awareness and interpretation, it is possible to grasp how one is aware and how that has come to pass in terms of intentionality – sense – object and context.

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It is possible to empathise and carefully consider the thoughts and feelings that arise about how others might be or how they understand self. Sometimes this can only be done in a vague way and the conclusions gained might be inaccurate, or even completely wrong, if they are not discussed with the others in question. Otherwise, through the basic human ability to reflect and make sense psychologically, it is possible to separate transient inaccurate thoughts and feelings from more accurate considerations.

With the introductions above in place, it is now possible to turn to attachment.

Introducing attachment The reader of A Secure Base will be forgiven for not finding the details of the “working models” of attachment relationships, because it is by suggestion rather than definition that the term has meaning (Bowlby, 1988). Working models are the internalised images of how other people will provide care or not and are parallel with empathising and mis-empathising. In A Secure Base, there is no statement concerning what is assumed in the stance taken towards attachment experiences, in order to distinguish what is relevant and what is not, to understand them. When it comes to using these ideas in sessions, the necessity to know how to make sense of what is happening predominates. It needs to be tempered with some hesitancy and the possibility of being mistaken though. And there is a need for clear understanding. For instance, specific occurrences need to be interpreted in order to know what to say and how to act in a responsive manner. What secure relating in therapeutic practice feels like is that both parties feel safe and relaxed overall, despite one of them needing to speak the truth and self-disclose in order to get help. The positive legacy of John Bowlby is that he empirically investigated the “glue” that binds people together. Sometimes the metaphorical glue of attachment, being in a positively-valued psychologically-intimate relationship with another person, 45

Talk, action and belief is stretched past breaking-point. When the glue is broken, it cannot re-combine the people involved. At other times, the glue can re-combine them as in the case of forgiveness where people re-connect. Bowlby began the investigation of the ties that can hold together the child-parent relationship, through researching what happens when that relationship is weakened for a variety of reasons. For therapy, because clients self-disclose about problematic aspects of their life, it is they who are most usually the insecure contributor to the relationship overall. If there is a problematic contribution from therapists, it is most likely that they get incorrect impressions of how clients understand the help they are getting. Despite the volumes of findings produced on specific facets of attachment, there is still no over-arching theory that brings all the pieces together. The need is to have a theory that is simple, memorable and shines light on key events with clients. Theory should be able to promote exploration of their material and understand how people think, feel and relate in the way they do. But the stances that predominate in attachment research are those that prefer the viewpoint of natural psychological science: A view that emphasises the role of biological and material aspects. The view of attachment that is right for practice and understanding relating is one that can understand and grasp a wide range of experiential possibilities. In an experiential vein, attachment is love and its upsets. Attachment is a means of understanding intimate two-person relationships where love, its disappointments, dangers and frustrations are investigated empirically at different stages in the lifespan. Attachment is intersubjective in that both parties contribute to the overall relation. By making connection with attachment, what is begun is a future project for understanding emotions and intimate relationships. Let us consider some key parameters in this assertion. Firstly, secure attachment holds within it some answers concerning accurate beliefs and understandings about nonthreatening social environments. What is remarkable about secure attachment is that gregariousness is self-rewarding. In the secure process, consistently good outcomes are achieved with others and satisfaction is gained for self and others. In terms of the value of others, and the ‘investment’ in other people, once good enough senses of self and other are established they continue. The next section provides findings concerning empirical research about how parents and children attach, and hence how two people experience each other. Attachment acts as a basis for how they believe, think, relate and generally act toward each other (Owen, 2006a). What this means is that human relations are congruent with the interpretation of self, and empathy about the view of any individual, where both persons are parts of a much larger complex whole. This larger whole includes thinking and feeling on behalf of others, whilst comparing their reactions (both merely possible and actual) to one’s own.

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The strange situation Attachment in all its forms shares some commonalities with affairs of the heart that can be seen through the strange situation experiment where the behaviour and distress of infants falls into four discrete types that can be understood in relation to each other. The strange situation is ‘a play in eight acts’ (Solomon and George, 1999). (1) Parent and child are introduced to the laboratory setting with a hidden video camera, and (2), they are allowed to settle and the infant is allowed to explore the room. (3) A stranger enters the room and initiates play with the infant. Then (4), the parent leaves the room and the infant remains with the stranger for three minutes. (5) The parent then returns and there is a first reunion while the stranger leaves. (6) But the parent leaves again for another three minutes leaving the infant alone. (7) Then the stranger returns for three minutes. And finally, (8) the parent returns for the second time, and finally the stranger leaves, bringing the experiment to an end. Instead of there being an infinite array of responses, the behaviour of infants falls into four fairly discrete forms of response. The avoidant response is where the infant explores the room and shows a small amount of distress on separation. But on reunion, the response is to look away from the parent and avoid physical proximity and touch, preferring to keep at a distance and stay focussed on toys that are in the room. The ambivalent response is that merely on entering the room, passivity and distress can be evident and the child does not explore. On separation, the child is distressed and agitated but when the parent returns, there are attempts at gaining physical contact or great distress and anger, or angry rejection or passivity. When the parent attempts to soothe the child, the attempts fail and the expression of distress remains. The third response is the secure one where the child explores the room but when the parent leaves, the child is concerned on the first absence and more concerned on the second. But when the parent returns there is an active greeting and smiling towards the parent with speech and gesture. If there is distress, this is expressed and physical contact and help are requested. When the parent provides soothing, the child’s distress stops and the child returns to exploring and playing with the toys in the room. The key point is that the secure child seeks consolation, accepts it when it is offered and it works: Care and concern from the adult (or care-giver) lead to soothing for the child (or care-seeker). There is a fourth classification which is rarer than the other three and is mentioned for the sake of completion: that is the disorganised or disoriented response. Throughout the eight stages of the experiment, the behaviour of the child lacks any discernable pattern and appears chaotic and motiveless. The behaviours and sequences of behaviour begun are contradictory, even simultaneously incongruent and unsustained across these small portions of time. Despite there being some 47

Talk, action and belief presence of the three other major forms of response, the relationship to the parent is unformed and incoherent and shows freezing, fear, confusion, trepidation and disorientation. The point of understanding attachment processes in two-person relationships is that the same fundamental processes for children are evident across different types of important intimate relationships and across cultures. What happens through parenting and early socialisation is that past social learning creates beliefs that create expectations concerning how self and others relate. The specific relation is a complex one of being able to anticipate how people are currently, in relation to how past other persons have been. This way of understanding intimate and psychologically important relationships is more all-embracing and empirical than the claim that the relationship with the major carer, usually the birth mother, is highly influential. It took John Bowlby, Mary Ainsworth and a host of other workers to explore what is constantly significant in caring and loving intimacy.

Dynamic thinking about attachment Despite the identification of the four styles of attachment, there has been a tendency to think of them as fixed. And without the fine experiential detail of the styles, it is impossible to use empirical findings to practice in therapy sessions. Terms such as “personality” and “ego” also tend to freeze a dynamic process and place a wrong attention on a moment in the responses of an individual, rather than understanding persons-in-relationship. This dynamic view will become clearer as chapters 5 to 7 progress. Let us start with some basic definitions of what it is to be in attachment with another. Some persons react ‘involuntarily’ in one way to adult attachment situations because of the force of how they feel, whilst others have choice about how to respond. The starting point for understanding attachment in therapy is to explain how one person can have many possible reactions in different situations. The problems of attaching with another are incorrectly understood if only one person in the pair is considered, or if one moment in a sequence of action is considered alone. The problems of attaching (as children, adolescents or elderly adults) have a similar shape. The major problems of attaching are role reversal, hyper-vigilance, inhibition, aggression, absence of attachment and exceptionally weak and emotionally shallow contact with others. These processes are only capable of being understood from the start to the finish of their order of play. Yet there are many more idiosyncratic types of attachment phenomena. What are significant about attachment are empathised changes in the degree of attachment, and the position of other and self in relationship. This dynamic account seeks to acknowledge attachment as responsive and not fixed.

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Ian Rory Owen PhD One form of the presence of the past in its influence on current relationships is denoted by the use of the term “preoccupied”. In the fine detail of the matter, it is possible to be preoccupied (dependent or needy) in at least three ways: Preoccupied and angry, preoccupied and socially anxious (“little paranoia”), and, preoccupied with a lost other person (through death, divorce or other broken relationship, psychological absence or distance from an attachment figure through dismissal, depression, or the other being emotionally unavailable through other means). These predisposing events at any point in the lifespan lead to adults who are predisposed to social anxiety, worry, low self-esteem, anxiety and depression in later life. The future of relationships for these cases is uncertain. From the first-person perspective: it is unclear whether it is better to cut one’s losses now, to prevent further distress, or whether it is better to try and make the relationship work by giving it further attention. Preoccupation and dependence concern the need to cling to someone. It can occur if the person feels they are about to be disconnected. Some people cling even though their actual attachment looks secure to third parties. Dependent personality disorder is an extreme version of preoccupation that concerns clinging in what appears to others to be childish and demanding ways, in which the responsibility for looking after self is abdicated in favour of manipulating them to make decisions and supply care and assistance in basic living. To conclude: What is being argued against is the static understanding of attachment theory - that when under stress people occupy a single position. The static understanding is occupying a single form of relating and interpreting others and self, in order to defend self against something that happened previously, that is anticipated to possibly be happening again. The way to read the map is that the two dimensions of figure 2 really need to show in-session movements in advance that represent the actual processes of attaching. The problem is that two persons are involved and it is too easy to reify attachment to become a static version of personality or egoic style. This is not the case even for people who are strongly paranoid. Even paranoid persons can hold down complex people-oriented jobs, be parents and remain with partners. Their paranoia is an over-used form of understanding and relating, not a wholly fixed ubiquitous position.

The map of attachment Attachment phenomena vary each in its own regular way. There is a connection between good understanding that leads to good practice and is accurately directed towards the phenomena of mood, self-esteem, anxiety and choice. Therefore, in addition to the map of figure 2, a dynamic reading of attachment theory is called into play to develop understanding of the connection between self and other.

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Talk, action and belief (0, 1)

(0.5, 1)

Paranoid, high avoidance

Dismissing, controlling

(0, 0)

(0.5, 0) Ambivalent, high anxiety

Fearfulwithdrawn

(0.5, -1)

(0, -1)

Preoccupied, ambivalent

Schizoid, avoidant

(1, 1) Aloof, controlling

(1, 0) Secure, co-operative

(1, -1) Preoccupied & attached

Figure 2 - The map of the world of attachment between two persons. Figure 2 sums up empirical findings by Helen Stein (et al, 2002) and Kelly Brennan (et al, 2002); whilst re-presenting them with a number of theoretical necessities to explain the most salient aspects of attachment (Owen, 2006a). Figure 2 re-presents the findings of Helen Stein and colleagues (2002) in a way that underlines the degree of attachment achieved and distinguishes a dominant mode of relating from a submissive one, with respect to the amount of attachment achieved. The basic grid described in figure 2 indicates how selves empathise others and apperceive themselves. The purpose of the figure is to create a map of attachment in general. Attachment between children and parents, and between adults, can be mapped along the dimensions of the degree of attachment and how people cope with the 50

Ian Rory Owen PhD degree of attachment achieved. Taking the horizontal axis first, on the left hand edge, there is, ideally and theoretically, no involvement with others. This in itself might be a defensive manoeuvre. The middle amount of attachment ideally states a position where others are half-trustworthy and can be tolerated to a degree. The centre point of the right-hand edge is an ideal area where others are empathised as non-threatening. Yet the horizontal areas above and below the midpoint, explain how people are dealt with in different ways. The left hand side of the figure represents fear and avoidance. It means that relationships and intimacy are avoided whenever possible. There are three distinct ways of avoiding contact. These are a dominant aggressive stance at the top, or a submissive one at the bottom, and a neutral one in the middle. The top side of the figure represents the various forms of dismissing that are due to paranoia and dominance. Possibly anger and sadness might be due to insufficient care-giving being provided. They share a dominant and controlling approach to others. The bottom side of the figure, preoccupied, refers to those who cling on to others even if they may be abusive, unresponsive and unable to connect. Being excessively focused on the past means that current and future relationships may be unsatisfactory or feared to be so. The bottom side is a submissive, appeasing and clinging approach to others. The mid-point of the right hand side of the figure represents secure attachment. For security, mishaps and problems occur but they are capable of being over-come. The top point of the right-hand side is a dominant position whilst the bottom one is submissive. The ultimate aim of the figure is to plot movements in two dimensions of a dance of care-asking and care-giving between client and therapist. The therapist should stay inside the co-operative and secure area, to the right-hand side, in providing care. Conditions for security include clarity of roles, attending to motivation and structured co-working. What the therapist role is about is enabling clients to enter into a secure relationship with the therapist, despite the beliefs, influences and assumptions that clients have that tend to take them away from secure relationships and towards social dis-affiliation and either dominance or submission. Firstly, moving across the top of the ideal of figure 2: (0, 1) A self who is currently occupying a paranoid position often values self as good but feels under attack from others. In the view of others, the paranoid person is not being attacked, but he or she withdraws to protect self from attack. To be paranoid is to be a dominant and withdrawn self who will attack, fear intimacy and so withdraw to protect self from attack because they are convinced that an attack is imminent. (0.5, 1) A self who is temporarily controlling and dismissing has high selfesteem with respect to what they are enforcing and so dismisses others through 51

Talk, action and belief feeling justified in providing this treatment. A controlling and dismissing self who is half-attached and often controlling, can make compromises in some ways. (1, 1) The person hides their ability to take control and dominate, and has high self-esteem and socialises. In intimate or work relationships, he or she takes control. The person dominates and has high self-esteem and attaches yet needs to control others. The person who occupies this ‘one up’ position can be intimate in some ways and maintain psychological contact. When this tendency is extreme, the personality disorders of the obsessive compulsive, anankastic and anti-social sorts occupy this area. The anankastic personality is excessively orderly and dutiful and may misuse their precision and conscientiousness if they also employ a dominant mode of relating. Moving through the middle of figure 2. (0, 0) The fully withdrawn place is where people are permanently nonattaching and stay alone like hermits. To be alone may not be felt as problematic but as a relief. Like the paranoid and the schizoid positions, people who refuse to attach lack a rich affective life and may lack expressiveness. They are excessively introverted and repressed and prefer to be unattached. (0.5, 0) The ambivalent place is being unsure about self and others. It is a place of both desiring the company of others and fearing it also. The type of relating is approach then recoil. The ambivalent place is the area of borderline movement. There can be changes between submission and dominance as well as disaffiliation and affiliation. The borderline movement can be towards others in a clingy way or away from them in rejection, shame or retreat. This pan-anxious type of relating is approach then recoil, followed by approach again, for instance, in being alone and fearing that no new partner can be found. (1, 0) The secure gregarious place is liking others and accurately appraising self. It is co-operative and needs no defences because there is nothing to fear, avoid or control. The gregarious place is the pro-social area of the therapeutic stance of being extrovert, confident, co-operative and agreeable with others. The benefit of prolonged social contact is that accurate learning occurs. The learning is understanding emotionally and being able to judge situations accurately in order to keep anxiety low and promote co-operative, friendly relations that are secure and capable of over-coming the inevitable problems that arise along the way. Finally, moving across the bottom of figure 2: (0, -1) The withdrawn and submissive position is one of low self-esteem and staying alone. The schizoid withdrawn and submissive position is one of preferring isolation and avoiding feeling bad about self in relation to others because it is expected that anxiety would occur. (0.5, -1) The preoccupied place may include low self-esteem and is one of having some contact with others. This anxious and preoccupied place permits some contact with others but also features withdrawal. 52

Ian Rory Owen PhD (1, -1) The preoccupied and attached place is one where there is low selfesteem and a backward-looking and unassertive way of being with others. This dependent, needy, clingy, preoccupied position asks for reassurance from others but is not reassured. It can become a place that can over-come losses in the past but maintains its preoccupation. It can attach but is needy in relating. What these nine places have in common is that all of them are responses to, and contributions in, the social world where their occupants have senses of themselves and generalised others. When understandings of self and others occur, there are always conscious emotions, even if the remembered object is in a longdistant childhood and the event in question has been remembered many times over. What figure 2 achieves is a basic ideal theoretical construction for explaining two fundamental forces that interact. The usefulness of it is creating a means of representation where actual interpersonal processes, personality styles and tendencies towards interactions between two persons can be placed into a whole so that all positions can be considered against the interaction of two fundamental forces. Let us think about the general tendencies of personality that occupy the ideal space. Introversion is the area on the left hand side of the figure whilst extroversion is the right. The horizontal dimension focuses on the amount of contact that people have. The far left indicates problematic amounts of introversion. The far left of the figure is the space where social skills are poor and the amount of interaction with others is low. If there is a long-standing absence of human contact for decades, and particularly during childhood and adolescence, then this will promote long-term depression, a sense of personal emptiness and restrict the capacity for emotional breadth and depth of experience. The centre of the figure represents neurotic, anxious and hence impulsive qualities because people who are generally anxious tend to avoid or are impaired in their role performance by the anxiety that they feel. Ambivalence means that they are torn in wanting to contact others and achieve their desires for attachment but they find life hard work. Ambivalent neurotic persons are lacking in the ability to use the feedback that life gives them and reduce their anxiety and stay stuck in the ambivalent position. The anxiety they feels impairs their performance and keeps them tied between fearing to advance towards others and fearing to pull away for fear of loss of the connection that they have. Yet both options of advancing and retreating remain the same. Ambivalent persons have two strategies for coping. The top half of the figure represents persons who have a tendency to dominate and so appear dis-agreeable and even antisocial to others. This is particularly pertinent in the top right hand quadrant that represents people who habitually attach but only in a dominant way. Dominant behaviour shows a disregard for the views of others and the assumption that the dominant view is acceptable. 53

Talk, action and belief The bottom half of the figure refers to a submissive style of relating which may correlate with low self-esteem. The secure portion of the diagram is where agreeability, extroversion and low neuroticism co-exist because security of attaching engenders accurate selfesteem and positive social contact. It is not as though people who are secure never have arguments or conflict but when there is negative feedback to be offered and boundaries to be set, they know how to do these things in a co-operative way with the minimum of fuss. The problems of people who are either too dominant or too submissive are that these general styles of relating create problems of negative consequences for self and others. If the manner of relating is fixed in one of these positions throughout the lifespan, then there will be serious consequences in all social contexts. What helps is having clear aims about what to achieve with clients and therapists trusting themselves to be able to help them achieve their aims. Therapists may or may not provide training in how clients can express themselves, but more often directly and indirectly, they help clients find themselves as people and help them reconnoitre where they are and where they want to go. The idea of life being a journey is a good one in that one cannot go forward without proper reflection on where one is and where one wants to go. The journey forward requires mapreading before action.

Summary What is required is a means of occupying a viewpoint ‘outside’ of being wholly enmeshed in the current therapeutic relationship. The viewpoint offered is a means of understanding relationships as a whole, in order to understand specific inter-actions between the two people meeting. What to avoid is having theory that obscures the phenomena. Theory must remain open to detailed inspection. When a theory is accurate, it shows its accuracy in the successful outcomes obtained through its application. However, the ability to apply theory in a human relationship is more difficult than it might appear at first. Anyone with a good memory could learn intellectual rules about how to assess and practice talk and action interventions. But passing a written examination in clinical concepts and practices is pointless. This is because practice is not a logical matter. Being armed with the right concepts that provide adequate fore-warning of the phenomena means that therapists take an initial understanding to the relationship that helps in understanding what clients experience and what is happening between the pair. But this is no guarantee that it is possible to help clients stay away from problems or and dead ends. Being able to identify a mis-understanding, where clients have got angry because of what they have wrongly presumed, for instance, is a social skill 54

Ian Rory Owen PhD which is only helpful when it is enacted in the moment. Although having accurate concepts help, it is no guarantee that even a highly socially-skilled therapist can make a positive outcome. Even when sensitivity and caring are clearly present, there are some clients who cannot take advantage of what is being offered them and do not understand the relationship conditions. Accordingly, having therapy can never have a guarantee of success or the feeling of being cared-for because some people are deficient in their ability to understand. However, therapists who have the right ideas and well-honed automatic skills are more likely to provide help. The phenomenon of empathy is not well understood. Empathy is the name of the phenomena where the experiences, beliefs, intentions, the playfulness or seriousness of others, is immediately caught without any volitional effort. This occurs because psychological meaning is transmitted through the perceptual givenness of speech and the visual appearance of bodiliness. Perceptually, the main contact is auditory and visual. However, what appears is a whole of carefully nuanced quasi-experience of other people, concerning what happened for that other person. What it meant and felt like for them. Empathising others means understanding them by seeing those persons and their perspectives in their world. Empathy is based on what might be current perceptually, but is linked to the past and the future. Mis-empathy is called “transference” and only this term is noted at this point and is dealt with in detail in chapter 6. A number of questions remain unposed about the relationship of the orthodox ideas of transference, counter-transference and the unconscious in attachment and the psychodynamic approach to therapy. Chapter 5 further introduces attachment dynamics in a general way, before presenting details of empirical research in chapter 6. Good and bad practice is discussed in chapter 7.

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5 The inter-relation between self and other Aim: This chapter further considers attachment dynamics in two-person relationships. There is a need to have good descriptions of attachment processes in relation to their objects to recognise and compare attachment styles in the therapeutic relationship and in the work, family and home lives of clients. The aim of this chapter is to capture relationship dynamics, in the language of attachment theory, as they apply to the therapeutic relationship and other psychologically important relationships. The key is understanding that multiple styles of relating can co-exist for the same person and occur sequentially across even small spans of time, such as a 50 minute therapy session. This chapter makes a number of abstract conclusions and propositions about the dynamics of attachment processes. The level of discussion remains purposefully abstract because there is a potentially infinite array of combinations even within two-person relationships that are mapped by the three major amounts of attachment: Avoidant as zero or minimally attached, ambivalent as half attached 57

Talk, action and belief and secure as fully attached. This chapter follows from the last with a focus on experiential and recognisable persons and processes. The comments below are derived from a wide reading of the attachment literature but detailed references are omitted in preference for creating an experiential theory of the major types of dynamics involved between an insecure client and a secure therapist. It is not intersubjective to focus entirely on one participant in a two-person relationship, so time is taken below to explain some of the basics of the dynamics between a habitually insecure relater who is in contact with a secure relater who remains entirely in-role as care-giver. The dynamics described below make reference to close personal relationships in order to make a tangible contrast with the working life of providing care. The details of nine types of attachment phenomena have been identified empirically by Una McCluskey (2005) and these are explained with diagrams as a dance of attachment in the next chapter. This chapter sets the scene to further introduce attachment as a central lived experience in the quality of life of human beings. Attachment is a whole that extends across social contexts and across time. Where the influence of time arises is that negative influences from the past can obscure the current accurate senses of self, others and their inter-relations. The faulty dynamics and tendencies to mis-understand need to be identified, understood and lessened. Definitions of caring as one-way or two-way are mentioned before defining the general dynamics of insecure and secure relating. After careful inquiry into the individual details of what happens in insecure relating, the general finding is that attachment, or the mere possibility of attaching, is understood as threatening, disappointing or a source of fear. On further inquiry into the detail, the following types of meanings can be found. The interpretative stance on self, as shown in internal dialogue, for instance, connects with specific thoughts about self and the emotions felt, and these thoughts and experiences coexist with the attitude taken towards self. The interpretative stance towards other people, as expressed through speech with them, also co-exists in connection with self. If empathic guesses and nightmarish beliefs about the intentions of others are accepted uncritically by self, what happens is that people respond emotionally and relationally, with respect to the evidence of what they feel and anticipate, and that can be based on nothing relevant or accurate. Particularly, when inaccurate thoughts and feelings about others remain unchecked with those persons, then there can be a number of negative reactions including a failure of self-esteem. As a consequence, self-esteem can be thrown on to the bonfire of fearful anticipations, for instance, that others dislike self and are laughing at self, when there is no evidence to support these imaginary experiences. There is a certain amount of changeability in the senses of self and others. The guiding thought is that the initial attitude and understanding taken towards self or other is what generates the feelings and meaning found. If there were no possibility 58

Ian Rory Owen PhD of change and variation, then therapy and maturation would be impossible. In this view of relating, what motivates decision-making towards, long-term and short-term goals, are the interpreted conscious meanings. This appraisal or donation of sense concerns the selection of a portion of evidence and a means of its interpretation (details in chapter 17). By definition, any sense of a person in one specific context is only a partial representation of the whole of that person. In the most general terms, the dynamics of a two-person relationship is where both parties respond to the empathised sense they make of the other, and the sense they make of themselves, in relation to the empathising of the other. Regardless of the personalities and roles of the two people involved, there are many possibilities about what can arise in terms of the communications that can occur between the two. For instance, anxiety can be communicated non-verbally, from one to the other. Fear of self-disclosure about something, may lead to fully or partially hiding it in verbal communications. Wariness about getting psychologically close in one person, can promote wariness in the other. Incoherent and disorganised verbal and non-verbal expressions in one person may or may not be soothed by reassurance and accurate reflections from the other. These types of problems lie between people and are effectively a problem for both persons: Not just the one who is anxious and seeking care, but also for the one who wants to provide it. These are the problems of attachment as they exist professionally and in personal life. Attachment exists professionally in therapy, in terms of providing care to clients who may have great difficulties in feeling sufficiently safe to speak the truth and get sufficiently psychological close to receive help.

Professional and personal aspects of attachment Attachment is the psychology of love, its success, struggles and disappointments. What is at stake is that attachment processes are responsible for the deepest joy and severest distress in intimate relationships. So the topic of attachment must be understood in order to facilitate changes from a poor quality of life, through working with the therapeutic relationship. Attachment covers a large number of pertinent areas for the practice of therapy. The following comparison of the personal and professional aspects of attachment makes it clear how the two are similar and different. Before making this comparison though, some things need to be mentioned as background for the particular descriptive approach made. The scope of attachment phenomena is not just the secure process between parent and infant or between two adults. There are a number of discrete types of insecure attachment processes that may co-exist with the ability to be secure under certain conditions. Like the simple types of intentionality, the processes themselves are unconscious but the end-products of experienced-sense are conscious.

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Talk, action and belief What is highly significant is that there seems to be an in-built understanding of what one’s birthright of security should be, because the cry of distress of infants is expressed in relation to when their needs for secure attachment are not being met. Securely attached infants and adults have distress at times. However, secure persons are more able to be soothed, are self-soothing and capable of asking for soothing and capable of soothing others. Secure care-givers may have never read a book on attachment phenomena but know in their hearts how to look after their infants and loved ones, practically and emotionally. For instance, secure care-givers are able to identify and alter the delivery of care across many contexts of their child’s life. Similarly, the ability to understand, interpret and deliver care can be directed towards others or towards one’s own needs. To cut a long story short, the style of relating in intimate relationships should be secure. Through comparison of the whole set of possibilities, it becomes possible to compare and contrast the composite intentional forms that occur within attachment relationships, personality styles and psychological disorders. However, something becomes fixed for the insecure defensive types of attachment that can become significant aspects of personality because dysfunctional patterns of relating can exist in one or more regions, or become generalised across many contexts and bring misery to self and others. For insecure relating, the general rule of thumb is that intimacy should be avoided because it is necessary to prevent the pain of disappointment from being let down in love, friendship and other types of intimacy. Defences are when people have interpreted their own needs, strengths and weaknesses in inaccurate ways. Accurate means being able to soothe self and others and protect self from real threat; whereas inaccurate means that distress can increase and impair empathic ability, other relationships, role performance, the mood and sense of self. Insecure attachment processes can become part of the personality in the over-defended acontextual forms of relating such as being schizoid, avoidant of love and security, unhappily promiscuous, over-defended or preoccupied and self-obsessed with past injuries to the sense of self that ‘need’ excessive protection from anticipated harm. Therefore, the topic of the defences, and defences that form part of the personality, is met because highly inaccurate mis-empathy and concordant beliefs and behaviours occur despite experiential evidence to the contrary. For the moment, it is noted that expressing liking and approval towards others tends to attract others to self; and expressing criticism and complaint tends to reject others. Likewise, the role of fear concerning the possibilities of disapproval and being rejected may also lead to avoidance of psychological closeness; self-disclosure and spending time with others altogether: Intentionalities of these sorts are the base of being defended against anticipated occurrences. The case of the avoidant position is that intimacy is refused and that may elicit rejection in the other. The case of ambivalence is that attracting 60

Ian Rory Owen PhD and repelling sequences co-exist with dominant and submissive ones. Thus, the ambivalent position elicits ambivalent reactions in those who try to get close.

One-way and two-way caring It is possible to spell out some of the major differences between attachment in the everyday life and the therapeutic relationship. These are noted as being either one-way or two-way care giving. Two-way attachment relationships are those between partners in dating and long-term relationships, in the extended family and between friends. The best way to describe the processes of love and good will in two-way relating, between equal care-givers and care-seekers, is to state that it is like a joint bank account. The metaphor is that the strength and on-going emotional value of a secure process of the two-way sort concerns the contributions and withdrawals from both parties. Security is maintained as long as the account is in credit. One party can draw on the joint account as long as they repay the amount they have taken out at a later date. However, if one party takes too much (for instance, is overly childish, controlling, demanding or needy and sets too many rules) then the joint account is no longer mutual and both become overdrawn at the Bank of Love and Good Will. The metaphor is a way of understanding how twoway care-giving and care-seeking is a mutual and reciprocal affair. For instance in parenting, both partners need to be on-board in a long-term relationship because childcare needs both parties to share the work load. A secure individual can be understood as having a personality and accompanying general senses of self and other, whereby they can be there for partner, friends, relatives and make on-going working relationships that are genuinely co-operative. Secure relationships can recover from arguments and differences of perspective. However, the metaphor of the Bank of Love and Good Will is only a metaphor when it comes to long-term relationships because both parties should be continually paying in to the account. And neither should need to keep account concerning who has paid in how much, because both know that each other pays in, and that both persons only make a small number of withdrawals (mistakes, mis-communications, upsets) in comparison to the mutual capital that they are collecting of love, mutual appreciation and respect. Indeed, the psychodynamics of long-term relationships and long-term friendships concerns the joy of giving that is continually reciprocated, where both persons are able to make the other feel freshly loved and validated on a long-term basis. Therefore, auditing the account (tallying up the giving and taking from mutuality) is unnecessary. Caring and loving are forms of the intentionalities of emotional and practical giving. The pleasure for self is to enjoy the giving to the other and the pleasure it will bring. When conflict happens (as it will) further payments from soothing reserves of patience, forgiveness and negotiation are required - rather than entering pointless 61

Talk, action and belief dominance and submission, attract and repel, dynamics. Both people need to be secure in order to give negative feedback and reach a compromise or agreement as quickly as possible. The other types of attachment relationship are one-way. One-way caregiving occurs in parenting, caring for elderly parents or relatives, mentoring junior colleagues and towards clients. In therapy relationships, the 50 minute meetings are the only point of contact and the provision of care is only from therapists to clients. This is not to say that there is no legitimate pleasure in providing care for clients. For instance, the immediate reward of the role of therapist is seeing clients understand in sessions, where the moment of understanding moves visibly across their faces, as they understand themselves and their situations. The better functioning, better mood and self-esteem of clients is a legitimate source of personal satisfaction for therapists and the reward of having understood clients correctly and been able to translate their emotional understanding into discussion and practical action that guides and facilitates the development of clients on a regular basis. The growth of clients is the primary pleasure of doing the work. The outcome of the therapy relationship, as a secure base, is helping clients replicate security with their partners, friends, family and work colleagues and helping them create other contexts where there can be security of relating in teaching and managing others. Therapy theory goes the further mile and has explicit definitions and beliefs about self and other, and understands the experiential details of how people draw such conclusions from their evidence (part III below). Furthermore, the role of therapist demands being able to identify secure and insecure phenomena, and so maintain the confident ability to place self in a secure position, no matter how strong are the emotions produced in meeting some clients, who may have no idea of the effects they produce in others.

The continuum: Avoidance, ambivalence and security Attachment phenomena need spelling out so that they can be recognised even in the moment of their happening or shortly thereafter, so that therapists can react swiftly to minimise any negative effects. However, because the type of relationship varies and the phenomena themselves vary often very quickly, there can be abrupt changes in relating and in the sense of self and other. What this means is that only the most basic descriptions can be provided. The wording below applies to all combinations of two people in a psychologically meaningful intimate relationship. This could be between parent and child, between lovers, work colleagues or therapist and client. The only case presented is the problematic one between an insecure self and a secure other.

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Ian Rory Owen PhD The guiding idea is that the major difference between avoidant attachment, where the preference is to keep the other at a safe distance, and ambivalent attachment, where there are many anxious attempts to reject and become attached, is one of proportion. All three types of processes can appear in one 50 minute interval as Una McCluskey shows (2005) in her detailed attention to the processes between client and therapist. In order to introduce the dynamics, let us first consider what it is like for semi-permanently appearing qualities of relating that seem to belong to individuals themselves. The following remarks concern what could be called a continuum between avoidant attachment – through ambivalence – to security. Different phenomena occur in moment-to-moment relating. There can be both habitually avoidant and ambivalent persons and avoidant and ambivalent processes between persons. (For the sake of simplicity, any combination is now termed “insecure relating”). The difference being that, on the one hand, processes are the meeting point between two persons, and do not belong wholly to the one or the other, even when there is a strong contribution from one party. But on the other, if a person habitually uses one type of relational style across many contexts and for decades, then that style is part of their personality and is taken to all social contexts and relationships in them. The following remarks are based on the conclusions of Judith Feeney (1999) who rounds up research findings for adults. The case of adult romantic relating is chosen first because it is familiar. The same processes apply for children in relationship to adult carers with certain adjustments.

Avoidance Avoidant persons show themselves through the bottom line of needing to stay distant. Withdrawal brings its own relief and Feeney comments that in adult romantic relationships, lack of passion, lack of commitment, low self-esteem and negative interpretation co-occur. Avoidant persons aim to be self-reliant and put limits on the amount of dependence, affection and intimacy because such processes may bring loss and disruption. Therefore, distance is constant and calming. Feeney concludes that negative intentions are empathised in the senses given to others and that there may be social anxiety, avoidance and lack of self-disclosure. Negative emotion, distress and complaint are suppressed in order to maintain the distant status quo. Overall, avoidant persons and the process of avoidance itself concern highly inaccurate empathising and apperception. Specifically, avoidance is maintaining a distant status quo by not complaining or being concerned by the other’s absence and lack of caring on return. This is a learned behaviour that can include being unconcerned about the distress of others as a way of tending to one’s own needs by creating a safe distance. It means that avoidant persons are alienated 63

Talk, action and belief from their own needs for intimacy, which could become a ‘burying’ of this need. It might at first seem that the avoidant strategy is entirely self-defeating and that it is wrong social learning to avoid and minimise intimacy and meaningful contact. However, the style of relating works by preventing upset. It is a defensive survival for harsh psychological environments. It becomes problematic when it is used in a safe psychological environment though. In dating for instance, avoidant relationships are “on and off ” and the avoidant person appears to others as having a lack of ‘glue’ in terms of being unable or unwilling to bond with their lover due to fear and lack of trust. Whilst the specific reason for the fear, lack of trust and specific behaviours vary, the tendency is to repel others rather that attract and hold them. In therapy, an avoidant sequence of events may start with clients asking for help but the message that comes across in their behaviour overall is ‘do not get close’. But the therapist needs to get sufficiently close in order to find out the details of the problem and supply care. Avoidant responses then may include ‘you have not cared for me’ even though it was they who stopped the process. •

Avoidance is not rejecting a real threat or avoiding someone who cannot be trusted because they are not available to be loved or do not return care after it has been given: That is adaptive behaviour and is not choosing to stop a relationship because it was not working for some bona fide reason.

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A mild case of avoidance is when secure processes can occur except under threat. Then avoidance may happen when the security of the on-going relationship is threatened. There can be impulses to reject, or rejecting feelings and moods, which may or may not be acted on.

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A stronger case of avoidance is that it can happen most of the time for most relationships, not just the most intimate ones.

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Avoidance can be a permanent feature of even the ‘closest relationships’ in the family and even with a partner when it is part of the personality.

Ambivalence Ambivalent persons are those who can become “half-attached” but their anxiety does not dissipate. For instance, if ambivalence is a semi-permanent aspect of personality it shows a number of contradictory facets in adult romantic relationships. Ambivalence is continually contributing discord, anger and hurt to others often without a means of resolving the storms produced because the reactions to the ambivalent person create counter-reactions in those around them. 64

Ian Rory Owen PhD There are contrary tendencies to cling and be dependent on the other - and reject, withdraw and be uninvolved. This co-exists with submissive tendencies and the ability to be preoccupied; and a tendency to dominate, be uncompromising and un-co-operative with others. Submissiveness has the function of aiming for love and attention from the other and making intimacy. If intimacy is not maintained, there could be the threat of rejection and abandonment and that would produce high expressed emotion, anger and distress. The overall tendency is towards anxiety and there can be the separation protest from an attachment figure. But contradictory emotions and behaviours exist such as jealousy, possessiveness, lack of intimacy, lack of passion and lack of commitment. Thus, a tendency to idealise the other co-exists with denigration of the other. The other can be dismissed and there can be a tendency to not know how self feels about contradictory and incoherent emotions and behaviours. What this shows is that multiple views of the sense of the same self and other co-exist. The ambivalent process is more complex than the avoidant one. There can be some accuracy of empathy and apperception. However, whilst an ambivalent person might be able to understand the distress of others and themselves to some degree, there are no actions that are able to decrease the distress they feel, as proven by the tendency to remain in relationship chaos and have on-going anxiety and distress. There may be some awareness of their own needs, but they are likely to be unable to satisfy them. Ambivalence is being torn between a fear of approaching others to make contact with them and a fear that is felt of potential loss and disconnection. The to and fro movements are initiated by the two-fold strategies of approach and withdrawal but once the instability has been brought to other persons it is they who respond ambivalently also. Ambivalence features two strategies and an overall incongruence. When wanting to approach another, the other is seen as positive and valuable – before the fear of closeness and consequent rejection sets in. When wanting to dis-engage the other is seen as negative and self must get away. The two tendencies to do not get accumulated into the one view of the same persons, self and other. In close personal relationships ambivalent relationship behaviour is confusing to others and decreases the ability of others to trust and invest love and caring in the ambivalent person. Accordingly, it is only with the greatest store of patience and the ability to swallow the hurt and confusion caused by an ambivalent other that a relationship with them can continue. There comes a point when the partners of an ambivalent lover, for instance, may decide that they are unable to take any more vacillation and contrary behaviour. In therapy, an ambivalent sequence of interactions will start with ‘care for me’ from the client, but then there will be a series of messages of the sort ‘that is insufficient,’ ‘that is wrong,’ ‘go away,’ ‘do what I want,’ ‘care for me,’ ‘do you not care for me?’ that may confuse even the most understanding and patient professional 65

Talk, action and belief helper. For the ambivalent client, there is negative mis-empathy where wrong intentions are attributed to the therapist with dominant (rejecting, dismissing) and submissive (clinging, dependent) contributions also. The view of the therapist may be that ambivalent clients appear preoccupied through the influence of past relationships and appear angry, sad and tense. •

Ambivalence features multiple strategies of approach and avoidance and could occur for secure persons when they are torn between different aspects and disparate behaviours of the same other person.

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Mild ambivalence can exist short-term in impulsive feelings and moods of desire for intimacy, alternating with withdrawal, submission and dominance towards the other.

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A stronger form of ambivalence can occur in most of a person’s relationships including the most intimate ones.

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Ambivalence can be chronic and on-going throughout the lifespan and be pervasive to all relationships and contexts if it is part of the personality.

Both avoidance and ambivalence share some of the same insecure relating phenomena and both features can be present in one person who can participate to some degree in secure relationships. The insecure phenomena occur at times of stress, or on the creation of new important relationships. Insecure phenomena can occur when getting psychologically close to another. If the distress felt and the thoughts made at that time are taken to be accurate representations of the intentions of others and the nature of the relationship, then it is likely that the experience of distress will be enacted and form the basis for attack or withdrawal or some other increase in insecurity.

Security Secure process is the ability to create secure attachment with others. If security is a personal tendency over decades and in many contexts, it is part of the personality. In childhood when people have felt deeply loved, cared for and valued by their mothers, for instance, (if that was the case) such an experience can be highly formative of the ability to re-create such security in many types of intimate relationship as an adult, in such a way that acts as a basis for the growth and exploration of the world by loved ones and self. The extent of confidence and trust in self and others means that there is security again on return. For the securely cared for, or loved other, and for the secure self, there is a store of positive 66

Ian Rory Owen PhD experiences that are capable of being re-created. Let us consider the secure process for secure persons in adult romantic relationships as an example. The key features of the personality of a secure relater are that they can provide and imbue in others an on-going sense of safety, love and self-acceptance. Security in romance features intimacy, involvement, trust, satisfaction with the quality of the relationship, co-operation, self-disclosure, problem-solving, compromise and mutual support. This type of commitment is on-goingly renewed and features low anxiety and provides positive self-esteem to both parties. There is a general tendency to have positive experiences and interpret experiences positively as well. A key feature of the secure process is that when problems and conflict arise, the relationship is self-correcting and that forgiveness, negotiation and compromise occur, and security is on-going into the future. Accordingly, relationships generally are positively-valued and there is the ability to discuss their dynamics. There is mutuality of respect and when distress arises, it is acknowledged and dealt with through social means that attenuate it and both parties are mutually-soothing. The conclusion is that accurate empathy and apperception exist for both parties in a secure process or between secure personalities. Secure persons provide care to others when they are distressed. They can receive care when they themselves are distressed. They are also able to understand and express their own needs to the other. •

Security is strongest when, as part of the personality, it occurs with loved ones, friends and colleagues and continues to exist even in the most adverse conditions.

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Less prevalent but good quality security can be a feature of most of a person’s relationships, except in adverse conditions.

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Less secure still is when there can be vulnerability and limitations to security that operate across one or more relationships or social contexts. For instance, security is maintained with a partner only, but not with friends.

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Finally, there can be an absence of secure process at all times, even with the most secure other persons and in the most secure of loving and caring contexts.

The general hypothesis is that security is a social learning that both self and the other are felt as safe through the intimacy of care and love. When negative emotions arise they are tolerable, capable of awareness and the expression of distress is acceptable to others (and self). When the secure self is distressed, it still feels itself worthy of attention and has no fear that its needs will not be attended to by the others. 67

Talk, action and belief

Overview of general insecure attachment dynamics In this section, the three major aspects covered are belief, apperception (selfunderstanding) and the empathised sense of the other. These items are linked in that beliefs are interpreted about the visual and auditory presence of the actual other person, in how they express themselves. Similarly, the apperceived sense of self and the empathised sense of the other inter-act in the moment to moment unfolding of a relationship. The topics of interpreting belief are the focus of attention in parts III and IV of this work. All that will be noted about beliefs at this point is that they represent the cumulative sense made of a region of experience. Beliefs can be accurate, explicit linguistic expressions of the sort “I believe that ...”. Or be expressed through emotion, action or relating about a region of experience (they can be accurate or inaccurate). So to summarise the initial standpoint, on the one hand, the thoughts, emotions and intentions of a secure other are the consciousness of that other person that is expressed to some degree through verbal and non-verbal communication. On the other, the insecure self struggles in getting close and attached, in a psychologically meaningful way, to a secure other person. Let us start with assuming belief as causative. Beliefs come from the past, especially traumatic experiences, and generally have the positive function of defending self from harm yet they have negative consequences. Defensive beliefs prevent intimacy, fend off relationships and so prevent the social learning and direct experience that intimacy has a positive value and is psychological good health. Secure relating is relaxed. There is no need to defend self because there are no threats. On the other hand, ambivalence and avoidance can create worry, for instance, that creates vigilance and experiences of low self-esteem that demand defensive actions to ward off anticipated, highly negative consequences. Fixed beliefs for insecure relaters may include the false belief of allocating excessive amounts of responsibility to self. But mainly, entirely because negative beliefs are born of the negative past but still operative in the present, they are by definition almost always inaccurate concerning the actual intentions of a secure other person. How the secure other usually appears is that the insecure relater jumps to wrong conclusions about themselves and the secure other. The most common understanding gained is that the current relationship is just about to go wrong (be insufficient, abusive, or “I am insufficient in relation to the perfect other,” etcetera etcetera). Or, the insecure relater mis-empathises that the relationship has just gone wrong from their perspective. These beliefs can persist even when the secure relater explains their feelings, thoughts and intentions. When proper evidence is provided that should modify the negative inaccurate belief that has been presented, it can be dismissed. There is also the case where inaccurate or 68

Ian Rory Owen PhD downright false beliefs are used to interpret self, and empathise and wholly misunderstand the current situation. The experiences of an insecure self, even in the presence of an expressive secure other, can be emotionally flat and empty or be high anxiety and non-specific ‘closeness anxiety’ about self or other. What is felt by the insecure relater can be highly inaccurate with respect to the experiences of the secure other. So, from the base of insecure beliefs of either avoidance, ambivalence or other complex mixed sorts – what needs to be noted is that an insecure relater can be highly inaccurately focused on self – or the other – or both. For the sake of simplicity of explanation, let us focus on the interpretive attitude towards self first. Although it is never in doubt that non-verbal emotion and verbalised thought co-occur about the same person. It can be possible to feel one way about someone that is different to how one thinks about the relationship with them and what should happen to make it better.

The insecure view of self What insecure relaters share is low self-esteem (but it can co-exist with momentary high self-esteem). The consequences of insecure relating are negative for self and other. The commonalities are that the insecure relater can be incongruous in their verbal expressiveness of their genuine non-verbal state. Because a large number of positive care-eliciting verbal and non-verbal messages can be sent from the insecure relater, all of which are meant in the moment, and because the fear of psychological intimacy is strong, the relationship can be pre-emptively broken off in the absence of any observable evidence for a third party, to support the action. The reason why the relationship is ended is because beliefs drive worries and produce negative emotional states that act as evidence. So the intentionalities of worry, pre-emptive rejection, and an anticipatory sense of hopelessness, can exist with numerous negative experiences that constitute beliefs about the past, the worth of self and the desirability of secure relating, that still effect the present. For insecure relaters, there can be fast changes that characterise ambivalence from love to hate, attraction to rejection, anger to guilt. The incongruity and disorganised expression can be simultaneous. For example, insecure relaters may refuse to admit that they are hurt. Or the incongruity can be sequential in jumping between two or more radically different stances in quick succession. Changes from being closed off and wanting to retreat from a secure other, to pre-emptive aggression and rejection of the secure other can happen, in order to prevent anticipated hurt and disappointment. This contrary behaviour can happen, for instance, in the absence of any actual attack or threat from others, apart from them just being psychologically close, open and available for support. The nonverbal incongruence of expression can hide emotions of fear or emptiness that are 69

Talk, action and belief not expressed verbally or non-verbally. What is expressed instead can be a bright cheerful demeanour and a chatty verbal style that gives no hint about what is actually felt.

The insecure view of the other In this overview, the co-occurrence of highly inaccurate empathising of the sense with an actually calm, non-threatening, explicitly caring other is the final piece of the whole. Despite the verbal and non-verbal communication of the secure person who states their intentions clearly and is calm and relaxed in the interaction, what insecure relaters empathise is something entirely different. Because of the general tendency to empathise the secure other as untrustworthy, uncaring and failing to provide even the most basic ability to listen and be present, the immediate felt-sense of the secure other is a further reason to withdraw, stop the relationship, cling or otherwise control, denigrate or attack the secure person in a paranoid fashion. Finally, the outcome for the secure carer (be it partner, therapist or parent) is a sense of confusion, injury, unprovoked attack, entanglement and resistance when trying to provide care to someone who has many positive qualities, strengths and intelligence. What happens for the secure other is a sense of getting nothing back from the efforts to reassure and care for the insecure person. Any withdrawal of the secure other to think through the hurt given them can be mis-understood as rejection or indifference, for instance. There is also a lack of reward from simply being together and enjoying the here and now inter-action, whatever the roles and identities of the two people involved. In short, the insecure relater wholly mis-empathises the person and intentions of the secure other, despite evident expressions of their genuine intentions.

The future of the relationship This section recaps the dynamics of relationships in a general sense, in order to think about how the immediate future and worth of the relationship is empathised in order to further understand the type of emotional reasoning that is happening. In overview, the continuum of the future is the following. (1) The avoidant process entails a distant stand-off. (2) The ambivalent process entails an untrustworthy uncertainty of being ‘on and off ’ with conflict. (3) The secure process entails a dependable future. Avoidant selves refuse contact with others for fear of entailing ‘unbearable’ experiences. This is the case of non-attachment where after decades of psychological non-contact, a certain type of indifference and restriction are 70

Ian Rory Owen PhD created that may mean that either basic social skills have never been achieved, or those that were attained have atrophied through lack of use. In the case of social skills that have never been attained, if this type of relating is all-pervasive, the terms “schizoid” and “avoidant” personality disorder could be used. But other cases are those persons who remain at a psychological distance and seem passive and indifferent to the distress of others. For them, the future of relationships with others is seen as too much to bear. What is desired is physical or sexual closeness perhaps, but not psychological contact and intimacy. The case of ambivalence is more complex and two types can be identified in terms of the view of the future involved. Overall, ambivalence is the type of relationship that is confusing to other persons around the ambivalent person. Ambivalent relaters are not sure themselves whether they want to stay in a relationship even with a secure other. They create contrary responses in others, in accord with the contrary beliefs and feelings they have. One form of ambivalence is where there are fluctuating senses of self and other. These senses are inaccurate with respect to the actual referent of self and other, as they occur in their social contexts across time. Ambivalence is a middle position where others are valued and sought; but also feared because of their potential to reject and disappoint. The sense of self is positive and negative at different times, empathising the same person both positively and negatively. One type of ambivalence is being attracted to someone, or to some type of relationship with another, but not having sufficient relaxation to meet with them closely because of the fear of negative consequences of emotional investment with them. This is a self-fulfilling anticipation because the hesitancy and reticence in the insecure person brings out a reciprocal response for the other, concerning the distance and apprehension that co-occur. The result in terms of the picture of the future is staying away from others and not having the experience of positive social contact that improves mood and self-esteem that come with ordinary social activities. However, a number of things need to happen, in order to find out if the pair has enough in common to be better friends. What happens is the arousal of interest and a movement towards the other, but for ambivalent persons, fear comes into play that is dealt with through dominance and control, and submission and clinging. A second type of ambivalence is where a good relationship is wanted with a good other, and a bad relationship with the same person, is feared. The ambivalentself alternates between two inaccurate senses. This may entail over-vigilance for feared experiences and a preoccupation with being disappointed because it is anticipated that attachment needs will not be met, for instance. This is a type of social anxiety where there is anxiety, approach and avoidance. (Eating disorders may entail a specific version of ambivalence with more complex entailments about what is trying to be achieved and avoided. For instance, anorexia has a motivation that when thinness is achieved, what will come with it is a guarantee 71

Talk, action and belief of social approval, see chapter 18). What these share is the belief that the future is uncertain but for different reasons. For secure persons in a secure process, the future is clear. The other is there for self and vice versa. It is easy to plan the future together and deal with problems as they arise. Secure attachment in sessions is the creation of co-operation and collaboration with the general public, no matter what they bring to sessions. Part of achieving this is to dis-ambiguate, explain and improve trust in the process and the therapist. However, what clients empathise of therapists is not necessarily what therapists meant to convey. The direct experience of being with therapists is the overall interpreted impact of what has been said and done with them, as interpreted and experienced through the manner in which therapists have been empathised. This is why it is important for therapists to be clear verbally, and congruent in their non-verbal actions, with respect to what they have said of how the pair will work together and how therapy works generally. For clients then, the future of the secure therapy relationship is safe and trustworthy. There is no doubt that the therapist will be supportive and helpful. In focusing on the ego alone, what security of attachment involves is a constant, flexible and adequate sense of self in accurate apperception. The abilities of the secure ego include being a constant self, with its specific type of self-regulation. Self-esteem is achieved and felt as the genuine worth of self, for society generally. For others, the understandings of the social world are accurate and realistic in the anticipation that self and others are good and trustworthy. So attachment needs are met because the understanding is accurate and enables psychological contact. Self and others are acceptable. Others are accurately empathised, more often than not. In a secure process, others are generally understood as worthy and capable of being liked, or in the worst case, tolerated in adversity. But the senses of self and other are impaired, absent or confused in insecure relating.

Conclusion on security Given that long-term close personal relationships and co-habiting require the on-going negotiation of roles, responsibilities and submission and dominance. Gaining co-operation in love, marriage and living together is easier in conditions of calm and confident security in which to make these negotiations and come to agreement. Rather than being unable to resolve outstanding issues and maintain conflict. In close personal relationships that are secure (dating, long-term relationships between cohabiting partners or with colleagues, family and friends), the following are the major qualities that show that secure attaching is occurring at an experiential level.

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There is a shared future that is understood as a positive safe haven. It is felt as a sense of stable on-going mutual caring: for instance, the creation of a home that has a sense of belonging. Love is in-part patience and respect for the views and well-being of loved ones.

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Long-term relationships are understood as relatively easy and the best option for long-term happiness.

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Good mood, accurate self-esteem and a personal-shared happiness are the most valuable creations in life and are worthy of a positive nurturing attention (not worry or neglect).

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Between loving partners, there is a comparatively easy ability to commit and great joy in sex for a monogamous couple. Love is also shown in the attention to detail in the little things in life.

In individual therapy with adults, some of the same processes exist but are modified by the inevitable need for professional boundaries, that it is a one-way provision of professional caring without love, and it has a short-term nature. •

Caring towards clients is not easily dispirited, prematurely brought to an end or rejecting: on-going support and problem-solving is being supplied.

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Caring is responsive in the moment. There may not be a second chance. It is the provision of immediate interventions and the ability to collaborate with clients, consulting with them about what needs to happen, concerning what potential solutions might be.

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Caring supplies motivation and helps clients become committed to their own on-going self-care and tackling shameful and painful topics.

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The outcome is that therapists are able to challenge and provide widely differing views of problems and solutions, without alienating clients.

As a final note on the dynamics of attachment, it can now be understood how people with low self-esteem can also be manipulative and do dishonest things. People believe that they cannot get what they want through asking for it, or negotiating for it, because they believe that they will not get it, then use force, lies, intrigue and deceit to get what they want.

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Summary In order to understand the nature of attachment and what it means for practice, some comments have been made on the centrality of the inter-relation between self and other. Once an understanding of the inter-relation between self and other is achieved, then it is possible to understand the dynamics of attachment, personally and professionally. One way of understanding the dynamics of security and the types of insecurity, is taking security as the leading phenomenon of an ability to co-operate, be close and gregarious and enjoy social contact as something worthwhile in itself. Of course, there are many idiosyncratic versions of attachment phenomena, but the above sets the scene for the analysis of therapeutic dynamics in the next chapter where nine, complex cases are discussed. The general interpretative principle is that different senses of any object of attention are generated because of the different attitudes taken towards the same person or event. The introductory case of an insecure self approaching a secure other has been discussed. For avoidant persons, being at a psychological distance is safe and non-threatening. Ambivalent persons crave closeness and fear it, which means their behaviour is erratic and frequently self-contradictory. Secure persons provide safety and caring for others and themselves in all that they do, except for persons who take more than they give.

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6 The basics of talking and relating Aim: This chapter concerns the core skills for practice that follow the inspiration of Sigmund Freud’s basic technique but are aided by the advances made by John Bowlby (1988), in capturing psychological reality as presented in the last two chapters in addition to more recent empirical advances by Una McCluskey (2005) that are noted in overview. Despite the focus on her research on individual talking therapy, it is believed that the same or similar patterns occur in all forms of therapy and other types of relationship. This chapter makes further contact with the psychodynamic tradition begun by Sigmund Freud but re-vitalised by an encounter with empirical research about attachment dynamics in talking and relating therapy. The previous theme of understanding two-person relationships through intentionality and attachment are furthered: nine specific patterns within research findings are commented on in detail and Freud’s key terms are explained to understand relating. Although there are several hundred models of talking and relating therapy, the choice of a return to Freud via attachment has the purpose of connecting with a major tradition of talking and relating. Attachment-oriented psychodynamic therapy is clarified and re-vitalised through the understanding of intentionality. 75

Talk, action and belief In addition to the last chapter, where the basics of attachment as a dynamic inter-play between two people were explained, this chapter concerns applying attachment to the therapeutic relationship to support talk, action and beliefrelated interventions. Talking and relating are common in providing care. This chapter first shows how some aspects of the stance of psychodynamic practitioners are helpful. Next, the proper use of the key ideas of resistance and mis-empathy, “transference,” are presented as relevant to practice. Mis-empathy is problematic because anticipation is inaccurate so that easy situations are expected to be difficult and the level of anxiety rises in relation to the anticipated difficulty of the task. Contrary to the discourse of alleged ‘unconscious emotions’ and ‘unconscious objects,’ it is here suggested that it is more helpful to intervene in what happens in such cases before, during and after actual contact. Thus, the focus on conscious experience leads to employing self-care methods. Some guiding ideas about how to think about the emotional responses of therapists are provided and these are taken forward in more detail in the next chapter. However, some innovations are made to make the talking and action therapies accessible to a wide range of people. Freud’s concepts and practice are explained; their short-comings and strengths are mentioned. Making relating and talking therapy accessible does not mean that everyone can be helped by talk, action or other varieties of psychosocial help. The role of therapist is not moraliser, rescuer, social worker, controller nor telling people how to live. The role of therapist can be explained in terms of generalities. However, situations with actual clients are always highly specific.

Defining communication Right at the outset, communication between two parties concerns the meanings that are sent and received. If a video recorder were to capture the verbal and nonverbal signifiers (the cultural objects that express what people intend) then what is recorded is only perceptual audition and vision. The message sent from one party concerns that person’s ability to encode a message that can be decoded by the other. Receiving a message properly requires decoding what was sent. In two-person relationships, what happens is not only are there contexts for understanding, of the current culture and society, but the history of the relationship itself sets up a shared context of understanding. Once people get to know each other well, it becomes easier to know how the other is likely to understand a message. This should help the speaker become better able to judge how to encode their verbal and non-verbal expressions. On the receiving end, and with respect to clients in therapy, it has to be noted that some persons have great difficulty in being able to understand a straightforward message concerning the aims of the therapy and what is expected of them. Therapists need to be flexible and responsive and be able to go with the flow of what happens in the minute 76

Ian Rory Owen PhD to minute changes in clients. Their message is a difficult one for some clients to understand. ‘The future is open. It is possible to take some personal control over mood, emotions and beliefs. Beliefs born of the traumatic and defensive past must not dictate the future.’ The actual life experiences of other people, to a degree, remain a foreign country which we can never visit. However, on hearing what it is like there, we can get to understand it and it may not be too different to some aspects of what we have personally experienced. The experiences and beliefs of other people are strictly intangible and only appear as wholes of sense because of the ability to empathise them through speech and non-verbal behaviour. The first and most important consequence of this for therapy and everyday life is that when listeners recount the stories of other people, it is only they who know how accurately they have been heard (if they are able to understand themselves). It is only when listeners put back their understanding to the speaker that the listener can find their accuracy. In many cases the fine detail of what is meant needs much more detailed discussion in order not to mis-understand or jump to conclusions. For listeners to the experiences of others, there is difficulty is grasping their message accurately, for different types of interpretive error can lead listeners away from what has been said. When listeners try to come to a conclusion about the experiences of another, then the believed psychological object of another person can be grasped in relation to guessing about the experiences that made it believable. Let us take this to the realm of psychological distress. When a client tells their story, it is the case that professionals believe what is being said. The anticipatory context is to accept fully the experience of the other as real and often as being potentially difficult to express: For instance, shame and inhibition may operate for clients in producing fear that inhibits the expression of the object of attention that needs to be spoken about. This is what Freud called “resistance” and this will become the subject of detailed discussion below with regard to practice. However, the gift of empathy is being let into the foreign country of the experiences of other people, to the extent that oneself can feel, imagine and think through what it means to be like that other person. In order to understand, then the goal of listening and discussion is to understand the psychological objects and processes of others as they experience them. The basic rule of not criticising and withholding moral judgements about clients is often sufficient to promote reflection and discussion, and lessen their inhibitions to expressing shameful problems. Such a sense of acceptance increases the likelihood of clients accepting themselves and increasing the extent of their sense of self to include the motives and intentions of others around them. The speech and non-verbal demeanour of therapists can lower resistance and permit clients to speak the truth of their lives. One condition for understanding clients is to enable them to trust the therapist and understand that they need to be honest in order for help to be provided. 77

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The psychological reality of attachment This section returns to Bowlby’s conclusions in order to explain attachmentoriented psychodynamic theory and practice. John Bowlby listed the five tasks of talking and relating therapy in the following way. They are worth mentioning because the principles also apply to other types of help. [1]… to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life… [2]… to assist the patient in his explorations by encouraging him to consider the ways in which he engages in relationships with significant figures in his current life… [3]… the therapist encourages the patient to examine ... the relationship between the two of them… [4]… to consider how his current perceptions and expectations and the feelings and actions ... may be the product … of… his childhood… [5]… that his images (models) of himself and others … may or may not be appropriate to his future; or, indeed, may never have been justified. Bowlby, 1988, pp. 138-139. The five points create an emphasis on the importance of security in the therapeutic relationship, despite its time-limited and strictly professional nature. The purpose of making the current relationship safe, co-operative and secure is that it promotes exploration of new territory, distress and disappointments. The safety produced decreases resistance to self-disclosure and so promotes exploration of the topics that need to be aired in order to receive help. The five points above are important and it is necessary to spell out what they mean for any type of practice. The first task of providing “a secure base from which he [the client] can explore the various unhappy and painful aspects” (p 138) is the fundamental necessity that the therapeutic relationship, or alliance, is a collaborative one. What this means in practice is that those therapists who create a sufficient sense of safety, help clients explore their painful experiences at their own pace. As we shall see, in Freud’s terminology, this means lowering resistance to enable self-disclosure and facilitating discussion of the problems in order to gain help. Bowlby’s second task of “encouraging him to consider the ways in which he engages in relationships with significant figures” (Ibid) is promoting a basic curiosity in clients to discuss their relationships with other people. The word “relationship” in the above refers to connections with people. But by extension 78

Ian Rory Owen PhD “relationship” could mean any relationship including those with self, ideas, cultural practices and roles in society. Bowlby’s third task of examining “the relationship between the two of them” (Ibid) means helping clients discuss the therapeutic relationship and the necessity of therapists being receptive to the views of clients. It means taking the opportunity for being open to feedback about how sessions are fairing from the perspective of clients, and being supportive even if clients are critical and therapists disagree. What the third task means is placing the received-quality of help on the agenda for discussion, as soon as the first assessment meeting. This is “asking for feedback from clients” and making it clear that therapists can also provide their feedback about how they think sessions are progressing. The fourth task is gaining a curiosity about how current problematic experiences “may be the product … of… childhood,” (Ibid), or some earlier time. It means that a great many explanations of current problems can be identified within the home lives of adult clients when they were children. Between childhood and adulthood (Richters, 1997), there is an identifiable progression of layers of the development of problems, often with recurrences of specific disorders, or additions of disorders of specific kinds. For the intentionality model, these need to be understood experientially, contextually and historically. Whilst there is no oneto-one connection between a specific disorder now – and its context of on-set in the past - some key themes can be identified through simple questions such as “how old were you the first time you felt that?” which often identifies the original context in which problematic emotions and beliefs began. The fifth task of analysing current “images (models) of himself and others” that “may or may not be appropriate to his future” (Bowlby, 1988, p 139) means working on the beliefs and senses of self, others and world at large, that are similarly related to childhood, specific traumatic events, or layer upon layer of traumata that have crossed the lifespan. It is a potentially contentious remark to state that a person’s psychological problems were “never … justified”, (Ibid). Perhaps, what Bowlby meant was that they were not logically justified - as opposed to them being psychologically and emotionally justified and understood. It is often the case that logical thought and emotion do not coincide. This does not mean that some dissociation has occurred or that the discrepancy must be reduced. Rather, conceptual intentionality is clearly not the same as affective intentionality in relation to the same object. Many interventions work by comparing the senses gained by these different types of intentionality.

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Contemporary research on attachment processes: The dance of attachment Una McCluskey has researched video tapes of two-person inter-actions in talking therapy where the facial and bodily expressions of clients and therapists were scrutinised with respect to the overall attachment process that unfolds between the two. She has found that nine patterns arise. Her findings are provided in summary in this section, with an eye to helping therapists become able to spot what might be happening in their sessions, in the current moment or shortly thereafter, and so be able to respond quickly and adequately to the experiences of clients. Bringing together the findings of empirical research with the theoretical view of attachment of the last two chapters, creates explanation of ruptures, pre-empting and re-securing of ruptures in the therapeutic relationship and provides an accurate account of therapeutic responsiveness. On closer inspection, what appears is that some clients avoid or are anxious with psychological intimacy (“closeness anxiety”) and will dismiss therapists who try to provide it. Una McCluskey’s empirical findings are re-interpreted in the following way (2005, pp. 221-5). One overall process is that clients ask for care with clear verbal and nonverbal components of their total message (p 221). In figure 3, the therapist tunes in to the intellectual and affective components of the message by understanding the affective state and the psychological meaning of what is being explained and is able to focus on the explicit verbal communication. In this case, both clients and therapists are secure. Care-seeking elicits responsive care-giving and clients’ needs are met. In these types of meetings, not only will therapists get job satisfaction but clients will get the service they want. This situation comprises clear and congruent verbal and non-verbal communications for both parties in being able to send and receive bodily-affective and spoken-content messages.

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Key – therapist is the darker circle and the client is the lighter one. Figure 3 – Client and therapist in a secure, optimal relationship. The second process that Una McCluskey identified was one where clients sent out complex verbal messages, with strong non-verbal affective components, in producing a total communication that is barely coherent: a chaotic request for help and understanding (p 225). Figure 4 shows that therapists respond by helping clients to communicate verbally. The chaotic care-seeking style is responded to in a containing, supportive and facilitative way, making clear the multiple verbal and non-verbal messages being sent in both aspects of the total communication from clients. When clients are disorganised and incongruent in their spoken and nonverbal bodily expressiveness, they provide weak and confusing messages about what it is they want help with, what it is that has happened, and what causes them trouble. Patience is required to stay with what is being expressed and to clarify it sufficiently, whilst reflecting the salient pieces back to clients to check that the sense that has been received is the one that was intended to be sent. Despite the dissonance and lack of clarity in the message being sent, messages can be received by therapists who reflect back a coherent narrative. The verbal response made can reflect the affect of clients and makes the form of relating between the two persons more secure at the end of the session than it was at its start. During the process of focusing on what clients want to say, there is an overall non-verbal relaxation that is observable.

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Figure 4 – Initially, the client is anxious and insecure but the therapist persists and creates a secure relationship. The pattern shown in figure 5 starts with a self-defeating request for help from clients. Clients ask for help but then refuse it, or cannot or will not accept it, when it is offered in return. Then they become psychologically out of reach to further attempts to communicate (p 224). If therapists make a mistake in this situation, it is one of allowing an agenda to be set by clients who then go on to disrupt their own agenda by the provision of tangles, worries and side-issues. However, clients might be playing a negative power game and therapists are either oblivious to this, or get caught up in the moment rather than being able to understand and respond to the overall pattern of communication. What can be concluded from this is that some clients are withdrawn and not psychologically contactable, even by the most patient and non-threatening therapists. It may not have been possible to spot this rejecting relational and communicative tendency during the assessment phase. When excessively resistant or avoidant persons have been accepted into therapy, then it is a consequence that care can only be provided with difficulty, as clients are out of reach even to secure and able care-givers. When there is a lesser degree of resistance and withdrawal, then therapists who do not draw out, or fail to pick up the affective or intellectual message spoken, will miss the message that clients are trying to express.

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Figure 5 – The client attempts to contact the therapist psychologically but the therapist is unable to respond so the client withdraws. A fourth case in figure 6 is identified as one where clients ask for care with clear verbal and non-verbal communication but are unable to get through to the therapist (p 223). The problem is that the therapist is verbally and non-verbally under-responsive to such a degree that clients are discouraged in asking for help. Clients then stop asking as they are unrewarded for their efforts. In this case, it appears that clients fail to contact therapists because the latter are aloof and un-contactable. Even fairly secure clients with some degree of insecurity and ambivalence find themselves unable to be cared for and soothed by therapists who cannot or will not respond, or otherwise fail to provide a sense of helpfulness and trustworthiness, or fail to communicate the basic ability to attend to the concerns of clients. Sometimes therapists might collude and avoid grasping the affective sense that they know is trying to be expressed because they do not wish to discuss it because of the pain, shame or embarrassment it would bring them.

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Figure 6 - The client attempts to contact the therapist psychologically but the therapist is aloof and dominant and the client withdraws. A fifth combination (figure 7) is when clients ask for help with clear verbal and non-verbal messages being sent assertively. But because of an insufficient response, clients become demanding in their requests before ending the session as either angry or withdrawn because of the further inability of therapists to respond (p 222). McCluskey found that the therapists first responded with rational comments, but these were insufficiently accurate and alienated clients who then responded by becoming angry or withdrawn. This might be because therapists did not comment on the non-verbal aspect of the communication being sent them. Verbally, therapists may have failed to focus on the client’s object of communication and then possibly became unprofessional in expressing anger or withdrawing. This might be because clients could never have succeeded in contacting these therapists who are, for reasons of their own, unable to understand and hence respond with care. McCluskey found that this happens even when secure and congruent careseeking requests have been persistently made. The reasons why therapists might fail to respond may include counter-resistance to the topic being discussed, but the effect for clients is that care-seeking ceases. (Counter-resistance is when therapists have inhibitions about discussing some subject and are unwilling to speak about subjects they find embarrassing, shameful or taboo).

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Figure 7 - The client attempts to contact the therapist psychologically but either the therapist remains dominant and withdraws, or otherwise withdraws, so the client also withdraws. There are further possibilities of what can happen in the psychology of providing and receiving care. A sixth pattern of inter-responsiveness is that clients ask for care with clear verbal and non-verbal messages at first, but are met by interruptions and diversions onto other topics (figure 8). At some time into the meeting, eventually the therapist begins to focus on the client’s object in discussion (p 222). Eventually, care is delivered by the therapist becoming aware of the affective component and verbal responses, and becomes focused on the object of discussion. For some therapists, time is required to tune-in to clients and respond. This may include time for just recognising their communications as expressions of care-seeking at all. For instance, when sound requests for care have been stated, therapists may have mis-understood the nature of the problem. This might not be due to incompetence but may be about over-coming difficulty before getting on to the same wavelength as clients. If clients persist in their requests, and gradually therapists become able to tune-in to what they are saying and expressing nonverbally, then good understanding can still be achieved.

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Figure 8 – The client becomes increasingly secure in their attempts to contact the therapist but the therapist is not contactable and becomes preoccupied with irrelevancies. A further example is when there are secure and congruent requests for help, but therapists are completely unresponsive (p 221). Figure 9 shows the case of clients who provide clear verbal and non-verbal messages but therapists interrupt, divert and alienate them from seeking help due to a failure to respond verbally on the topic of discussion. Perhaps, some therapists do not have the skills and lack confidence to know how to respond in some situations, so they do not respond. Consequently, they may appear withdrawn and uncaring. The consequence might be that therapists are ‘sacked’. In this case, clients stop asking for help in the session itself because there has been a type of role reversal.

Figure 9 – Whilst the therapist is withdrawn in responding, the client remains secure in asking for help.

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Ian Rory Owen PhD An eighth pattern is where clients ask for care but dismiss it when it is provided (figure 10), possibly because resistance anxiety about self-disclosure has occurred. In asking for help, clients feel exposed and vulnerable about the implications of telling their story fully (p 224). Therapists may focus on the non-verbal affective expression and inquire after it, only to be resisted. But perhaps the manner of the inquiry is so that it leads clients to become alienated and they withdraw completely through creating a psychological distance.

Figure 10 – The client withdraws throughout the session and the therapist is unable to create a secure relationship. Finally, the last pattern of inter-actions that McCluskey identified is where clients express themselves non-verbally but are also resistant and only provide muted, verbal communications of what it is they are bringing to the session (p 223). On the therapist side of the inter-action, the therapist is either not aware of the nonverbal component of the total message expressed, or does not use it or comment on it (figure 11). Instead, therapists stay at a verbal, rational and intellectual level and the opportunity to discuss the immediate events of the session are missed, leading clients to become unresponsive and withdrawn in the session.

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Figure 11 – The client starts the session anxious and insecure and continues to withdraw whilst the therapist is unable to create a secure relationship. These nine combinations shine some light on many more fast-changing possibilities. The next three sections concern the ideas and skills of the psychodynamic tradition, then the research findings of Una McCluskey will be visited once again.

The positive contribution of Freud Despite the criticisms above, it would be wrong to state that Freud has made no useful contribution to contemporary theory and practice.To explain this conclusion, what is required is a full restatement of what “resistance” and “transference” are to show that they are ubiquitous and how understanding them helps practice. Transference or better mis-empathy is the fact that people can, from time to time, mis-understand due to false ideas, assumptions and apply wrong social learning: Other people (and the situation self finds itself in) are mis-interpreted. This produces immediate inaccurate emotional understanding; or visually-created or linguistically-created emotions are felt that are the outcome of internal dialogue. Most often what is felt is frightening, unhelpful and the result of the initial misempathising. The general principle is that inaccurate or false understanding exists in relation to what could be felt in approaching the same person or situation, in a different way. For instance, a relaxed and open manner of attending to someone produces a relaxed experience; whereas fearfulness about the same person means he or she is terrifying. This is an exemplary case. Below the phenomenon of keeping private experiences away from becoming public, called “resistance” is discussed first. It is explained that what is generally called “transference” is inaccurate empathy. The best aspects of attachmentoriented psychodynamic practice are its attention to the in-session dynamics and identifiable conscious experiences. Given that problems with the relationship are 88

Ian Rory Owen PhD of primary importance to the delivery of care going wrong or getting sidetracked, then it is necessary to attend to the quality of the relationship and make any problems with it capable of being discussed. Possible reasons for it not working then become capable of being resolved. The intentionality model claims that working with resistance and misempathy (transference) are the core social skills of any form of therapy. Social skills are towards a specific aim - whether or not that aim is achieved (or even achievable). “Skills” refers to the personal choices and abilities of working towards and achieving a specific outcome with a specific other person or people in general. Social skills make social results. Gaining positive outcomes with a wide range of client personality and problem types requires the application of skilled action towards the facilitation of psychological change through self-care. For instance, the use of non-verbal and verbal skills by therapists is in relation to the expressiveness of clients. The difference between the two persons is that therapists must exercise choice and skill; whilst clients occupy the care-seeking role.

Resistance The phenomenon of resistance to self-disclosure is where speech might have begun or internal dialogue could be expressed, but full discussion of a topic is broken off, for fear of the consequences (Freud, 1912b/1958, 1913c/1958, 1920g/1955). What appears to an attentive therapist is a sudden about face in speech, a sudden halt, a change of subject or the attempt to suppress crying, for instance. Such changes are tangible and public. Yet the immanent feeling of inhibition (about a taboo topic of conversation perhaps) is not explained. Resistance is a complex inhibiting anxiety that prevents self-disclosure for fear of rejection that would come after an attempt at speaking the truth and gaining connection to the other person. Resistance functions as protection from rejection because speaking the truth about self is expected to create displeasure, criticism and lower the value of self in the eyes of the other: It is not a confident and secure approach towards the other. Resistance concerns the anticipatory empathy of how clients anticipate therapists would feel about them, if they were to tell their shameful and embarrassing secrets. However, the necessary self-disclosure to begin therapy requires a positive valuation of clients and positive actions towards them, or they will cease to attend and may never present the real issues with which they struggle. Freud was right that clients need to speak the truth. What this means in terms of understanding resistance and working to reduce it, is that the sense of threat needs to be monitored and lowered, and responsiveness from the carer needs to increase. The problem is that clients have a version of low self-esteem and social anxiety when they anticipate rejection, contempt, disapproval or aggression from therapists and feel bad about themselves in connection with what they expect. 89

Talk, action and belief The remedy is for therapists to ‘show willing’ and accept clients: by defining the roles within the therapeutic relationship, providing clear accessible means of increasing co-operation and so increasing the self-approval of clients through demonstrating actual approval of them within sessions, verbally and non-verbally. This decreases the negative anticipation of resistance. The general strategies for decreasing resistance are validating the negative experiences of clients (when it is bad, say so, to help them accept their own suffering). Secondarily, using empathy for making verbal responses checks that therapists have grasped what is going on and works out how clients might feel or react, in order to stay close to their current experiencing in the session. The basic mechanism for this type of communication is that human beings are intersubjective (if they are not autistic, antisocial, angry or narcissistic and have had good social learning). The name for empathising negative affect about self in the mind of other people is paranoia – and that is the opposite of pronoia. Pronoia is the general anticipation that other people are generally positive about self, and simultaneously, that self is acceptable to them. Pronoia is part of the overall generalisation that oneself is acceptable and that others find self so. This is a key condition for the existence of attachment security and is part of the object constancy of self and others that enables the overall integration of their good and bad aspects. Pronoia is not the case for avoidance and ambivalence. In ambivalence, contrary senses of self and other co-exist and cannot be brought together. In avoidance, the empathised sense of the other about self is that the other is a potential threat and that self is insufficient. Hence, avoidant selves believe that others feel negatively about them. Therefore, there is no possibility for psychological contact. If ambivalent selves cannot integrate the good and the bad senses of self and other, and prove that they themselves and others generally are benign, then there will be no progress towards security. Resistance varies concerning the type of taboo topic that is being spoken about. Low resistance topics are those that are easy to disclose and ask for help. Medium resistance topics are those where clients find it difficult to estimate how their workers will receive them. How this becomes problematic is that insecure clients make wrong empathisings about how therapists will respond. And that the inaccurate empathic anticipations of how therapists might react are sufficient to prevent anything but the slightest mention of the topic. What happens is that the topics that clients would like to discuss become partly expressed. This might be because a topic is mentioned euphemistically, or an aspect of it is mentioned hurriedly in passing on to a different safer topic altogether. Or, some disguised communication occurs about a part of the topic that is then hurriedly dropped in favour of something easier to discuss. If a medium resistance topic is mentioned in full, and that leads to a positive response from the therapist, then clients may re-evaluate their reluctance to self90

Ian Rory Owen PhD disclose and re-evaluate what discussion of a fearful topic means for their selfworth. Thus, talking therapy shows its strength in dealing with complex topics through creating accurate understanding. Speech has its restorative power through being related to a non-judgemental accepting other person (Freud, 1915e/1957 pp. 201-202, Rogers, 1957). The non-judgemental response enables acceptance and change through altering the meaning of what is being spoken about and increasing the likelihood of there being positive consequences. Finally, high resistance topics are taboos that are anticipated to bring terminal shame if discussed, so they cannot be mentioned. Therefore, there is no possibility of getting help in these areas because the topics have never been made public. The positive outcome of gaining self-acceptance through being accepted by the therapist will not occur and this is a missed opportunity that arises as a result of insecure attachment in the form of shame plus social anxiety. The therapeutic aim with respect to resistance is to keep the relationship in a working state and help clients self-disclose and feel comfortable. The means of doing this is to prepare clients for self-disclosure and ask their permission to begin asking questions. If they show distress, resistance or cry, then it is best to ask if they wish to continue in order to gain explicit permission to do so, rather than pressing ahead in a thoughtless manner. The state of best practice includes creating and maintaining informed consent and willing participation in therapeutic activities, whatever those are. The ideal state of relating includes therapists pre-empting the possibility of client drop-out. It means making the time-limited relationship secure and responsive in therapies of all lengths. The precise means of doing this in sessions, and through supervision and reflection between sessions, is too detailed for this work. What comes with understanding resistance is being able to know when to restate agreed aims for the meetings, when to re-negotiate a focus, when to lessen the resistance anxiety that clients can feel, and how to explore their experience by creating a trustworthy and safe setting. For clients, there is already enough danger felt in speaking about taboos and matters that have remained un-discussed for decades. What therapists need to do is facilitate the self-disclosure and exploration of their unique perspectives.

Mis-empathy “Transference” is an inaccurate portrayal of the phenomena of meeting with another person because, as Sigmund Freud defined it, it does not connect with clients’ experiences. This is why transference and its practices are abandoned in favour of understanding how mis-empathy occurs and its associated emotions. Freud believed that transference is the transfer of emotions about persons who would now be called “attachment figures,” from the family of origin (1905e/1953, 91

Talk, action and belief p 116, 1914g/1958, p 150, 1925d/1959, p 42, 1940a/1964, pp. 177-8). In summary, it is more accurate to state that senses from the past attachment figures can get re-created in the present and added to current persons, but there is no ubiquity in this. And the senses added might only be short-lived and occur at times of acute stress. So with the proviso just mentioned, a rule of thumb is that similar senses concerning problems from the past get re-created in the present and added to current others, including the therapist, so that the empathised sense of the intention to communicate of the other person becomes obliterated. Mis-empathy concerns generalisations about others that are often related thematically in some way to previous traumatic events, not necessarily those in infancy or childhood, but previous senses can influence or wipe out the current empathising of persons here and now altogether. Mis-empathy can be occasional or an excessive influence. Mis-empathy can be directed towards therapists or not. It can be the same inside of sessions or outside of them, or not. One case of mis-empathy as part of general social learning is the following: Physical and sexual attacks on children, particularly when they are less than four years of age, persist in the production of adolescents and adults who share a number of possible problems. One aggressive defence is being ready to blame others and refusing personal responsibility. But other versions can arise. Some persons from precisely the same background may feel excessively culpable and blameworthy for events around them and this leads to low self-esteem, guilt and depression. Mis-empathy can be defensive. If it is excessive it can become part of the personality and occur in very many social contexts the topics of personality and defence are major ones and will be returned to below. When there is good rapport with clients, it is often the case that even when the mis-empathy of therapists occurs, it need not utterly disrupt the progress of the sessions particularly when it can be understood and corrected. If mis-empathy of clients were encouraged, or clients were encouraged in guessing about the intentions of therapists, then what would happen is that inaccurate imagining would be added to the already negative, usually fearful anticipations that clients have about the actual intentions of others. One version of mis-empathy is inaccurate anticipations by clients, who prospectively think, feel and relate, according to negative anticipations. This could happen in actuality or merely in the possibility that they might meet someone, or something bad might happen in social life. The sources of mis-empathy are varied and can be specific traumatic occurrences, or due to numerous occurrences that create generalisations, or exist in relation to feared circumstances which if they were to occur, would be distressing but bearable. There is a link between misempathising and belief in the social world, but the topic of belief is not going to be tackled yet.

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Ian Rory Owen PhD Accurate empathy is seeing the person and grasping his or her view and intent. The reality of their qualities and lifestyle always remains other, yet it can be known accurately and responded to via the reactions of a number of others. The target of mis-empathising is most often attachment figures who are psychologically close: like partners, parents, children, siblings and close work colleagues. In therapy practice, in some cases it is impossible to check assumptions about the intentions, attitudes and innermost feelings of clients towards therapists. So the lack of certain information promotes the possibility of inaccurate belief and consequent inaccurate empathy. The intentions of others remain guesses, are imagined visually, or exist only in what others’ internal dialogue is auditorially imagined to be. What go with such experiences are emotions that are felt in the absence of the actual occurrence of what others feel. The influences on mis-empathy are historical and associated learnings that become caught up with contemporary and anticipated events. So the present and future become misconstrued in specific and identifiable ways. When mis-empathy is understood as a living phenomenon, it is a better explanation than “transference” because it avoids a number of intangible claims that Freud made about there being ‘unconscious emotions’. His claim that “in psycho-analytic practice we are accustomed to speak of unconscious love, hate, anger, etc., and find it impossible to avoid even the strange conjunction, ‘unconscious consciousness of guilt,’ or a paradoxical ‘unconscious anxiety’” is disputed (1915e/1957, p 177). These claims are found non-sensical because only that which is experienced can be talked about. In conclusion, it appears that the function of inaccurate empathising has the purpose of preventing harm by anticipating possible problems, thus protecting self and preventing possible distress by generating anxiety as part of a state of readiness and preparation. Prior to that there is a psychological whole for each person that is tied to what appears perceptually and what is “given” or conscious through memories, associations, implications and anticipations. Discussion has meaning on the basis of there being an enabling whole of intentionalities in relation to cultural objects and their senses. Speech makes sense by referring to meanings of many sorts and many ways of speaking.

Working with resistance and mis-empathy In order to use the distinctions from research presented above, it is necessary to note that any verbal interventions could be chosen to meet the needs of discussing a current problem in the therapeutic relationship. The aim would be to re-establish co-operative working and increase security in the overall relationship. The psychodynamics of care-seeking and care-giving concerns how security and insecurity of attachment can be present in two-person professional relationships. 93

Talk, action and belief Future research could identify how ruptures in therapy can be repaired and understand how to provide help to those persons who are ‘damaged,’ whilst identifying those who are hard to help or possibly beyond the ability of therapists to provide any help. Whilst the analyses of McCluskey cited above are framed in terms of care-seeking and care-giving, it is possible to identify specific moves from each half of the pair that contribute to the nature of the dance overall. Let us focus on how the nine patterns above can appear in individual therapy. From the perspective of clients, the internal thoughts and experiences of the therapist are unknown. In the most general terms, the therapist is another person and there are some aspects of their experience that are forever unknowable such as what they really think about their clients that cannot be expressed because of the professional role. However, therapists are business-like, calm, relaxed, friendly and purposeful. Discussion of talking therapy is the public expression of the salient details sufficient for the therapist to be able to grasp the proper meaning of what is happening. What is actually discussed is the meeting place between what therapists can say professionally, in connection with what clients feel they can say, given their previous experience of how the therapist has responded, about which they might have previously expected to receive some criticism. On the client side, there is the verbal expression of the object of speech. The affect felt about the verballyexpressed object is shown bodily, plus, the attitude to seeking-care is expressed: The three parts form a total communication. There can be resistance at expressing the object of concern – as clients speak freely, they may suddenly remember some relevant details from the past, and the process of telling their tale enables them to feel something of the emotion concerning their topic of speech. What was outside of awareness comes into it, in the act of explaining it. What clients’ cannot see about themselves (the non-verbal manner of expression, the expressions on their faces, their non-verbal presence and their tone of voice) are aspects of the total communication that provide information about the emotional message sent. Empathy works both ways, however. Clients empathise the sense of therapists as they respond. What therapists do not know about themselves is how they are being received by their clients (unless they ask but still they may not get full feedback). But the actual perspective, current emotion and complete understanding of clients, might never be properly explained. There is the total ability of clients to ask for care and show themselves in an intimate way to the therapist-stranger who might well be completely unknown. On the side of therapists, there should be some awareness of the emotion of clients. There is an intellectual, affective and imaginative ability to empathise clients’ predicaments and verbalise empathic responses that explain what therapists do and how they respond. On the side of clients, there are four commonalities derivable from the empirical conclusions noted above in the section on the dance of attachment. 94

Ian Rory Owen PhD There can be clear verbal expressions about the object of concern, the current affective relation of clients to it and their affect about expressing themselves in the relationship. But there can be some resistance to making the object of concern clear for various reasons. For instance, clients resist and contain the logical detail and block expression of their affective state because they are shame-faced and expect criticism and disapproval. Or there is a poor, disguised expression of the object and the current affective state that does not get adequately expressed. Therefore, help cannot adequately be directed to the problem. Alternatively, there can be disorganised or angry verbal and non-verbal expressions that may be due to the help received so far, or are a commentary on being in the care-seeking role rather than about the therapeutic relationship or the object of discussion. On the side of therapists, what can be seen in-between the lines of the analysis made by McCluskey (2005), is that there is the possibility that the expression of care is accurate empathy that is returned in such a way that clients successfully receive it. This produces co-operation and brings clarity to the treatment. Overall on these occasions, therapists have successfully understood the verbal and nonverbal expression of the object of concern, the emotional aspects of it and grasped the detail of the problem. But a number of problems can arise for therapists when they have difficulties in understanding. Therapists could focus exclusively on the logical content of what clients say. Or therapists could make poor responses that miss the point, or make minimal or insufficient amounts of verbal responses in discussion. Therapists could fail to clarify responses through not asking pertinent questions and clarifying the inaccurate understanding that they are receiving and so maintain false impressions of their clients’ needs and experiences. Due to any reason, therapists can fail to understand affect and non-verbal presence, the verbal manner of expression about the object of concern and the overall manner of asking for help. This is a failure of empathy and hence any responses will miss the point. There can be disorganised, angry and conflict-laden responses from therapists who are confused, or otherwise lost in trying to help, or feel defeated by the responses of clients that are not what they expected or usually receive when in similar situations with other people. Finally, sometimes therapists cannot engage some clients, have insufficient or negligible psychological contact, and fail to understand the expressions of careseeking transmitted to them and remain psychologically withdrawn. The causes of this lack of psychological contact need to be found and remedies made to prevent them continue. 95

Talk, action and belief Once these pieces of the puzzle have been identified, it is then possible to correct them if they occur. If there are problems of dominance and submission within the therapeutic relationship, or another type of relationship, then these can be resolved by allocating responsibilities for specific areas. This permits the allocation of dominance to one person within a two-person relationship in a specific area, in negotiation for the dominance in another area. It may be necessary to review performance of the allocated responsibilities, but the idea is to enable one person to be in charge of a specific area of choices or permissions in the relationship, in an explicitly negotiated way. There may well other variations on the themes stated above.

Summary From the perspective of attachment theory, the problems with the wrong understanding of Sigmund Freud’s original technique and the justifications for unresponsiveness are easy to diagnose. The psychologically austere conditions of orthodoxy do not highlight the “unconscious proper” of clients (Freud, 1940a/1964, p 160). Rather, the lack of responsiveness, excessive psychological distance and lack of care contribute to clients being able to remember their responses to similarly austere unresponsive situations. Hence, clients respond to the psychological reality of aloofness and lack of responsiveness in the here and now. The real absence of warmth and responsiveness wherever it occurs, promotes the selection of previous experiences similar to the current situation, and promotes anticipating future experiences of a similar sort. Austerity, lack of warmth and blank reactions promote psychological distance that elicits past and current experiences of psychological distance, loneliness, feeling ignored and unappreciated, lack of support and guidance. Overall, the emotional responses to remembered and anticipated scenes of distance and austerity make the provision and receipt of care difficult if not impossible, because the relationship is heavily skewed. The following two points from the psychodynamic tradition are stated by way of closing the chapter. •

Resistance needs to be monitored and kept low, to get clients to speak, in order to analyse problems together. If clients want to self-disclose something shameful and embarrassing, then what needs to happen is that the level of resistance-anxiety needs to fall sufficiently to enable the disclosure to happen. Resistance is wanting to get help but fearing the consequences of shame, low self-esteem, disapproval and rejection at the possibility of speaking the truth. Resistance-anxiety inhibits self-expression and defeats the necessities of self-disclosure, expressing distress, remaining in the therapeutic relationship and the experience of being focussed-on in an unswerving positive way 96

Ian Rory Owen PhD by the security-providing therapist. To reduce resistance is the opposite of remaining self-contained. If the fears and vulnerabilities of clients cannot be brought out, then progress will be hampered. Only after disclosure and discussion does it become possible to know how to intervene collaboratively and promote clients to self-care. •

If clients find the therapist aloof because he or she will not answer questions about the therapeutic process, or in other ways, will not explain the technique and its uncompromising constancy, then clients accurately empathise their therapist as hierarchical, at a psychological distance and inflexible. These impressions are accurate and not entirely related to their childhoods. These impressions about therapists are not “transference” but an accurate empathic understanding of what is happening. Mis-empathy is by definition a misrepresentation with respect to current other persons or situations. This distinction is achieved experientially by finding evidence of what others think, feel and intend, concerning how they relate. Rather, than accepting without question the senses that are born of inaccurate generalisation.

Theory should specify the stance that it takes in making sense of specific regions of evidence. These regions are such as belief and ‘cause’ about the provision and receipt of care and verbal and non-verbal communication. They require an explicit means of how to make sense of being with clients in the moment. There are many ways of interpreting the relationships of clients within orthodox psychodynamics. Usually, clients find the silence provided anything but “creative”.

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7 Working to increase security Aim: This chapter explores in more detail how to understand and work with the therapeutic relationship co-operatively. No specific comments are stated about what should be done with people who qualify for a personality disorder (according to the checklist definitions in Diagnostic Statistical Manual IV, American Psychiatric Association, 1994). It is argued that the principles of good practice work for all persons regardless of their diagnosis. This chapter has a focus on strategies for relating that are related to the psychodynamics of attaching in twoperson therapy relationships by recognising that emotions are complex indicators of the state of a relationship as it unfolds across time. The idea of a dance of attachment accounts for the dynamics between both parties. Arguments for good and bad practice are made. The sequence of presentation starts with the dynamics of the provision and receipt of care as the major factor that shapes the emotional reactions on both sides of the therapy. The topic of how to create and maintain the security and clarity of the therapeutic relationship is begun (and continued in more detail in chapter 19). The topic of the importance of being in-tune with non-verbal two-way inter-actions is introduced. Emotion is understood as a basic form of 99

Talk, action and belief intentionality and relatedness. Emotions are complex products. For adults in particular, emotions can arise through internal dialogue and other intentionalities like the visual anticipation of specific events. There are situations where more complex inter-actions may occur between what is visually imagined, and what a person believes they would feel if that scene were to come true. These situations are dealt with in detail in chapters 16 to 21. Some definitive remarks are provided on what constitutes bad and good practice in the basic medium of talking and relating.

Overview Furthermore, something needs to be stated concerning a theory of change that connects relationships to meanings, beliefs and conscious senses of the same referent. Because a wholistic view is provided, it is necessary to jump ahead in order to present the whole. But the details of making sense, hermeneutics, are not presented until chapters 11 to 13. Because the level of argument is general, then the language used below makes claims about general occurrences without claiming universality or making truth claims, but rather remarking about general tendencies and capabilities. The view of the intentionality model is that working with clients is a complex whole. In this light, the complex whole contains a huge number of possibilities concerning the combinations of client distress, the nature and severity of presenting problems and the ways in which therapists can help. It is impossible to make clear every possibility and decide in advance what to do for every combination and permutation. Still, the role of therapist is to help the majority of the public successfully. Generally, the help that is offered is for a huge number of combinations of problems and personalities. Theory fulfils its role by providing helpful commentary on what is likely to work and why. Talking therapy really means relating, understanding and knowing how to act in any situation. What is demanded is a clear model of relating that is not too complex, but sufficiently complex for use in a large number of different situations. Attachment theory is used to satisfy this need. The insecure forms of relating may be related to: •

Pre-emptive attack because of the anticipation of attack.

•

Domination and control because of the anticipation of being controlled.

•

Withdrawal and hiding away from others because of the anticipation of distress that will be caused by rejection or relationship failure.

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Ian Rory Owen PhD •

Submissiveness and clinging because of the anticipation of rejection and preoccupation with past hurts.

Insecure attachment fears in adults in individual therapy arise through different ‘causes’ and have different accuracies with respect to their objects. For instance, closeness anxiety is fearing that there is or there could soon be a disappointment, a loss, a sense of shame about oneself, on getting close to the therapist or another. Closeness is a source of anxiety not relaxation because it can lead to rejection, disappointment or disapproval. The specific situation of therapy is that therapists are nominally secure relaters whose knowledge of attachment dynamics informs how they speak and relate and can be used to process their emotional responses. Even so, mis-empathies of clients do occur and should be identified, understood, contained and not acted on because these thoughts and feelings are born of inaccurate understanding caused by beliefs and the accumulation of their past personal and professional learning. The central motivating factor between defensiveness and secure connection is that there is a tipping point mid-way between approaching others and withdrawing from them. The nub of defensiveness and insecurity of attachment is that for the self in everyday relating (and for insecure clients in therapy), if the desire for connection and soothing through human contact is less than the fear of distress that being psychologically close, intimate and being hurt may involve, then this ‘pessimism’ will lead to withdrawal. If the fear and withdrawal predominate and the person acts in-line with how they feel, then they will be incongruent with their attachment needs. But if the desire for contact and security is greater than the fear of distress due to rejection, or failure of a valued relationship, then there will be ‘optimism’ that promotes gregarious contact with others. If there is the desire and social skills that enable attachment to occur, there will be actions and satisfactions that are congruent with the attachment needs. With this key distinction in mind, it becomes easier to understand the dynamics of attachment presented in the next section.

The dynamics of attachment as the greatest contributory factor The processes of this section refer to the core dynamic associated with the attachment-oriented view of providing and receiving care within any type of therapy. Attachment is the commonality at the heart of personal relationships as well, be they friendships, or within the family, or within sexual and loving relationships between partners. 101

Talk, action and belief The empirical research on attachment in two-person relationships is that the feelings generated usually concern inaccurate understanding in the therapeutic relationship: What Freud called “transference” and “counter-transference” are types of mis-empathy. Transference and counter-transference are inaccurate empathies that occur with insecure and defensive expressions of care-seeking and care-giving in attachment, within the confines of a professional time-limited relationship. Counter-transference was only ever mentioned in-passing by Freud (1910d/1957). To be precise, mis-empathy by therapists can contribute to insecurity of attachment in the therapy relationship. It is an unhelpful contribution of the helper towards the relationship overall. Mis-empathy is inaccurate understanding of the aims and intentions of others that are often negative, in that people fear harm, or experience disappointment or frustration because of their past learning. But inaccuracy might also be due to unrealistic expectations that are incapable of being met by reality. Mis-empathy might be aimed at one’s own family members or another person, or occur in the anticipations of what will happen between any two persons. Furthermore, mis-empathy is anticipatory in the general case of the event that there might be someone who might be met.

Towards a sufficiently secure therapeutic relationship The dance of attachment referred to in chapter 6 is a fundamentally different way of re-stating what is generally called the transference-counter-transference relationship in psychodynamic therapy. Here it is referred to as the attachment dynamics concerning the provision and receipt of care. Less formally, the dance of attachment concerns the pushes and pulls between therapist and client. Let us recap the situation as described in the last chapter as the continuum between avoidance through ambivalence to security. For simplicity of discussion, I will assume that the therapist is an ideal care-giver and always occupies the secure position of offering soothing, positive strategies and comments in order to simplify the explanation. What needs to happen for clients who are insecure relaters is that they need to be able to cross the gap from avoidance and withdrawal, and go through ambivalence, in order to get sufficiently close within the temporary and professional relationship. It is a necessity for clients to explain their problems in sufficient detail through therapist enabling low resistance and creating a positive sense of the therapeutic relationship and themselves as safe and trustworthy. The change-over to the secure position needs to be mentioned in order to describe what can be the case within a temporary and professionally-structured relationship. If clients are sufficiently secure they can trust, relax and set aside their fears – what they will find is that safety, kindness and a basic interest is shown in helping them. The experience itself functions as positive evidence that they can present their needs and distress, and find that they are still acceptable 102

Ian Rory Owen PhD because their need for care can be satisfied by the therapist-stranger who ‘wants nothing from them,’ but is motivated by their vocation to be altruistic and want to help. What motivates therapists is the pleasure of being good and seeing clients improve in mood and various areas of their lives. The type of changes that are possible are many but all are based on increases in security, as shown below with respect to figure 2 in chapter 4. The person who is semi-permanently avoidant, or who currently occupies an avoidant position, metaphorically, has ‘furthest to travel’. One way of thinking about avoidant persons is to state that their psychological distance serves the purpose of preventing the distress of loss by refusing closeness. For some people, this might be a lifelong position that they have been unable to get close for this reason since infancy. For others, avoidance may have been a position adopted in adulthood due to divorce or bereavement or as temporary way of dealing with anticipatory disappointment. For the avoidant person and the avoidant process, there may be profoundly influential memories of loss and rejection, a refusal of the positive warmth of being intimate and great difficulty in getting to feel safe and secure in human company. The half-attached position of ambivalence has more complex difficulties concerning the prospect of getting close. Whether ambivalence is a semipermanent aspect of personality or a less permanent form of insecure relating that is more reactive to the real or anticipated dynamics of a specific relationship, what is common to ambivalence is the formative presence of anger and anxiety that drive short-term, contrary reversals in feeling and behaviour. Setting aside the submissive care-seeking strategy and the dominant rejecting or demanding strategy to others, what is at the heart of ambivalence are the changes between seeing the other as capable of both providing care (a positive sense) and seeing the other as rejecting or insufficient (a negative sense). When there is hope that the other can be caring, then there will be positive behaviour towards the positive anticipation. The tipping point between becoming more or less attached often concerns the anticipation of what will happen in the relationship with the other person. If the other person is sufficiently desired, then it will be clear that self will want to move forward. But if contact with the other is seen as detrimental to self, then there will be less contact rather than more. The tipping point operates in attachment of all types. Specifically in therapy, from the perspective of clients, there is a decision to be made about the prospective worth of self-disclosing and an estimate of the benefit that might be gained from it - as opposed to the potential costs that self-disclosure might bring in terms of the pain felt, the risk of rejection and disapproval. Negative feelings can come from anticipating being rejected. The pain that rejection or disapproval would bring can be strongly anticipated and needs to be quelled or over-come because the balance can also shift the 103

Talk, action and belief other way. Specifically, the negative can predominate and if the anticipated or interpreted sense of the caring provided and the future of the relationship is felt to be insufficient, then withdrawal will occur and the ambivalent use of avoidance will be triggered.

Criteria for promoting secure attachment Attempts from a secure other to reassure the insecure relater and return to psychological contact usually work when they are timely. If however, there are too many withdrawals (and too many submissions or dominances) then even the most patient secure other will get tired of the hurt and disappointment entailed for themselves, and they may be tempted to leave their secure position of continuing to offer care and attention. If they were to do so, this would be evidence that the other is no longer secure, so confirming the negative sense that the insecure person had predicted. See Table 1 which is a brief reminder of the position in chapter 4.

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Ian Rory Owen PhD ‘Grid reference’

Self

Intersubjectivity

(0, -1) Avoidant, schizoid

Withdrawn, Not achieved no distress

(0.5, -1) Preoccupied with separation, anger or loss

Empathised to be Preoccupied angry, Preoccupied, Fearful of or fearful anxious ambivalent unavailable. Other rejection, feels attacked and dys-regulation, sulking or loss semi-gregarious, could respond in a variety of ways. clingy or angry.

(1, -1) Preoccupied distracted

Distracted, Preoccupied, not reparative to wholly involved others

Can connect. Preoccupied, depressed & neurotic attachment. Care seeking deficient.

(0, 0) Withdrawn

Avoids care giving

Others are good but Attachment avoided. not achieved. Withdrawn. Care seeking inactive. Care giving not received.

(0.5, 0) Ambivalent, fearful & approaching

Some attaching Socially anxious, fears rejection

Ambivalence of anxiety, retreat & approach. Attachment positively & negatively valued.

(1, 0) Secure

Ego constant, Secure, open, coself-regulated, operative self-worth achieved, accurate understanding, gregarious, good social skills.

Secure regulation, Non-threatening mutual satisfaction senses of others and accurate & supportive anticipations of context for exploration, care the actions of others. Except giving sought when there is actual & accepted. threat. Satisfying Rewarding, relationship constructive & satisfied. Social life established. enjoyed.

Not attaching

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Attachment process

Sense of other & possible responses

Attachment not achieved, care giving avoided.

Avoided. Other withdraws or feels ignored.

Ambivalent: Feared, avoided & wanted. Other may feel anxious also.

Talk, action and belief (0, 1) Paranoid

Wary, attacking Paranoid, dys-regulated responses to ‘attacks’

Feared, attacked, Pre-emptive rejected or out of attacks on misempathised carer, reach. Other feels attacked & could so care giving possibly defeated. respond in a variety of ways. Needs remain unmet. Care giving not trusted.

(0.5, 1) Controlling, dismissing

Self-reliant, controlling

Not reciprocal

Dismissed, Dismissing, angry dominance, conditions of worth applied. Other feels controlling. controlled, attacked, manipulated, ignored.

(1, 1) Aloof dominant, dismissing

Controlling

Not mutual

Controlled or Attached yet aloof, dismissing, fighting control or ignored. withdrawn.

Disorganised Pan-anxiety, A tendency dys-regulated. towards not attaching, coFailure of occurring coherence between emotion and understanding - or coherence not yet attained. Context

Reflection on Total of cototal of self empathic manners of being-with. experience and comparison to others.

Pan-anxiety, not attaching. Chaotic & ineffective careseeking tangles. Rejects or defeats care-givers.

A tendency to be influenced by the prior attachments. Other feels confused, attacked, anxious.

Total of felt senses Total of of empathised combinations others plus some of attachment possible responses. seeking and receiving processes.

Table 1 - Explaining what Helen Stein’s findings mean. The listing of aims below is made to mention the types of changes that are possible. Or the opposite could occur. The more secure positions could give way to less secure ones, in which case all the arrows below would be reversed. 106

Ian Rory Owen PhD paranoid → dismissing → secure fearful-withdrawn → ambivalent → secure avoidant → preoccupied → secure aloof → secure dismissing → secure ambivalent → secure preoccupied-demanding → secure preoccupied-attached → secure The aim for relating is simply to increase the ability of clients to be secure in the time-limited and professionally-provided intimacy of the therapy relationship. The precise detail of how this can be cannot be specific because of the near infinite number of variations in actual occurrences. However, specific criteria for good and bad talking and relating practice are stated below. How to relate in the light of attachment theory is as follows. Starting with the ideas laid down by John Bowlby, there is confusion between the terminology of the psychodynamic heritage and the visceral emotions felt in attachment phenomena. One core aspect of psychodynamic therapy is discouraging negative mis-empathy by identifying and pre-empting negative guesses about the true intentions of therapists. Indeed, the therapeutic relationship should be carefully monitored to ensure that it is positive overall. Where conventional psychodynamic therapy goes wrong is eliciting negative thoughts and feelings about therapists, and then having no adequate means of putting them right. This makes a hard job much harder. The positive legacy from Carl Rogers (1957) and John Bowlby (1988) is that being psychologically present in the sessions, and psychologically in contact and responsive, is a much better way of working because it is sufficiently active to promote a secure relationship. Indeed, being psychologically present is the first enabling “condition” for change (Rogers, 1957). This does not mean self-disclosing about any aspects of the personal life of therapists but being able to monitor and work with the therapy relationship and not lose psychological contact, credibility as a care-giver and worth with clients. What is being urged is the achievement of a sufficient amount of responsiveness in therapists that promotes the responses of safety, co-operation and self-disclosure in clients.

Introducing the social skills for talking and relating What is being suggested as good practice is not entirely new but a re-statement of some basic guidelines for relating and the practice of talking and discussing the groundrules of practice. What helps is having an agreed focus for sessions and providing information about the therapy itself and detailed explanation of the procedures and understandings provided. Such matters should be open to 107

Talk, action and belief debate and explanation, if necessary. The desired state of affairs is to produce a professional relationship with informed consent, boundaries and clear agreed aims and interventions. Whilst self-disclosure about the personal life and troubles of the worker is taboo, it is the first rule of therapy to be in psychological contact with clients (Rogers, 1957). What this means is that therapists are responsive and make varying amounts of verbal responsiveness, over and above responses that merely acknowledge that clients are saying something. For therapists, to contain their feelings and act accordingly is to be congruent with them. To be congruent is a core idea of Husserl’s phenomenology in that he noted that it is possible to express what one feels non-verbally and verbally (1952/1989, Supplement VIII, p 333). Security-increasing interventions are any verbal and non-verbal actions that work towards the outcome of a clear co-operative relationship that centres on the well-being of clients. It works through being attentive to their distress in the moment of its occurrence, through daring to empathise what clients feel and being able to tolerate it and respond in supportive, constructive and problemsolving ways. I am assuming that therapists are empathic and on-goingly sensitive to the perspectives of the people they meet. Although it has to be noted that some clients are verbally and non-verbally incongruent and have great difficulty mentioning what it is that truly troubles them. A further position between secure and insecure is attempting security of attachment: Earned security is where people who have been insecure work to overcome their previous insecure tendencies (Pearson et al, 1994, Phelps, Belsky & Crnic, 1998). Having earned security is when it is possible to keep in psychological contact with other people, maintain and develop friendships and belong to groups of people who have common interests. Earned secure people may have fear about entering social situations but persist with their social life despite the occasional experience of self-doubt and other negativity. Through years of practice, good social skills and social learning develop through social contact and ultimately, even in profound cases of abuse and neglect, security of attachment and accurate selfesteem can be attained. Most schools of practice agree that structured relationships with agreed verbal contracts about the focus of sessions are a basic aspect of good practice. But in matters more complex than this, there are no facts, just inter-related viewpoints to guide practice. A good quality therapeutic relationship is one that encourages clients to participate and know they are responsible for themselves to the full extent of their ability (Boss, 1958/1963, p 73). The aim is to create a positive relationship overall, where difficulties between therapist and client are open for discussion, starting at the assessment phase. The aim of this general strategy is to promote good will and keep clients motivated, despite their potential resistance to self-disclosure. What secure attachment means in practice is that problems of 108

Ian Rory Owen PhD insecure relating can be brought out in sessions and soothed. The base material that needs to be accepted and worked with is emotion and relating. Doubt from clients may concern what their experiences are, what they mean, where feelings come from (because of gross lack of empathy from abusive others), whether their experiences make sense, if clients are congruent with themselves, and what they can congruently express about themselves. If therapists are clear about their motivations and contributions to the shared relationship, then this will help them reduce insecure contributions. Let us consider what the term “social skills” actually means. To have good social skills is to know how to act and what to say in a wide variety of situations to enable types of contact between people or bring unsatisfactory contact to a close. Social skills are about making others and self comfortable and at ease. These skills concern how to be in the moment and how to work towards specific outcomes with people through encouragement and feedback on their progress. Generally, this improvisational ability is pro-active and pro-social in helping people communicate and be in contact with each other. Social skills are social in that they circulate. Social learning is closely related to social skills in that social learning is about recognising how a person is and what they are capable of because of one’s knowledge of people from a wide range of walks of life in society. Social skills concern how to deal with a wide variety of situations and how to position self with respect to those others. For therapists, it is good to be relaxed with clients and confident. If therapists feel that they can deal with almost any eventuality with confidence, and be able to get along with clients from all walks of life, then a pervasive sense of competence has been achieved. Because therapy is time-limited ultimately, security needs to be established early on and contact is limited to scheduled meetings. The easiest conditions for good work are when clients and therapists feel comfortable with each other. Some types of negative emotion for clients can be over-come in the course of the sessions as they unfold, and as the penny drops, clients begin to understand properly that helpful conditions and opportunities are being provided. The specific way that therapists feel is not material for disclosure but can be used through reflection and supervision and return to clients and establish sessions on positive lines. The reason for this is that discussing how therapists feel means that an ordinary social relationship has commenced. Therefore, there is a circular relation between bad understanding and bad practice, that leads to an unhelpful understanding of the phenomena of clients (who are ignored, not responded to, do not have the rules explained, etcetera). Whereas what the intentionality model aims for is a closer circling between good initial understanding, leading to good practice that is effective in promoting change that confirms proper understanding of the relevant conscious phenomena. Sometimes there is mis-communication about what one party thinks the other 109

Talk, action and belief is intending that is due to mistaken understanding of what it is that is being suggested or implied. The problems that clients have are that bad experiences in the past can act as justification for a host of bad current behaviour, and to be blunt, clients have not learned from their own bad experiences and repeat the same mistakes. What follows next is a comparison with how a talking and relating therapy should not be structured; to make it clear how to be present in the relationship without being over-powering.

Discussion of bad practice: Criteria for decreasing security This section returns to the original influence on psychodynamic talking and relating set by Sigmund Freud. Practice as a whole exists in the shadows of its founders. One of the most influential thinkers and practitioners was Sigmund Freud. Although what he wrote on technique is almost 100 years old, it is claimed that his key concepts apply to any form of therapy. How he practised was to monitor the difficulty in self-disclosing which he called “resistance” and this had the practical aim of returning clients to self-disclosure and telling the truth about their experiences (Lohser and Newton, 1996, p 166). “The overcoming of resistances is the part of our work which requires the most time and the greatest trouble”, Freud concluded (1940a/1964, p 179). He worked out how his clients were mis-empathising him and he called that “transference”. Whilst there is much of value in his ideas and practice some of his ideas and practices in a contemporary light are unacceptable for a number of reasons. Freud saw his technique of “creative silence,” un-interrupted listening, as a means of making memories that had previously been defensively forgotten spoken and conscious. He believed these remain unexpressed material because their emotional consequences were too shocking. He thought that memories and unspoken material lost their power to control and delude consciousness, when they came back to consciousness and were expressed through speech in order to be understood and act as self-knowledge. Freud reasoned that when the objects of memory were once regained and properly understood, they would lose their power to exert control over current conscious experience, choices and the sense of self. There are some situations where these principles apply. But these views have been distorted by some writers to become a technique of the ‘violence of silence’ and the promotion of psychological distance and passivity on the part of therapists as the genuine way of deploying Freud’s ideas. To be silent, aloof and unresponsive was never Freud’s manner of relating (Lohser and Newton, 1996). When creative silence is excessive, clients fill the vacuum produced by therapists. So what clients say, how they think and feel and how they relate in return, are 110

Ian Rory Owen PhD specific to the context of a therapeutic relationship that is genuinely oppressive, unresponsive, dismissing and uncaring. This wrong understanding of Freud’s original practice has negative effects for both clients and therapists. Let us take the response for clients who are given no explanation or guidance concerning the therapeutic relationship. For “orthodox” or “classical” psychodynamic therapists, there are a number of troublesome consequences of their wrong understanding of Freud’s practice. As trainees, they find it anxiety-provoking to be silent when they first practice creative silence. The small numbers of interventions they practice are a straightjacket to creativity and caring. There are only three acceptable orthodox interventions: (1) creative silence, (2) “interpreting,” naming the causes of clients’ difficulties, and (3), saving the boundaries of the arrangements of the meetings. When the psycho-analytic frame and roles are set then there are only two interventions: silence and interpretation by the therapist. But as a consequence of their minimal responsiveness and their unswerving attention on clients, therapists who follow these basic rules, without attention to any other concerns, fail to realise that they are being aloof, unresponsive and appear psychologically withdrawn and unavailable. In fact I would go as far as stating that the psychological reality of the situation, according to attachment theory, is that therapists who act in an unresponsive way are correctly empathised as being unresponsive and uncaring. For therapists, it is a serious mistake to be silent and unresponsive and believe it has no effect. Excessive silence within the context of being asked for a caring response has a negative effect that could be avoided by being sufficiently clear and responsive. No social situation is an impartial context for self-disclosure and all verbal and non-verbal communication inevitably shapes the responses of clients. Both individuals take something personal and past-oriented to the inter-action and use that in acting in it and making sense of it. The theoretical belief in the unconscious proper is rejected because it implies that the task of therapists’ is to speak about an unknown and unknowable object. Freud’s idea of the “unconscious proper” is “mental material” that has “no such easy access to consciousness, but which must be inferred, discovered and translated into conscious form”, (Freud, 1940a/1964, p 160). This is intellectually illegitimate because it is an attempt to make something exist where there is nothing to appear. It is a manner of theorising by intellectual guesswork that ignores conscious experience in favour of creating concepts that point at an experiential void. The conscious-preconscious distinction can be understood when something, which is spoken about as a story (about one’s past, for instance), becomes clearer after giving it some attention. This case is where a preconscious object is made conscious through talking and focusing on it. As it becomes more and more conscious, it could become a full and vivid memory, rather than just a 111

Talk, action and belief linguistically-represented story, that one had previously only apprehended through speech or internal dialogue. But psychodynamic reasoning about unconscious objects and unconscious forces in opposition is unfounded (Owen, 2006c). So there is no need for theories about symbolism or the predominance of infancy on adulthood. Unconscious objects cannot exist because it is impossible by definition to have any experiential evidence of them. Similarly, contrary to received wisdom in psychodynamics, it is wrong to think that every human relationship is entirely structured by the influence of the past. If sessions are helpful, then positive feelings towards therapists are reality-based gratitude. If sessions are unhelpful, clients have the right to complain. Feedback from clients should be sought to minimise any negative effects of undisclosed dissatisfaction. For the intentionality model, a lack of therapist responsiveness is the communication of low involvement and lack of care. Also, because of the misunderstanding of the basic rule – that therapists shall be silent and clients shall speak, to the extent that this is the only activity occurring - then the basic rule makes a void that becomes filled by the imaginings, anticipations and interpretations of clients. This produces spurious material for the understanding of the ‘unconscious of clients:’ what they do not know about themselves but what allegedly they should know about the causes of their emotions, relationships and behaviour. However, what is produced in that context could not be further from the truth. A person subjected to minimal contact and undaunting observation from a complete stranger will fill the void of the psychological absence with imaginings and rememberings that arise from similar situations that they have experienced. Because of the barrier to establishing genuine psychological contact of insecure relating that can be contributed from either side of the relationship (Rogers, 1957, Bowlby, 1988, McCluskey, 2005), and the actual psychological distance within orthodox psychodynamic therapy, what is already a difficult task for both people is made a good deal worse because of the technique employed. Clients struggle to express themselves in an all-encompassing silence. Therapists struggle because they are not permitted to enter into a fuller and more supportive dialogue. Both are cheated of satisfaction. Clients fail to get what they came for and therapists do not provide their duty of care if they provide the violence of silence. It is unsurprising that orthodox therapists who are gagged by creative silence, find that so many people in the population struggle in expressing themselves, in what to their eyes, is a safe and accepting relationship. But the problems of the “classical” relationship are clear to attachment theory. Therapists over-look their own lack of participation in the two-person relationship and then allocate the cause of distress entirely to clients because theory dictates that the responses of clients are due to their parenting when they were infants. This is a problem of being in a two-person relationship and not accounting for the role of the therapists’ 112

Ian Rory Owen PhD influences in it. The problem is a theoretically-maintained lack of empathy plus an inability to understand intersubjectivity.

Criteria for bad practice Even the best therapists make mistakes from time to time, so this section on bad practice discusses general aims rather than guidelines that must never be broken. From the point of view of understanding attachment, bad practice becomes clearer to define and understand. Let us consider some general points about bad practice. Bad practice is any event where therapists permit or encourage, by omission or commission, the therapeutic relationship to get worse, become impaired or falter without trying to intervene and make it more secure: The quality of the relationship is not entirely the result of the actions of therapists but they are the ones who are responsible for trying to make it workable, should problems arise. For instance, asking clients to guess the intentions of their therapists is bad technique. It is selfdeluding to create a vacuum of silence and unresponsiveness that clearly fails to meet the needs of clients, and then proclaim that they are demanding, childish and angry because of their childhood when it is the lack of care in current meetings that clients are angry about. In summary, the view of the abdication of responsibility in the provision of care is as follows. Bad practice in talking therapy, and the talking and relating aspect of action therapy include no informed consent for interventions and no clear structure in meetings or across series of them. Bad practice includes, not responding, dismissing, criticising, not taking client concerns seriously and persisting with an interpretation, even after a full and frank discussion has shown evidence to the contrary. Bad practice includes believing that every difference with the therapist’s view is refusal and personally critical disagreement. On the contrary, clients have areas of competence and well-being and these should not be ignored. It is bad practice for therapists to act on their feelings without some consideration of the likely consequences of their actions. This is not to rule out the place of spontaneity but to argue that being spontaneous is the operation of virtuoso therapists who can ‘improvise,’ after they have mastered the basics of the relevant decision-making processes that are necessary, so knowing when to be spontaneous with interventions and initiate free conversation. Bad practice occurs when the legitimate questions that clients have about treatment are not elicited or not answered. If there is lack of discussion of the therapeutic relationship and lack of explanation of the rationales for it, the meetings and the form of help will be unclear for clients. Therapists who do not explain matters pre-emptively and provide no initial briefing about what is going to be supplied by way of care, should not be surprised when clients feel angry, confused and let down. If a pedantic attention is provided to rules for relating 113

Talk, action and belief and the frame in which meetings take place, then this communicates a focus that is not about the concerns of clients. If clients are not encouraged to be involved in, and responsible for their own progress, then chaos and wasting sessions may follow. When therapists are over-optimistic in accepting clients who cannot be helped by what is being provided, then this is not providing a duty of care. If the therapeutic processes used conclude with clients feeling frustrated, depressed and aimless, then the sessions will have no value because they provide no help. The consequence will usually be that clients fail to attend. If clients remain and express anger and disappointment, then these feelings are clearly understandable in the light of attachment theory: care has not been provided. Specifically, negative contributions from therapists are those that coerce, or create explicit hostility and show a lack of connection with clients’ needs and views. This is not to state that the whole of the relationship is the responsibility of the therapists, nor to think that the job is easy and will always go ahead without miscommunication, conflict, disagreement or pressure. It is to state that therapists should be flexible and provide care in a skilled way that can go back and forth between general theoretical principles and the minutiae of the specific situation. When others have acted without any apparent reason, and clients have felt powerless, without personal agency and control for decades, then what security of attachment means is the constant repetition of a soothing and rationalising influence from therapists. What security provides has been remarked on by a number of writers. The terms that have been used are “support,” “empathy,” “validation” and “consistency”. What these amount to are increasing quality of life, ameliorating distress and getting clients to realise how hard they have been on themselves and how they have contributed to their own distress through the absorption of negative influences from the past (Gilbert, 1989). Therapists could provide a judicious and simple to understand explanation of how clients feel in a session. But the choice of words should never be such that it risks the provision of help. If clients do not understand what is being said to them, then they should be encouraged to ask because they have a legally mandated need of explanation. Therapists are in the role of providing care and helping self-disclosure. The problems and successes of the relationship as a whole are seen clearly when therapists have concepts that enable them to understand both parties in the relationship. It is the role of therapists to lead by providing dependable understanding first. Even so, it is practically and ethically mandatory to get agreement for interventions. Therapists are consistent when they stick to what was originally said at the assessment or in previous reviews of progress in sessions. This principle applies to both persons, but particularly the therapist should be able to handle, contain and understand even the strongest emotional reactions. In this light, any inconsistency away from co-operation, collaboration and security may often be a result of therapist inconsistency and inability to handle negative 114

Ian Rory Owen PhD emotion raised by the material that clients have been talking about. The way to work with such situations is to identify and understand them and nip them in the bud before the flowers of insecurity, conflict and argument bloom. The basic form of relating being argued for is to have an interpersonal style that operates between limiting conditions, some of which are as follows: •

Providing a basic sense of safety to promote exploration of client material, however taboo that material is for them. Therapists find and remove obstacles to understanding and action.

•

Being consistent in keeping the boundaries that have been set but not being overly strict or excessively focused on frame management.

•

Being encouraging but not completely without assertiveness. Making comments on potential dangers to the well-being of clients.

•

Being clear in stating what might be helpful, how it could be achieved and what to work towards and what it might feel like, but not telling clients how to live.

•

Being supportive and encouraging clients to do things that might be helpful for them. But the amount and extent of supportiveness needs to vary with the ability of the person to look after themselves.

•

Helping clients take responsibility for themselves but not to the extent that they feel excessively burdened, and that there is no time for discussion and experimentation.

•

Encouraging clients to use rationality to think through the consequences of actions, when it may help prevent harm. One criterion for good practice is for therapists to begin discussion and provide helpful responses that defuse and explain situations that could be tense and might lead clients to cease attending. A second criterion for good practice is that any feeling, impulse or mood towards self-harm (in a very broad sense of what is bad and damaging towards one’s own best interests) are experiences that should not be trusted and should not be chosen as evidence for action.

On the emotional reactions of therapists If therapists do not feel self-confident and feel they have nothing to offer, then that is probably because their theory and practice are ineffective or wrongly applied. Wrong practices and false prior understanding rob therapists of vocational satisfaction and make them ineffective. Therapy, like other relationships, can only 115

Talk, action and belief deliver its worth if the relationship is sufficiently valued by clients, the insecure party, who is more likely to feel more negative worth in it and is more likely to bring it to an end. If the relationship is refused, then it is certain that the promise of its potential worth will not be delivered. The difference between therapeutic and social relationships is that social relationships feature two-way self-disclosure and can focus on mutual interests. But in therapy, the focus is on the client in the new skewed arrangement, with no personal self-disclosure from the therapist and full self-disclosure from clients. This serves the purpose of making the therapy relationship entirely focused on the needs of clients. If therapists were preoccupied with their own shortcomings, believed they had social inabilities, felt lack of confidence and experience in life and work, then they will introduce insecurity into the relationship. It could even be the case that some topics are too threatening for therapists and they prefer to change the topic to something less threatening. This is called “counter-resistance” because it is an inhibition of responsiveness from therapists towards clients, where there should be no impediment. For instance, a client can make an ambivalent and resistant turn, after a more open and trusting request for help. The desired response of a supportive comment that acknowledges the difficulty in speaking might be sufficient to enable self-disclosure. But if that response is lacking in the short-term, clients may ‘sack’ therapists who have not been able to grasp their communication, even if it was delivered in a coded, whimsical or euphemistic way. From the perspective of clients, they thought they had clearly presented an issue. But the inability of therapists to grasp it, ‘permits’ clients to run away from it and therapists end-up feeling dumped and used. However, sometimes, the perspectives of some clients will be beyond the grasp of comprehension, for a variety of reasons. In short there should be no self-disclosure of the details of the personal life of therapists. Whether therapists are straight or gay, have children or not, is irrelevant to practice. If such details are disclosed they may not always disrupt the sessions and make them unworkable. However, it might be necessary to explain that the therapy relationship is not an ordinary social relationship and that therapists are constrained by various rules. One rule is not fraternising with clients. However, the emotions of therapists are a supply of relevant information that requires reflection and interpretation. Any strong emotion that is felt by therapists is cause for concern and should not be acted on, but kept private and taken to supervision or be subjected to personal analysis at the time of it happening, if at all possible. Or otherwise, strong feelings need to be understood before action is taken. The emotions of therapists represent the current state of the relationship with clients in a visceral way. However, such experiencing occurs through the sum total of the past plus the anticipated future orientation. It has to be noted that the good intentions of therapists are not in doubt, but even the most 116

Ian Rory Owen PhD skilled, experienced and qualified therapists are not immune from receiving false impressions about how clients make sense of the intentions of therapists. It is only through open discussion, where clients are encouraged to speak their feelings and impressions that therapists can get a chance to know what they actually think and feel. The dynamics of helping insecure relaters can entail negative emotions for their helpers and these feelings need to be understood because therapists should not act on them without thought and understanding. Given that the general desire of therapists is to help, if there are any difficulties, one of the easiest traps to fall into is for therapists to think and feel that clients are ungrateful and not trying to participate in what is being offered. If clients complain that they do not feel helped, then that can be easily heard as personal criticism. If therapists want to rescue clients who are not improving, then it is therapists who could end up feeling bad about themselves, if clients do not improve quickly. One way that therapists could protect themselves is to be angry in return for the failure to appreciate their efforts in trying to provide help. Therapists who lack selfawareness could fall into the trap of verbally attacking clients for not participating in the co-operative effort, for instance. In sessions, specific types of actions from clients motivate specific re-actions, feelings, thoughts and memories in therapists, and vice versa. The difference is that therapists do not immediately speak their thoughts or feelings or act on them. Their emotional self-control, self-awareness and knowledge of their role helps them reflect on what has happened, contain their own reaction in order to consider it, then decide how to act therapeutically.

Working with client emotion One way to work with the emotions of clients is to explore their experiences verbally and encourage the expression of the unexpressed. Some clients hardly dare breathe a word of what they feel. So encouragement should be provided to help them speak. Those who come from families that are high in expressed emotion, or where there is freedom to shout, scream and act on any impulse, then they have learned to be ‘incontinent’ about how they feel. Such events are unhelpful and do not improve clients coming to make sense of themselves. Strong emotion generally impedes rationalising (the use of conceptual intentionality in internal dialogue, speech or writing). On the contrary to the idea that emotional expression is always right, the intentionality model is more cautious and believes that what needs to happen is proper communication between the two parties in individual therapy. Good communication makes a hard job easier. The intentionality model answer is for therapists to have clarity about the current state of the therapeutic relationship and know what they have to offer and when it is likely work or not. Another strategy is working to decrease the excessive emotional expression of 117

Talk, action and belief persons who are fixated and overly expressive of a narrow range of their feelings. Clients can be exquisitely sensitive to certain situations and are able to evoke the same or similar problematic implications with therapists, as they have done in everyday life. A greater attention to conscious experience on both sides of the relationship would show how the mistakes of therapists hurt clients. But clients have a tendency not to express their criticism and hurt. For therapists any strong negative feeling (that is not a general warmth, desire to help and understand) needs to be understood and managed. It is possible to interrupt a stalemate and explain what is helpful. Clients have to be able to say things that are true for them in asking for care.

Five recommendations for good practice Five recommendations are now made to deliver some of the promises already set down in creating a sketch of a whole of the basics of practice, as these concern the difficulties of providing and receiving care. Attachment theory is a perspective that claims to understand slow-changing habits and positions within intimate relationships. It is a form of empirical research and a powerful means of describing the pushes and pulls in close personal and professional relationships. Five assertions are made about criteria for practising. Firstly, for therapists, practice should be easy and enjoyable most of the time. Secondly, therapists should know what to do in most situations. Theory is the major cause of talking, relating and other interventions in practice. Practising is applying theory of the social skills that are the provision of care through enabling changes in types of intentionality. Practising with most clients should not be excessively tiring or onerous, even when working with people who have extreme trauma and the ‘personality disorders’. The great majority of clients are relatively trouble-free in terms of the problems that they create for therapists, emotionally speaking, when they have been properly prepared for the practice provided. For therapists, the feeling gained from meeting the general public should be warmth and positivity, despite the often shocking nature of the origin of their problems and understanding the limitations that they face. If strong emotions are felt by therapists (negative or positive) then that is reason for understanding the therapeutic relationship and the contributions of both parties. If there is strong emotion, then action needs to be taken to keep clients attending by identifying what is happening and correcting any problems that prevent the delivery of help. When meetings with clients are painful, frightening or upsetting, they are understandable in the context of clients and therapists’ personal histories. The third criterion is that therapists should be deeply satisfied by the work and enjoy meeting new clients and maintaining contact with them. When meeting clients 118

Ian Rory Owen PhD is unsatisfying, that is significant and should be a rare event. Clients who are aggressive, manipulative, sarcastic, sadistic or who have pain that elicits the pain of therapists in response - or otherwise, if therapists wish to stop them from attending – all these experiences are reason to understand what is happening in the meetings. These and similar emotions should not be acted on without careful thought. A fourth criterion is that if therapists are unsatisfied by their work and find it particularly hard to help their clientele (regardless of the level of difficulty in the chosen population) and that clients do not respond to their interventions, then these lacks in satisfaction and effectiveness are cause for concern and need to be rectified in the short-term through supervision, re-entering training, a change in the client population or other means. Fifth, it is regularly possible to help people self-care through finding how current problems are maintained, how they continue to exist in an on-off fashion, and how the ego is related even to passively-constituted senses: It is possible to help people reduce, manage and sometimes eradicate very long-standing problems (parts of their personality) and make personality change. This is not creating miracles. It can be achieved on a regular basis through applying basic principles such as helping people understand themselves and employing action therapy towards specified aims that are sought-after.

Summary Chapters 4 to 7 have been an appraisal of the received wisdom on how to create co-operative relationships and good communications in individual therapy. In the next part chapters 9, 10 and 16 will further deepen the attention to detail by discussing defences and personality styles, but these topics are side-stepped for the moment. The problems of talking therapy concern the limits of its applicability. People generally have inertia to change. Whatever the problems that arise from their personal history, there is a certain investment in a way of life. What has been appraised in the above are mis-empathy, security of attachment and aims for relating. The chapter has concerned a deepening of attention to the detail of these experiences, to make it clear what they are about. Bad practice and problematic situations can be pre-empted or attended to when they occur. The general assumptions of any course of questioning or intervention need to be clearly stated and related to client experience in a way that is justifiable and capable of consideration by clients. Such a theory should be capable of justification, to make therapists transparent to themselves, so their beliefs are open to revision and empirical research. Therapists should make it clear that the quality of the

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Talk, action and belief relationship will be discussed. This should be done in an open way that invites comments from clients. Social skills are not just for the benefit of one person, but for the purpose of easing communication. What is important is that therapists lead and can find out where clients are on the map of attachment and so make clear agreements about what should happen in the meetings. Therapists must be able to explain what, how and why the meetings need to be one way or another. Relating is reciprocal and mutual. Others react to self while self reacts to others. Focusing on one person prevents consideration of the inter-active processes between people. Intersubjectivity really means the study of the conditions for the existence of the moment-to-moment inter-responsiveness between people in the sense of empathising the non-verbal presence of others and knowing self in relation to them. This mutuality and reciprocity forms a context for understanding verbal communications (Kern, 1993, 1997). Social skills are the execution of the responsibility to understand the social situation and lead in it in helping there be a time-limited secure relationship. The individual capability of therapists’ to connect with clients, communicate and agree a focus in the meetings, varies with the current caseload that therapists have and how they feel supported by his or her environment of supervision, managers, colleagues and their home context. Talking therapy often assumes that action will be forthcoming after detailed discussion, but the assumption does not explicitly promote acceptance, reflection and increase motivation for action. There comes a point, even in exploratory talk, where a turn to planning action and homework would be more effective and a proper strategy to take – as opposed to yet more exploration that may not encourage clients to take control of their lives. If a specific course of action is being suggested for clients, then it should be within their capabilities and be something that is wanted sufficiently for them to over-come ambivalence and fear. It is still the case that clients need to be able to reflect, understand, re-interpret, re-learn and act differently. The next chapter is on the dynamics of changing behaviour. The next chapter deals with how to help people make changes in their choices and actions as an extension of talking and relating, as part of the most basic modality of understanding the psychodynamics of providing and receiving care that enables change.

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8 Action, choice and motivation Aim: This chapter defines the scope of helping people change their practical intentionality. Changing behaviour has been proven to be the best and quickest possibility for making psychological change (Longmore and Worell, 2007). This chapter is included in this part because practical change is very important and motivating clients to change themselves is the central aspect of creating change in the personality, in attachment relationships and the life experience. The general principle in taking action is that doing work brings rewards and finds relevant evidence on which to make further choices. Self-directed behavioural change is potentially the key principle for achieving personality change and lessening many types of distress. How to facilitate change in others is included in this part of the book on the therapeutic relationship because it is a core part of practice. This honours the importance of facilitating behavioural change. The psychodynamics of facilitating psychological change in another person are discussed. The focus is on the means of helping change occur through encouraging clients to take action. Whilst there is research to support the fundamental processes of classical and operant conditioning (Walker, 1984, 1987), these are only part of the reasons concerning how human beings can condition 121

Talk, action and belief themselves, or be conditioned by powerful others, into having emotions and experiences of specific sorts that involve negative self-limiting consequences. This chapter expands the understanding of behavioural techniques to connect these ideas and skills to meaning, experience, attachment and relationship change. The satisfaction and achievement of change, and attempts at change, become more understandable after desire for change over-comes the need for protection: If there is merely desire and preparation in thought - but defences, fear and anxiety are too strong - there will be no attempt at change. Whilst the function of defence is self-protection, when defences are too all-encompassing, they defeat satisfactiongaining behaviour as well. Thus, goal-seeking is defeated through excessive and over-generalised safety-seeking, an inhibition that prevents the acquisition of the positive, as well as preventing negative hurt and damage. This is a very general statement and is true in attachment dynamics as well as in other aspects of living including what are called ‘personality problems’. The sequence of topics in this chapter starts with explaining the new understanding of action as a type of intentionality, a type of being related to self, other and world. The next step is to argue ethically, that treatments that have the highest likelihood of promoting change should be offered first. Next, the key issue of exercising choice and being motivated are crucial to helping clients change in ways that they want. Some thoughts on the extent of the ego are made by way of a conclusion.

Behaviour therapy Behaviour therapy and behavioural experiments (Bennet-Levy et al, 2004) are referred to as action therapy as part of the broader view of the intentionality model. In getting change, the overall beneficial outcome is attained through understanding and the practice of skills towards clear aims, moderated by on-going reflection and feedback on the progress made towards the desired outcome. Behaviour therapy is a set of techniques for dealing with the physiology of distress and promoting the competent practice of skills and social roles. The interpretation that behavioural theory makes of the human condition is meaning-minimal. This chapter is about the much maligned behaviour therapy way of helping people over-come their fears by encountering them in a controlled way. However, the practice of behaviour therapy concerns motivating clients to over-come negative experience (encountered from the feared object or situation, for instance) by firing their enthusiasm with the future promise of achievement. Specifically, enabling other people to change their behaviour is motivating clients to expend effort, in doing work of a specific sort, when they may have avoided such behaviour previously. For clients, taking action provides first-hand immediate experience of the results of their labour in terms of raising their own self-esteem, better mood, 122

Ian Rory Owen PhD greater flexibility of movement and choice, and other benefits. Action therapy is promoting clients to tackle their demons of fear, disgust and strongly negative anticipation. Action is a mental process in the intentionality view. The problem with the theory of behaviour therapy is that it is overly natural scientific, when its practice is anything but scientific. It involves encouraging clients to ‘jump through hoops’. The job of therapists is to teach clients how to jump through these hoops without pressurising them, but helping them make clear their positive reasons for changing. It is possible to choose one’s attitudes towards objects, persons, states of affairs as Jean-Paul Sartre (1943/1958) and Viktor Frankl (1946/1964) have shown to good effect. Sartre was put in prison for writing a satirical play about the Nazis in World War Two. When he was imprisoned, he decided that he could choose his own attitude about his imprisonment. Similarly Viktor Frankl was imprisoned in more than one death camp by the Nazi regime. He realised that the loss of hope could be terminal in this situation as he saw that some of his colleagues who given up hope, died as a direct result of the loss of sight of a positive future. Behaviour therapy works through the necessity that to sustain well-being, people must decrease self-neglect, reduce risky behaviour and begin positive and satisfying activities with others. Clearly, it is ethically unacceptable to apply pressure on clients to change. But there is no practical need to apply pressure on them either. A great deal of the practice of helping people take action is about motivation towards self-care and helping people nurture themselves to the same degree as they would gladly care for others. The diagram below provides the basic theory of behaviour therapy in terms of intentionality.

Intentionality about an object of attention Classical conditioning

↓ ↑ Associated or resulting negative affect ↓ Practical or mental avoidance of negative affect

→

↓ ↑ Temporary relief provided by avoidance of negative affect

Stand-alone problem - or of personality functioning Operant conditioning

Figure 12 - General behavioural formulation. 123

Talk, action and belief Figure 12 is a general behavioural formulation expressed through the terms of intentionality. If it is true that classical and operant conditioning are responsible for all types of psychological problem, then the management of anxiety through defence, for instance, is a possible alternative for interpreting attachment problems as well as other types of association. The problem is how to take observable interactions and infer that specific composite forms of intentionality are occurring between care-seeking and care-giving. For the behavioural perspective, operant and classical conditioning are applicable to many forms of problem. The on-set of problems is due to pairing by association or classical conditioning (top half of figure 12). The maintenance of the problem is through negative reinforcement, avoidance of unpleasure and the use of defences, in the bottom half. Classical conditioning concerns the arousal of the sympathetic nervous system that promotes fight or flight and is the production of readiness anxiety that promotes protection and avoidance. The problem is that such arousal tends to ‘go off too soon’ in promoting panic and premature withdrawal from a feared object. Classical conditioning is where conscious senses get added together, so that the presence or possible presence of one object connects with the presence of another emotion, experience, idea or meaning. Similarly, Husserl claimed there are a number of over-lapping conditioned senses that exist in entering the social world of meaning, through learning what the perspectives of others can be (1950/1977a, §51, p 112). Husserl made an oblique reference to “pairing,” (which generally means Pavlovian classical conditioning). Let us be clear about the phenomenon that is under consideration. This is the phenomenon of word-less immediate sense and meaning. Such immediate understanding is initially word-less. When affective intentionality is at work, it is called “primary emotion” (see chapter 19). Words come later in trying to express the understanding of what is experienced. Operant conditioning (or negative reinforcement) is when the parasympathetic nervous system is aroused producing relaxation and recuperation. The principles for reducing operant conditioning or negative reinforcement are to note that the defences promote ‘safety’ through only providing temporary relief from unpleasant or ‘unbearable’ emotion. The way to weaken and reverse this process is to start with the easiest change, so clients can compare what it is like to not use one of their defences; to the overall experience of using it. What usually happens is that the person gains more time and energy and wonders why they ever persisted in using the defence. The repetition of avoidance and negative reinforcement occurs where temporary relief is gained that not only rewards the avoidance itself but also maintains the primary emotion. Emotions can be classically conditioned and negatively reinforced. How to work with conditioning is discussed in the next chapter. Whether every emotion and meaning is conditioned is probably unlikely 124

Ian Rory Owen PhD (as there are other ways of making sense of situations by dint of holding them up against contexts of various sorts). So whilst some problematic meanings might be first acquired through conditioning, and negatively reinforced through temporary relief, this is not to claim that all meanings are created this way. If therapeutic processes conclude with therapists adding extra difficulty to clients, who were already hard to help, then not only are clients hurt, but therapists fail to receive job satisfaction because of their inability to enable progress due to institutionalised justificatory ideas and techniques. What clients can experience is confusion and powerful emotions over which they seem to have no control because they do not realise how they themselves contribute to feeling how they do. For instance, Julia worries for 18 hours a day that bad things will happen. She does this for days on end until her self-esteem and mood drop and she goes to bed for a few days because she is depressed and angry with herself. It is only when a major event in the outside world makes her get out of bed, in order to deal with major negative consequences, that she returns to her duties and obligations in ordinary living. This example shows that people can feel taken over by their own emotions and fail to include their choices and behaviour as being at least partly-responsible for their negative moods. In this way the senses that clients make of themselves are that they are useless, mad, unlovable and anxious. Therapists armed with the definitions of intentionality and the psychological disorders are able to account for the connection between worry, withdrawal and low mood. Because the ego is involved in its own suffering, this is the beginning of an answer through this realisation. Being able to catch self in the moment of worrying and bring it to a close, for instance through thought stopping, is a key ability that can bring problems under egoic control. Thus, change occurs through self-awareness, moving towards release and renewal at throwing off the bad influence of the past and starting out afresh.

On choice If a person were to change their own behaviour, then in a great number of examples, they might be able to feel better and may have solved a problem that had given them distress. But the fact of the matter is that people have problematic behaviours and distress caused by their choices and do not change their behaviour. Why does change not occur? What stops the alteration of behaviour? And what promotes it? The Serenity Prayer leads the way in providing clarity on the subject matter of choice. Authorship of the Prayer is in dispute so it is not possible to state who was the originator of the following verse. God grant me the serenity to accept the things I cannot change; 125

Talk, action and belief courage to change the things I can; and wisdom to know the difference. Living one day at a time; Enjoying one moment at a time; Accepting hardships as the pathway to peace. Despite the religious overtones of the above, the categories asserted by The Serenity Prayer are agreed. There are some things in life that cannot be changed yet some that can. If people were to accept what cannot be changed about themselves, others and the way of the world, they would feel a burden lifted from them. Yet there are times when it is better to stand alone, fight and struggle for what one believes. With respect to what can be changed it is only right to work to become who one would like be and what one would like to do. The first step in taking action is deciding how to change what one can. The ego can take action to re-balance its mood and self-esteem, even if the only change is an increase in self-acceptance and nothing else happens at all. In order to help clients make choices, they need to choose new options that helps stop or reduce their current problems. Action, choice and motivation are some of the consequences of talking and relating interventions. Therapy helps people make new decisions about thinking, feeling and taking action. Changing behaviour can quickly earn the prize of making some small change in the overall whole of current lived experiences. This helps to lift depression, self-esteem and reduce anxiety. When behaviour is recognised as mental activity about specific real objects, ideal or imagined ones, then clients can be directly asked to give informed consent towards specific sought-after outcomes. In the light of intentionality, behaviour is consciously chosen and willed practical intentionality. Defences, or safety behaviours, extend to include a lack of attainment, often for spurious reasons. For instance, Peter, a survivor of physical abuse tells himself that he must stay home and look after his dog rather than go out and find a girlfriend. As a factual statement, what he tells himself is untrue. Peter could take the dog with him or give it to a neighbour for the evening and go out. Even when he clearly understands himself and fully agrees that he could do these things, and realises that he could look after the needs of his dog and himself. He still chooses not go out and find a girlfriend because he is afraid of “nothing in particular”. Peter just finds the prospect daunting. His choice is to prefer the lack of a girlfriend to the effort involved in getting one. It is a choice of preferring the least bad outcome in the short-term rather than going for the best outcome that might entail rejection. The remit of action concerns following through a previous decision to do something that is difficult. Helping clients choose action is covered in therapies such as behaviour therapy, cognitive behavioural therapy, gestalt therapy 126

Ian Rory Owen PhD (Wertheimer, 1944, Köhler, 1970) and motivational interviewing (Miller and Rollnick, 2002). Emphasising action as part of therapy is useful when clients have accurate understanding of their problems but do not follow through with action. Or when people know what is right for them and have decided on a course of action, but do not see it through to its full accomplishment. Clients who are still at a pre-contemplative stage, in respect of making behavioural changes, can only remain in the assessment phase of therapy. Only when they give informed consent and become ready to participate, can interventions begin. If persons keep doing what they have always done, then they will keep reaping the same harvest that they already have. For self-directed behavioural change to occur, it has to matter to clients that there are sufficient bad consequences for them to stop, so that a new behaviour can be chosen. (This choice extends to directing the choice of objects of attention from one intentionality to another, for instance, giving up focusing on fearful imagining, in favour of thinking of something reassuring). If clients are uncertain about making a choice or about what they want, then the right evidence needs to be gathered and understood in the right way. Some clients may already have more than enough of the right evidence telling them that a specific behaviour is harmful and brings nothing positive, but still they do not give it up under their own motivation prior to therapy.

Practical intentionality as part of the whole Action therapy requires a suspension and alteration of the current meaning of a fear, in order to encourage proper action. What action therapy feels like for clients is going through an invisible barrier of fear and inhibition, on the way to greater freedoms and choices. What it deals with are anticipations (most often) about things that do not exist in reality or in a logical sense. Anticipatory fear is about something that might happen, but it has not happened yet. For instance, if anyone anticipated with belief that there is a spider in the bathroom and they are afraid of spiders, then the fear that there might be a spider is such to prompt 40 minutes of fearful checking for spiders before taking a shower. Taking action in therapy has its remit for those clients who understand the ‘causes’ of their feelings, thoughts and impulses and understand how they relate to others, but who are not self-caring in their actions: Their actions are insufficient with respect to their needs and the minimum amount of effort required in order to connect self with others. This amounts to a failure to take action that promotes neglect of psychological needs. Self-neglect can happen even when the whole problem has been properly recognised and understood. Personality and identity are expressed through a number of general purposes that contribute to the total set of actions carried out in any one day. Action is 127

Talk, action and belief physical expression about how one is and how one believes self, the current situation and others, to be. Some things cannot only be talked about, imagined or remembered. They have to be done for them to exist. Doing is a mental act, at base though. The tendency to act is not unconscious or obscure, but is part of the sum total of how a life has been lived so far. The totality of actions can be interpreted according to how belief, understanding and a certain type of lifestyle express a specific way of understanding. To put the worth of taking action into a nutshell is to assert that “the reward is in the doing:” People only fully realise the benefits of a new behaviour after they have done it, although they could imagine what the reward might be like beforehand. Therefore, what decision-making requires is a basic understanding of the nature of taking action. The advantage that the intentional formulation of behavioural principles has over behaviourism is that it is able to see how consciousness is related to what is believed to be real, or not real, and it can capture this relationship in a tailored and precise way. Hence, the forms of intentionality that clients use are clear and able to be related one to the other. In the intentionality model, this is seen as dealing with threat, usually with problematics that include some contribution from self, even if the amount and type of contribution is not identified as a problem before therapy begins. The new self-awareness is understanding how clients are contributing to the problem in the recognition that the previous ‘solution’ is unhelpful. Action is one part of a greater whole. Specific actions themselves are parts of complex, co-occurring wholes of emotion, thinking, relating - and complex arrays of awareness and commentary on one’s own and others’ views. Any specific action is the expression of the intentionality to act and inter-act, between others and self, between the past and the future. The next three sections change the subject to focus on the ego and its ability to chose and consider the relation of the ego to its social contexts.

The extent of the ego The ego requires definition because it is all too easy to use this term without realising to what one is referring. The ego, the lived sense of self, appears through relationships, actions and experiences that are either due to inherited temperament or utterly engrained psychosocial influence, so strong that it cannot be altered by new psychosocial influence of any sort. Those who have suffered early neglect, physical, emotional and sexual abuse are unfortunately in the position of having had psychological trauma so early in life that may have existed for so long without treatment, that its influence can become semi-permanent. The ego is that which people take to situations and relationships with others. It does not refer to the effects of trauma or other social learning that are variable or disappear across the lifespan due to new experiences. Those influences that are part of the ego are 128

Ian Rory Owen PhD those that can only be curbed with great difficulty and self-control. What is amenable to change through self-motivated change and the psychosocial influence of therapy meetings is the “personality”. Genetically inherited traits themselves cannot be altered but understood, accepted and managed. The view of the intentionality model is that the core of the ego is spread across a number of social areas through time. If some trait of the ego is biological, there is nothing that can be done to change it. So personal choice and social life are areas for managing self, mood and functioning in a preventative way. (More will be stated in chapters 9 and 10). There is a question concerning the extent of the ego because there are choices to protect self, create and use self-defences that can become set as a lifestyle or classifiable as a personality disorder. Part III of this work considers beliefs as causative of over-defensiveness in these ways. Because beliefs are also considered as choices to believe and consider something real, then some choices are not reappraised until decades after they have begun. This is particularly surprising when the outcomes are painful and self-limiting, and when attachment needs do not get met. These questions belong to the study of the qualitative basis of personality and psychopathology, understood as the consequences of choices that are predicated on belief and the felt-senses that they initiate and sustain. Part of action therapy is coming to realise the extent to which habits contribute to one’s sense of self and the relation to one’s involuntary and immediate intentional habits. Becoming aware of aspects of self over time is the way forward to owning problems and doing something to minimise them. This is often called self-observation or self-awareness. What it means is coming to be able to survey the aspects of self in relation to others without fixation on one’s own perceived inadequacies. In the early stages of therapy, perhaps even at the first session, any relevant behavioural change is likely to produce a positive change in mood and may help to relieve some of the tension that is felt, so a better mood is achieved.

Choosing and wanting Clients could choose to stay the same, or they could choose to bear the tension they currently feel, or they could choose to act and attempt to make a difference for themselves and those they care about. The point of action therapy is to encourage people to exercise judgement and choice. Targets are selected towards positive additions in lifestyle, habit and habituated choice. Or changes can be negative in choosing to stop doing something harmful and limiting. Either way, being motivated to understand the basis of problem-causing thoughts, sensations, emotions and problematic behaviours is best achieved through understanding intentional relations between these parts of the whole. The real inner track of practising behaviour therapy actually concerns motivating clients to want to 129

Talk, action and belief alter their own behaviour. The key is to employ positive motivation to encourage clients to choose positive options. For them, the motive to change offers altering mood, gaining more freedom, more time, more relaxation and greater self-esteem. It helps them know that they can make these changes for themselves. And if they so wished, clients could make further changes on their own projects by applying the same principles. Choice is part of free will and decision-making. Considered choosing in therapy requires people to think through an outcome in detail, to imagine what it would be like and find if people are willing to invest the time and effort to work for what they want. If when started the desired outcome is achievable and worth the anticipated amount of effort, then it should be made into a project for self. If the goal is no longer wanted or appears “too costly,” then it will cease to be sought after. The definition of choice is: If people value outcome A over outcome B, then they will choose A more frequently than B, over any time period. Any specific behaviour is a choice of one action in preference to others. The consequence is that commitment to a new lifestyle requires a renunciation of the old way of life; and a sustained commitment to making new choices. This does not involve unconscious factors in the Freudian sense but means letting go of choosing the problem. The problem requires replacement by new acts, through exercising skilled action for a prolonged period of time. Any slips back into old ways are excusable and do not destroy the progress made. Action therapy is about increasing motivation for clients, to achieve what they want and helping them choose positive experiences over negative ones, through renouncing the past. It is the general premise of action therapy that it is possible to choose what one does, thinks, imagines, anticipates and experiences, despite the strength of negative emotion that one might have. Even in the cases of sudden death of a loved one through murder, people can still act to minimise the negative impact on themselves and others. What helps is gaining a greater understanding of the negative consequences of problematic emotions, in order to produce more choice and understanding to guide further action. For instance, Samuel enters therapy because he gets angry easily in family life, at work and with friends. With friends, the consequences are that Samuel regrets what he has said and done. But by himself so far, this has not led to changes in his behaviour. His therapist asks him straight out if he thinks it is worth it overall for him to continue in this way. If there is no clarity about wanting a target, then drawbacks will later appear. Where action begins is asking for commitment towards chosen aims. One way forward is asking clients to act differently for a specific time and frequency of action, to see if the effort is worth the outcome gained. If the effort is not worth it, then clients have the right not to change and remain at the level of only having emotional and intellectual understanding of self. However, if the behaviour change option is taken, then the person has chosen to stop being neglectful of themselves 130

Ian Rory Owen PhD and their needs. He or she is the most important person who can promote or prevent their well-being. Changing one’s behaviour can be arduous because there is no one else who can do the work. One way of encouraging new behaviour is to ask clients to be committed to making changes themselves, so that they own the need for self-help and this takes away the unethical demand to apply pressure on them to do tasks for which they are insufficiently motivated. One way to motivate clients and allocate responsibility is to ask explicitly for clients to be committed to confronting fears, impulses and habits and become active in caring for themselves. After having explained the treatment of talking or action or both, therapists need to ask for commitment to work in the therapy. Gaining informed consent is ethically and practically necessary for any type of therapy. This is particularly the case in taking action where practical change is being encouraged. It should be clear that what is being recommended is self-help towards aims that are entirely owned and clearly wanted by clients.

Personality and social choices This section covers some of the difficulties found in encouraging clients to alter their social lives and how they place themselves with respect to other people. The view of the personality and psychological problems as a biopsychosocial whole applies and that is the topic of chapters 9 and 10. For the moment and in preparation of some remarks on working with the personality, a link is required between the abstract discussion of choice and value above, with a concrete notion of what is being chosen. In order to find genuine, lasting happiness, suitable social contexts are required of partner, family, work and friends. However, any discrepancies between self and the chosen social contexts need to be negotiated. The aim is for a good fit between self and others, increasing mutuality and a common interest in the same cultural objects. In achieving adaptation to the host community, the individual works to alter self to fit in with others. This choice is not bad, morally speaking. But it will take effort to produce an overall inter-action that is acceptable to self and others. To make no attempt to connect with other people is a high price to pay and a decision that is made every day, in every possibility of making the chances to meet new people and enjoy their company. The ability to co-operate and become part of a social network is probably one of the most important things in adult life. What needs to be improved is the ability to deal with others. Given that good social skills reduce social anxiety for self and others and increase security; and poor social skills increase anxiety, social dislocation, maintain isolation and attachment insecurity, it can be seen that the importance of a good fit between self and social context provides happiness; or can result in the maintenance of poor 131

Talk, action and belief mood, low self-esteem and pervasive unhappiness. In the region of social skills, there is difficulty in tightly specifying any situation because social settings are fluid and people do unexpected things that are incapable of prediction or control. Therefore, in creating behavioural experiments for social situations, it is easier to specify basic aims and let clients work out how to attain them in relation to their own abilities and needs. The “pay off,” the benefit of satisfying social contact, comes after effort has been expended to achieve it, not before. Indeed, the area of making choices and applying effort is key for social existence. There are not many choices that are available. 1. If there is no change chosen for self, then it might be possible to change others to accept self. 2. If there is no change chosen for self, then it might be possible to find a new social context for self that accepts self as it is currently. 3. If there is no change chosen for self, and self begins to fail in its ability to cope, then the situation can be interpreted as being one where the map of the social world and self in it, is insufficiently accurate. Possibly, the tacit understanding of self produces distress not harmony. If neither self nor the social world changes, then it is likely that distress will increase and self will become impaired, emotionally and socially. 4. If there is no change chosen for self, except to self-accept, then it may be possible to change one’s own attitude and learn to accept the current social context and stay in it. This option is about a change in understanding only. It concerns an increase in the accuracy of the map of the world. This might also be an introductory option for clients and does not entail them committing to achieving change. 5. Finally, changing self can be chosen, irrespective of staying in the current social context or leaving it. The nature of the change is not just an increase in the accuracy of the map of understanding of the psychological world. It requires action from self in the direction of increasing adaptation and giving up negative beliefs, behaviours and experiences that belong to the past. This theory of social choice sees people in social movement and as parts of social contexts where there are choices, even in the most traditional rule-bound cultures. Moving from one culture to another may win new freedoms but will not escape the fact that any culture constrains and limits its individuals in some way. The limitations of social obligation vary. Relationships do come to an end. Psychologically, people can move away from their families (for instance, their parents or their children). People may choose not to follow the religion or traditions of their culture of birth. Making new social choices concerns the ability to identify and work towards changes and choices. Given that a large part of the personality concerns 132

Ian Rory Owen PhD dealing with other people and one’s own reactions to them, then it is necessary to have some understanding of what it is to find a suitable social context. This next section comments on the necessity for the ego to want its targets sufficiently in order to put in the effort over a period of time and persist in working towards their targets.

Motivation supports choice Helping clients make choices towards some form of action includes altering mental activities themselves. Accordingly, within the personal sphere of what is thought, felt and remembered, when insufficient effort and a lack of skilled action are applied, the outcome can be low self-esteem, for instance. Alternatively, when sufficient skilled self-care happens, then self-esteem is achieved as a basic satisfaction. When clients understand that they are participating in, or indeed, creating their problems, they say to themselves “I have problems a, b and c. I don’t need problems x, y and z as well”. This is the point where they can choose to become self-caring and put in the commitment to change. One choice for clients would be to accept all the consequences of a current lifestyle or problem and choose to remain the same. If that were so, and whilst persons elect to keep problems, it means they believe that the negative consequences are worth the relief gained. Alternatively, there is the situation where therapists motivate clients to try something new, that is less problematic, and that involves decreasing the negative consequences of their previous attempt at a solution. The current psychological problem is most likely an attempt at a solution and will bring with it negative consequences that clients complain about. But because it also brings them distress, it means they expend energy. Yet psychological problems bring help in the form of negative reinforcement to wipe away some unpleasant feelings, even if only for a short time. Helping clients make decisions in relation to their anticipation of negative outcomes can be pursued in the following ways. The patterns contained within choosing, in connection to the outcomes, are that there can be poor (unhelpful, self- and other-harming) choices that lead to low self-esteem as a result of reflection on the unhelpful outcomes gained. Once there is the anticipation of negative outcomes and negative self-esteem, in the light of them, then there could be an aversion from choice itself and further difficulty concerning making decisions altogether. For instance, clients could further choose to defer decisions, no matter what the outcome of a decision might be. This is procrastination and it appears illogical from the perspective of those who feel able to act, choose and get themselves to where they want to be. Procrastination is a choice from the

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Talk, action and belief perspective of those who fear being judged, for instance, and choose not to act in order to avoid the anticipated negative judgement. It is necessary to not put pressure on clients to change and be honest with them about the extent of the therapist’s own role and the extent of the clients’. One of the ways in which action therapy works is in encouraging the exercise of personal choice over emotions and moods. No matter what the negative emotions are, and how strongly they are felt, emotions are not detrimental to well-being. Nor do emotions necessitate action of any sort particularly if those actions are damaging to self and others. One example is road rage, although there could be many more. If another driver has made another angry through their inconsiderate behaviour, then it does not mean that the offender should be punished by retaliation with inconsiderate behaviour. Refusing impulsive action with respect to hot emotion is the exercise of egoic choice and self-control in dealing with one’s own needs and in contacting other people in mutually satisfying ways. One simple way of exploring whether and how to change, and finding out about the degree of ambivalence and desire to change, is to create a grid with four combinations of the two variables staying the same or changing; and the advantages and disadvantages entailed in each option. One such situation for consideration is the relief gained by self-harm. The leading question being “is it worth it?” What is usually the case is that the relief gained from the pain is short-lived and what happens, once the relief has worn off, is that low self-esteem, self-criticism and depression increase. The pleasure of self-harm is a relief from strong negative emotion that dies away and can be followed by the greater unpleasure of negative thoughts and feelings. The disadvantage of giving up the self-harm is that the negative reinforcement “high,” the relief will be lost, but so too will be the negative self-criticisms and low self-esteem that follow after the self-harm. Whilst the negative impact is “not worth it,” clients may be unwilling to let go of the instant relief mechanism that self-harm brings. The problem of self-harm is seen as a broad class of events and will be returned to a number of times below. Clients need motivation to be self-governing and achieve, through deciding to act in opposition to very long-standing sensations and emotions. The problem with the long-standing nature of these difficulties is that topics become all too easy to assume and so people jump from one thing to another. For instance, one habit of choice might be that the tiniest amount of frustration calls for a full bottle of wine to be consumed. The process of choice can be expressed metaphorically: Choices and the learning that go with them are like pruning a fruiting bush. Pruning it helps make the bush grow in a particular way. The less shoots overall, the stronger the remaining shoots will be and the better quality fruit they will bear. There is only so much growth that can be achieved each year, and if every shoot were to grow, the bush would expend its life force in trying to make every shoot grow and it would not produce a good crop of fruit. With regards to drinking a 134

Ian Rory Owen PhD whole bottle of wine after experiencing a small frustration, then if this choice were to cease, then there would be room for new growth in the time where the alcohol consumption had been. The other side of choice is that negative motivation is usually not so powerful a motivator because fear abounds in people’s lives and to not do X requires thinking about X then choosing not to act, which can sometimes feel like something is being taken away, especially by the therapist, and such an impression should be avoided. Consequently, it is better to find positive reasons for changing and help clients explicitly elect to work towards specific positive ends. For instance, a person who is anxious and depressed might make bad decisions based on the panic and desperation that they feel. Their unsuitable decisions will further compound the problems they face. Anticipation of negative outcomes may also be connected to worry, increased anxiety and depression, and these lower selfesteem. An intervention as simple as listing out their positive aims is a means of re-connecting clients to their cherished values and the outcomes they desire. Another more detailed example of how motivation actually exists in practice is the following. Anticipatory fear comes through in a number of problems such as worry, social anxiety, phobias, and other problems that are future-oriented in that a problematic situation is anticipated. Most often, what is anticipated bears no relation to what does happen when clients enter the situation. The intentional relations are usually visual anticipation that produces negative emotions, or the linguistic repetition in internal dialogue of catastrophic and negative consequences that common sense calls “worry” and psychopathology calls generalised anxiety disorder. Problems are compounded when people think of something catastrophic, but do not take the visual scene or internal dialogue forward to an answer to the problem they have anticipated. The consequence is that clients use their mental faculties to create anticipated problems and omit problem-solving and planning altogether. One intervention is to take a problem forward in time to create a potential idea for a future solution or begin discussion of the prevention of it in the first place. For instance in agoraphobia, an internal dialogue is “I will be in town and I will faint and people will see me lying in the street and think I am a fool”. The intervention is “if that did happen, what would you do?” The aim of the intervention is to encourage clients into thinking through their analysis of a potential problem a step further to find potential answers to it.

Promoting behavioural change as the most ethical therapy In action therapy, the role of therapists is to help clients make choices rather than accepting blind habit, impulses and assumptions that are unhelpful in promoting their overall well-being. Therapists must honour whatever clients choose – even if 135

Talk, action and belief that is no change at all. The therapists’ role is to help and motivate clients achieve their aims. Therapists should not use force or try to make clients want things that they do not want. Applying pressure will poison the relationship and add unnecessary problems. Clients need to be self-governing in their time outside of the sessions. New actions are required in order to create new emotions. The action itself is necessary in order to feel differently about the same situation. But any outcomes will have negative and positive consequences. Outcomes will require some effort, learning and practice. Sometimes on-going practice is required and that will take time or entail not doing something else. New action is required in the heat of the moment. The outcome is often greater relaxation, confidence, happiness and feeling less tired. For instance, Paul, who was fearful of rejection, remained a pornography-user for decades without feeling able to find a partner. Paul chose to buy pornography and masturbate in preference to finding a partner and this kept him emotionally safe but single. Yet Paul never let go of the idea of getting a partner. It was not until he gave up pornography and opened his heart to rejection and acceptance by another that he was able to start dating and search for a suitable partner. The responsibilities of client and therapist are clear. Clients ask for help and are clear about wanting to change their behaviour and explore the experiential benefits that it might bring, whereas therapists are the facilitators of these changes. One therapeutic skill is to work with clients to create achievable aims. Learning a skill itself can be broken down into the following pieces. One thing to notice is the difference between justifications that support remaining the same; as opposed to those that promote experimentation, if nothing else. It is easy to spot the difference between “I can’t” and “I won’t” in someone else, but much harder to see it in self. Changing some aspect of the current scene requires maintaining a course of action in the real world, by being true to some idea of what is best for self and others. Although choosing and acting in new ways can be distressing and arouse substantial amounts of fear and anxiety, plus other negative emotional responses, it is within the scope of practical intentionality to be able to improve the self-esteem and mood quickly. A good action target is one that is measurable in time and quality and observable by self and others. For instance, to “do ___ every day for ___ minutes and for me to start ___ each time” is a precise outcome. Targets also include not doing something or minimising a self-harming behaviour to a specific time limit and frequency. This is how action therapy, behavioural experimentation and self-help exposure work in the service of making new beliefs become manifest. Changing behaviour and beliefs work in personality change as they do in reducing and minimising the negative effects of psychological disorders. When learning a new activity, there are stages through which the learning progresses. The first stage is known as conscious incompetence as the person knows how to act at an intellectual level, but does not 136

Ian Rory Owen PhD achieve it effortlessly. There is a transition to unconscious competence that ends in a skilled execution of the task without explicit thought or conscious connection to the ego. The difference between the beginning and end of learning is that the first few attempts will be more difficult and the performance achieved may well not be particularly good. However with repetition, the overall performance becomes quicker, easier and better, as the execution of the skill becomes more involuntary and automatic. The next section provides details of how to effect change through a program in which clients choose a series of increasingly anxiety-provoking situations in order to reduce the anxiety and avoidance that they had previously experienced.

Healing through exposure to anxiety Action therapy has its remit in breaking learned associations, habits and selfconditioned emotion-complexes. It works by directly dealing with the physiological level of distress and increasing the ability to tolerate discomfort. It promotes helpful new behaviours. With help, clients can choose each feared situation and practice staying with negative emotion until it subsides. If for any reason the fear does not fall, then there should be longer exposure and more repetitions until clients feel sufficiently confident to move onto the next level of difficulty. This is done by listing out all the fearful situations (or compulsive behaviours), explaining the procedure and asking them to challenge themselves in a way that is achievable. For instance, asking clients to set the amount of time that the exposure will last and recommending daily practice of it, if that is at all possible. There are simple principles for altering conditioned emotions such as fear. What are noted below are the principles of exposure therapy. The example of over-coming fear is used although many other frustrations and negative experiences could be over-come this way. In the following absence of real danger, fear is never an acceptable reason, genuine evidence, to mean that an action should not be attempted. 1. Break a large problem down into a number of smaller achievable tasks. Clients can start with the easiest ones and work through them to the hardest, in steps chosen and controlled by themselves. 2. Merely staying in a fearful situation will help. Clients who make a commitment to stay in a fearful situation until the fear falls will be able to alter the conditioned lived-meaning of being in that situation. 3. Daily practice is best if this is at all possible, the more repetitions, the better. If clients are in doubt about their progress, they can stay at the same level of difficulty and practice the task some more. 4. The use of distraction or relaxation techniques is unnecessary to over-come fear. The best way of over-coming fear is to spend more time in the feared 137

Talk, action and belief situation. The fear will fall through staying in the feared situation and not exiting whilst the fear is still high. The time to leave the exposure situation is when the fear has dropped and that in itself produces the new learning (new association or pairing between the situation and emotion). 5. Rating the amount of fear experienced, recording the time taken for the fear to fall and making notes of what happened all help record the progress that is being made towards the chosen targets. However, if there is acute distress that clients are struggling to tolerate, then distractions can be used as a means of staying in the fear-provoking situation until a more relaxed state occurs. The intervention above is followed through by asking clients to go to a problematic situation and check out their anticipatory beliefs and compare them to what did happen. This is achieved by having clients list their beliefs about what will happen before entering the situation. That listing is then compared to what actually did happen when they went into the situation in making a new more accurate set of beliefs about what actually happens in the present day. Taking new action is best achieved by specifying the amount and way in which effort and time can be spent in caring for self and others. Distractions can be used if possible, as can relaxation techniques. But neither distractions nor relaxation are necessary to over-come fear and anxiety. They merely help clients tolerate the negative experience that they are already committed to fight. It is possible to increase an experiential focus that lessens negative experience. Altering the intentional object, finding a new one, maintaining a focus on a new object and reducing anxiety, are part of the structure of everyday life. Like planning for an expedition, the first thing to do is to agree a destination. Only then is it possible to work out the enabling conditions that are necessary in order to achieve the journey. Action therapy can be explained with metaphors of “playing one’s cards right” or like “being the pilot of an aeroplane, tasks are like a flight. Setting the destination and take off are important but that does not mean that the pilot cannot take the controls. Making the journey and the landing enjoyable and comfortable, are all part of the pilot’s job”. Such metaphors should enlist the person in their ability to choose to look after themselves. Clients are often delighted with the products of their effort and learn that negative emotion is no reason to refuse taking necessary actions. Also, because of new actions in the real world, immediate increases in self-esteem and mood are possible. However, if nothing is ventured, nothing will be gained. Making behavioural change can elicit distress and low self-esteem but on the way to progress that far outweighs the negative experiences.

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Summary Similarly to the previous four chapters, this chapter focuses on behaviour as part of a complex meaningful whole for the purpose of co-ordinating the interests of both people within the therapy. Some perspectives in therapy see behaviour therapy as a non-event. For them, behaviour therapy is understood as a poor relation. But such prejudice does not connect with the empirical justification for its effectiveness and its central role in bringing change in dealing with the problems of the personality and other psychological problems. Since Paul (1967) and in more recent research (Longmore and Worrell, 2007), behaviour therapy has an excellent track record in promoting change. However, what change concerns is the desire for making choices in what to feel about experience. There will be many disappointments and negative experiences and it is an addition of pain to them to stay focused on problems far in excess of the ability to generate good feelings and solutions. Action therapy presumes that work of some kind will have to be done in order to reap the benefit of feeling differently. The fastest way to change how self thinks and feels is to act differently. If clients desire change, then they should be congruent with that desire and act accordingly through bearing the hardships involved in making the desired outcome manifest. This takes time, effort, dedication and striving through hardship. It is concluded that the quickest, most effective and most ethical way to start individual therapy is to encourage clients to improve their own moods as a way of beginning change in multiple, adjacent experiential fields of thought, feeling, the sense of self and the empathised understanding of others. •

If there is self-harm, in the broadest possible sense of that term, psychologically and physically, then choosing it needs to decrease. Changing behaviour often entails choosing abstinence of a problematic behaviour. If clients are committed to increasing self-control for their own reasons, and are sufficiently dissatisfied with the pain and damage that obeying impulses produces, for instance, then half the battle is won. Stoicism is a virtue. The remainder of that battle is increasing commitment and motivation and choosing behaviours that will bring desired rewards.

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Therapists help clients be congruent with their aims and abilities. For instance, if they want a partner, therapists can encourage and support clients in beginning the actions necessary to find one. This is a complex social task and their imagination and anticipation show what people want, need and expect will happen.

Lack of certain knowledge of the future can impede making a choice between two or more alternatives. When faced with the choice of what and how to choose, then just making an explicit choice can be freeing. This can be boiled down to 139

Talk, action and belief a motto of “enjoy what you choose to do”. But choice also concerns not doing harmful things. A second motto is “avoid doing anything that would be harmful for you”. Effort, practice and skill will pay off and if a choice is intricate and hard to achieve, but would be good in the long run, then the effort is worth the outcome. Action therapy deals with reducing the physiology of distress and avoidance. Change requires being comfortable overall with taking some risks: comfort comes after a period of discomfort. Changing behaviour may require increasing the ability to tolerate frustration, by electing to have small doses of it, to be able to increase the capacity for hardship and learning to tolerate distress. Stoicism is not to be confused with self-harm. The most general type of action therapy is planned and sustained self-care. But this requires the fulfilment of lower conditions for its possibility. One lower condition is promoting understanding of the problem through the means of formulation on paper by a simple diagram that sums up the most relevant factors at hand. There is a question about how to work with those clients who cannot or will not participate in action therapy and make changes. One motto for encouraging positive motivations is “the other side of fear is freedom”. In order to help clients get out of the hole that they have been digging, requires them to stop digging and to know when enough is enough. This means taking into account what makes a sufficiency of any negative outcome. Meeting the demands of social roles, balancing tensions, re-addressing social deficits and meeting attachment needs are at the centre of personal choice as it connects with the social expanse. Following through with action is an assumption of therapy. Action begins where insight ends: Action brings further understanding at emotional and intellectual levels that surpass, in richness and immediacy, what can be gained by mere discussion, reflection and new interpretation. Clinical reasoning is explained concerning the links between belief, verbal and non-verbal meaning in part III.

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Part III Psychopathology, belief and the treatment of belief

PART III Psychopathology, belief and the treatment of belief

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Talk, action and belief This third part of the work opens a new all-embracing intentional connection between the parts and the whole. Now that the previous explanations are in place, it is possible to focus on the intentionality of belief. This part comprises five chapters that re-visit many of the points introduced above but now demonstrates belief as a commonality between distress and providing help through talk and action. It shows how a clear understanding of belief and re-interpretation can enhance therapy. This part widens the scope for practice by way of development and recapitulation of the previous parts. The sequence of chapters below begins with a major re-statement of the intentionality model for integrating therapy towards the conscious meanings of clients. A clarification is made concerning how people can be understood within a view of what it is to be a person who has psychological problems, rather than focusing on an excessively narrow understanding of personality problems. What is rejected is the idea that anyone who passes a checklist of a certain number of symptoms, or who gains over a specific number on a questionnaire, qualifies for a diagnosis of “personality disorder”. For a number of reasons, on the contrary, the diagnosis of personality disorder frequently leaves clients and therapists in an uncomfortable place where neither knows how to proceed. By itself, “personality disorder” is not a solution to a problem, nor can it help in solving the type of problem identified. Rather, a wholistic view is created of the connections between personality, problem, mood and self-esteem. Personality is understood as a process that develops across the lifespan and links together many areas of functioning and experiencing. Making-meaning and belief are explained to capture the core experience of understanding another human being. Be it in discussion or more generally still, in trying to understand people in general, it is argued that belief and understanding are living occurrences that create problems. Yet work on belief and understanding hold possible answers for clients. When belief and understanding are themselves understood, it informs the ways in which therapists can intervene. What is presented here is the necessity of self-understanding and self-care for clients who have major long-standing problems that may be detrimental in numerous aspects of their lives: The cure is that plain old-fashioned insight and self-management of the chosen lifestyle, role and identity are required. Chapters 9 and 10 form a pair on the most general view for practice. Chapters 11 and 12 form a pair on interpreting belief, formally explained as a type of psychological hermeneutics. Chapter 11 covers the consideration of realms of lived experience by the philosophical terms hermeneutics and belief. It is a truism to state that awareness, reflection and re-interpretation are employed in therapy. These same processes occur in all relating, emotion and everyday life. Chapter 13 introduces meta-representation to aid understanding and making distinctions in lived experience. 142

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Understanding Brian as an example of the freedom in making sense For this work, both hermeneutics and belief are at the heart of making sense of the world psychologically. In order to illustrate the myriad of perspectives in the everyday world, therapy practice and theory, a scene from a film is chosen that exemplifies how different people make different senses or meanings out of precisely the same occurrence. The reason why they do this is that each person takes a different initial understanding to the same event. When they make sense of it, if their initial understanding was wrong or inaccurate, then the sense they make of what happened will also be wrong or inaccurate, unless they can correct it. When the character Brian, in the Monty Python film, The Life of Brian ( Jones, 1979), runs away from some Roman soldiers who are chasing him after he had been arrested, Brian finds himself having to give a prophetic speech in order to disguise himself amongst other prophets who are in a market place. But whilst improvising he attracts a small gathering. Because the soldiers are looking for him in the market place and are close to him, Brian suddenly loses his nerve and runs further into the market place in order to hide. But as he runs, the soldiers see him trying to get away. Brian buys a gourd in order to hide but he drops it as he runs away from the soldiers who spot him again and chase him once more. However, the assembled crowd who were interested in what Brian had been saying, run after him saying that he is a genuine prophet. Brian tells his ‘followers’ to “go away” as he is trying to get away from the soldiers who are still looking for him. In trying to make an escape, Brian gives away the gourd and loses his sandal in the confusion. Brian runs off, leaving his ‘followers’ behind who discuss what to do. One of the followers holds up the gourd and she says that it is a sign of Brian, ‘the new prophet’. Those who followed Brian wonder what it means for Brian to have lost his sandal. One follower calls out that the loss of the sandal is a sign from the true prophet Brian and that all who follow him should do likewise, and take off one sandal and hold it up. There is robust debate about what to do. The woman with Brian’s gourd insists that the gourd is the genuine sign from Brian. The crowd discusses how they should act. One man calls out that Brian’s new followers should take off the same sandal, to show that they are true followers of Brian. Another calls out that they should gather together all the shoes of Brian’s new followers. The woman with the gourd shouts out “his gourd,” holds it up, and asks all present to follow the sign of the gourd: “He has given us his gourd,” she implores them. The other man picks up Brian’s sandal and says that it was Brian losing his sandal that is his true gift to his followers.

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Talk, action and belief One member of the crowd tries to pull sandals and shoes off people’s feet to make them become followers in the right way. For him, Brian’s message is that his followers should gather their shoes together in order to prove they are his followers. The woman with the gourd shouts, “No follow the gourd!” The man who is trying to pull shoes and sandals off the crowd says, “No gather shoes!” Another cries out that the shoe is not a shoe but a sandal but it obviously is a shoe. Then there is an argument about the sandal not being a sandal but a shoe. The end of the scene is where a man (played by the comedy actor, Spike Milligan) steps out from the crowd, to pray and makes a rational well-argued speech about Brian’s message to his followers but nobody takes any notice and the crowd disperses in various directions to follow the sign of the gourd, or follow the sandal, or run after Brian, who by now is long into the distance. The point of this story is that so it is with academic debate in philosophy and the schools of psychology and therapy, according to the view afforded by hermeneutics. There is little consensus, but many schools and much debate about what the signs mean and what people should do in order to adhere to the signs that are claimed to have one meaning or another. The point for trainees and experienced practitioners is that without consensus each will do as they please, select portions of evidence and interpret them how they will. The remarks of this part of the book serve to show how the intentionality of belief can make sense of the links between psychopathology and practice. Therapy is attending to the phenomena of providing and receiving care, and working out from that evidence, what the experiential differences are among observable distinctions, and hence, what intentionalities exist concerning psychological processes and the expression of the personality. These distinctions also concern how to treat any specific person and which problems to work on first. However, the waters are muddied for gaining conclusions, because there are so many divergent ways of making sense of the relevant phenomena. Thus, a difficulty in making sense is both a problem and just the way things are in making sense of any topic whatsoever. There are a small number of necessities in understanding the role of intentionality in practice concerning talk, action and belief.

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9 The psychological worldview of the intentionality model Aim: In a deeper return to the introductory remarks of chapters 2 and 3, this chapter provides more detail of the understanding of intentionality that is taken to understand psychopathology alongside everyday conscious experience. This chapter returns to the need to identify and make theory about conscious experience. The type of theory argued for is not scientific but meaning-oriented. This chapter provides deeper theoretical statements for practising the intentionality model. The psychological worldview of the intentionality model is that life occurs through various types of awareness about various types of objects of attention. Intentionalities that produce different senses of objects can be grasped in various contexts even if those contexts are interpretive ones of understanding, or perceptual or psychological contexts. However, proper explanation in practice concerns making explanations in terms of intentionalities, when explaining how a memory experientially co-occurs in the perceptual present, for instance. The aim

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Talk, action and belief is to support and explain here and now reasons for making changes and taking an experiential approach to talk and action-oriented interventions and self-care. The sequence of this chapter is to start by making concrete the tool of understanding intentionality as the commonality for understanding personalityfunctioning, psychological problems, practice and self-care strategies – as one whole. Next, further details of the intentionalities are sketched in terms of their specific types and how they create a meaningful whole. Next meaning and the general term “cultural object” are broached as a means of introducing what it is to be a self in relation to another person. Next some basic parameters for a qualitative psychology of the sense of self are noted before noting the changeability of the sense of self as a meaningful experience and then closing the chapter.

Introduction The intentionality model of theory and practice is based on the theoretical stance of Edmund Husserl, the twentieth-century German philosopher who began phenomenology. However, the ideas provided are not going to be argued with close reference to the original texts. What is going to be presented are tangible means of providing help for a wide range of personalities and problems. The manner of explanation is based on conscious experience. The aim is to have theory arise out of the careful consideration of experience. No matter how difficult that is. The starting point for the intentionality model is interpreting what is conscious as the result of intentionalities that produce lived experiences and meanings. Whatever sense is conscious is understood as a part within a greater whole. Any conscious sense is comprised of an intentionality turned towards the object of attention in such a way that consciousness knows that it is conscious. The following practical and theoretical problems of how to understand meaning and experience are over-looked by current models of psychological formulation in the talking and action therapies. Theory makes psychological processes explicit. Theory is necessary reflection on experience, leading to adequate explanation of what highly intuitive therapists do in a split second: They can jump to an empathised, guessed or presumed answer that may or may not be close to what is happening for clients. The problem is that the intentionalities of other people, and the senses of their mental objects, never appear to self. This is a problem because of a lack of theory concerning how to understand the conscious experiences of other people. For instance, to see someone crying says little about what they feel. The affective intentionality could be loss, happiness, relief or anger. Most therapies agree that self-understanding is crucial to promoting wellbeing. In the technical vocabulary of this work the terms apperception and empathy are used to cover the generation of sense of self and other and note that they are in an inter-active relationship where the sense of one affects the sense of 146

Ian Rory Owen PhD the other. By means of recap and development, it was the claim from the preface onwards that what the intentionality model offers is a tool for understanding both the personalities and problems of clients so providing a uniting language between the everyday world that they inhabit and the technical world of therapy. This promise of usefulness is now going to be made actual by spelling out a fundamental psychology of qualitative experiences. Some definitions need to be made that are introductory and orient major terms to the core aspects of what it is to be a human being in a social context across time. The terms chosen are to relate the word “self ” to the lived experience of being in relationship with others. This is an irreducible whole. The word “personality” is used in a technical sense in developmental psychology and psychiatry, as will be explained in the next chapter. What needs to be understood is the link between the lived sense of self (including all the many verbal attributions that could be made by self and others) and the personality. Self lives, reacts and influences its context - as opposed to personality which is the result of classifying styles of relating. The self as a living being exists in social contexts of various sorts. When the self is healthy it develops accurate, constant and coherent sense of itself and other persons and it can deal with the social world with all the trials and tribulations that are involved. The social world can be classified into establishing negotiations and co-operative relationships in non-attachment relating and security in attachment relationships. The problems of dominance and submission, for instance, can appear in both dealing with the world at large – and in more intimate and meaningful relationships (with partner, family, friends and close colleagues). Good mental health is establishing secure attachment and negotiating the social world at large in the long-term. It is maintaining the ability to relate even in the event of permanent loss of attachment figures (through death or relationship break up or psychological distance) without the use of excessive defences that prevent happiness and satisfaction. The same hypothesis will now be stated in the negative, to show what it means for the combined view of understanding problems of the personality and the axis I psychological disorders in this relational view. Mental distress is when inaccurate, inconstant and incoherent senses of self and others are perpetuated that interfere in coping with the social world and defeat the attainment of secure attachment. Inevitably, when there are problems in relating with other persons (be they intimates or strangers), if there is mis-empathy and mis-apperception then these problems will not be negotiated as well as they could be. And, in the event of distress, change and permanent loss of attachment figures, as there will be, then if excessive defences are kept (in the absence of their need), then there will be further negative impacts on the quality of life and general functioning. The ability to cope with basic psychological needs for happiness and satisfaction will be impaired such that a depression, for instance, is maintained 147

Talk, action and belief for decades of the lifespan. In this case, the on-going sense of loss contributes to preventing finding new attachment figures and the satisfactions of connecting with them – because defences operate too widely and harshly. Specifically the so-called personality disorders are seen in a very wide view, including all persons who have long-standing difficulties in establishing a coherent sense of themselves and others and in gaining attachment satisfaction. The key for cure is to help clients understand their defences and aims and facilitate their achievement. The analysis of defences is part of formulation and understands the function of the personality and specific disorders. The next three sections are a return to the role of intentionality in understanding psychological life.

Intentionality as the link between personality, problem, practice and self-management Given that words are labels for experiences in psychological life, distinctions between the most basic perceptual sensations of the present moment, plus the awareness created by presentiations (like imagining, empathy and anticipation) are basic for emotions, which in-turn are basic for moods and patterns of behaviour that are longer-lasting. Where intentionality shines is being able to capture the links between the sensations of wanting love and attention, hunger, tiredness and being aware and interested (or not). Intentionality differentiates the way that consciousness can choose its own directedness towards what is sensuallybased and include higher types of understanding. Choice exists though and it becomes possible to control and direct attention in a skilled way, choosing what we experience and what we express to others or not. It is possible with skill, to alter negative emotions and moods and distract self away from these experiences, if being excessively focused on them is destructive. If change and self-control were impossible, there would be no therapy and psychological change would be impossible. The practical aim is to discuss and agree with clients what intentionalities are driving their problems: This is achieved through a hermeneutics of interpreting beliefs because what is believed to exist and how it believed to exist, is what is responded to emotionally, behaviourally and in terms of relationships between persons. For instance, a key difference is how to judge when to be cautious because there is actual threat - and when to be relaxed and confident in the absence of threat. This and similar distinctions are at the heart of many personality disorders and psychological problems. Any thought, feeling or relationship with another can have a variety of meanings. The meanings can be explicit in thought and speech. Meanings can be inexplicit in emotion and non-verbal communication. Or the 148

Ian Rory Owen PhD meaning of an act or relationship may not have been reflected on, or not yet adequately thought through. If it is the case that reflection and interpretation have not yet occurred, then this does not mean there are ‘unconscious senses’. It means the pattern within conscious experience has not been made sense of yet. What wins the trust of clients and the therapist is having ideas that become practised skills that provide actual help, and focus on the nature of problems as clients experience them. The first thing to do is understand the nature of the problem, so to know where and how to intervene. But the basic problem remains the same: What is demanded is a basic understanding, a formulation of ‘cause’ and effect leading to action, to make the transition to a psychological solution. It is generally thought that belief causes anxiety. And the explicit formulation of beliefs and their disconfirmation is the best way of reducing anxiety (Salkovskis, 1991). By extension, it is the case that other emotions and problematic states can be helped by staying in previously fear-provoking situations. For instance, belief should be not confused with mere conceptual intentionality and it becomes possible to understand how affect and conceptual intentionality can sometimes agree and disagree with respect to the same object of attention. Empathic understanding is a medium that works both ways. Generally, the other person’s experiences are empathised through the totality of the verbal and non-verbal aspects of an inter-active communication, where what is perceived, visually and auditorially, acts as a carrier for the greater psychological meaning of what might be happening for the other person. The sense that the other communicates makes sense with respect to the experiences of self of the psychological object that the other person might be talking about. But the process of communication is fallible. It can be the case that therapists fail to understand perfectly and clients fail to explain perfectly. What is occurring psychologically is not merely the transmission and receipt of concepts. While it is true that reflections and summaries of what is received psychologically, improve the transmission of psychological sense between the two parties. It has to be noted that the experiences of others only quasi-appear for self - as does their perspective, intentions and the part of the world in which they live. This means that care is required and any potential conclusions drawn by therapists are always tentative, open to discussion, further refinement and revision. The next section states the case for intentionality of belief as a model for understanding the experience of others.

More detail on the intentionalities Intentionality is pertinent to the psychology of therapy and everyday life because people relate to the senses of objects that they believe exist, in the manner in which they believe them to exist. This means that intentionality captures the phenomena 149

Talk, action and belief that comprise psychological reality. Psychological reality is a variable end-product strongly influenced by the initial attitudes and understanding taken towards situations. Commonsense is the result for persons who believe and disbelieve. Psychological reality does not concern material things that exist here and now for all, as communal facts. The concept of intentionality is sufficient to capture the non-material manner of the existence of a personality style plus neurotic and psychotic problems. It is the case psychologically that what people are afraid of, for instance, is not current, might not happen, and possibly may never have happened. The logical facts of the matter are not representative of what persons anticipate and experience in reaction to what they believe psychologically. However, what is raised by intentionality is understanding how various sorts of meaning are inter-connected. Temporality is important because all experiences occur in a temporal flow and have a temporal orientation. This topic is important and will only be mentioned in passing now, before coming back to it, in the way that it structures the understanding of evidence in chapter 17. The non-verbal influence of the past is that past decisions, experiences and meanings are formative and can be crucial in narrowing the lifestyle and influencing current choices. Different intentionalities can be congruent or incongruent with each other, with respect to the same object. This is what happens when logical thinking and emotion are completely different with respect to the same situation. It is a future project for pure psychology in 1925 to investigate the differences between temporary perceptual illusions and longer-lasting perceptual evidence, for instance, in order to understand how experiential evidence accrues across time, and so provides a solid basis for belief as opposed to senses that explode and dissipate and so get disproved after a length of time (Husserl, 1962/1977b, §19, pp. 96-97). There is interference between strong emotions in obsessive compulsive disorder, for instance. The consequent high anxiety and emotional arousal felt frequently impede the ability to problem-solve and rationally analyse immediate experience. Reason that is in-step with emotion recurs when the overall intensity of arousal falls. High emotional intensity thus inhibits helpful action and interpretation. Emotion is often a more powerful motivating force than logical thought. Intelligent and capable people may act in their own worst interests because of how they feel rather than what would be good for them. Hence, it can be good to act in accord with reason rather than in accord with fears that are out of proportion to the actual threat that is present. Specific types of sense are found through experiential immersion in regions of experience of different kinds. Husserl concluded on the species of intentionality by comparing and contrasting the way that memory and anticipation provide their different types of givenness within the overall context of the perceptual present. In overview, the current moment is an open space into which the past and the future flow and are super-imposed on the present. For instance, the most 150

Ian Rory Owen PhD fundamental genus of intentionality is the passive occurrence of the duration of time. The next most fundamental genus is perception that includes the felt-sense of the living bodiliness of one’s own body, leiblichkeit in German. Perception is the genus in which people and inanimate things are perceived as being bodily present in a current moment. Perceptions can occur “with identity” or “without identity”, (Marbach, 1993, p 178). Many signified meanings are linked to what appears perceptually or to conscious awareness of the visual, auditory and kinaesthetic objects of voluntary and involuntary memory. Thoughts, emotions and beliefs can be about what appears to imagination and anticipation, or hallucination and dreaming as well. Perception is mixed with understandings from other intentionalities and other time-frames, past and future (Bernet, Kern and Marbach, 1993, pp. 141-154). What happens in perception is that the ever-present window of the now is open, not only onto what is self-given as real right now (Husserl, 1948/1973, §42a, pp. 175-7). The now is also the window that opens onto the past, the future and the imaginary. Perception contains within its openness, super-impositions of influence on the current meanings that appear (Bernet, Kern and Marbach, 1993, pp. 116125). This includes the super-imposition of psychological influences by means of connection with the social sphere of what other people might think, feel and do. These influences are created through different means. Some of these influences arrive through explicit language, concerning what people have said. While other influences might concern what might happen, for instance. Because of the nature of the complex co-occurrences and novel perspectives that can be taken, there is no limit to the re-interpretability of any one object ( Jaspers, 1913/1963, p 356). Potentially, it can be re-appraised in any number of contexts, from any number of perspectives. Such is meaning. Whilst there is no guarantee of meaning and no ability to stop re-interpretation, this freedom of movement means that painful psychological meanings are at least capable of being re-appraised. “Intentional implication” is the technical term that means that intentionalities are connected to each other in various ways. When understanding what another person is talking about, there occurs, the perception of the other in vision and audition, the conceptual intentionality of the logical content of the discussion and empathy with respect to understanding the non-verbal presence of the speaker in connection with the psychological meaning of the perspective that is being discussed. It is easy to understand empathy by comparing it to logical communication. If we only understood each other intellectually, then the world would be an entirely logical world of facts, certainties and probabilities. This is why it is so easy to mis-understand text messages sent by mobile phone. There is no accompanying meta-message to indicate the attitude in which the logical content is being sent. Gregory Bateson defined meta-communication in the following 151

Talk, action and belief way, “human verbal communication can operate and always does operate at many contrasting levels of abstraction… e.g., “My telling you where to find the cat was friendly,” or “This is play” … the vast majority of … metacommunicative messages remain implicit”, (1972, p. 177-178 ). The next higher genus is two types of presentiation. The first species is purely mental representation. Its species are imagination, recollection and anticipation: These are “forms that just intentionally imply or modify perception”, (Marbach, 1993, p 108). The second more complex species involves an association between what appears and what is meant. For instance, in pictorial representation in visual art, what is actually perceived, paint on a canvas, stands for the depicted object, a landscape perhaps. Pictorial presentiation ‘depicts,’ ‘associates’ or ‘overlaps’ sense between the signifying item and its signified content. An alternative way of stating the same idea is to write that pictorial presentiation is when there is a “double intentionality” of perceiving and decoding the depicted scene that points to a “double object:” the perceived canvas and its depiction (p 128). In detail, a depiction of x is “intuitively representing x” in “an activity where the intentionally implied perceiving in the mode of non-actuality is taken to be of the x as it appears in the picture y which, at the same time, is actually perceived; this kind of activity obtains in pictorially representing x that entails intentional reference to a double object”, (p 179). In a different wording still, y, the painting, represents x, what the painting is about. Pictorial presentiation links y to x through the medium of paint and one of the genres of styles of painting. Empathy is somewhat similar to pictorial presentiation in that the nonverbal communication of the body of the other indicates what their perspective is towards the object of their attention. Let us deepen the attention to empathy. The living expressive body is the marker of non-verbal attitude that expresses involvement in the world. Specifically, what does appear about others are their bodies visually and their speech auditorially. Empathy is the intentionality whereby we may have learned sufficiently what the perspectives of others could be, on the same cultural objects that we see, hear, feel and talk about. On hearing another person speak, empathising is to quasi-feel what that other person felt and have an appreciation about what still further other people feel, who are being discussed. Empathic understanding is a fundamental subject matter for therapy and the human sciences. The difference between the perceptual presence of human beings to each other, and the psychological meanings that are carried by speech, bodily sensation and non-verbal presence, is that the intersubjective world of meaning occurs as a signified whole, comprised of higher composite objects based on and related to, the here and now sensation. People enter the social world in a particular way. Empathy is the ability to quasi-experience what other people experience. Our experiencing of what they experience is the creation of an empathised object, to 152

Ian Rory Owen PhD give it a name. The empathised object is what selves’ experience of what the other persons’ experiences. Empathy is at the heart of understanding of intellectual, social and psychological meaning. Empathy is unlike perception (yet it is allied to it). What appears empathically is a sum of understanding that is greater than its parts. There are a number of negative states of self-feeling and self-relationship that occur because of the condition of social possibility called “intersubjectivity” and the intentionality of empathy. Rightly or wrongly, each self has an empathicallycreated picture of what others think and feel about self that is determined from the speech and actions of others towards self. The sense of self in the other, as it were, can be derived through habit, memory and emotional conditioning. It could be a generalised belief explicit in language. Or be implicit in actions, relating and emotions. When the value given by self to self is negative and temporary, it could be called low self-esteem or embarrassment. When the value given to self is negative and a long-lasting aspect of the personality, it is called shame. Shame is when self is believed and felt to be corrupted and socially unacceptable because of specific deeds, thoughts or aspirations. Shame concerns the repressed and taboo aspects of being a person. Shame is for the most part undiscussed and may never be made public. Shame is linked to semi-permanent long-standing self-criticism due to the conscience attacking self. Shame may be linked to moral anxiety, or the feeling that one is unlovable and has broken a number of rules concerning what a good person should be and how to act towards others. When these ideas on self are added to understanding of the other, and given that psychological meanings exist within the sphere of empathy, it is argued that the overall inter-connection is what enables communication and sharing codes of meaning. However, if the codes are different for two persons, there will be misunderstanding. Social conventions and symbolic cultural codes of all types are like languages. The rules of grammar, spelling and punctuation have to be appropriated and used in the standard manner in order to communicate. Individuals cannot make up their own system or they will fail to communicate. Symbolic cultural codes dictate how people in a culture expect the proper performance of gender identity, role, non-verbal expression and dress codes for different occasions will be carried out (Owen, 2008c). If the codes are not standardised or if people were using two or more communicational codes, then there would be mis-communication or failure to communicate as people would be speaking different languages. The difference between pure guiding ideas - as opposed to practice and research about practice - is that any deficit within the social skills of therapists can be seen in persistent errors in helping clients in a wide variety of ways. Consequently, a motto for the responsibility of therapists is “you are as effective as the outcomes you make with the clients you have”. Let us take an example to make the concepts become more tangible. 153

Talk, action and belief In overview, the intentionality model answer, concerning making sense of client experience for formulation, requires the following realisations. The central phenomenon is empathising clients through discussing their problems with them. The first item to understand is that psychological understanding itself is far greater than the logical content of what is said. When therapists empathise clients, the intentionality model believes that therapists are aware of how the conscious attention and choices of clients are turned towards an object through empathy, the type of intentionality that produces a specific sense of the view of others and how their object of attention is understood in one or more of a number of competing contexts.

Putting the pieces together: Intentionality, sense, object, context Intentionality comes in many forms. The term “intentionality” and its adjectival form “intentional,” concern the many ways in which consciousness can be conscious-of any object of attention. The range of states of consciousness include sleep, dissociation, hallucination, dreaming, moods, emotions and believing what does and does not exist: What is believed and what is incredible. Although intentionality is used to highlight processes that vary or hold constant across time, it is the case that contexts around objects are also relevant. Four contexts are assumed across the process of psychological change (see below, figure 13). 1. Context of the on-set of long-standing personality and more transient psychological problems. 2. Context of maintenance of problems and their influence on each other. 3. Context of re-interpretation is formulation, a translation of what clients think of them into the professional vocabulary of ‘disorders’. 4. Context of re-experiencing: Clients can achieve often through altering their understanding, behaviour and attitude. What this analysis distinguishes are the intentionalities that occur in current perception, in relation to speech and empathy. Visual perception, hearing, speech and empathy can account for most psychological understanding. The other important things to notice are the orientation in perspective and time towards the future and the past: the self is in the centre of its part of the world. Let us take these four contexts and explain the processes at work. Contexts one and two are already existent before assessment. The first context is the one in which the problematic behaviours first began. They are the birth place of a problem, a belief, a feeling, the sense of a relationship to another person or thing. 154

Ian Rory Owen PhD The context of on-set was a lived context of conscious meanings and experiences. What has begun is that false beliefs and inaccurate senses of the perspectives and intentions of others have occurred as learnings that become generalised and reapplied in the context of maintenance in the present at an assessment. Context one is the originating problem of intentionalities that gave rise to distress, false belief and generalised empathic mis-understanding about others. Context one is the problem as clients experienced it. But of course, the situation is not just considering what clients are experiencing. Understanding is the gateway towards change. The context of maintenance is that clients take false beliefs, inaccurate generalised understandings and re-create something similar to, or a development of the first problem, and maintain it. Often this means that learnings from the first context get generalised and beliefs proliferate, rather than attenuate. Once clients enter assessment and their situation is understood, then re-interpretation occurs where therapists make distinctions about intentionality: between the truth of the senses believed by clients and identify the mis-learnings generated from the first context that are then re-applied in the second. Context two is where clients take false belief and mis-learning (based on intentional acts) into new contexts in their home life. The false beliefs and mis-learning are applied to the new context in such a manner that the belief and mis-learning are sustained and supported and can become more generalised. It should be apparent that any one object could have many senses or meanings, according to the way in which it becomes conscious and how it is approached. Also, it is the case that the context in which an object appears (simultaneously at a moment in time, or developmentally over a span of time) makes a good deal of difference according to what it means. This is particularly so with the case of psychological objects such as the state of a current relationship, what a psychological problem is, or working out what an emotion is about, even when at first it seems to be about nothing in particular. In dealing with meaning, any referent object has a manifold of possible senses, according to the perspective towards it and the context in which it is placed. But neither of these senses, from contexts one and two, are full or adequate representations of the objects at hand. Context three is when clients understand that their experiences are partial representation of the objects, and are obtained as experiences because of what they bring from the past into each current situation, where the problems recur. Therapy takes clients and their understanding in the consulting room and makes distinctions between the lived sense about context one (beliefs and mis-learnings generated in context one and ‘re-experienced’ in context two) but neither of these are full representations of all the senses that are applicable to the object at hand. Change is indicated by the intentional explanation of the problem made through formulation. Just understanding how 155

Talk, action and belief there is a problem and how it is maintained can attain some lessening of the problem for some people. What can be changed are specific senses of the object-referent and the types of intentionality involved. For instance, the intervention of writing a letter to someone without sending it, works to decrease distress through promoting reflection about affect, recollection and expressing previously unexpressed thoughts and making them public in the conceptual intentionality of thinking and writing. The past does not change. What changes is the sense of the past object, the relation to it and how frequently the recollection is made and for how long it becomes a focus. Hence, the fourth context is re-experiencing problematic situations to further acquire new senses of the same object, in order to gain new learning about it, alter explicit and implicit beliefs, and for instance, work towards secure attachment in life. Healing is gaining fuller experience, of more senses of the same object, in order to weaken the impact of the false belief and mis-learning that have been over-influential. The positive changes that occur through therapy are a fourth context. Context four is when there is further acquisition of new senses of the same object, through altering the intentionalities employed. Everyday living is comprised of many complex combinations of mental processes. Regarded singly, there are many forms of action, understanding and experiencing meaning that provide different senses about objects within the world as a whole. All these can be adequately covered by a simple rubric. An intentionality of a specific sort creates a sense or meaning about any object of attention within some context. Context is a key concern and was referred to as Hof in German or horizon (Husserl, 1913/1982, §28, p 52). Let us run through these terms.

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Figure 13 – The relations between intentionality, sense, object and context. Sometimes clues to new understanding overall are attained by a change in perspective. Perspectives can be different through performing the same behaviours more fully, with a sense of enjoyment and relaxation for instance, rather than distress. A change in perspective is a re-orientation in place and person, like going from being in oneself in a nervous way, (such as the effects of being raped) to occupying any new perspective in a way that dilutes the negative impact. Changing perspective is not an answer in itself but may promote changes in affect, empathy and understanding of the intention of the rapist towards self as a survivor. “It wasn’t my fault. I was drugged and then attacked and left in a toilet cubicle to wake up alone”. In this example, the change concerns understanding that there is evil in the world and that the survivor of rape did not invite the attack. The progression across the four contexts is one of understanding on-set, recurrence and development of problems, through making understanding shared between client and therapist, leading self-motivating clients to have corrective emotional and relational experiences. The view of psychological change through talk and action is that the problematic senses can change to less problematic ones (through overall reappraisals in language and feeling and practising new behaviours and skills). Let us take the concrete example of someone with obsessive-compulsive disorder. Psychologically and emotionally, Andy has visual images that he believes as being accurate representations of what will happen. Andy believes that if he 157

Talk, action and belief did not wash the walls for an hour every day, as he has done for the last 15 years, he imagines his house would fall down. His emotions are proportional to what he would feel: the terror of what would happen if the house did fall down. Emotions that are felt about any ‘cause’ are real in the sense that they are felt-representations about some past, current or future relationship or event. If an object is conscious in a specific way, corresponding emotions are felt in the present. Therapy for Andy meant understanding that he had obsessive compulsive disorder since childhood as it had not previously been recognised that he had it until he was 30. The maintenance of the problems was understood through hermeneutic questioning. Through formulation on paper came the revelation that there was a specific pattern to his worries. Finally, when he set his own targets and chose to reduce the washing he found that the images that he had of his house tumbling to the ground never came true. This next section focuses on understanding psychological meaning as a social phenomenon accessible to all, a public event.

Meaning is a social phenomenon This section introduces some of the detail of social learning that is achieved by empathy in a more tangible way. Meetings between people have a number of characteristics. As the example of two people sitting at the same table and looking at the same vase can explain, the psychosocial world is open to view the mutual objects of commonsense attention. The same occurs for the psychological life that we share. It is now possible to extend the basic definition of the object of attention already mentioned. A specific type of intentional relation to an object provides a specific conscious sense. Each view of the object varies depending on the manner of approach taken. For instance, if the object of attention is a vase on a table, then when looking at the vase whilst sitting down at the table, a specific sense (view or profile) appears for self. If one were to stand up and keep looking at the vase, there would be a different sense of the same item. This is a very basic example of how there can be many senses of the same object. Empathy occurs when self understands that a second person can see the same vase as self but the other sees it differently because of their perspective on it. If one were sitting with another person at the same table, then through empathy, one would be able to quasi-experience something of what another person might be viewing of the vase. The ‘almost’ experiences of what other people might think and feel put the social into social life. The example of empathising what another person sees of a vase on a table - is only an introductory means of explaining the role of empathy in social learning across the lifespan. Indeed, other people’s views form the social world and are the main conduit through which 158

Ian Rory Owen PhD information passes down through history and spreads out between people. As chapters 4 to 7 showed, there are complex ways in which the conscious experience of psychological attachment, fear about it and the consequence of rejection, can be interpreted as obeying law-like connections. The view is that social learning creates a great deal of psychosocial experience for people generally. However, when people understand each other psychologically it makes a world where people make sense. Then the smallest fragment of information can speak volumes about the nature of what happens. For instance, merely looking at a child with a sad face enables the understanding that something is wrong for that child. There is intentional implication between people and this is intersubjective: people are co-interested in the same objects of attention. Objects are meaningful between subjects. When two or more people are together, each person’s views of the same topic of attention become entrained, one with the other. When we meet someone we know we have an anticipation of how he or she is and what they will do and say. Their views and our own become connected. Similar inter-connection can happen in social contact. In order to explain the general view of things, ideas and people as public or cultural objects that are open to inspection from a large number of perspectives in society, the next section discusses the understanding of a song, before returning to understand the view of persons. The point of the section is to explain the general principle that any cultural object is a public object that is potentially available to all persons to inspect and experience. The view of meaning is that people are capable of different simultaneously ‘true’ views of the same and that the same person can view the same thing differently.

On cultural objects Objects of attention are of many sorts and whether they exist or not, it is their public accessibility that is most pertinent. So it is best to call them “cultural objects” to reflect their accessibility and note the role they play in the shared life. The term “cultural object” refers to all meaningful public property. The example below is a song but cultural objects can be emotions, psychological problems, thoughts, persons and roles, physical acts or any discussible object. Intentional objects are cultural ones in that they are socio-cultural and belong to a family, social context or a group. The definition of cultural object extends to include bodies and human relationships for we “are cultural objects for one another”, (Husserl, 1962/1977b, §16, p 85). By extension, other persons, psychological problems and the psychological meanings of what people say are conscious senses of cultural objects, comprised as follows: “The sense is not found next to the matter which expresses it; rather, both are experienced concretely together. Thus, a two-sided material-mental object stands before our eyes”, (p 84). The most general point to grasp is that any object of attention has well159

Talk, action and belief known conscious senses, for members of a group or society (p 85). Thus, cultural objects point to other objects, their senses and to other groups of people (p 86). For instance, some physical items are classifiable as types of use-objects and these show human purposes in making things (p 89). The specific nature of the pointing between a cultural object and the sense it has (p 86) is called “semiosis”. The multiple senses that an object may have are sometimes concordant with each other and sometimes in conflict (p 88). Through familiarity, senses are “impressed” on their objects (p 85). These associations of sense are well-known by advertisers, film makers, writers, and marketing departments who work to create qualities for their brands and add value to otherwise homogenous products by linking them to an exciting idea or a valued celebrity figure. Advertisers and casting directors know this and can indicate styles and attitudes easily by recourse to recognisable characters that are well-known because of the mass media. However, following Husserl, meaning is a social phenomenon. The theory of cultural objects explains how psychological objects are understood in multiple ways, by professionals and lay persons. Indeed anyone in society has a view, even if that view is not well justified. Lay people interpret the everyday world as well as therapists. Emotions, speech and behaviour indicate when a person is angry, happy or depressed. Intentionality is a more differentiated way of designating how meaning appears for human beings. Let us take the case of a song to explain the public openness of the same object. Music is an ideal cultural object when it is written down. However, each performance by a musician brings a musical score alive for any potential audience. The music is usually within a specific genre, such as pop or classical. The music suggests a mood. If it has lyrics, then it occupies a context of one of a possible number of ways of verbally characterising what the song is about. There are music styles within in a genre such as rock, blues, jazz and folk. Let us take the concrete example of the Irish folk song, Danny Boy, as an example of understanding how there can be one melody but many senses of what it means. Danny Boy is a wellknown haunting song that has a number of wider meanings (Hunter, 1997). It is a “rebel song” played by Catholics who were in dispute with Protestants and tells an unclear story of loss and a potential reunion. It is a cultural object because it is capable of appreciation by anyone who does not know Irish history, or the English language, and may only hear it as a melody. For people who know of “the troubles” in Ireland though, the song takes on different senses, according to which side of the sectarian divide that the listener has allegiance. How listeners are influenced by their beliefs about freedom fighting, terrorism, imperialism and the role of religion in the life of the state will influence the meaning of the song. Similarly, the therapeutic relationship and the specific meanings discussed within it, follow the same sort of alteration of sense of the type shown by the contextualisation of the song Danny Boy within Irish history and other relevant topics. 160

Ian Rory Owen PhD There are further similarities to the public ways of discussing and understanding relationships between people, when they apprehend each other within a relationship. People are cultural objects for each other - and their relationship is capable of discussion and alteration. Relationships between people are not static but dynamic with both persons “dancing with each other” in moves that influence each other. The mark left can be enriching and joyous, or feeling guilty toward the other, for instance, through shame that one has not treated the other well enough. What also occurs in the type of cause and effect between people is that there is no guaranteed outcome that is predictable from the same type of relationship. There are cumulative effects and the role of choice to be taken into consideration. What intentionality shows is that meanings have highly complex types of constitution and that the simplest thought or feeling has links to wider and wider spheres of meaning. For instance, the answer to the question “who are you?” can generate a number of complex answers. The possible answers to the question indicate aspects of personal identity in identifying self in relation to others through definitions of job role, by being a parent or a child, or by stating home geographical location. It could be possible to define self through mentioning sexual orientation, religion or race. There are less precise signifiers that indicate personal being, such as non-verbal attitude and with respect to the expression of one’s position in life as a whole. None of these aspects are what are classed as personality in the sense of it being a lifelong characteristic or relational style. The personality includes other aspects of self that are brought to all contexts that are entered into. Personality includes a semi-static and acontextual manner of relating in close personal relationships. The diagnosis of a personality ‘disorder’ or some psychological ‘disorders’ are only a small aspect of a person’s identity in comparison to the other aspects as a whole, as noted above. People can easily have multiple senses of self and others. This is because people have multiple aspects. It is quite possible for contrary aspects of the same individual to be operative sequentially, in that impulsivity can exist whilst driving, and careful methodical attention to detail will happen when the person gets out of the car. Similarly, narcissism and low self-esteem can co-exist for the same person in temporal succession. The next section works to emphasise the experiential referent of the concept of self as lived experiences.

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The living sense of self as the basis of personality The comments of the next section are made with respect to ‘self perception,’ strictly the apperception of self by self. Call it “apperception,” “self-image,” or “the sense of self,” or “ego,” what these refer to is the lived experience of self in social contexts. To understand self is part of the developmental ability to make sense of self across the decades and means bringing such experiences into a complex whole. These comments are parallel to the esteem and empathised sense made of other people in chapter 5. (Because empathy is more complex, it is returned to in chapter 19). Understanding the sense of self made by self is a means of the meaningful connection with the public world. The phenomena about self-understanding are important because it is strangely easy to mis-understand and not know one’s own strengths and weaknesses through a large variety of influences. Self-understanding is when self makes sense of itself as a social being so, for instance, problems with self-esteem co-exist with problems in social life. By way of an example to explain the fundamental experiential stance taken, let us consider what it is to be a self in context. Consciousness has a self-reflexive relation to itself in its social context and this in itself is a way of explaining the theory of intentionality in action. Let us look more closely at the centrality of the inter-relation between self and others, with the focus on self. The terminology is abstract and seeks to portray the general case of how a person has senses of themselves that are accurate and inaccurate, with respect to the whole of their life experiences. The same general case could be one of empathising what others think, feel and intend. Sigmund Freud’s original definition of the ego was “Das Ich,” literally “The I,” that was translated into English as “the ego”. So since the beginning of therapy, the sense of self was always an experiential sense that required a complex narrative. The ego is the sense of self that can be called a self-presence. It was well-described by Jean-Paul Sartre at the beginning of Being and Nothingness. Sartre concluded on Husserl’s behalf that: “If we wish to avoid an infinite regress, there must be an immediate, non-cognitive relation of the self to itself ”, (1943/1958, p xxviiixxix). “Of course consciousness can know and know itself ”, (p xxvii). “What can properly be called subjectivity is consciousness (of ) consciousness”, (p xxxvii). It is as though every experience is recorded as a self-experience. What these comments mean is that consciousness is inherently conscious of itself while it is turned toward any object of consciousness, external or internal to itself. When this idea is applied to understand the many types of unhappiness, it becomes clear that not only are there potentially identifiable biopsychosocial causes, but that the quality of the unhappiness is a self-reflexive message from self to self – concerning what needs to change. Indeed, this is why there is a vicious circle between low activity and low mood that leads to the self-awareness 162

Ian Rory Owen PhD of knowing that the mood is low, and that the basic expectations that self has for itself are not being met. Self-awareness is a basic type of feedback by self on itself. Similarly in this light, happiness is the direct evidence that things are going right. In the wider sphere of human development and therapy, self-presence is the root to a wholistic view: Given that personalities and psychological problems are already attempts to put things right, what needs to happen in therapy is that clients need to be helped to progress a stage further. The unhappiness generated by partially-successful attempts at a solution is feedback, a clue, about what needs to happen to make a new attempt at getting a better solution. In the philosophy of consciousness, the intellectual analysis of experience, the word “apperception” is used to define self-understanding (Leibniz, 1704/1981). Apperception makes it clear that understanding self is not perception at all. To perceive oneself is to look in a mirror, feel one’s own body sensation and hear one’s voice. For instance, if one were to look at oneself in a mirror, nothing psychological appears perceptually. However, the person who is self is the sum total of human relationships and social contexts to which self has contributed throughout the years. These are processes of relating. The resultant meanings are added to the perceptually appearing self. What is psychological is the network of meanings, associations, self-talk and other intentionalities that get added to what is perceptual. As Husserl put it “consciousness ... is a performance accomplished in demonstrable forms ... the essence of conscious life [is] an intertwining, motivation, mutual implication by meaning ... [that] has no analogue in the physical” or material world (1962/1977b, §3e, p 26). What he meant was conscious experiences are wholes of various sorts, for individuals, groups and communities (Bernet, Kern and Marbach, 1993, p 73). The background of past learning and the intentionalities are what enable objects to make sense whether these are works of art and literature or whether they are social skills that are working towards some social outcome. In this light, psychological problems are fixed false or inaccurate senses that are due to false or inaccurate belief.

The basics for a qualitative psychology of self in context Some aspects of self-experience are sensual whilst others are due to interpretations of the meaning of an emotion, event, process and the context in which the meaning is found. Apperception is the interpretation of self from a specific vantage point. Any sense gained is due to interpretation of bodily sensation, emotion, relationship events and other circumstances. To apperceive self is a complex on-going process. Apperception concerns a host of possible interpretations of one’s experiences, thoughts and actions - in comparison to the sense made of others. Apperception can be an appraisal of one’s worth to others and society, or any other sense made about self by self. 163

Talk, action and belief To spell it out, it is frequently the case that a person can feel one way, think in another way and act in a completely different way altogether. This is not the result of severe pathology but merely the way things are. Humans can be irrational and incongruent. They can also weigh up contradictory thoughts, feelings and intentions and decide well, by attending to all the relevant evidence. To do so requires bearing indecision and unknowns and rationalising to come to a decision. What can be formative is the internalised style of self-talk that is the product of previous socialisation. For example, the action of tormentors and oppressors are taken as models for how self should treat itself. Formative prior experiences in adulthood contribute in relation to how people ‘position themselves’ and understand how their progress towards desired outcomes is progressing. The social learning is that selves often treat themselves on the basis of how they have been treated by others, to whom they have been psychologically close, attached. This phenomenon is described and properly related to attachment psychodynamics that accrue across time. Apperception is selves interpreting themselves within the full set of self experiences with others and how they empathise how other people self-understand, how they apperceive themselves. A further aspect of apperception is having emotions about one’s own emotions, or feeling emotion even at the mere prospect of possibly feeling a certain way. This can take a variety of forms such as fear of sadness or fear of shame, for instance. For some people, these self-reflexive emotions in apperception can connect with negative reinforcement and may demand the use of defences, self-harm, drink and drug usage to obliterate the prospect of the feared emotion, whether it is actually felt or not. Some frequent problems of apperception are those of low self-esteem and its cousins: self-neglect, self-criticism, self-directed anger, self-punishment, self-limitation, self-obsession about one’s own believed-vulnerabilities, shame, embarrassment - and their antithesis - pride. Related beliefs concern the sense of self in relation to others and the world. There could be the belief that there is “not enough for me” in the world. Or that self is unlovable. Self-doubt, self-pity and self-sabotage also exist. Problems can be caused by self-contradictory conflicts between personal aims and priorities, like wanting to be loved and close - and fearing being taken over, rejected or surrendering to the unknown. There are no specific outcomes for these beliefs, but a number of developmental life positions could occur as a result of them. From this vantage point, let us consider how people work out the value that is shown to them and the value that they show others around them in their speech and actions. Self-worth is important because it is a passport within social life, according to the valuing of self by self, and the value shown to self by others, because of gestures and actions: In close personal relationships, self-worth is the 164

Ian Rory Owen PhD net result of loving and being loved in return. One consequence, for instance, is when people declare themselves to have insufficient self-esteem; they avoid social opportunities that others with sufficient self-esteem rightly take as being open to them. Given that empathy is an entry into the social world, self-esteem is one aspect of self-understanding that is gained through understanding self in relation to other people through a variety of intentionalities. As chapters 11 and onwards will explain, it is the on-going interpretation of life experiences that maintains these beliefs. The outcome of such considerations are both accurate, functional beliefs and inaccurate dysfunctional ones that destroy role performance, and maintain the inability to love, work and play. Primarily, the intentionality model is for experiential understanding and change - and against unjustified dogmatism. It is against lack of self-reflexiveness in understanding human existence and its habitat. It is also against a lack of attention to the evidence of conscious experiences and the intentionalities involved. It is part of normality that human beings are inconsistent and incongruent from time to time. It is the degree of variability across time and the lack of expression of the whole story that are noticeably different. People are not always congruent with their own intentions and emotions even when they permit others to over-ride themselves in the full knowledge that they will be the losers and others will take advantage. Yet there are other situations when it is argued here that people should not be congruent with how they feel when it is their own best interests that will be damaged by their forthcoming actions. Specifically, those who are too easily discouraged, or act on fear and expect that they will be not liked and turned down – when there is plenty of evidence to the contrary – are those who should not be congruent with how they feel, but should rather be congruent with the desire to enhance their own well-being. For Edmund Husserl, it is just a fact that thoughts and feelings about the same object can be different. For Carl Rogers, the same situation would be referred to by the terms “congruence” or “incongruence” between thought and feeling or feeling and action (1959). Psychodynamics would call the same “unconscious conflict” whereas Richard Stott would call it “rational emotive dissociation”, (2007). The example of how the sense of self is social is introductory to show how the sense of self occurs in its relations to others across time. What is being pursued is a priority to understand how consciousness creates the senses and relationships we experience. From this perspective, suffering concerns meaning-specific and context-bound problems. The solution is understanding how consciousness works and how it connects with the consciousness of others. When intentionality is understood, what is explained is how people (who are in mutual contact with each other) think and feel about each other. The role of being able to understand and discuss intentionality is explaining what happens between people when they make 165

Talk, action and belief sense of mutual objects and each other. The means of doing this is often through the effect of past learning. Theoretically, what is required is a means of knowing how to interpret what appears. Making explicit to oneself one’s reasons for doing things is self-knowledge that in-part is the outcome of accurate apperception and interpretation. So already existing feelings, thoughts or believed conclusions about the value of self feed future apperceptions of self. Changes in psychological wellbeing, for better or worse, involve complex changes in aspects of intentionality, object and duration of attention - because these parts are connected to one another.

Varying senses of self Let us turn to the experiential example of the same person who has varying senses of self. There can be a unitary sense of self. Or for the same person there could be clear, double senses of self that are concurrent. If so, this would create a sense of tension and difference. A completely different sense would obtain overall, between two indistinct senses of self, where the senses were both current but indistinct: in the sense of them sharing some key features. In this case, when consciousness focuses on itself, what appears are oscillations between two aspects of self. There is yet another example where there are two senses of self, but they vary through time so that the overall effect is that the sense of self changes from one to the other and back again. The overall production of feelings is one of changes between two poles or dualities, which could be confusing, dependent on whether the ego can hold both senses in consciousness at the same time and create a unified sense. Or in other ways, be able to understand the ‘causes’ of their thoughts and feelings and understand the contexts in which they arose. Because self and other co-exist and are inter-twined in this introductory definition, what this means is that when self is foreground; the role of others is in the background, and vice versa. What comes through is that there is a link between prior understanding and the totality of choices, experiences and actions made and in the current moment. There is a further possibility when the sense of self that is experienced is so indistinct that it disappears. Then what is experienced of self (or another person for that matter) is a confusion of needs, triggers, emptiness and dangers that have no overall clear sense or meaning. In this case, the difference between multiple, unclear senses of self are similar to those experiences of self that are single, unclear and chaotic. There is no discernible understanding of the overall sense, concerning what is and what is not self. Thus, a mostly undifferentiated sense of self is poorly represented in feeling and thought because self-awareness gained through selftalk ‘discussion with self ’ refers to multiple, confusing experiences: Such private and internal discussions about self by self, have not coalesced into a clear pattern (a unitary sense of self might eventually become the case). On the acquisition of 166

Ian Rory Owen PhD new experiences, there can be the sense of a shift from an ambivalent dual sense of self, to a more unitary sense. For instance, it is possible to feel good and bad about self successively. For some people, it is difficult to hold the two different senses in mind at the same time. This is particularly relevant when a person is depressed and feels bad about themselves and their losses. Across a sufficient expanse of time, the same person can go from low self-esteem about one topic, to high self-esteem about another. However, the problem of low or fragile self-esteem is compounded when a temporarily bad sense of self is mistaken for the whole of self being bad. Similarly, if good aspects of self are held with unshakeable value and pride, to the exclusion of actual shortcomings, or if there was a general unsubstantiated over-valuation of self, and if that were to stand for the whole of self, there is the problem of narcissism. Whilst the focus is on the sense of self, the other could easily be substituted in the following analysis of the types and clarity of the senses of self. However, the psychological milieu is shared and “what goes around comes around” in terms of the verbal and non-verbal senses that circulate. The psychological world of self, cultural objects and others are temporal and intersubjective ones. This means that objects of attention appear in connection to other people, past and present. For the client, the sense of self can be in focus or not, and its senses can be single, dual, threefold, or in other ways fragmented or not currently conscious. Where self-understanding arises, it exists in relation to the public standards of culture, the family and society. For instance, one way of understanding self and placing self with respect to others is shown in clothing, hairstyle, non-verbal communication and speech. These express consciousness and how a person is conscious of themselves in their immediate reaction to their surroundings. Yet the openness of consciousness is that any individual is open to other persons. Anyone’s attitude and manner of doing things is on general display. What follows next is a short round-up of the import of the novel perspective that has been presented by way of explaining what intentionality is and what it does.

In closing: The use of these ideas Psychological existence is not like material existence. Psychological existence is intentional in the sense that if something is believed to exist, then it exists for the believer, even if it exists for no one else. Thus, psychological ontology includes illusion, delusion, inaccurate belief, the anticipation of the future and the remembrance of the past, plus accurate interpretation of proper evidence and inaccurate interpretation of irrelevant evidence. What exists psychologically includes some of the following, for instance. 167

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Remnants from childhood can include wrong understandings of the intentions of past others that are wrongly applied to current others. The beliefs and understanding were gained at the original time of their occurrence and have never been scrutinised since. Remnants from childhood may have no current means of being scrutinised, or in any way investigated, concerning their truth or falsity.

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Ambiguity, lack of clarity, disguises and misleading appearances can arise through confused beliefs, in relation to multiple, confusing senses of the referent. This means that there is potential difficulty in coming to experiential conclusions on the sense of an object – whether that object is the sense of self, the sense of another person and their intentions and views – or for any other object of attention.

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Current negative reactions in the present relate to bad things that might happen but have not yet occurred. Current negative reactions in the present are often fearful ones that may lead to avoidance. That means that fear and avoidance are on-going and have not yet been over-come. The human being is not completely logical. And because the future is a genuine unknown, then people may head towards it with fear and constriction and so are unable to grasp its opportunities.

These ideas can be used for devising care plans and comparing different approaches to helping with the same personalities and problems. One way in which the ideas can be used is as a means of assessment and for designing interventions. This starts by attending to the content of the speech of clients. The first focus on content enables the definition of a problem, in its un-detailed form. What can be grasped immediately is that an explicit theoretical position is to hand. The explicit understandings brought to the situation are at first in the background, until the problem has been discussed sufficiently, and finding relevant events and understanding the detail. That might take between five to 20 minutes. The background knowledge of the therapist concerns the classification of personalities and syndromes. As clients speak, they indicate the beliefs and other conclusions they have drawn. Sometimes the problems are the current effects of influence from long-ago. In other situations, the problem is current, and in a small number of cases, people are turned towards the immediate expectation of a crisis. What clients talk about are the objects that occur in the past, present or future. As they speak, the experience becomes current for them in some way. When a psychological object becomes conscious for clients, its meaning comes into the room, and depending on its sort, its influence becomes present to the person hearing the account. Thus, to talk about anything is to share the experience, or at least to make it quasi-appear and became public through discussion. 168

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Summary In this model for practice, preference is given to the meaningful and experiential over the scientific. Apart from the reasons already stated, according to the intentionality model, a great deal of psychological life is not apparent to psychology as the science of material foundations. What is not apparent are the immeasurable psychological meanings that co-occur with what appears as perceptually given, imaginarily given, as a visual or auditory memory and other such types of givenness. Observable, measurable experiences and the understanding of what the speech and non-verbal communications of others mean are interpreted, even when they immediately appear as a conscious sense. The nature of psychological reality, its objectivity, is dependent on conditions like the relationship with others, the material physicality of the body and its nervous system. What drives a great deal of conscious life are the intentionalities that are adopted that produce specific senses about the objects that are given attention and found in various contexts. Life is a complex whole comprised of discussible experiences, cultural objects, in complex over-lapping connections with each other. Cultural objects are any that are open to the public: ideas, things, tools, practices, songs or historical artefacts. Generally, the theory of intentionality is identifying the ideal relations between the ways in which consciousness can behold its cultural objects. To recap the point made above on the nature of consciousness, following Edmund Husserl (1950/1977a, §18, p 43) and Jean-Paul Sartre (1943/1958, pp. xxvii-xxxvii), the basic experience of consciousness includes self-consciousness. Consciousness is self-reflexive. Experientially, the sense of self co-occurs with the thoughts, emotions, actions and meanings felt. This is why when things are going well, mood and self-esteem are good. When things are hard, or anticipated to be hard, then there can be the felt-experience of anxiety or depression. Emotional conflict and the consequences of having emotions are part of consciousness and self-consciousness (and is not a sign of alleged ‘unconscious conflict,’ whatever that is). For instance, the sense that a person has of themselves, their identity and life, is not the same as the intellectual classification of personality. Any classificatory system of personality types could miss the point of the experiential basis of consciousness and self-consciousness. On the contrary, a broad view of the sense of self is adopted: One that is sufficiently broad to capture the identity of an individual as the sum total of their inter-actions with others. The problems of personality are not merely current difficulties in doing things, but the difficulty of beginning something that could have been achieved at a younger age. The next chapter looks forward to the comprehensive position called the biopsychosocial view of humanity. What a biopsychosocial position assumes is that 169

Talk, action and belief it is possible to bring together both sides of an ontological dualism. The dualism is the difference between psychological understanding of the experiences and psychological objects of others - and squaring that with psychology as a science, as exemplified by Robert Plomin’s heritability research. This raises the necessity of much future theoretical and practical work that cannot be done in this book. The theory of the intentionality of consciousness understands conscious phenomena yet rests within the biopsychosocial view of personality and psychological problems as a whole. Empathy is like a hologram and is only roughly linked to what appears to visual perception and audition. Overall, intentionality and empathising are the ‘causes’ of meaning. Meanings are social. The huge number of perspectives on any object of conscious attention comprises what it is for the object to exist and to understand it. Belief is explored in detail in chapters 11 to 13 and 16.

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10 The biopsychosocial view of personalities and problems Aim: This chapter makes a connection with the mainstream view of psychology and argues for collaboration between the biological, psychological and social aspects of research into human being. Let us consider what the biopsychosocial means before going on to any new topics. The perspective hypothesises that the biopsychosocial on-set of the personality and psychological problems becomes the biopsychosocial maintenance of the personality and problems. Consequently, the major intervention is engaging the ego in its own self-understanding and self-care. Long-lasting pervasive effects on personality-functioning are biopsychosocial. The intentionality model distinguishes three co-occurring types of cause. Ultimately, chapter 16 spells out the means of formulating clients by asking a series of open questions and interpreting what they say. Before then, several details need to be secured. By understanding intentionality, it is possible to grasp how people make choices about their intentionalities and behaviour in life. There is no need to postulate permanently unconscious emotions or unconscious motives 171

Talk, action and belief because there are none although people do have some motives that are not constantly in their consciousness or are not properly understood by themselves. There is the necessity of citing conscious observable evidence and making clear arguments concerning cause and meaning. The established view in psychology is fixed on ‘natural’ or materialistic approaches. This chapter works to expand and co-ordinate three adjacent sets of influences on human being. Human nature and specific abilities are due to three different influences: biological, psychological and social. The sequence of topics below is to explain these three simultaneous interacting forces on personality and psychological problems. Next, personality and psychological problems are considered as a whole. A discussion and conclusion end the chapter.

Introduction According to the biopsychosocial perspective, there is an unknown, complex causative relation between the biological, the psychological and the social. The biopsychosocial perspective is an answer because it takes into account three concurrent aspects of being human. The biopsychosocial perspective demands a future consensus about precisely how the biological, psychological and social dimensions of human being mutually influence each other. The biological refers to that portion of human being that is material, physical and genetically-inherited. The psychological refers to the dimension of free will, choice and the intentionality of being related to what is believed to exist. Belief occurs through forms of intentionality such as perceiving, anticipating and recollecting pertinent evidence. The social refers to the influence of culture, society and history as they are handed down through the medium of the family and those around us. There is mutual influence between each of these three aspects as several writers have noted (Engel, 1980, Kern, 1986, Gabbard, 2000, Plomin et al, 2000). What the biopsychosocial perspective means is that the psychological is immersed in the social and shaped by the biological. The biological aspect is concrete and lends itself to some degree of measurement. The psychological and the social are meaningful, contextual and more abstract than the biological. Yet the psychological and the social are not entirely immaterial.

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Fig 14 - The relation between the biological, social and psychological. As figure 14 suggests, the three aspects of the biopsychosocial co-exist. Only when persons are in a coma are they without waking consciousness and social connection. Part of the psychosocial influence is the influence of past social learning that produces belief and understanding in the present. A lifespan developmental view believes that happiness and unhappiness are on-goingly brought about by partners, family, friends and work colleagues that form the closest circle around the individual. Personal life concerns the quality of life as one’s most prized possession. Threats to attachment satisfaction within the closest social circle need to be rectified in order to protect the shared happiness of self and loved ones. The main research question for the biopsychosocial perspective concerns how to understand the full set of conditions across the lifespan that contribute towards the ability to choose any activity or experience. In order to stay focused on sessions, let us consider a general case of the phenomenon that is being interpreted. For instance, adults who have been physically abused as children can adopt lifestyles that are dangerous and may do physical damage to themselves in a number of ways. One way of understanding this is to interpret their selfdamage as internalising their abuser and that their current self-harm is replication of their abuse on themselves. What is being interpreted is the connection between two events: one in the past and one current. For instance, the event in the past 173

Talk, action and belief was that Brian was repeatedly punched by his father. The event in the present is that Brian abuses alcohol and gives himself hangovers. Brian previously used to bang his head on walls when he was a child. Now he damages himself every night with alcohol. The way of interpreting this situation in the version of the biopsychosocial perspective propounded in these pages is that the research question is to ask “what enables this problem to happen?” Or equivalently, “what are the conditions for it to be possible?” Where the specific problem in question is alcohol abuse leading to hang-overs that last all day, only to be followed by more alcohol abuse. The way in which the interpretation is made is to distinguish the “lower,” more fundamental conditions of possibility, that enable “higher,” egoic action and choices, like the repeated abuse of alcohol. One way of explaining the relation between lower enabling conditions and the higher outcomes is that a lower condition is the biological body that enables consciousness and social intercourse to exist. However, historical and social contexts also enable the here and now to exist. When it comes to thinking about the enabling conditions for communication, and then if both persons in a therapeutic relationship can be mutually relaxed, then that will enable clients to discuss highly distressing and shameful aspects of themselves. What also counts is the mutual meeting of attitudes of the two persons, where each reacts to the interpreted sense they have of the other. If the therapist can continuously provide attachment security, conditions that enable change and clarity about the purpose and methods of the meetings, then communication through encoding and decoding of verbal and non-verbal messages will be optimally possible. But the attitude of clients will also influence how the meetings unfold because the mood and immediate emotional state of clients will contribute to how they make sense of the speech and non-verbal presence of the therapist. The conditions of prior history, current events and future consequences in the biopsychosocial view are as follows. The biopsychosocial view is a multi-factorial one. It combines three forces and sketches their combined whole according to the ways in which each part can agree and conflict with the others. The view believes that any specific type of personality and accompanying psychological problems arise from the inter-relation of the three major parts of human being: the biological, psychological and the social. In overview, what is being claimed is that there should be consideration of the factors whereby any identifiable type of personality (with its choices and frequently repeating patterns of connection with others) is comprised of the influences of three types of cause. The psychosocial ‘causes’ are unobservable contexts of prior learning and contexts of formative influences on the way persons run their lives. The consequence is that personality traits, recurrent types of choice and repetitive action, the family constellation and aspects of the sex lives of human beings are co-created by the traits that contribute to the sense of the person that people make themselves be. For example, how people rate their 174

Ian Rory Owen PhD own attractiveness comparatively with respect to how they rate the attractiveness of potential partners is a key determinant in the quality of life. All three aspects of biopsychosocial cause co-occur with observable sets of skilled choices and actions that can be seen in ‘snapshots’ in sessions or understood from discussion about people’s lives as a whole. The unfinished project of the biopsychosocial perspective means that there is a lack of certainty about cause altogether – of that we can be sure. Attempting the biopsychosocial perspective in practice means that it runs ahead of certainty for the reasons noted above. The problem of a lack of a unified account is under-pinned by the problem of the natural attitude that over-values the findings on the natural and discredits the contributions of the psychosocial. But the biopsychosocial perspective is committed to its own conclusion: There should be a compromise situation in the human sciences where both sides of a duality are permitted to make contributions in co-operation. Problems arise when disciplines are too narrow in their scope and could become more fully functional if they were to see the larger picture. Specifically, if each of the psychological, social and biological influences continue in a disconnected way, there will be no proper appreciation of the complex inter-actions that actually exist. Because of the differences in the social sphere, between the extent and inter-actions between personal choice and the social, there is the possibility of seeing how individuals contribute towards life with others. It is ultimately possible to sketch an individual’s biopsychosocial nature and key choices, in comparison to how other people structure their lives according to different values and choices. If in the future, it becomes possible to know from a person’s genetic make-up what sort of personality tendencies and psychological factors to which they are predisposed, then the mental health services will be capable of being properly guided by science. Until that day arrives, a certain squaring of the circle is required in order to make the biological and the psychosocial fit together. The way this is achieved here is to prefer the needs of clients for simple explanations that promote self-care that meets the experiential reality of their problems. Heritable causes of psychological problems and personality–characteristics are currently only capable of being grasped by statistical average. Until this state of affairs is rectified, there is uncertainty about the meeting of natural cause with psychosocial ‘cause’. In these pages, what is experienced by clients is given priority in order to tailor-make interventions by formulating personality and problems together and using that understanding to create a means of knowing how clients can change themselves and their behaviours. The theoretical and practical task for the human sciences and therapy for the twenty-first century is creating the detail of the biopsychosocial view. This is no easy under-taking as it means making a cohesive whole from three major bodies of evidence that are very different. The approach to the human biological substrate is genuinely scientific and shown by studies like behavioural genetics 175

Talk, action and belief and psychophysics. For the intentionality model, the proper approach to the psychosocial region is meaning-oriented and qualitative. The overall task of working with genuinely scientific findings and meaning-oriented ones is difficult because their approaches are entirely different. The biological structure of the personality is underlying and potentially causative of tendencies towards action and specific types of relationship. But biological causation can be mediated by reflection and self-control under the direction of the ego. The biological truth of the individual currently remains hidden to psychological science as well as consciousness. But it is also the case that no aspect of the expression of personality is hidden, in that it is capable of becoming manifest to self, and others around self, even when some aspects of self might only ever be expressed in imagination such as sexual fantasy. Biological

Psychological

Social

Negative traits

Adaptive life choices, coping with traits.

Supportive

Negative traits

Maladaptive choices, not coping with traits.

Supportive

Negative traits

Adaptive life choices, challenged but coping with traits and others

Unsupportive, threatening, damaging

Negative traits

Maladaptive choices, not coping with social challenges.

Unsupportive, threatening, damaging

Positive traits

Adaptive choices

Supportive

Positive traits

Maladaptive choices, selfdestructive

Supportive

Positive traits

Adaptive choices, coping

Unsupportive, threatening, damaging

Positive traits

Maladaptive choices, not coping with social challenges

Unsupportive, threatening, damaging

Table 2 - The biopsychosocial inter-action overall. For any constellation of psychological problems and for any personality type, the causes and on-going maintenance of factors are the same: A complex inter176

Ian Rory Owen PhD action between the biological nature of the individual (in terms of their genetic inheritance that is often most evident in childhood) exists in a dynamic interplay with personal choice, lifestyle and the relation to the social environment as a whole. There are many contributions where neurological damage, for instance, could be ameliorated by a nurturing lifestyle chosen by the person and sustained through a supportive and safe social environment that could, cumulatively, offset the negative effects of the neurological damage. Or even in some cases, positive psychosocial experience could reduce the neurological damage itself. However, there are mixed forms of complex inter-action between natural cause and psychosocial ‘cause,’ where there are physical limits to the psychosocial influence of therapy. If a gene is present, the social context will have to trigger an initial stressful experience before a personality problem or psychological disorder can occur. Let us look at the detail of the three simultaneous inter-dependencies.

Biological Let us start by considering the state of play in biological research into inherited traits for tendencies to be aware conceptually, affectively and practically in various ways. What Robert Plomin and colleagues have found is that any specific single disorder may have a heritability factor, from generation to generation, due to the ability of a gene to manifest a disorder (Plomin et al, 2000). On closer inspection, what this means is that biological cause demands a psychosocial context with sufficient stress to trigger the disorder. For instance, if a disorder is 40 per cent heritable, it means that 40 per cent of people with the gene are susceptible due to genetic factors on average. If the other 60 per cent of people with the gene do not get the disorder, this must be because of psychosocial protective factors or other genetic protection. However, the same psychological disorder could be caused by psychosocial factors. So it is necessary not to confuse predominantly natural cause with predominantly psychosocial ‘cause:’ “nurture”. Even so, what science studies are occurrences that are due to natural cause and psychosocial ‘cause’. In the heritable, “nature” versions, genetic factors are important but need a threshold of psychosocial stress to be exceeded before the disorders become manifest. But in the psychosocial, “nurture” forms, environmental factors are solely responsible. The actual figure of the amount of heritability is an average gained from interviewing persons with the disorder. It is not a precise figure and does not apply to individual cases. Biologically, there is the neurological and physical history of the individual. Biological cause concerns significant traits that are shared with other blood relatives, plus any contributory material events and changes like drink and drugs usage or neurological damage. Biologically, there are inherited tendencies, traits and predispositions of the four major types of personality reported by John Livesley discussed below (2003, p 70). However biological traits and predispositions can be 177

Talk, action and belief encouraged or opposed by choice. It takes self-knowledge to work out what one’s biological tendencies are in relation to one’s blood relatives. Once self-knowledge is achieved, it requires the ego to manage its traits if they are problematic. For instance, the damaging consequences of being impulsive need to be curbed to increase the ability to tolerate frustration and avoid damage to self and others, in a wide sense of the word “damage”. What cannot be altered by choice is the biological basis of self. Because of fixed traits, from the perspective of trying to understand influences, traits can be confused with fixed beliefs. But what can change is shared and public. What is authentic to the self is immutable across the lifespan. It is only those problems that are insoluble and completely resistant to psychosocial influence that are fully authentic. The upshot is that self should not blame itself for things that it never chose. Biological traits are un-chosen and in a sense do not belong to self because they are the genetic inheritance passed on from parents.

Social Social ‘cause’ inter-acts with natural cause from the biological substrate and the cumulative effects of personal choice across time. Social ‘cause’ is different according to the part of the lifespan in which events occur. So according to the psychological age and developmental ability of the person, understanding the events of infancy, childhood, adolescence, early adulthood, and what has happened in later adulthood, will lead to understanding how the current longstanding problems of personality are in existence. Asking questions at assessment begins understanding how the course of a person’s life has been evolving. The journey of life can be seen, for instance, as people coming away from a bad past; or having entered a phase where things get worse. For a small number of the population, metaphorically they never left the horrors of childhood and have never properly entered adulthood in a confident way. The way to understand clients is empathically, from their ‘inside outwards’ though. The intellectual projection of ideas is acceptable if that concerns conscious experience and clients are given the chance to understand the conclusions made, and are allowed to disagree with them. The richness of the intentionality model is to be sufficiently flexible to capture the fine details of what people experience and provide an accessible vocabulary for representing what they experience. The social viewpoint regards the familial, cultural and historical influences as formative. However, the first step is to understand the role of the past. Some account of these influences will provide understanding of the content of people’s lives. Socially, there is the full history of social contexts and what their influences have been. These include the social influences from the schools attended, the peer groups chosen, events in the family and the overall effect of teenage years. The calls from family, work, culture and societal laws and norms mean that 178

Ian Rory Owen PhD there are social demands and conventions that should be obeyed. These define the locally acceptable ways of being. Individuals who refuse to conform, run the risk of the consequences of breaking these taboos. In order to be pro-social and ‘get along with the neighbours’ in life, it is necessary to repress some aspects of self in order to adapt to the mores of the larger community. There is the folk psychology of commonsense culture that enables people to interact in a fairly uniform and co-ordinated manner. The good social life is one where there are secure relationships and mutual satisfaction. Where it is possible to choose or reject specific persons and social contexts.

Psychological Egoic psychological ‘cause’ inter-acts with social ‘cause’ and self can choose how it responds to natural cause. Egoic ‘cause’ is the exercise of choice and how to give attention to any object. Selecting one option in any situation of possible choices is part of the full scope of striving, deliberation and skilled action. Such matters are the business of everyday occurrences and contribute to the psychological realm. The term “personality disorder” is challenged because what belongs to the ego is what remains after attempts at psychological change and influence. An egoic style is really a social and intentional style. For instance, people who over-use one type of insecure attachment process or one manner of relating, appear as being of a fixed type when they have a number of different styles of relating with other people, or relate differently in different social contexts. What needs to be explicit is how they use interpretative beliefs about how they make sense of different sorts of situation, for instance, in being confident at work but fearful of intimacy in their love life. Most of the population have a pervasive personality influence from childhood and adolescence and some aspects of this might be self-limiting and some sort of tendency to be nervous and have low self-esteem in some contexts such as a job interview or in making big decisions. Egoic ‘cause’ also inter-acts with natural cause from the biological substrate. Biological cause is operative from infancy onwards and perhaps can best be noticed in early life when socialisation is still incomplete. In later life, the extent of biological inheritance is still in evidence, yet perhaps there has been a greater weighting from socialisation because of the capacity to become able to estimate the strengths and weaknesses of self. Thus the role of social learning is steering a course towards chosen life goals. The life goals of twenty year-olds are not the same as that of forty year-olds, for instance. And some change in the beliefs and values that guide the life course is needed to make sure that a proper balance of satisfying activities is being pursued: one outcome is making alterations in the home-work balance, for instance (Traeger, Daisley and Willis, 2006).

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Talk, action and belief Psychologically, there is the personal way of experiencing and reflecting on inter-actions with others. How a person makes sense of themselves is the result of complex mental, affective and actual inter-actions. Any preferred ways and types of problem-solving adopted are central to understanding the region of personal choice and how that has played a function in creating a specific status quo. Making a choice (in love, family or generally) concerns making sense and dealing with the consequences. Choices should bring rewards and will require effort to make them manifest. The intentionality model agrees with Jean-Paul Sartre in that it is possible to interpret the course of a person’s life along the lines of the choices and decisions they have made (1943/1958, pp. 561-563). Secondly, other outcomes are by default of not choosing at all and so allowing circumstance to dictate an outcome or a state of affairs. A third way of choosing is by explicitly choosing not to take any action at all and being clear that the consequences of this are for the best. An outcome can occur through self being unable to choose an action, whether in the past, present or future. Finally, there is the option of deciding to accept the values of others and do what they expect. The psychological includes the realm of personal choice and selfunderstanding. The ability to understand how mood and self-esteem are the result of specific factors is part of the ability to maintain an optimal direction in life. Maintaining a good mood and self-esteem concern making choices that are good for self and others, by considering a broad selection of what is possible and responding to differing situations across the lifespan. Specific windows of opportunity arise and disappear, possibly never to return. Moments of opportunity are times when formative decisions are made. Key relationships could be formed or broken. Values and lifestyle choices are set in place and may not be re-considered for decades, even in the face of evidence to say that they are unhelpful and harming. The feedback mechanism is set out of balance in this case, because even when the set of preferences that has been chosen and is still being adhered to, provides negative consequences it is usually the case that the positive consequences of the choice are still worth it. There are some cases where there are no worthwhile aspects to defensive choices and that they only bring misery and no pleasure or defensive satisfaction.

Addressing personalities and problems as a whole This section argues that the convention for dividing psychological problems from personality types in Diagnostic and Statistical Methods IV (American Psychiatric Association, 1994) is contrary to the biopsychosocial understanding of human being. The type of overall causality at play for personality and problems is multifactorial, comprised of both nature and nurture. Personality is in-part coping with how self is biologically, plus being in-relation to other people and in relation 180

Ian Rory Owen PhD to the cumulative effect of self choices and projects. Understanding personality means learning what the technical terms mean face-to-face over a span of time. In assessment through questioning, it is possible ask somebody to reflect on their own lifespan, by asking them how things have been for them, across ten-year periods in their life. The answers provided show the developmental influences that explain how they are in the here and now. Specific styles taken in personal, business, family life that produce the same type of problematic outcome are the ones to focus on. These are things like permanent suspiciousness, pervasive anger, all types of childishness in adults, and those that produce the same old outcome of upset and disappointment for self and others. Intersubjective problems and positions that are recurrent, persistent and happen every year, and during most months of that year, are the problems of personality. The word “personality” stems from the Greek prosopeion meaning mask. The etymology of personality begins with the ancient Greek tragedic theatre where there were a few male actors who played the major parts. An actor would wear a mask when he was speaking a part, in order to tell the audience which character he was playing. By extension, personality is primarily what we show to others. It is a role or identity that is permitted and recognisable: a mask to get by in life with respect to social mores and the standards of culture and society, with its taboos and permissions that demand repression of some aspects. The social persona is often dropped in therapy when clients reveal their true fears and inadequacies. However, the sense of self grows harder to change and influence across the years. Relationships between self and other become problematic when no sustained intimacy can be maintained in the primary relationships of friends, family and love life. By extension, putting on a recognisable stereotypical manner of voice, the use of specific words and non-verbal gestures is characterising self according to general public knowledge of what people generally think about people of a certain type: police, nurses, teachers. Or of behaviour of a certain role (like to be a husband or wife, what it is to be a best friend or work colleague) or style: being flirtatious, angry, distant or serious.

Personality as social At its widest scope, the personality is a general style of responsiveness to all objects of attention. It can be viewed as responsiveness to various domains of the whole of life as well. One key area of responsiveness is with others. More specific domains of responsiveness are the style of responding to people in family and work, for instance. The slow-changing style of relating in various contexts that is personality (and it overlaps with the felt-sense of self or ego) so there is some difficulty in defining it. Personality is wide-reaching in that so many important contexts of activity and experience comprise a life. Personality is not just personal 181

Talk, action and belief abilities but is also closely tied to role, as Karl Jaspers noted (1913/1963, p 431). Jaspers believed that there can be internal conflict between parts or aspects of the same person and this reflects the self-contradictory and multi-faceted aspects of human nature (p 433). These tendencies are part of human nature generally and show that a person is interested in different activities and pastimes, some of which vie for attention. When personality is problematic what is referred to include the effects of how self has been treated and how others are loved, dealt with, kept or rejected. Personality disorders are syndromes in social contexts that generally refer to inflexible, deeply - ingrained adaptive and maladaptive patterns of relating to self and others that are inherent to self, and are not contextually-bound responses but happen across a number of social contexts. The individual takes their semi-fixed tendencies and defences to relationships with others. The problematic fixed aspects ‘cause’ hurt, dismay to others, disappointment and negative emotion. The problematic aspects of personality may be present throughout the lifespan and are often clearly present and promote distress, for self and others, from adolescence. As the basis of them is biological, then medication alone may not help. Personality is a complex inter-action of factors that are unique for an individual. Following John Livesley (2003, p 47), it seems that the personality ‘disorders’ are capable of being understood along four of the five aspects of the “big five” or “five-factor model” of personality (Goldberg, 1990, McCrae and Costa, 1996, Saulsman and Page, 2004). The five factor model is known by undergraduates the world over according to the mnemonic “Ocean”. Ocean refers to the following five aspects: O – Open to new experiences – as opposed to being closed, rigid, fixed about experiences and dogmatic. C – Conscientious, dutiful, self-starting – as opposed to being impulsive, lacking self-control and self-discipline. E – Extrovert, trusts others, enjoys social contact – as opposed to introvert, a need to be alone to digest social contact and a preference for one’s own company. A – Agreeable, co-operative, compassionate – as opposed to hostile, oppositional, argumentative, callous, confrontational and antagonistic. N – Neurotic, anxious, emotionally dys-regulated, impulsive, vulnerable to negative emotion and mood and has difficulty coping with everyday activities – as opposed to being object-constant, capable, and self-knowledgeable, self-soothing and self-assured. What Livesley has found are that the problems of the personality disorders are capable of being mapped onto the CEAN aspects of the five-factor model. The problematic types of personhood are extremes of conscientiousness, dutifulness and being excessively dogmatic, rigid and fixed or being irresponsible and feckless; excessive extroversion or introversion; great difficulty in being agreeable and co182

Ian Rory Owen PhD operative or tending to be antisocial; and excessive neuroticism (emotional and relational dys-regulation, object-inconstancy) – as opposed to being able to cope. Let me elaborate. These aspects of personality describe in an active way, from the inside, what it feels like to be in the social world. Conscientiousness is living to strict rules to the extent of neglect and lack of care to self and others because of excessive self-control according to strong ideals and values concerning ‘necessity’, that mean that others can get caught in the dutiful person’s high standards. Conscientiousness becomes problematic when it is connected with a dominant attitude towards others in attempting to make them comply with the same standards. If conscientiousness is a major part of the personality, then it becomes anankastic personality disorder (mentioned below). The extroversion-introversion dimension is close to what has been described above as the continuum between avoidance, ambivalence and security. When warmth is shown to others it attracts them and helps them feel good about themselves and feel wanted. An assertive outgoing attitude towards others creates a positive social grouping, family life and the community of friendship with overlapping relationships of a group of people who know each other. Introversion and the lack of pro-social behaviour are the absence of such connections. When introversion is excessive it is called schizoid or avoidant personality disorder. The term agreeable is the opposite of antisocial. Being agreeable is pro-social, trusting, altruistic, capable of adapting and empathising others – whereas being anti-social is to be untrusting and aggressively dominant. Being anti-social is being self-interested and aggressive, callous, unresponsive and dismissing of the needs, feelings and perspectives of others. If the anti-social tendency is excessive, it breaks the morality of commonsense culture and the laws of society. If it is excessive as a lifestyle, then the person appears charming but cold, angry and suspicious and is generally destructive, where there had been harmony. Finally, neuroticism is the opposite of being robust, optimistic and positive concerning a coherent sense of self and others and the ability to be securely attaching. Neuroticism refers to instability, impulsivity and a general tendency to over-react emotionally and behaviourally that can also feature anxiety and self-doubt about the ability to cope. Neuroticism is a pervasive sense of vulnerability to threats in general. Neuroticism can be understood as having a weak, absent or empty sense of self and a core belief that self is vulnerable. Hence, the emotional dys-regulation and inability to soothe self can be interpreted as outcomes of this belief. Emotional dys-regulation and the ability to over-react are linked to the short-term tendency to over-estimate the anticipated consequences of negative experience that become accepted as entirely representative of complex situations that have not yet unfolded. These four features of CEAN can become the building blocks for more complex patterns of action and experience that span different social contexts.

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Talk, action and belief What can be further drawn from this analysis for the intentionality model is that the problems of personality include faulty self-interpretation and empathic ability that are impaired with respect to the local norms of accurate understanding. Because of the lack of accuracy, there is a narrow range of emotions felt and those experienced are extremely intense and labile. John Livesley (2003, p 70) believes that there are four major types of personality disorder (schizoid, borderline, antisocial and anankastic) and that the many variegated types of personality problem are versions of these four basic types. Schizoid people are anxious generally and prefer to avoid, detach and withdraw from company. They minimise their contact with others in order to minimise their exposure to risk. They might be open only to impersonal human contact or have a narrow social life with a very small social circle. Schizoid personality is avoidant of contact with others and may also miss the sustenance of human love and kindness but prefer to prevent the hurts and disappointments that it may also bring. What occurs with a schizoid personality is a lifestyle that is narrow rather than broad and rich. It is close to what has already been defined as avoidant attachment but with a touch of paranoia added, as others are empathised as being generally intrusive or demanding. A schizoid person is highly sensitive to others yet fails to express emotion and their own need for friendship. He or she appears blank and withdrawn. Generally, the personality behaves defensively to protect itself, reject others and withdraw from social anxiety to the extent there is an overlap with the short-term problem of “social phobia”. Borderline personality is having strong reactions to what is happening in the present moment. It is driven by past memories and retained experience in relation to anticipated catastrophes of what might happen. There are strong emotions. Panicky reactions mean that what is happening in the current moment is overwhelming. Borderline personality, according to Grinker, Werble and Drye (1968), refers to four distinct groupings that all share anger as the main overused affect but that facet co-exists with dependence towards others, plus a lack of ego constancy in possibly lacking a sense of self altogether (emptiness), lacks in the consistency of relating (relationship chaos), and anger and anxiety when getting psychologically close. Depression may happen due to a sense of loss at not being able to attach and interact to their own satisfaction in relationships across different social contexts. The borderline personality has been linked to selfharming behaviour in recent years but this is just one aspect of a complex number of features in a syndrome that centres on attraction and rejection, dominance and submission, and being excessively open to new experiences. The openness is to the extent that there is difficulty in creating identity. What results is identification with transient experiences of strong negative thought and emotion. These emotions are inaccurate responses but get believed as accurate portrayals of events.

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Ian Rory Owen PhD Being anankastic, excessively conscientious and dutiful, is to be worried about doing the right thing in relation to abstract rules and that may entail a sense of resignation. Anankastic personality is a desire for excessive orderliness, precision and scrupulous attention to detail, frequently including an excessive sense of responsibility and a punishing conscience that also crushes self and can feel attacking when the standards of self are applied to others. Anankastic personality disorder can occur with obsessive compulsive disorder, depression and procrastination and be seen as the root of perfectionism and workaholism. It is not an adaptive characteristic to a profession or lifestyle and feels like being out of control in terms of the rigour required to meet the desired standards for good performance. Anankasia is excessive conscientiousness that over-rules the ability to be social and prevents satisfaction and enjoyment. The antisocial character is someone who purposefully disregards the harm they do to others but they might be empathic in the sense that they do understand what the perspectives of other people are. Rather, their callous behaviour is because they are sadistic and enjoy the damage they can wreak on others. The antisocial person gets pleasure from telling lies, exploitation, manipulation, being uncaring and deliberately provocative. The main feature is being ruthless, selfaggrandising and remorseless to the extent of lacking guilt when caught with overwhelming proof of their wrong doings. Yet the same person can elicit and manage the impressions that other people empathise, to the extent of frequently appearing charming and talented. Except that this is born of a sense of overentitlement and being beyond the rules that govern ‘the little people’. In some cases, there is a tendency to violence and the enjoyment of lying for its own sake of creating an impression in others. These are the most common personality characteristics and they are listed here to emphasise that they employ composite intentionalities and will have strong relational effects on other people. Conscientiousness might over-ride extroversion and so produce a workaholic or excessive care-giving mentality and produce tension and dissatisfaction. The next section focuses on personality as a chosen topic for sessions because it is capable of change. By understanding and rational striving to be different it is possible to create phenomenological change. The view in this work as a whole is to formulate the problems of personality in the same way as formulating axis I disorders. Effectively, no account is made of the ego but, for instance, a relational or self-esteem problem is formulated according to the understanding of intentionality. This functions to raise motivation and because there is a complex whole of interactions between self and social context, it is possible to encourage clients to choose a different lifestyle.

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Understanding the defensive function of the personality The topic of defence is introduced below and returned to once more in chapter 16. Defences serve a variety of functions. When they are part of the personality they can serve the purpose of protecting self by increasing anxiety which has the function of producing preparation for fight or flight. Otherwise aspects of the personality functioning defend an empty or vulnerable sense of self, even to the extent of disconnecting a person from their attachment needs by trying to cover them over with work, distractions, pleasure or other means. The insight of Livesley cited above is added to the direct understanding of what it is to be sociable by showing how self is with others. Once it is understood that personality is about how to be recognisable to others, and that functions to hide and protect some aspect of the identity of the actor and fend off vulnerabilities, it is understood that personality is about the necessity of telling others what the role of self is in relation to them. Defensive aspects of personality concern negotiation of the relationship that is achieved with others across time. What is called “the personality” is the summation of the biological, the psychological and the social. The hypothesis that early trauma is the psychosocial cause of the personality is not new (Gitelson, 1963). However, there can be traitcaused personalities as well as mixed forms of biological and psychosocial cause. Any stasis or inertia means the positive consequences of defence outweigh the negative drawbacks of the situation. If a solitary lifestyle is a defensive choice that prevents rejection and disappointment in love it may also prevent other more general types of being connected with others. Personality is declaring who and how one is. Being a style of person includes the personal understanding of how decades of moods have been created a multifaceted existence of close personal relationships, family life and achievements at work. Non-verbal communication shows our basic attitude towards others and how people share or hide their interests. To sum up critically, it is believed that the category of “personality disorder” is the outcome of a lack of thought. The term does not work because it does not differentiate between substantially different structures of the personality that might qualify for the same categorisation according to a psychiatric textbook. For instance, a personality functioning might be historically-created and more socially defensive or it might be more formed by biological traits. Psychopathology requires a detailed explanation when that is going be discussed with the individual in question. It needs to realise the implied message that it sends out to the world of mental health professionals and the public. What passes for ‘personality’ is a combined style of functioning across contexts of time, place and person: what is referred to is a style of creating self in inter-action with others. The style of interacting is usually aimed as staving off the anticipation that past events will repeat and that the immediate future will be as bad as the past. 186

Ian Rory Owen PhD The classificatory system of eleven types of personality (American Psychiatric Associations, 1994, pp. 629-673) is unacceptable because people regularly have features of more than one category. And apart from that, human beings can exhibit co-existing contrary facets of functioning in different areas of their lives: For instance, high neuroticism and high agreeability can co-exist. It is possible to be an extrovert at work and with established friends and a shame-faced introvert when it comes to dating and making new friends. Arrogance and low self-esteem can co-exist for the same person at different times. Or co-exist for the same person but about different areas of their life. Accordingly, the traditional view that physiological symptoms, social life, relating, psychological disorders and personality diagnoses are separate is a misleading view of the whole. It is easier to note that the personality processes form a whole and recognise how a specific part of it is being focused on. Personality syndromes show a wide range of variations and are comprised of many complex uses of the intentionalities. Specifically, even when two people have the “same” classifiable type of personality disorder, they can be highly dissimilar in other ways. If a person has sufficient aspects to qualify for a classification, then that label only refers to one part of the overall personality functioning. For instance, what modify the impression of a person’s degree of functioning are co-occurring social markers, such as a verbal accent that may indicate class or educational level. The manner of dress and hairstyle can also indicate membership of, or connection to, a cultural group. On a more private level, personal thought and feeling might be taken as sufficient to indicate a specific sort of personhood because of their embedded experiences in their family of origin. In the same way that consciousness is turned to the outside of itself and is potentially aware of its own workings, how a person has a personality is better represented through the understanding of personality as a process. Personality in context could be expressed by the invention of a neologism to emphasise the active performance involved: The self-reflexive verb to personality oneself is sufficient to indicate that the ego makes a number of habitual decisions and acts on its beliefs and the social position that it has adopted across long spans of time. But within social situations that are unthreatening, full defensiveness might be employed. How persons have personalitied themselves in the past is not necessarily how they can personality themselves in the present and future. People personality themselves by adhering to choices, values and lifestyles in complex ways that lay down a previous path of choices that indicate a future course of events. Change in personality can occur if people understand the error of their ways by a developmental formulation of their personal history and understand their defences, including the way that they are unnecessarily defending themselves. It is possible to identify how people (skilfully or otherwise) style and create themselves and their personality as a playwright might create a role for an actor: through 187

Talk, action and belief the details of choosing a vocal tone, a specific way of speaking and framing their message by their non-verbal communications of bodily presence. Whilst major personality theories each contribute to the understanding of personality, none of them are a consensus view. Personality is a self-characterisation like an actor taking a role. It can vary according to various contexts. But the major factors at hand are biopsychosocial: nature and nurture. The motto is “personality is a process”. It unfolds across the lifespan and from context to context. Personality is partly the self ’s own creation, its own choice. Some aspects are driven by choices, lifestyle and the sense of self. For instance, a person can over-compensate for their own felt-sense of inadequacy and difficulty in making themselves socially – and so become a driven over-achiever, perfect parent or hedonist, according to choice. For instance, some such ‘mistake’ can be the major rule by which a person subordinates other aspects of their overall lifestyle. Thus, the functions of living can become overly-dependent on specific parts of the whole. This can create problems if one of those parts then ceases, so there is a major crash in mood and self-esteem. The overall inability to function is called a non-psychotic “nervous breakdown”. The type of problem here is an excessive dependence on one means of maintaining the overdefended status quo. For instance, a precarious balance could be easily disrupted under the conditions of exhaustion and excessive strain over a long period of time. The functioning of the personality can be explained in the following way. Effective functioning leads to satisfaction. Dysfunctions (all kinds of impairment of role, poor management of needs and mood, etcetera) lead to varieties of unhappiness. The parts or elements that comprise the lifestyle are activities within the home, work, relationship with partner or the absence of one, and the relationship with self. Any of these parts have multiple functions in terms of creating happiness and unhappiness. The general tendency to achieve balance is to decrease dependency on any single part - and to broaden the creation of happiness across them all: “Not putting all one’s eggs into one basket”. Many of the parts can contribute to specifically good functioning, like the inter-actions between the amount of time spent on work as opposed to that on the home (e.g. caring for children and parents) whilst at the same time devoting time to the happiness of self (hobbies, friends) and maintaining the primary attachment relationship with a partner. However, a conclusion can be drawn in the light of what has been stated about the nature of the ego, choice and the primary role of understanding and the practical intentionality of behaviour: the treatment of problems of the personality is primarily self-care requiring understanding by clients of themselves and their social situations. Personality change requires commitment towards working to change behaviour with respect to clear aims for self and others. Generally, change is in the direction of adapting self and managing mood to fit attachment needs with the reasonable requests of others. This is a principle of change and the 188

Ian Rory Owen PhD gateway for the pragmatic technique for personality change: The role of therapists is to help clients understand themselves (beliefs, intents, emotions, choices, moods etcetera) and motivate them to act differently according to clear aims of their own choice, and to help them act with dedication and patience towards these aims until they are achieved, if possible, or that a sustained attempt at them has been made. To explain the way of working with the personality is to state that clients should be prepared for changing themselves. Primarily, clients have to understand themselves and want to be different. Secondarily, clients should be committed to putting in time and effort to change their behaviour to find what degree of satisfaction and improvement is attainable. But there is no guarantee that success will be achieved particularly when the stated aims involve other people.

Discussion Apart from the five dualities of OCEAN, in other ways human beings are sufficiently complex so that contrary tendencies co-exist: such as being argumentative about football and co-operative about cooking with others in the same kitchen. It is possible to be co-operative when helping colleagues at work and destructive with neighbours who one does not know. The making public of private values in achievements (in the broadest sense of the word “achievement”) is another major indicator of how a person is, according to the sum total of their achievements in life. All these aspects of everyday living show the way that the personality exists and is tacitly understood within commonsense folk psychology. Personality and attachment style are co-existent because something that is part of self gets played out in the creation of intimate relationships. What I am arguing for is a broad view of personality and personality disorder. I am not arguing against the fact that people can have very considerable fixed problems and that they cannot break out of them without the utmost effort and re-thinking their choices and values. What I am arguing for is an appreciation of what personality is. For instance, it seems to be the case that personality becomes semi-permanent in early adulthood and thereafter achieves some fixity and is acontextual to a degree; whilst there is still some possibility for learning and self-change after that time. Accordingly, if the personality does not become properly fixed until 20 to 30 years of age approximately, then children cannot have a personality disorder because their personality is still in formation. I am arguing against a slavish adherence to the idea that a diagnosis of personality disorder is somehow an answer. For the intentionality model, agreement with a checklist says nothing about what a person is capable of, particularly in caring for themselves and making satisfying contact with other people and finding satisfying work. For the majority of people, the ego is capable of being involved in its own self-care rather than neglecting itself. Whilst it is untrue to claim that the ego is responsible for all biopsychosocial 189

Talk, action and belief influence; self-care is necessary in all cases because the ego is responsible for its own welfare. Living requires self-control because the consequences of some actions are limiting or damaging. For instance, for actions to be truly impulsive, they must only be occasional and out of character. If a choice is being made on a weekly basis and has been so for the last 40 years without fail, then that is part of personality. Similarly, it is possible for the ego to be active and passive in creating its future. It can be encouraged to express its free will. The ego is the source of self-care in the biological, psychological and social domains. But if the ego does not look after its resources, and those of the best interests of loved ones, then there will be increases in disharmony and distress. However, appeal to the ego to self-care is a way of reducing such distress and creating well-being. Thus, the ego can be causative. The ways in which it acts are adequately understood against the background of how psychological aims and processes have meaning in society. The scope of what is accessible to the ego is that personal choice can lead to effective self-management of the mood and lifestyle. The ego has responsibility for its own welfare. For many people this is straightforward, habitual and never becomes problematic. For others who have never lived in the way of looking after themselves, then it is shocking for them to realise how much and for how long, they have betrayed their own prospects through a host of self-damaging and excessively self-limiting behaviours. By way of concluding this brief overview of what is called “personality,” the general tendency in personality problems is creating defensive barriers when there is no current threat requiring the creation of them. This can result in being “over-defensive” at a general level of the personality in its social functioning: The personality closes itself down and never returns to a more expansive style of trusting, being open and welcoming towards others. This may be a life-long occurrence that is made worse, for instance, by the felt-need of the individual to attempt to control and subjugate others to their wishes. But people who are self-obsessed by their focus on their own interpreted vulnerabilities should not be automatically assumed to be narcissistic. People who are self-obsessed with their own emptiness and vulnerability are overly-defended but that might be feardriven. Sometimes, defensiveness spreads across a number of areas in life.

Conclusion for the biopsychosocial view The overall conditions of possibility of the biopsychosocial whole need a theoretical account of how relations within one aspect impact on another. The contribution of the intentionality model is to think how the spheres of history, society, culture, family and specific occurrences impact on personal choice, conscience, style of relating and free will. The empirical investigation of the relation to material 190

Ian Rory Owen PhD cause in the proper sense is “heritability”. Yet its findings are tied statistically to psychosocial ‘cause’ (Plomin et al, 2000). Biology is destiny to some extent, yet the psychosocial aspects are also relevant concerning how people adjust to the biological traits that are given to them. What should happen is acknowledgement and adjustment to one’s traits. Traits should be understood as biological instinct, like sexual orientation and gender identity (Beijsterveldt, Hudziak and Boomsma, 2006, p 655). Much of core personal experience is biologically-inherited particularly in childhood and adolescence. Yet living sexual orientation places self with respect to family and others. Personality includes all aspects that are longstanding and difficult to change and some of which might be incapable of change even after medication. What can be concluded is that it is over-ambitious to posit a ‘one-size-fits-all’ assumption of known causation without being able to stipulate with certainty in each client’s case, precisely to what degree his or her problems are naturally caused and psychosocially ‘caused’. Complex inter-actions between nature and nurture are in play. If problems are caused genetically it means that clients will have to manage the negative consequences of their genetic endowment. Alternatively, if a person’s problems began and are maintained psychosocially, then their ego will be ‘causally’ involved to some extent. It is also true that psychosocial stressors will affect the material nature of the brain and body. However, therapy is part of the continuum of everyday experience and is psychosocial not biological. Currently, neither psychosocial therapy nor scientific psychology can formulate the precise shortfalls about how brains or chemicals in the bloodstream are deficient. But the practice of helping should not have an excessive reliance on biological matters without relation to the practice of talking, relating and influencing. What is argued for is a greater clarity about the medium of therapy and the nature of the intentionalities that create meaning in relation to social life. Theory is concerned with justifications that might be acceptable across the schools of practice. Therapy is the psychosocial alleviation of the overall constellation of personality and psychological problems. One strategy is appealing to the ego to alter and modify its behaviour, social life and personal choices, and manage its biopsychosocial existence overall. To have psychological problems and long-standing problematic aspects of ‘personality’ mean that there is a biopsychosocial inter-action occurring across the lifespan for any individual. But there is also the case of repeated choices and continuing the same behaviours that have always been chosen. People like what they know. And if something is found to be ‘right’ early in life, or to serve a defensive purpose, then it could be on-goingly chosen thereafter without adequate reflection to check and make sure that it still provides satisfaction, as opposed to other lifestyle choices that contribute to new and better types of satisfaction.

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Summary Therapists have a complex task ahead of them. The main part of practising can be described as attending to others through providing the clear sense that the content and manner of the meetings have value. Sessions have value because they directly address the problems of clients, enable change and provide explanations that impart value and the sense of being helped. However, contrary to the received wisdom on personality disorder, the many facets of personality disorder co-exist, for instance, like borderline personality disorder and schizoid personality disorder, because anyone who has one of the borderline personality forms will tend to have a small social circle (Grinker, Werble and Drye, 1968). What this means is that treatments for changes in personality functioning must work from within the set of motivations that clients have and give them choice and control over the quality of their lives. The three factors of the biological, the social and the psychological co-exist. •

Biologically, self did not choose its physical tendencies yet the ego is burdened with understanding and accepting whatever its inheritance is. The ego needs to work to promote its own well-being and not poison its own physical existence.

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The realm of the psychological concerns managing personal choices with the aim of making an informed choice to self-care and alter objects of attention, the manner of intentionalities towards them and the duration of time spent on any selection. Contexts for understanding the current lifestyle need to analyse problems as well as indicate the answers. The motto is that “the best things in life are free”.

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Socially, there is the current context and the accumulation of effects from past contexts that influence the personal ability to understand and act. The current and future social contexts should be chosen with care and any problems within them managed.

There is much to do in terms of helping another person understand how they are socially and who and how they seek out others. The sort of persons who are chosen as intimates and how they are loved and related to, comprise the core of a life. In some cases, it may take 10 to 20 sessions to understand the actual connection between personality style and the inter-relation with co-occurring axis I psychological problems. No matter what the specific mixture of the amounts of 192

Ian Rory Owen PhD biological, psychological and social cause are for any one individual, the usefulness of belief is that it sums up the problem of defining overall cause with simplicity and memorability. It creates a focus and engages clients’ abilities to look after themselves. The intentionality model acknowledges the complexity and interrelatedness of everything and everyone. Within the whole, it is possible to identify specific areas and tendencies.

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11 Hermeneutics and belief Aim: It is argued that prior to measurement and applying statistics, there should be a clarification of social experience, meaning and the psychological life. This chapter introduces the themes of hermeneutics and belief in psychological life that belong to philosophy. It shows how they are relevant to practice and everyday life. Hermeneutics and belief are not part of natural science but part of philosophy and the qualitative study of how consciousness works according to interpretative explanations. These explanations will lead to understanding psychological functioning and so to self-care principles. This chapter provides the basic information on psychological hermeneutics and belief. As Hamlet put it, “there is nothing either good or bad, but thinking makes it so”, (William Shakespeare, Hamlet, Act II, Scene ii). The next three chapters concern belief. The pre-amble of the last two chapters has been necessary to set the scene for a wholistic understanding. The sequence below moves from the most abstract ways of sketching out the problematic, towards becoming more detailed and concrete in showing how the ideas apply. The focus on conscious senses demands explaining to clients, supervisors or

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Talk, action and belief colleagues, through the means of being able to interpret intentionalities in the conscious experience of others.

The nature of belief Belief is half-way between thought and emotion. It has a mediating role in being able to strike a balance between these two types of representations. Working with belief in therapy has the purpose of re-thinking to alter negative emotions. Or new emotional experience can be promoted through checking the controlling thinking that permits the range and depth of emotions felt. Belief can promote the ‘head over the heart’ and the ‘heart over the head’. Working with belief produces an overall congruence with intentions and enables them to become manifest and shared in a constructive way with others. In short, belief is an act of the rationalising and deciding ego. Belief produces semi-constant senses that are often inaccurate in the present but may have been accurate and defensive in the past. The referent of what others feel and intend is never adequately portrayed until it is re-appraised in the light of a range of evidence with a more open perspective. Namely, an interpretive stance that is curative or restorative is one that turns clients back to the world without foreclosure so that their own negative beliefs and experiences can be re-evaluated in the light of proper evidence and a justified understanding of it. Interpretation, making sense, is the means of concluding on beliefs about regions of conscious evidence. In parts of psychology, the philosophical role of interpretation and hermeneutics is investigated empirically and referred to by a variety of names such as “attribution,” “selective attention,” “appraisal,” “information processing” and “bias”. The specific types of bias that often appear in therapy practice are inaccurate negative senses of self and others, and the persistent inability to work through negative self-worth. To restate the role of belief as a positive principle: Believing should not be decided in advance of the evidence in a way that keeps clients stuck. Believing should stay sufficiently open in order to understand. Beliefs can be understood as ‘causes’ in both talking and action therapy. Beliefs are interpreted as ‘causative’ of specific events but may get generalised across other domains of life. The usefulness of the concept of belief is that it sums up highly complex situations and renders them into short explicit statements of the sort, “I protect myself socially because I believe that if I went to a party nobody would take an interest in me”. The general strategy is understanding implicit and tacit negative emotion, through increasing awareness, reflection and interpretation of such experience, to formulate explicit beliefs in simple statements of the sort “I believe...” that wrap up complex states of affairs that ultimately may include unknown causative factors. The therapeutic adoption of new accurate explicit beliefs means rationally choosing explicit statements by attending to the full range of relevant evidence about any topic, as a 196

Ian Rory Owen PhD way to maximise the potential of clients to have a positive quality of life. Explicit beliefs act in a functional and helpful manner as the means of promoting self-care, security of attachment and may be turned towards specific projects like getting a suitable partner, or how to get on with problematic colleagues at work, or other realistic aims.

The argument of this chapter The method below is an intellectual argument for one perspective, with respect to claims of psychological reality and proper interpretation. Below is an argument for the adoption of an explicit hermeneutic perspective in therapy. When hermeneutics is accepted, it permits the study of psychological events between people or for individuals, according to the inter-relation of intentionalities of different sorts, with respect to conscious objects of different sorts. Understanding the structure of psychological problems for each individual is required before obtaining informed consent, and discussing and planning therapeutic action. The function of theory is to point at what is important. Clients and therapists need explanation, instruction and explicit reasoning to make psychological change. If aims and means can be specified, then there is hope for increasing quality of life. Theoretical understanding is necessary for therapists to understand relationships and emotional reactions, and work out how to act to provide help. It is argued that intentionality, meaning, desires, fears, beliefs and their formulation are not topics that fall within the scope of natural psychological science. Belief concerns the qualitative experiences of ordinary living and the transition from problems to some form of their solution or management. In order to understand psychological meanings and experiences, there has been an ornate and complex preparation so far. The key factors are how to understand the work of consciousness in creating belief that drives action, feeling and thought. Specifically the way of working with beliefs is to make them explicit in language with clients fully involved in the process. The aim is to conclude in a collaborative manner on current beliefs that are accurate with respect to the current situation and the abilities and potential of clients and so the new restorative beliefs are part of accurate self-knowledge. The view is that the problems of the personality and the psychological disorders can be re-presented to clients as being due to psychosocial causes of earlier problematic social situations, such as living in poverty, violence and insecure attachment. The aims for protection are greater than the need to embrace risk concerned in getting attachment and other satisfactions. When this happens a defensive system is in existence and the needs for defence predominate which can lead to attachment needs being neglected in order to achieve defensive compromises and protections. The old defensive beliefs serve the purpose in the original context of being there to fend off real world problems and potential problems. 197

Talk, action and belief However, when the desire to engage with risk and meet attachment needs is greater than the desire for protection, then attachment needs can be met and psychological satisfactions of other sorts can also be earned. When this is the case the operative new beliefs are in-line with the current actuality. This latter case also covers the situation where there might be biological causes operative also. Even when there are biological causes present, these are covered well by the use of selfcare aims and targets through the use of explicit beliefs concerning how to achieve and monitor the achievement of specific outcomes. Hermeneutics is the name for making sense, understanding psychologically, interpreting evidence, and so applying emotional and social intelligence in order to define explicit beliefs and move towards outcomes. New concepts are applied to emphasise what all persons do when they make sense. There are numerous ways in which the terms hermeneutics, belief, and hermeneutic stance apply to tangible psychological examples and explain the differences in overall experiencing. Rather than staying at a level of abstraction, the work of believing needs to be made clear. The work done by believing, its outcome is the result of a complex intentionality connected to the ego and its free will and the ability to rationalise, relate and emote. Primarily, believing is working out what and how psychological events are real (or not, what they are not like). For the intentionality model, the qualitative data needs to be interpreted from such a position that it makes general sense. One case would be understanding influences in the lives of adults who have been traumatised as children, who remain psychologically damaged for decades after the initial events. What this means is that checklists of symptoms need to be read via the ideas of empathy, temporality, belief and intersubjectivity, to work out what symptoms mean as continuing psychosocial processes across the years. Like the comment of Edmund Husserl, that the map is not the territory (1901/1970a, §20, pp. 727-728), believing is making a map of the psychological world of what self is like, what specific and general other people are like, and what the present and future will hold, and what the meaning of the past is. Beliefs can be said to be implicit when they have not yet been made conscious through interpreting emotions, mood and relationships with others and the relationship with self. Beliefs are generalisations that might be automatic, involuntary and passive. Sometimes beliefs are highly context-specific concerning parenting or falling in love. Or at other times they are highly non-specific. The good news is that implicit beliefs can be made conscious, re-thought and re-learned. Where the intentionality model differs with other approaches to belief is that it acknowledges the difficulty of concluding when thoughts in language are sufficient descriptions and explanations of experience. Let us begin with some concrete examples. Implicit beliefs can be about something, some situation, or person in relation to someone. Andrea feels as though she has nothing to offer the world. She behaves as though she will never get a partner, even when eligible bachelors show 198

Ian Rory Owen PhD an interest in getting to know her and ask to spend time with her. Andrea also rejects friendship when it is offered. After many years, Andrea dates a man and for first the time permits him to hold her hand in her own home. However, what she feels is non-specific intense fear although she wants to make the relationship committed and sexual. At this point, Andrea breaks off the dating relationship and asks that the boyfriend leaves immediately. Andrea is not fully conscious of what she believes, because she does not generally focus on the full extent of her feelings and behaviours. From an external perspective, it is possible for others to work out what she believes about herself, how well she is able to meet her own attachment needs, and what she believes in relation to boyfriends. Interpreting Andrea is as follows: Implicitly because of the strong fear that Andrea feels on getting physically and emotionally close to the possibility of love and caring, it is possible to interpret her fear as a defensive one. Despite her conscious intentions to be in love again and find a long-term partner, she feels that she needs to protect herself from disappointment and maintain a safe emotional distance. Altogether, the implicit belief is “love is dangerous” emotionally, whilst the explicit belief in language is “I need a partner”. There is nothing unusual in this type of incongruence. Whilst there could be the mistaken conclusions that emotions are mostly non-egoic understanding, that is not the case on further close inspection. So what could be called “egoic understandings” are those that are more closely connected to the reasoning and choices of the ego, there are also those understandings that seem to be immediate and without any apparent connection to the ego because they are “passive” and arise spontaneously and involuntarily. Chapter 19 goes further into the ‘causes’ of the emotions. Explicit beliefs are when emotional, relational and other long-lasting complex regions of living are raised into language. The simplest way of expressing beliefs is to create phrases that are expressed in the first-person: “I believe...”. Given the detail of the situation, what could be said to Andrea is something like the following. “It is as though you believe you do not deserve love. Is that right?” The other beliefs expressed by Andrea in her feelings and actions are “I am not likeable”. “I will never be in a long-term relationship”. “I must not let people get close to me”. The usefulness of interpreting beliefs is that it renders complex situations into clear statements that can act as a spur to making changes and experimenting with new thoughts, behaviours and ultimately creating new emotions and moods that satisfy attachment needs.

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Different interpretations of self at different points in the lifespan Let us take another example that explains the terms that are being introduced in this chapter so that it is possible to understand the whole before looking at the parts. Jonathon, as a young man, wanted to have girlfriends and find a wife and make male friends. But he was frequently too afraid to go to places where people might be. His general interpretative stance on himself and his empathising of other people was that he believed that other persons were more attractive, more able, did not have any problems and were confident all the time. But he, on the contrary, believed he was an oddity, full of fear and had no ability to talk to women whatsoever. His hermeneutic stance on the conscious evidence of his experience and his view of others was circular in the sense that it was an understanding that produced its own evidence that maintained the original understanding. Twenty years later, after three broken marriages and having become a success at his chosen type of work, Jonathon as a middle aged man at last realised that he could talk to women and make friends easily. He realised that he was friendly and outgoing. He could walk into a bar or social club and handle any situation. He realised that he could flirt with women easily and that he enjoyed this type of social contact, even to the extent that he knew that he was good at it and that he felt confident and relaxed while doing it. Given that 20 years of experiences of dating, sexual relationships and being in long-term relationships had gone by, overall something positive had happened. Life had taught him something and Jonathon had got a positive message. Theoretically, what are the differences between young adulthood and middle age for him? When Jonathon was a young man he interpreted himself negatively in unfair comparisons to other people. His assessment of himself socially, sexually, intellectually and emotionally was unfair to his own strengths even at the earlier time. Problems were encountered during the next 20 years, when that old set of beliefs (and their accompanying experiences) cast shadows across his current activities. Even at the time of his early adulthood, his beliefs were unrepresentative of his own strengths and were excessively based on the strong value that he gave to other people. But because of their worth, and his lack of it for himself, Jonathon was not able to step out of the prison of his own beliefs. This made difficulties in choosing suitable wives because he chose anybody who would have him, rather than somebody who would be right for him and with whom he could fully commit and stay married. Implicit to his emotions, thoughts and fearful actions with women in particular, was that Jonathon had interpreted women as flawless beings and expected them to be constant and always ready to care for him. He believed that any girlfriend that he would have would attain and remain in a state of idyllic 200

Ian Rory Owen PhD bliss and that it was his task to make this happen. Because actions, thoughts and emotions are consequences of what was believed, when things did not go to plan there was confusion and more ‘evidence’ to support the belief that he was no good and unable to make wives or girlfriends happy, like Jonathon believed he should. The details of Jonathon’s development are as follows. Through therapy, it was possible to find that what he believed, thought and felt, about dating for instance, were different at different times. When Jonathon was having a bad day and his self-doubt was operative, he could still tell himself negative things about his achievements and feel self-pity. But on a good day he could feel that he was of sufficient worth and that he should have an attractive, happy and confident partner. What became apparent through questioning, and the writing of formulations with him, was that self-doubt was expressed in his internal dialogue about his own capabilities in a long-term relationship, particularly his own ability to communicate and reciprocate loving attention over a long period of time. What Jonathon could feel were two separate sets of emotions. What arose first and foremost were negative feelings about himself in relation to a non-specific possible partner. On the one hand, the negative feelings were a fear of intimacy and low self-esteem because he did not feel worthy in relation to the possibility of being loved. Jonathon could feel empty and had felt so in the context of times of not having a partner and staying single. Whilst on the other hand, there were strong positive feelings at the prospect of a long-term relationship, having children and enjoying family life. Therapeutically, what happened was that once these private thoughts and feelings were made public in sessions, and formulated and discussed concerning the context in which they arose, they then became open to scrutiny in a way that did not happen when they were kept private. When these beliefs and experiences were undiscussed, they had the power to remain as negative emotions and beliefs. But on being made public, his beliefs had their negativity re-appraised and their negative force either spontaneously evaporated on speaking about them, or was open to rational inspection which sought to explore the thoughts and feelings to find out how they made sense. The differences that occurred through therapy were that Jonathon’s explicit beliefs about himself were evaluated and the negative ones were recognised as worries that might have had some accuracy in teenage years, but were inaccurate reflections of his social, occupational and dating successes as a middle aged man. What changed was his hermeneutic stance with respect to the proper body of evidence, in checking his explicit beliefs, to make sure they were accurate portrayals of his experiences and abilities. However, Jonathon as a middle aged man was able to find precisely the same situations as his youth (of dating, flirting and making male friends) highly pleasurable. In later life, it finally dawned on him explicitly that talking to people in a singles bar, or on a holiday for single people, that it was he who broke the ice, who asked for phone numbers, who was able to remember people’s names and 201

Talk, action and belief what they did for a living. The difference between the two situations of his youth and middle age is that Jonathon had been able to revise his implicit fearful and negative beliefs that were a harsh view of himself and his excessively positive view of others. In short, he had become better able to appraise and conclude on himself and others. His mature ability to interpret himself in terms of his experiences at dating women and making male friends was more accurate, in that he realised that he was able to do these things without fuss and worry, and this enabled him to believe that the evidence of his social and sexual relationship successes. Jonathon concluded that he could potentially find a girlfriend and start a sexual relationship with ease. What then became important was finding the right sort of woman and to treat her with love, trust and patience (rather than finding anybody who would have him). To formulate his good functioning is as follows: When he acted well in social situations, he knew that he was meeting his standards and so he achieved positive and accurate self-esteem that was in-line with the evidence of other people’s reactions to him. This altogether enabled relaxation that then promoted his ability to be socially capable. Theoretically, the differences between the early and mid-life points on Jonathon’s lifespan show a change in his interpretative stance on himself in relation to others. He changed his means of selecting a certain portion of conscious experience as evidence, and created accurate explicit beliefs. This is an example of psychological hermeneutics. Hermeneutics in psychological life is the qualitative study of how people make meaning and sense, in the minutiae of everyday living and the wider formal study of psychological situations including how to conclude on psychological experiments. The remainder of this chapter supplies more detail of the distinctions that have been begun in these examples.

Overview of psychological hermeneutics The term “hermeneutics” is a new one to most therapists and psychologists. What will be explained below is a brief overview of some definitive comments from philosophy to explain it. However, in order to explain the term properly with respect to therapy theory and practice, what will be cited are a number of examples that show the worth of naming experientially understood-phenomena as hermeneutic. Let us start with a definition: A hermeneutic theory concerns interpretation or making sense in an experiential way. An exemplary phenomenon where belief appears in everyday life is the phenomenon that is called “transference” in the psychodynamic tradition that is more precisely rendered as mis-empathy. Misempathy is a mixture of a strong tendency to mis-interpret something of another’s verbal and non-verbal communications in a specific identifiable manner that elicits 202

Ian Rory Owen PhD specific responses from others and is not open or barely open to the meaning of evidence to the contrary. Thus, mis-empathy is not just mis-understanding the emotions, perspective and intentions of others but is connected with beliefs that anticipate confirmation of the false understanding and may actually elicit responses that are then taken as confirmation of the false understanding. Most generally, psychological hermeneutics is the formal study of how consciousness makes sense of people and situations. All theories are hermeneutic in that they have some way of deciding and concluding on what something means. The study of hermeneutics itself is self-reflexive in that it explicitly knows how it makes sense and justifies the conclusions that it draws. An interpretation is a specific act of making sense. Just to account for understanding by stating that one person listened to another and knew what they were talking about is insufficient. In speech, what appears immediately is often apparently clear meaning. However, what actually happens, particularly when psychological matters are being discussed, is that empathy donates the meaning of what the other person is talking about. What is heard are mere sounds. The meaning grasped is far in excess of mere sounds. What is grasped is the whole experience of what it is like to be that other person, in that context at that time. The way that lived experience is interpreted by the intentionality model is to understand that consciousness appraises or donates sense to perception and other types of appearance such as imaginings, anticipations and rememberings (Husserl, 1929/1969, §107c, p 287). Sometimes how this can happen is that people donate their prejudices and assumptions and so the phenomenon that appears for one person is not the one that is given to others. In prejudice, for instance, the object is not properly grasped. One person who formalised the hermeneutic process was Wilhelm Dilthey who wrote that the “first... epistemological problem” is differentiating between significant understanding as opposed to background experience (1976, p 262). Hermeneutics is demanded because of the ubiquity of making sense, qualitatively and theoretically, in deciding meaning: The whole must be understood in terms of its individual parts, individual parts in terms of the whole. To understand the whole of a work we must refer to its author and to related literature. Such a comparative procedure allows one to understand every individual work … more profoundly… So understandings of the whole and of the individual parts are interdependent. Dilthey, Ibid. The key phrase is “understanding of the whole and of the individual parts are interdependent”, (Ibid): Wholes and parts of them are co-understood. The name for

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Talk, action and belief the phenomenon of the new understanding that is made through the influence of the old one is the hermeneutic circle. Hans Peter Rickman has defined it as follows: The to-and-fro movement (called the hermeneutic circle) between interpreting individual phenomena and interpreting the whole of which they are supposed to form part is characteristic of all interpretation … There is … no absolute starting point, no rigid framework of assumptions on which an interpretative theory can rest... Interpretation… is a matter of getting at the meaning of human phenomena… of discovering from their expressions what people think, feel, and want. Rickman, 2004, p 73. Hermeneutics is most acknowledged in literary criticism and qualitative psychology where it is the watchword for clarity in justifying the means of drawing conclusions. What hermeneutics means for therapy and understanding everyday experience is that there is no un-interpreted meaning, ‘just there’. There are no single meanings as facts, plain for all to see. Understanding hermeneutics means understanding that beliefs are interpretations of the perceptual and psychological senses that accrue about an object. The term “hermeneutics” means a formal way of making sense of something by interpreting it in a specific way. This abstract term will be made more concrete in further chapters. For the moment, hermeneutics can be defined as formal ways of making sense of any topic in an explicit way in language. Such ‘methods’ for interpreting can be self-reflexively brought to any area, as sets of assumptions about what counts and how meanings are constructed. The point of the hermeneutic circle is to make vague and superficial interpretations more explicit and spell out why some event or sign means what it is claimed to mean. What wins the day is deeper understanding that is better justified with respect to the relevant parts and wholes of evidence. The hermeneutic circle constrains understanding and people operate within its confines. Hermeneutics can also refer to theories of understanding within a region of academic study: This is a discussion of the larger, enabling conditions for understanding of a specific sort to exist. Such disciplines are literary criticism, film studies and studies of the creation of literary works in their social and historical contexts. In this expanded sense, there could be a meta-theory of understanding for psychology and therapy. For instance, research of the non-verbal expression of emotion cross-culturally would be such a field of study. Or the cross-cultural study of different childparent attachment patterns cross-culturally (Konner, 1982) or within one culture across its history.

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Understanding in everyday experience What the hermeneutic circle means in therapy is that interpreting an experience about what something is, or what some situation means, demands reflection and self-awareness. The hermeneutic circle is self-reflexively knowing that the new is being understood in terms of the old. What is at stake is how to interpret, make sense of, phenomena that are about understanding others to whom self is relating. Simultaneously, people understand themselves and respond to their empathic understanding of others. The relationship is between understanding and the understood phenomenon-in-action. One of the core aspects of therapy is helping clients’ self-care in the direction of changing beliefs, thoughts and actions - in order to change understanding – and hence affect, mood and self-esteem. Taking action improves relationships to self and other and is the congruent consequence of being committed to new beliefs. Changes in behaviour entail further changes such as being able to reflect on the ability to achieve, and so prove the worth of the effort expended. Trying new behaviours is a learning experience that means containing the negative emotions involved, living with occasional increases of anxiety, depression and bearing frustration, in order to get the desired changes. Hermeneutics in everyday life occurs in becoming depressed, for instance, as much as it does in shaking off depression. The work of hermeneutics is judging the differences in the intentional relations between self, others and shared meanings. Understanding the everyday life is a starting point. However, what a focus on lived understanding means for the academic studies of psychology, psychopathology and therapy are that these disciplines are part of commonsense everyday experience, “folk psychology,” as it is sometime called. Meanings that are capable of being verbalised come into focus, and go out of it again, and there is a relation to a complex whole of another sort called temporality: the connection between the past, the present and the future, as lived experience. Because the attitudes of approach create experiences that are then interpreted from a specific standpoint, there is no ultimate justification of any interpretation made ( Jaspers, 1913/1963, p 358). Indeed, claims about meaning are capable of being challenged and re-thought. Despite this lack of scientific status, the hermeneutic circle means that circling around a topic is required in order to find approaches to it that are genuinely relevant: for example changing from depressed low self-esteem approaches - to confident, patient and curious ones. For instance, mere intellectual knowledge about swimming is never enough. Swimming itself is what really provides expertise. A negative example of generating accurate understanding in practice is when Roz, a trainee therapist, takes on five persons each with bipolar disorder in succession. As each person is seen, the initial intellectual knowledge of Roz grows and becomes deeper as she practices with each person. At the end of seeing her five clients, the understanding Roz has gained has become an integral 205

Talk, action and belief part of herself. So she no longer has to consult introductory textbooks but has an immediate access to her practical understanding of how to help people with bipolar disorder. Because the subject matter is understanding and interpretation (from a specific stance or attitude with respect to people) understanding is incomplete and evades completion, in empathising and areas of academia. Accordingly, there is no hope of complete justification and there are always structuring assumptions that shape the meaning-oriented outcomes gained. When it comes to self-understanding and empathy, these form a whole that is prior to an attention to any part of it. The term “unconscious” is not used because of its unhelpful psychodynamic connotations. But the end-products of the intentionalities of consciousness are descriptively unconscious when they have not yet become objects of awareness. The better way of naming these is to call them “preconscious”. Returning to Hans Peter Rickman: Clarification is not achieved by moving from the general to the particular and vice-versa but by relating the less complex to the more complex. The logical difficulty is the same in both cases. This continuous back and forth is logically unsatisfactory, but perfectly familiar and is called the hermeneutic circle … We are confronted by specific ways in which parts are related into a whole. The constituents of physical entities are linked by spatial and temporary contiguity and causal mechanisms. The wholes we are concerned with here are linked by meaning … Description and explanation cannot be sharply distinguished. Rickman, 2004, p 112. By way of summing up, hermeneutics in therapy, psychology and everyday life is the formal analysis of ways of making sense. In its most formal scope, hermeneutics is how any school of psychology or therapy makes sense of any specific situation. The formal and global ways of making sense also apply in any relationship because people act according to the sense they make of their two-way connection. How they act depends on the accuracy of their ability to distinguish what is going on, as opposed to some worry-based conjecture, for instance. When it comes to psychology, what hermeneutics and the explanatory idea of the hermeneutic circle mean is that what is perceptually there for all to see and hear bears no one-to-one relation to the senses made of it. This is the case when psychological cultural objects are considered, particularly those in therapy. It follows that what hermeneutics means is that the factual recording of perceptually observable events means nothing specifically in itself. This is why summarising and reflection of the understanding gained must be given back to clients, for 206

Ian Rory Owen PhD checking and further discussion. What occurs perceptually is the mere tip of the iceberg that has meaning brought to it. When people mis-understand the same topic and have different reactions to the same shared event that is because how they make sense of the same perceptions are entirely different. Specifically, they are different because of what is brought to an observable event is what makes sense of it in connection to how it appears perceptually. What hermeneutics means is that there is plurality of interpreted senses - and a relativity of sense to the perspective taken. In the qualitative realm of lived experience, there is no one-to-one correspondence between what appears and the meanings that it might have. This is because empathisers bring to the current situation various contexts of understanding (sometimes called “worlds” or “horizons,” the idea being that what is within a horizon is the totality that can be seen by the person in question). There are a large number of beliefs, theories and explanatory contexts that can make sense of a situation. In relationships, there is the overall historical context of the meetings between any two people, plus many other factors that do not appear perceptually. What the hermeneutic circle describes, with relation to the qualitative experience of knowing and understanding other people face to face or in other situations, is the priority of non-verbal immediate experience and understanding that has been accrued across the lifespan. Acquired learning to date has the major role in forming understanding in the present moment. This is a qualitative conclusion of the priority of the whole of previous learning. Immediate new understanding occurs in empathising a specific person telling a specific story, or it can occur in listening to an account of childhood or some other matter that is being discussed. The words that describe the lower intentionalities are terms like elementary, fundamental, implicit, involuntary and automatic. This understanding (and its beliefs, experiences and memories) is also called “common sense” which is apt because such learnings are common within the same culture and society. For any linguistic group that shares the same cultural experiences, there is a lingua franca of psychological experiences of what it means to be happy or sad and how to recognise these experiences in anyone in the street. (A lingua franca is a pidgin language that enables people of different languages to communicate in a very basic way. This is not to claim that the understandings are universal or that there is universal competence in being able to understand them). What the fundamental base of understanding grounds is the specific ability to interpret specific situations. When these specific situations are immediately understood, and that sense is put into speech, higher conceptual intentionality represents non-verbal felt-sense. Thus the explicit understanding of psychological processes contributes to the overall store of theory and clinical reasoning. In conclusion of this section, psychological hermeneutics in everyday life refers to any person’s specific receipts of immediate felt-sense or intellectually207

Talk, action and belief reasoned acts of interpretation of any psychological topic or situation. Empathy is the intentionality that delivers the non-verbal felt-sense of what other people say and intend, believe, do, think and feel. Specific fundamental empathisings are part of the greater ground of common sense that is part of being human. Higher, more formal psychological hermeneutics are theories concerning how understanding exists in formulation, psychopathology and treatment, for instance.

Belief as the result of interpretation For the qualitative approach of therapists who listen and respond, the ability to explain psychological processes and objects rests exclusively on how conclusions are drawn from what appears. However, the intentionalities themselves never appear - only their end-products. Any given sense could be disputed according to what has happened objectively, subjectively and causally. Interpreting is supplying rules or general knowledge in order to explain an experience. It is not just observable and describable experiences that are involved. What is involved are the conditions for understanding what the same observable and describable experience is, its function or purpose if any, and its specific or general meaning. Accordingly, the psychological field is open to multiple interpretations. Two important aspects of therapy are interpreting the presence of the past and its influence on the present (if this is traumatic influence, for instance) and creating new corrective experiences in the session and through homework. The discussed and agreed understanding is used to set explicit homework, self-directed homework or it creates implicit changes in self-understanding brought about through discussion in sessions. In talking therapy, discussion alone creates spontaneous changes in meaning, merely because it is airing a topic in a safe and trustworthy relationship. However, if these changes are insufficient, more needs to be done in the form of action therapy. Belief is an intentional act of a willing and choosing person that is close to how people make sense. Believing what exists or not in a social world is tied to how it makes sense. Previously, cognitive behavioural therapy and other approaches have over-looked the expertise of philosophy in attempting to clarify the relations of concepts to experience for several hundred years prior to the invention of the therapies. Several areas within philosophy sum up the analysis of the relation between prior understanding and the current understanding gained of current phenomena: Beliefs are the outcome of interpretive work done concerning what exists (or not) and make conclusions on the manner in which that object, person or their qualities exist. Statements concerning what exists are “ontological” ones. Statements about the ways of interpreting and formal ways of making sense are “hermeneutic”. Ways of knowing are “epistemological”. Beliefs are judgements concerning what exists and are not factual or measurable but more fundamental. Scientific psychology is unable to grasp these lived experiences. Fundamentally, 208

Ian Rory Owen PhD lived experience is unscientific. The necessity of experimental studies is to understand that the more derivative experiences (of thought, action, relating and emotion) are higher consequences of the more fundamental conclusions about what is believed and how it is believed. Cognitive behavioural therapy has correctly identified the usefulness of belief since the work of Albert Ellis (1962) who grasped the role of conceptual intentionality in what people say to themselves and others. This same insight was also present in the work of Pierre Janet in 1894 (cited in Ellenberger, 1970, p 413, n 90) and Alfred Adler (1931). For Janet, conscious fixed ideas are of three types: derivative fixed ideas, stratified fixed ideas and accidental fixed ideas (Ellenberger, 1970, p 368, Janet, 1894). But since Ellis’s original adoption of belief from philosophy, there has been a loss of the source and nature of belief in therapy. Hermeneutics has been applied in some areas of psychoanalysis (Tuckett, 1994) and other areas (Owen, 2004). Belief is a key topic in philosophy and that is its rightful heritage. What humans believe has powerful consequences. The remainder of the chapter formalises the definition of belief in the psychological life.

The philosophical understanding of belief It was Plato who recorded the thought of Socrates. Socrates made some key distinctions about belief in Book Seven of the Republic and his distinctions are still noteworthy today (Plato, 360BC/2007). He made the original distinctions between true knowledge (noesis) as opposed to belief or mere opinion (doxa). There are further distinctions between genuine reason (dianoia) based on justified thought, not mere thought (episteme). Belief is further subdivided into belief proper (pistis) versus mere illusion (eikasia). These six terms are split into two camps: one ‘true’ according to personal experience or accurate and the other inaccurate. On the one hand, there could be accurate beliefs concerning the whole of some relevant area of evidence. Any degree of certainty about the relevant evidence could only come after detailed consideration of it. The amount of accuracy attained in any case would need to consider the particular conditions for the possibility of the object and processes under consideration. For example, there are key differences in the following psychological situations. True knowledge (noesis) appears after a detailed immersion in the situation at hand, or it can be gained from a detailed analysis of exemplary and definitive cases, both positive and negative. Reason is proper reasoning that arrives from the inherent distinctions within a field. Dianoia is genuine reasoning pertinent to particular regions and areas and may be limited to a single or small number of similar cases. Proper pistis, accurate or justified belief arises finally after consideration of what is or might be real and how it is so. These three accurate states of affairs can occur verbally or non-verbally. If non209

Talk, action and belief verbal senses are expressed in language, then the words chosen, and the type of explanation provided, are important for re-considering what can be concluded on and what it means. On the other hand, inaccurate senses of the whole or the object of attention can be distinguished from accurate senses for the following reasons. Mostly, the beliefs used are long overdue for re-consideration. Most problematic psychological beliefs by which people operate are tied to their youth and earlier. Mainly, the beliefs are fear-provoking and the fear generated inhibits useful and necessary actions. Mere illusion or appearance (eikasia) usually happens only through a snapshot about the object, due to fearful consideration of it through memory, association or imagination of some catastrophe. The reason why eikasia is illusory is that it is a part, a momentary sense that should not be considered, but is incorrectly accepted as representative of the whole. The illusion is “mere” if it is expressed in internal dialogue, for instance, and then haphazardly accepted for no other reason than “I thought of it” or “somebody said it was so”. Thought that has no hope of meeting its object, of understanding the intentionalities that enable understanding, is episteme if clients inaccurately experience the object of attention. Similarly, doxa, mere opinion, occurs in the sense of vulgar belief in popular myths, false beliefs and wrong received wisdom. These are beliefs that wrongly refer: be they implied beliefs contained and expressed in actions and emotions, or if they are expressed in language. Such haphazard beliefs are the products of mental acts that produce inaccurate senses of the object and its context because their manner of reference produces a lived-sense that should not be confused with what could be found through better attention to the object. Let us consider a concrete example. For instance, Gloria is agoraphobic and ‘cannot’ go to the town centre. What appears is intense fear about what might happen. Her problem is anticipating having a panic attack and fainting in the street. Gloria believes what she imagines will happen. Gloria can imagine that people will disapprove of her lying in the street and think that she was a “no good,” and incapable on drugs or drunk. Gloria anticipatorily empathises that the public will disapprove of her. Gloria makes this prediction with full belief, so strong that the sense of disapproval she creates means that the town centre is a place that cannot be approached. Once, Gloria had a panic attack. When she began to anticipate its recurrence, she felt anxious just at the prospect of having another episode. When she did this repetitively, even before leaving her own front door, then it all became too much. So that the possibility of a panic attack became a ‘certainty’. This is process was a selffulfilling prophecy because the anticipatory fear was so strong that she became handicapped by the amount of anxiety and did not feel like trying to leave her home.

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Ian Rory Owen PhD Ultimately, when Gloria did venture into the centre of a small village near her home, although being afraid, she enjoyed the experience of being outside once more and was able to do her shopping herself. It took another two months for her to venture into the local town centre on a Sunday morning. But after that, she was able to revise her beliefs and found that her conscious experiences about being in towns were entirely different to what she had anticipated. This is what is meant by having a better attention to the evidence. The next section is a technical one that explains the philosophical stance which is suggested as being suitable for supporting practice. It is included here for the sake of completeness.

Husserl on belief Edmund Husserl focused on concluding from experience about how consciousness is turned to other consciousness, and the conditions of possibility for that to occur. Husserl’s approach to belief can be pieced together by an attention to his texts. What makes his view of belief serviceable for psychology and therapy is that his approach was one of an experiential grounding (1913/1982, §136, p 327). He took a wholistic experiential method (§147) that attended to the accrual of positive and negative evidence across time (§138, p 332). Husserl’s approach begins with general descriptions of what it is to be aware of things, people, ideas and self (§35, p 70). It progresses by interpreting what appears according to what is constant and what is variable. It ends with concluding on the necessary relations of how forms of intentionality are related to objects of various kinds. For him, it was always clear that the act of believing is tied to emotion (§117, pp. 279-280). Husserl’s approach to belief was intricate. Some of the main aspects of it are as follows. Firstly, the evidence that appears might be confused or distinct (§123, p 293). Or the evidence could be ambivalent to the extent that visual illusions can appear where two visual objects, two meanings, appear about the same perceptual material. In this case, the extent of the nature of the object appearing itself is ambivalently understood: “at first a perceived object is there with simple unquestionedness, in certainty. Suddenly we suspect that we may have fallen victim to a mere “illusion” … The thing “suggests itself ” as possibly a man. Then a contrary deeming possible occurs: it could be a tree which, in the darkness of the forest, looks like a man who is moving”, (§103, p 251). Husserl interpreted belief from the manner of givenness of any experience, something he called the “How of appearing”, (§99, p 244). By which he meant that when something appears, it does so in a specific way as remembered, imagined, wished for, feared, loved and every other sort of “givenness”. The manner of appearing, also called the “how of givenness” (§103, p 250), means that to establish an act of belief overall, requires assessing the inherent qualitative experiences that are relevant through prolonged 211

Talk, action and belief consideration of them. For this qualitative approach, only prolonged experience of an object and discussion with others can show if it is accurately known or not. What Husserl claimed would appear were various qualities of objects, existing and non-existing (§106, p 254). By attending to, and being immersed in detail, Husserl held that experientially, the truth-so-far would appear. Old beliefs could be rekindled (§115, p 273). For instance, merely possible belief that something might or could exist (§113, p 264), is one “character” of the believing act. Wishing and desiring are cousins of believing, for instance (§114, p 270). Indeed, the component experiences that lend themselves to believing are subject to combination and disjunction like a grammar. For instance, beliefs and their evidence can be added or a decision has to be made: Sometimes, it is either one thing or the other, but not both (§121, p 288). The technical terms that Husserl gave to these aspects of the believing intentional act and the believed (or disbelieved) object are as follows. To have a belief was sometimes called occupying a position or “positing” (Setzung), whilst there are a large number of intentional modes of believing. These modes include certainty, doubt, assuming and questioning and were also called the “modalities” or “characters of belief ” (sometimes “thetic” or “belief character”). Furthermore, it was noted that just because beliefs could be explicitly formulated in language, that did not mean that belief is synonymous with a linguistic manner of expression (§§125-7). Rather, if a belief is expressed in language it is explicit whereas it could be implicit by dint of non-verbal experiences that happen such as emotion, mood or behaviour (§127). Another place where Husserl made some definitive remarks on the nature of belief in relation to the ego are useful for supporting the relation of these ideas to actual practice. In 1925, Husserl defined the ego as having a unique style of “properties of character” that exist and are expressed through believing and decision-making (1962/1977b, §42, p 164). What he concluded is that the decisions of the personality are based on its beliefs, to the extent that the ego and the sum of its beliefs are mutually creative of each other. The keeping of beliefs can lead to happiness; whilst the loss of previously cherished beliefs can lead to unhappiness. The next section takes this philosophical treatment of believing to understand psychosocial events.

Psychological beliefs Now that the role of hermeneutics and belief have been formally introduced, it is now possible to grasp belief in more detail. Firstly, belief is only part of the wholistic view of the biopsychosocial perspective. Understanding belief begins with making clear the difference between senses obtained from specific perspectives; and the nature of the referent or object as a whole. A simple rubric is suggested 212

Ian Rory Owen PhD for understanding behaviour, relationships and associated experiences. Leaving emotion and imagination out of the picture for the moment, the rubric is that initial beliefs guide actions that provide outcomes. When noted in this order, what is being stated is the viewpoint of the self who acts. Persons who act hold their beliefs in a context of what is considered possible, a world of the possible. Their actions occur in contexts of what is possible as opposed to impossible (or possible for someone else, or potential for self, but the proposed acts might be socially unacceptable). The desired outcomes have been consciously striven for, yet they may also entail consequences that are unwanted and painful. It is often the case that aspects of the personality and psychological problems begin as attempts at solutions, defences and positive coping. Yet they incur increasing negative drawbacks, as they are maintained over time. Psychological beliefs are socially learned through experiences in the family, schooling and social learning in the neighbourhood. The importance of hermeneutic beliefs in therapy is that clients can be interpreted as holding beliefs that determine their behaviour, emotion and relationships with others. Furthermore, through believing one way or another, people come to hold beliefs about themselves and their connection with others. Hermeneutic beliefs play a major role in psychological life in that they interpret what exists or not, what is possible or impossible. For instance, the set of intentions, thoughts, feelings, and anticipations that comprise agoraphobia, like the case of Gloria cited above, concern a whole series of experiences that are not related to the possibilities and actualities that exist for people who do not have agoraphobia. Agoraphobia concerns living in a fearful future where people are certain that bad things will happen and their feelings are congruent with their negative anticipations. The degree to which agoraphobia is treatable concerns the degree to which people are willing to stop holding fixed beliefs about their world. This is asking them to experiment with beliefs and actions contrary to what they feel will happen. Beliefs concern evidence and perspectives for interpretation. Beliefs can be fixed across decades of time, yet are intermittent in their effects that are active in emotion, action and relating. When beliefs are currently active, because of the triggering current context, they are “on” as ‘causative’ of experiences: It means that the psychological problem is current. When the beliefs are “off,” the problem is not current. Belief is a type of intentionality that brings together relevant experiences and gives them weight. (When something is disbelieved it is literally incredible). Belief has its usefulness in being able to join a definition of problems to the sketching out of possible solutions. It does so in a manner that is easily understandable and helps creating self-care strategies. Beliefs differ from thoughts and emotions in that they are a means of summing up complex emotional, relational and historical accruals of events. It is possible to interpret any situation to say that a client acts “as if ” they believed 213

Talk, action and belief that____ is the case. It has been argued that emotions might be accurate or inaccurate representations. However, thoughts and emotions can co-exist in a state of confusion. For instance, one form is that people know intellectually that they are acceptable to others and that there is no need to be afraid. But what they feel is that they are worthless and the consequent fear is accepted as bona fide evidence that supports belief to avoid others. In some cases, the incongruence between emotions and thoughts about the same object can be problematic in itself - and in other circumstances, the differences are understandable. For instance, if a person tells themself that going to a party will be horrible and that they will not meet anybody, then the emotions of fear are congruent with the thoughts of being reluctant to attend. Functionally, if the person does not go, then the congruence between thoughts and emotions about going to the party is problematic because it is assumed that it would be good for the person to attend. For instance, if a mother decides to send her son to a distant school because it is better for him overall, but it is difficult to travel to each day, then there feelings are regret at causing him difficulty and thoughts that do not ‘fit’ the regret (in that she knows logically that it is better for him). But the overall outcome is given more importance: He should attend the better school. There is incongruence between feelings of regret - and thoughts of her son’s positive development. Overall, the decision is made on his behalf. In general, the principle is that when it comes to attaining desires, there may be both wanted and unwanted consequences involved that make the decision complex. Indeed, this realisation explains how many psychological problems are maintained because they achieve a desired ‘pay off ’ but also entail a ‘cost’. Accurate belief and understanding describe and explain phenomena through prolonged experience creating accuracy of understanding. Inaccurate belief and understanding mislead, obscure and hide phenomena through a variety of means. Problematic beliefs are a type of psychological ‘cause’ that influence living in the world. Beliefs constitute defences. Defences structure the psychological problem and the personality of the ego, its relations with actual others, and the thoughts and emotions they have. Change can occur through conscious re-evaluation of these beliefs and ‘causes’. The final two sections round-up loose ends concerning belief and an experimental approach to it in personal development.

Implicit and explicit belief Explicit and implicit understanding and belief concern intentionality. The problems of interpreting evidence are part of what needs to be over-come in helping clients get through inaccurate generalisations, ambivalence, fear and inhibition, and not knowing what they believe. Discussing intentionality is 214

Ian Rory Owen PhD part of the means for discussion and agreeing actions with clients. There may be explicit beliefs expressed in internal dialogue or discussion. At other times, it is theoretically possible to interpret a person’s immediate emotional response or immediate meaning - as being due to implicit beliefs. Chapter 16 provides detailed connections between developmental contexts and belief as ‘cause’. For the moment, it is sufficient to note the major difference between unrealistic belief as leading to negative emotion and problematic behaviours – as opposed to realistic beliefs that leads to a life of balance and fulfilment. The target of creating new beliefs is to lead to helpful outcomes. For instance, worry in the form of visual anticipation of problems that are repeated for hours, produces fear that leads to avoidance of the feared possibility that was anticipated. Improving the situation occurs through taking the same intentionalities and objects of attention and re-deploying the intentionalities onto thoughts of making plans and solutions, and thinking about realistic, happy, safe and satisfying events instead. The situation of worrying, although conscious, might not be reflected on and interpreted, so that it exists implicitly and continues to promote fear and avoidance. The role of interpreting and making belief explicit, through discussion and formulation, is a way of handing an understanding back to clients for them to consider. It makes the process of worry explicit so they can understand how they contribute to it in order to help them stop themselves doing it. For example, implicit understanding happens in the experience of Ron who has been mugged twice. Ron is walking in a street in daylight when he sees two men running across the road towards him. Immediately, he fears that they are about to mug him for the third time that year and he is frozen to the spot in fear. As they get closer to him, Ron realises that they are both wearing tracksuits and that they have just come out of a sports club. Suddenly, he realises that they are joggers and not muggers. This is an example of implicit understanding because the meaning received occurred immediately and without conscious thought. All the same, it was mediated by his past experiences. Explicit understanding is linguistically-mediated and occurred in this situation when Ron told himself “I am stupid” and felt angry with himself as a consequence. (This example is the one I have called “secondary emotion” in chapter 19 because the emotion is a consequence of internal dialogue, for instance). In conclusion to this section, acts of belief are part of the ego’s ability to choose and decide rationally. This is why effort and explicit decision-making play a role in psychological change, where there is inertia to be over-come. In the professional sphere, beliefs are theoretical and justificatory with respect to the different fields of therapy. When the constraints and contexts of clients are considered, it can be noted that when there is a psychological disorder, social learning seems to have stopped and the beliefs produced become fixed. There is a

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Talk, action and belief problematic set of emotions, thoughts and avoidances due to anticipation of what might come to pass, that is built on the model of past experience.

Therapy examples To sum up the above, the hermeneutic circle is a general theory of understanding or interpretation, one of many such theories. In this case, the hermeneutic circle is a psychological hermeneutics. One example is the understanding of psychopathology with respect to how to practice. If a trainee therapist memorised Diagnostic and Statistical Methods IV (American Psychiatric Association, 1994) it would not mean that he or she would be able to interview clients in a semistructured manner, to find out if they had specific disorders. What the full understanding of psychopathology takes is greater than the mere ability to retain and reproduce intellectual knowledge. The prior understanding that is sufficient to interview people about psychological problems and their personality, is the ability to practice the application of book-learning and so hone the overall skill of interviewing people in a non-intrusive way. So before going any further, the sort of psychological hermeneutics that is relevant for practice concerns any way in which the meanings of psychological situations are concluded. One such area could be relating current psychological problems to the time of onset. The hermeneutic circle shows itself in taking any current psychological problem and asking clients when it first occurred, in order to place it developmentally and socially, in the context of its beginning. Overall, this can be identified as a hermeneutic circle. Accurate understanding shows the phenomenon; whereas inaccurate understanding hides it. As noted above, the phenomenon of anticipating that future personal relationships will be of precisely the same sort as a previous one is an exemplary occurrence. Mis-empathy is the false anticipation of the future in the present, based on the model of the past. Say, a marriage has ended in an acrimonious divorce. Frances is divorced and strongly believes that divorce is likely in any future marriage. So she refuses to begin dating for 15 years after her divorce. The most general case here is that a specific prior understanding is predicted to repeat - in the face of an as-yet unknown, not yet happened occurrence. Different examples of the hermeneutic circle are as follows. There are difficulties encountered in attempting to grasp a new phenomenon because it is hampered by prior understanding. Mis-empathy happens in situations where bias is projected: like sexism, racism and ageism. Another case is where there are self-fulfilling prophecies of theoretical beliefs that are supported by ineffective research about bodies of evidence that serve to maintain current beliefs and practices. Negative self-fulfilling prophecies exist contrary to the relevant type of research into the relevant body of evidence. 216

Ian Rory Owen PhD The hermeneutic circle is a way of stating the fluidity of meaning and the principle of the on-going re-interpretability of what anything means. It is possible to interpret belief from the nature of the repetitive problems that clients have. For instance, Julie wants to be liked by others, yet she is so afraid of not being accepted that it inhibits her in starting to form friendships. If Julie ever permits herself to begin a friendship, she is very sensitive to the possibility of being dismissed, rejected and humiliated. She has a strong sense of shame and weakness associated with having needs for friendship. So much so that Julie is wary and sees rejection in the way someone looks at her or she hears it in a tone of voice. If Julie interprets rejection as happening, she frequently withdraws from furthering the friendship altogether. Belief shows itself in this type of insecure relating. Julie believes that others will reject her. The hermeneutic circle on this occasion is that her old understanding is brought to new social situations with such force that the old understanding is maintained even when there is evidence to the contrary. Because understanding is only one part of a whole, what also happens is that her old understanding is expressed in her thoughts, emotions and relating to others. Julie believes that wanting to be liked makes her unacceptably weak. So since being a teenager, she has tried to be completely self-reliant. This is not a happy state of affairs and she cannot maintain it. Her beliefs exist with respect to a small portion of the overall evidence. But Julie does not take into account her withdrawal from others, in trying to be self-reliant. She mis-interprets others as rejecting her, even when they do not. Rather, it is Julie who leaves them prematurely. Other people are surprised at her sudden absence and wonder why she is so standoffish. Help for Julie involved an experiment to break the previous hermeneutic circle of her strongly negative manner of interpreting and believing. She temporarily tried a suspension of limiting her inhibiting beliefs - in order to have better contact with others. To her surprise people did not insult her or ignore her, but invited her to spend time with them. Julie became able to stay in social situations despite her fear of rejection, and her hyper-sensitivity to being rejected. When she did stay, she found that “everybody” did not reject her. The world turned out to be a friendlier place than she had believed. But she needed to alter her behaviour in order to find this out. While she kept withdrawing from others prematurely, they did not have the chance to get to know her. Consequently, she got no invites to spend time with other people and she made none herself.

Summary How the intentionality model improves on cognitive behavioural therapy is to show how the conceptual intentionality of discussion links to the whole of meanings of various sorts that are contributed to by other forms of intentionality, that get coupled with the attention and meanings of others. The general stance put forward 217

Talk, action and belief above is that all acts of understanding of immediate sense, and interpretation expressed in language, arise through active and passive processes. The term “passive process” means automatic, involuntary, pre-reflexive and spontaneous psychological processes that are at a distance from the ego. Yet the senses created through passive processes produce conscious senses for the ego to receive. Active processes are those where the ego is involved in choosing and driving forward a particular line of experiencing and action. Among psychological problems, there is not chaos but a regular structure named by the terms intentionality, sense, object and context. Interpreting any situation experientially and immediately is the first therapeutic action. Cultural objects are any objects of attention whether believed or disbelieved by self or a cultural group. What this means for interpreting beliefs is that conclusions about others should be qualified with respect to specific others, and the history of what has happened between the client and that person. Explicit beliefs are the outcome of awareness, reflection and interpretation of regions of experiential evidence. Accurate beliefs enable people to get what they want and are shown in mutual happiness and fulfillment. Inaccurate beliefs (whether explicit or implicit) maintain unhappiness for self and those around them. Natural causation is not at work in the processes that create meaning nor is meaning entirely based on operant and classical conditioning. People are free to think, imagine and say to themselves things that are inaccurate or untrue. However, if these inaccurate senses are believed and this brings constriction, distress and other negative consequences to self and others, then there will be problems of personality and other associations. But after a more sustained attention to the matter in hand, the inaccuracy should lessen. People are free to think oppressive, insulting and untrue things, but need to realise the consequences. Inaccurate beliefs lead to unhelpful habits that far outlive the initial provision of temporary relief. Proper beliefs are proven in the sense that they lead to effective action. The ego can monitor and maintain a good mood through learning from experience. Psychological belief shows its non-logical nature in that it is possible to believe in something that has never existed, does not exist currently and may never come to pass. Only a model of intentionality can fully grasp the nature of belief. The position being urged is to acknowledge one’s limitations and the great difficulty in being able to decide on complex matters, particularly in the case where there is no consensus. People are free to believe anything that does not threaten public safety or cause damage. People could hang onto beliefs that drive problems that stay the same for decades and bring outcomes that are unwanted. They are free to do nothing to change their beliefs and behaviour. But overall, it is incongruent to keep a problem that is capable of reduction and control by selfcare, particularly when clients are actively seeking help by attending therapy. 218

12 Examples of interpreting belief Aim: This chapter focuses on talk, action and belief as parts of the same whole. Hermeneutics and belief are demonstrated not just for an action therapy but for any talking approach. Beliefs can be about relationships to some idea, value or context, or about self, other and world, in any time frame, past, present or future. This chapter discusses belief and how to understand it in relation to intentionality and the presence of the past, by providing a number of clinical examples. It furthers the attention to the intentional act of belief begun in the last chapter. Examples show how the intentionality of belief has a role in understanding the creation of psychological problems and begins to explain working with them. The aim is showing how the property of philosophy - intentionality, belief, hermeneutics and evidence - apply in everyday life and therapeutic practice. To sum up the story of the function of understanding and belief so far: it is argued that accurate empathy and apperception, psychological mindedness and emotional intelligence are due to social learning that provides accurate understanding and beliefs. These are accurate because they permit choice of action and successful goal attainment, rather than engendering limitation, dissatisfaction, pain and confusion. Human beings have a general tendency to 219

Talk, action and belief safeguard themselves by believing that the present and future will be as bad as the past. Anticipation functions as psychological defence. However, sometimes the defences are highly inaccurate and when wrongly applied, can deaden and destroy rather than protect. Cases are discussed to show the pervasiveness of beliefs concerning how the sense of self exceeds the traditional boundaries of thought about the alleged separation between the psychological - and the intersubjective or interpersonal. The first section starts with understanding distress, the object of therapy. The second section shows how beliefs accrue and problematic psychological beliefs can be related to traumatic events at a previous time, where there had been sustained threat and uncertainty that still have an influence on the present day. The third section applies the idea of belief. Cases are considered to show the worth of the ideas.

Unchanging belief as representative of problems Let us consider an example to make these abstract issues more concrete. Although there is some difficulty in spotting the trend, there is an observable similarity between Anna, the little girl who felt self-conscious in going to buy a tin of cat food from the corner shop, directly over the road from her parents home when she was three - and Anna, the forty-five year old woman who can blush on occasion and feel stupid, despite intellectually knowing that she is a capable person in many other ways. The original incident of being frightened to go into a shop when her mother asked her to walk over an empty street to it, and being prepared to buy a tin of cat food, are associated with the same feeling as the one that she gets when she gets nervous in meetings with colleagues. The sense of being frightened occurs even though the current meetings are with peers who Anna logically recognises are her juniors or equals. The feelings of non-specific dread and fear in the meeting, and the feeling of expecting to be attacked by colleagues, have different types of relation to the current context. The point of identifying beliefs, determinable in the current moment, is that on entering a context where the fear arises, it is possible to interpret it as being driven by a tacit belief that produces fear and social anxiety. One way of interpreting belief is that traumatised adults and their childlike abilities remain ‘frozen’ in time. For instance, adults can remain in a state of panic, inability, despair and fear attack from others (paranoia) due to influences from decades before. For clients, the conviction that was decided years previously continues in its influence. It is not until therapy or personal reflection that a belief is identified in language and challenged. The example of young adults who leave home for the first time shows that the beliefs they have are not unconscious. Implicit belief can be expressed in emotion, relating and behaviour. It has not 220

Ian Rory Owen PhD yet been made explicit in language. For instance, in Paul’s home, his parents had shouting matches, were violent with each other and destructive of property on a regular basis. Paul copied them as role models. Outside of his home, if things were not to his liking, he would beat up friends and shout in an uninhibited manner. Paul followed his parents’ model without question until he came to realise that his friendship circle at university was getting smaller and smaller. For clients, the style of belief about psychological problems usually concerns defensive, decontextualised, unreviewed, ahistorical, unqualified generalisations and absolute statements that may first appear in one domain of life and become generalised to other domains without reflection. Negative inaccurate beliefs are inflexible and therefore inappropriate to many situations. They create false limits on the holder’s ability to gain satisfaction and happiness. Helpful beliefs are explicit, consciously held and capable of being revised in the light of new information and hence, they are accurate. The manner of interpreting client material in sessions starts with problematic outcomes. It interprets and discusses with clients to find which beliefs drive which outcomes. When therapists interpret the senses of clients and their problems, the order of intentional analysis is as follows. What appears to therapists are the outcomes and moods of clients, that can be interpreted as the chosen outcome of believing overall, even if the beliefs are implicit, tacit and prior to reflection. Whatever the experiences that comprise the outcome overall, they can be considered in the context of understanding personalities and psychological disorders that entail positive choices plus a number of unwanted consequences that are dysfunctional and distressing. However, therapists interpret the beliefs of clients in the developmental context of the accrual of problems and their inter-action with lifestyle and social context. By way of explanation and recap with respect to hermeneutics and the biopsychosocial view, interpreting explicit belief is a decontextualisation: Specifically, the expression of belief in language is a de-contextualisation because it takes complex wholes of experience and renders them into short explicit statements. This serves the pragmatic function of making short conclusions that can be discussed explicitly with clients and forms the basis for creating aims, homework and self-directed homework and other interventions. A major part of providing therapy is interpreting the beliefs inherent in the emotions and patterns of relationships that people have in terms of relating to others, self and cultural objects in the world. The understanding provided helps clients move on and is designed to explain how people are and who they feel themselves to be, in comparison to others. Some interpretations are more formal and global, for instance, in the sense of a hermeneutics of the psychology of the on-set, maintenance and amelioration of psychopathology. Other interpretations are voiced more intimately and address immediate events in the session. Further interventions comment on what therapists think clients are discussing, in order to 221

Talk, action and belief make sure there is an overall accuracy of communication and that both persons are turned towards the same problems and potential solutions.

Examples of belief driving self-harm and self-neglect Another example of the use of belief is interpreting what drives self-harm and self-neglect because belief can be understood in connection to the inability to understand and be capable of satisfying one’s own needs. For instance, a whole set of problems arise due to not being able to find satisfaction in social life and this might lead to self-harm. Depending on the age when self-harm began, there are differences between small children who hit themselves or bang their heads against walls as opposed to teens and adults who cut themselves. The initial belief is that self is bad. Self is angry at itself and wants to punish and hurt itself. The damage or pain caused is ‘good’ because of the belief that self is ‘bad’. When the achievement of a positive ideal does not happen, reflection on self creates negative emotion. The failure and the emotion confirm the belief that self is bad and initiates an attempt at selfcontrol of a specific aspect of their experience. The self-control further punishes self and the physical pain usually brings the negative emotion to an end and satisfies the desire to hurt self. But overall, holding the initial belief serves to maintain the problem. Let us consider two cases of self-harm. Toni hates herself, cuts and punches herself to express the anger and tension that she feels about her hatred of herself. This is because she breaks her own strict rules for good behaviour on a daily basis. But when Toni has caused herself enough pain she is satisfied and stops. The vicious circle is that she believes that she is bad and must be punished. But because she has punished herself, she feels bad about doing that. When construed like this, Toni has no escape because her negative actions create consequences that trigger more negative actions. Without her understanding this circular pattern of events, there is little possibility of her making changes on herself. For instance, Robert is self-harming, suicidal and has no friends. He was bullied by his father in order to “make him into a man”. Robert’s attitudes towards the world, others and himself show his beliefs. Specifically, he feels uncertain about every aspect of himself to the extent that he does not know who he is any longer, and that when he drinks alcohol, he feels a great release from the burden of his worries. His type of depression is such that he fantasises about what he could do and how he might get friends. But in his sessions he has “nothing to talk about” due to the fear that he will be judged. The only aversive experience he has had was his father’s treatment of him. But because of his lack of social life and life experience generally, he has no direct experience of himself that can tell him what he is like and what he likes to do. Consequently, the types of problem that 222

Ian Rory Owen PhD Robert faces are mixtures of aimlessness and fearfulness that lead to avoidance that maintain his low self-esteem and prevent him from finding his strengths and weaknesses. Robert lacks a region of evidence from which to draw conclusions because of his social isolation. His beliefs are explicit to himself. He believes he should be socially active and successful but he does not know how. He compares himself to his peer group of other young men and finds himself severely lacking. He is convinced he is not like other men and that he never will be like them. It is necessary for him to be socialised as a young man because he never had the basic experiences of making friends through schooling as a child. Similarly, some adults have not yet been able to make better sense of themselves or have not interpreted themselves in anything other than a negative and exclusively narrow manner. In such situations, the sense made mis-represents them, and this realisation is made only, when it is discussed with another. Let us consider a different type of example altogether that shows the role of belief in operation where there is difficulty in concluding on someone’s intentions.

Sheila: An under-performing manager In order to understand how interpretation of another’s beliefs can act in a social situation, let us consider an occupational example of an under-performing manager. This case of another’s behaviour can be explained by belief. Given the principle that people act according to their positive intentions to achieve something useful, then their behaviour can be interpreted as belonging to a person who has intentions different to those expressed publicly. The phenomenon to be interpreted is the link between audible speech and observable non-verbal presence – as opposed to the actually invisible intentions and wholly private attitudes of others. Because there is no one-to-one guarantee that human beings will speak the truth, nor show it facially, then there is always the possibility that what they do express means something other than what it is claimed to mean. For instance, there is a major difference between purposeful deceit and violence - and mistakenly poor performance. This leads to the opening up of an interesting set of differences. Sheila is the manager of a small team. When thinking about Sheila, there could be inadvertently poor performance of her role that could occur for reasons of a temporary and unintentional social skills failure. In that case, her actions might upset others but are without intent to harm or deceive. But, if the poor performance of the role is due to factors inside personal control and are a matter of choice, then the actions are deceitful and violent to others. Let us consider it some more. Let us start with some general thoughts to set the scene. In an overview that focuses on the contributions that one person brings to his or her social context, the 223

Talk, action and belief question “what is the problem?” is closely related to “how to interpret the problem?” And “where is the problem?” When the latter is asked in a temporal and almost spacial way concerning how it lies between the client and other people. When there are recurring problems in individual therapy, the only person who seeks out sessions is the client. What is to be understood is what they say of what they think, feel and experience. The specific interpretations made judge between the outcome described (that needs to be recognisable in terms of intentionality), and the empathic understanding of the intent and belief-map of the world that clients have. This means distinguishing between the parts of the whole that clients are describing. Let us return to thinking about the understanding and social skills of Sheila, the excessively controlling manager. In general, if a person’s understanding of themselves, others and the world is accurate, then they are able to maintain connection with other people. Their social abilities are good and proven. They are usually able to get along with others of different ages, races and social backgrounds. When conflict and problems of relating are encountered, they can be dealt with effectively. If Sheila’s understanding is good but her social skills are poor, then with observation and feedback, it may well be possible for her to correct her social skills deficits and find out how she is under-performing and help her. If Sheila’s understanding of the social world is poor, in that she has fixed inaccurate empathising of others all-round, and the social skills observable by others are poor, then there will be haphazard communications with others. For instance, if she does not follow traditions for polite conversation, does not listen to others and, at least, heed advice when well-meant, or if she is given feedback that she does not use to correct her deficits, then the expectations of others for minimally good behaviour will be disappointed and social inter-action will be hampered. If Sheila’s understanding is poor and she has good social skills, then it might be possible to help her get better understanding by showing her how her understanding is faulty with respect to the evidence. And so helping her understand and correct her lack of skills. However, there is a final possibility. If Sheila’s understanding is good and her social skills are good, then maybe she is manipulative. In such cases, the ability to get others to do one’s bidding is linked to the probability that, when applying pressure on others, they will not fight back or complain. If this is the case, then Sheila is a liar and manipulator who banks on her employees not comparing notes amongst themselves and so she has inaccurate empathy because she fails to predict how they will respond. With further knowledge of the situation it transpires that Sheila chooses to tell some of her team secrets and then asks them not to tell. This is done for selfish reasons because she aims to control the behaviour of her team. Sheila 224

Ian Rory Owen PhD purposefully mis-represents situations to each of her team, in response to her fearful understanding of the financial situation of her company and her desire to control. In this case, what did actually happen is that her employees compared notes on how she treated them and so Sheila created resistance to her desire to control because once her employees realised they were being played off, they organised themselves against her. The analysis above is made by comparing distinctions among types of intentionality. The understanding of psychological situations is called “metarepresentational” and is the topic of the next chapter.

Closing discussion Cognitive-behavioural therapy is correct to claim that painful emotions can be changed by altering thoughts and behaviour (Ellis, 1962, Salkovskis, 1991). The fuller explanation of what cognitive behavioural therapy does, is that like other approaches, it alters meaning and the means of creating and maintaining meaning. Because of the predominance of the psychological whole, change does not just concern two parts of the whole, thought and behaviour. Secondly, cognitive behavioural therapy is right to claim that internalised speech can be ‘causative’ of emotion, mood and behaviour. But the approaches that comprise cognitive behavioural therapy omit details of what they do in reconsidering meanings. The intentionality model reading of human development is different to the view of Judith Beck (2005) because it is more self-reflexively clear that experiences can be interpreted to show that explicit or implicit beliefs are present. This is not to claim that beliefs are unconscious, temporarily or permanently, but rather to be self-reflexive about what people do when they make sense of the experiences of others. For instance, emotions, impulses to act, a general fearfulness without any conscious object - are capable of being interpreted as showing that an implicit belief is in play. For instance, a person believes that getting close to others is dangerous because they are fearful. Yet no one in particular may be getting psychologically close. The person experiences fear and disappointment in anticipation of being rejected by a new partner, prior to beginning the search for one. The institutions of family, culture and society enculturate children to have psychological commonsense in understanding themselves and others. It is the role of therapy to go further in being able to account clearly for the manifold of everyday understandings. Although young adults may leave the family of origin, it is striking how influential early experiences are, many years after they have left the nest. The point is that psychological cultural objects (any observable or discussible event) require commonsense psychology to make sense of such situations. For change to occur, awareness, reflection and re-interpretation need to happen prior to a commitment to work towards new experiences. Clients need 225

Talk, action and belief to understand and agree the worth of making explicit choices and be committed to putting effort into making them happen. For instance in health anxiety, at successive times, people dis-believe then believe that they have cancer. Prior to therapy, holding belief itself is not the object of sustained attention. What therapy does is promote awareness, reflection and interpretation about the act of believing and its consequences. What is given sustained attention is the anticipatory belief, for instance, that they will die any day soon in an unknown way. In therapy, it becomes even more fully the object of attention, so they can become much more aware of the effects that believing has. The intervention of bringing beliefs to awareness and interpreting them, makes explicit beliefs that are open to conscious scrutiny. Specific intentionalities such as anticipation, avoidance and attachment can be interpreted and discussed with clients to find out if they agree about the explanation of psychological belief-‘causes’ that have been supplied. What appears is the outcome of what clients have done in their lives so far. The beliefs of clients create positive and negative consequences. But from the here and now view of therapists, what appears is what they are told - to which is added their understanding of what anything means and how it could have been made.

Summary Because of financial instability and technological change, the world today is not the same as 20 years ago. And even over a period of 20 years, it has become impossible to guess how communal life will change across the next 20 years, “for the times they are a-changing,” as Bob Dylan tells us. Accordingly, the psychological world is changing fast and in an unknown way. Not only might there be global warming and globalisation in commerce and industry, but the nature of the family, work, friendship and intimate relationships are changing also. Beliefs need to keep apace with the actuality of the current situation and make a balanced judgement about actual existence and potential for how things can be. Beliefs and desires that lead to action comprise a whole in that people’s actions are ordered according to what they want and what they believe exists (across the past, present and future). Beliefs concern what is interpreted to have been existent, what is currently existent or that which is about to be existent. Desires concern actions that aim to achieve needs, according to what is believed. Many personality and psychological problems concern a mistaken need to protect self in the absence of real danger. Once a sufficient amount of satisfaction of needs is gained, then the action can cease until the need reappears or a new need arises. As a rule of thumb, when there are personality and psychological problems, it is because the belief map of the world of an individual does not meet with the psychological reality of others and the social context. Personality and psychological 226

Ian Rory Owen PhD problems themselves are influences from the world about the inability to meet others accurately and the demands of ordinary living, concerning the inability to go with the flow and alter one’s reactions to the actual social situation in the moment. Prior to reflection, it does not appear to conscious understanding that the emotional and relational consequences of something that was mistakenly believed to exist are the same as if it did genuinely exist. After reflection and reinterpretation, a person can feel relieved, only by talking and understanding how they have been so powerfully influenced by their experiences as a child or teenager. In so many cases, the negative emotions that are felt currently are the result of inaccurate or downright false beliefs often that make no connection to plenty of evidence to the contrary, then or currently. What is noted about evidence is the overall congruence between problematic outcome (emotion, relation and behaviour that supports beliefs) and the maintenance of beliefs about self, others and world that form the problematic outcome. Specifically, the vicious circle metaphor is the overall circular congruence between a self-fulfilling prophecy and a problematic outcome: in distinction to the difference between realistic aims and a good outcome. Distressing experiences can be classed as evidence that then defy the attempts of clients at solutions for decades after they began. Such feelings are certainly conscious, although the beliefs that create them may not always be in consciousness nor understandable by the person who holds them. Getting a handle on any complex psychological problems requires interpreting the role of belief that is either expressed in language explicitly or implicitly in the actions, emotions and relationships of the individual. One way of interpreting belief is to conclude that traumatised adults and their child-like abilities remain ‘frozen’ in time. For instance, people can remain in a state of panic, inability, despair and avoidance due to fear of a repetition of attack from others for decades. The interpretative stance taken is focusing on belief as pragmatically responsible for functioning and quality of life, whether belief is entirely causative or not. Belief is taken as a heuristic in order to manage relationships, mood and other experiences. Beliefs form a bridge running from what the person wants to do – across the details of how they can do it – to the other side of the consequences that are likely from doing what they want. Beliefs are about what is understood to exist or not. Hence, interpreting how belief produces experience and behaviour is a central concern for daily living and therapy. Belief can be used to understand aspects of the influence of the past and how it can remain influential across decades of the lifespan and produce consequences. When beliefs are emphasised, it has a practical utility of identifying a ‘handle’ for the purpose of grasping the ‘weighty luggage’ of psychological problems. Frozen beliefs represent personalities and psychological problems because once they have come into existence, they can become fixed and influential across a number of regions of experience. Perhaps some survivors of abuse, trauma and 227

Talk, action and belief neglect will never be able to eradicate the problems of anxiety, fear in attachment relationships, low self-esteem and difficulty in knowing their own needs and abilities. Yet the possibility of making improvements arises once an explicit intellectual understanding of them has been attained that enables discussion and action. The intentionality model is a means of discussing with clients how their conscious senses relate to their intentionalities, over which they have choice and control. The act of belief is fundamental in that it selects a specific portion of evidence and interprets it in a specific way. Generally, a believed sense represents a referent. What can happen is that the referent can be mis-represented. The proper body of evidence as a whole can be inadequately considered, for instance, a harsh, depressed or fearful manner of interpreting mis-represents an incomplete portion of evidence that is used to decide self-worth and the attitude of others to self. It then follows that belief ‘causes’ thought, emotion, relationships and the senses of self and others are interpreted in similar, characteristically negative ways. Of course, free will and emotional self-control exist, so it is untrue to claim that emotions of any sort inevitably cause a person to act one way or another, in the material sense of cause. To analyse and rectify the mis-interpretation of evidence, what is required is a means of interpreting identifiable complex wholes and that is the topic of chapters 17 and 18.

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13 Meta-representation and the developmental origin of belief Aim: This chapter continues the focus of the last two chapters and further sharpens distinctions that have been made throughout the work concerning the comparative means of making sense and identifying psychological functions within the whole of life. The general concept of meta-representation is defined and examples of it are provided that show its use in opening up important distinctions for therapy and practice. Meta-representation has already been touched on above several times. Below, it is made explicit before the next part of the book on practice is begun. The terminology is precise yet abstract so examples are necessary in order to make the distinctions clearer. This chapter concerns a meta-representational view of beliefs and associated matters. It was the ancient Greek philosopher Epictetus who wrote that people are disturbed “not by the things which happen, but by the opinions about the things”, (2004, p 3). This is an ancient precursor to what is currently called making metarepresentational distinctions between different senses of a referent and different 229

Talk, action and belief forms of intentionality. When representing representations, an abstract and ubiquitous distinction is made that connects with the general case of Edmund Husserl’s comment on the relation between the map and the territory. “The outline of England drawn as a map may indeed represent the form of the land itself, but the pictorial image of the map which comes up when England is mentioned does not mean England itself in pictorial fashion... as the country on the map. It means England after the manner of a mere sign... our naming intention is fulfilled... by... the original object which the name represents”, (Husserl, 1901/1970a, VI, §20, pp. 727-8): Maps represent territory. Maps are symbolic, finite systems that show the key features of complex inter-relations; whereas the experiential territory of the biopsychosocial whole is a near-infinite variation. Theory is map-making. Practice works according to theory. People show their maps of life according to their behaviour and whether that satisfies them or not. In some cases, the beliefmaps people have made might be highly inaccurate with respect to the territory of people in general, specific situations and themselves. Also, some map users get lost and believe their maps more than the territory or cannot relate their map to the place on the actual territory where they are – or other confusions occur. Meta-representation is a key experiential distinction that has already been used several times in the above. In psychopathology it means being highly specific about which mental processes become over-used. It helps in understanding the cumulative damage caused by trauma, defensive functioning of the psychological problems and the personality. Defences themselves are meta-representational distinctions between what is appropriate and inappropriate and explains the difference between the two. Meta-representation also explains the differences between the fear of attaching and the desire to attach and how different views of the same thing are accounted for. All forms of intentionality exist in a social context. What a social context means is that human relating, in individual therapy for instance, is such that both client and therapist respond to each other as a shared context. Consequently, the inter-actions between people are due to the affective sense and the cognised sense of the other and the affective and cognised sense of self. If this is not realised then there is a mistake between the sense that is felt and the object of attention that it is about. This distinction will be made clearer below. Meta-representation is representing relations of representation. It is the study of representing and representations. The most basic definition of it is comparing a representation (be it written, photographic or experiential) to that which it is about, the represented. One fundamental case is the relation of lived experience to the perceptual and meaningful object that the experience is about. For therapy, the most basic meta-representational model is the relation between intentionality, the sense experienced about an object in its context, to the experience or set of experiences that the model is about. A further subset of meta-representational activity could be about the belief map created about a territory, where the intentionality of belief is what is in focus. 230

Ian Rory Owen PhD Of course, people do not have actual maps with them, when they want to find out about a new person or decide how to act in a social situation. The ‘maps’ they have is a means of denoting what their identifiable beliefs are with respect to their experiences and behaviour, that are understood as the outcome of those beliefs. Other more general relations between a representation and the represented are media like photography, literature, theory, discourses and hypothetical constructs that represent an ideal or actual (or even imaginary, fictional) set of circumstances, an object, process or event. Because a general means of relating is being modelled, the class of events that can be considered is large. What can be represented are perhaps specific individual occurrences – or highly generalised real or ideal objects could be portrayed – like human nature in general or the specific real behaviour of the group of people 35 to 40 years of age who currently live in Leeds, UK, for instance. When dealing with meta-representational issues, what comes to the fore is the question of how accurate a representation is with respect to its represented object. Judging the degree of accuracy requires a comparison between a specific representation and a full experience of the represented. Further, more complex psychological processes can be highlighted. Each time one aspect is highlighted, other aspects are put into the background. One example of this is focusing on defensive beliefs with respect to the need for protection from actual threat. This is really a simplified version of a much more complex territory, where there are many instances of psychopathology that are developmentally accruing and social in nature. There is the connection with other persons to consider, in addition to the purpose of the defence and the purpose of the attachment process at hand. Accordingly, the sequence in this chapter is that first of all meta-representation is defined with respect to lived experiences. Because intentionality is all-encompassing, the qualitative analysis of it is metarepresentational and the types of distinction made are general. Meta-representation is explained in meaning and belief with respect to the guiding idea of the difference between a map and the territory that it is about. Next, meta-representation in relating between people is discussed. Then links are made with respect to judging accurate and inaccurate experiences of the same object. Then the concept of metarepresentation is discussed in its application to understanding defensive beliefs as these exist within highly complex social and historical settings. Finally comments are made about the empirical study of beliefs in developmental psychology. Meta-representational differences are linked in the social view of cultural objects, changes in belief, accuracy of comprehending experiential evidence and empirical research on developments in believing and understanding what others believe (Owen, 2004). The chapter considers how there can be a place for social reality in therapy’s understanding. The concept of meta-representation is not new and has its source in an empirical view that fits with the idea of intentionality (Perner, 1991). Meta-representation ties intentionality to human development.

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Defining meta-representation Fundamentally, consciousness is a medium of the representation of social reality. A theory of consciousness is one that concerns the representational capacity of consciousness to relate to what is personally or consensually believed to exist. Explanations concerning intentionality lead to making “meta-representational” differences between the types of sense achieved due to the perspective taken. Zenon Pylyshyn was the first to clarify the need for a self-reflexive understanding of what it is to interpret the connections between consciousness and observable actions, with respect to their objects, within the theory of mind approach. In 1978 he wrote that meta-representation is the “ability to represent the representing relation itself ”, (p 593). The representing relations in question are links between what is observable, felt and thought, for instance, in relation to the forms of intentionality that are believed to have produced those senses. This distinction is useful, general and a point to tease out a number of differences below. The activity of representing representations of conscious awareness is a very general one. One area in which it primarily occurs is, for instance, being able to discuss how people see or hear. However, all theoretical conclusions, concepts and models in psychology and therapy concern how people represent their experiences and so presuppose the ability to discuss intentionality: the ability of consciousness to be aware of the same things in different ways. Hence, distinctions about representing representations will be made clear in a number of ways across this chapter and in the remainder of this work. Meta-representation enables distinctions between the truth of conscious experience at a specific time; as opposed to the many other senses of the same object of attention that could be experienced from different perspectives, and from manners of approach. In order not to lose track of the “ability to represent the representing relation itself,” (Ibid), let us note a few meta-representational differences that are part of all theory-building and concern telling differences in experience. It is possible to grasp that the means of focusing on the change from psychological problems to potential solutions in the intentionality model is a meta-representative distinction: The ability to distinguish a specific sort of intentionality that is responsible for a specific sense of an object within a context is a meta-representational distinction. Meta-representational explanations include accounting for how one person can have two views of the same object (usually successively but sometimes simultaneously). Another case is accounting for how two people have their different views of the same object, simultaneously or successively. Another case is understanding the different types of intentionality. And that experiencing one type of intentionality may not necessarily lead into or necessitate another type of intentionality. The worth of the view of intentionality is to understand that a “thought is just a thought” and a “feeling is just a feeling” and neither necessitate any actions or other consequences. When psychological 232

Ian Rory Owen PhD problems are hard to help, it can be because there is an elision between feeling, or an impulse to act and the action itself. In obsessive-compulsive disorder for instance, there is no pause for reflection but action straight away on what is worried about and felt. The same lack of reflection, self-understanding and inhibition of choosing the problem can occur in other psychological problems. Meta-representation makes possible some key distinctions. The first is a general case of being able to understand how other people (or oneself or a theory) is representing something. This is a very general type of distinction. Let us make it more concrete with respect to empathy. Empathic understanding is at base being able to grasp the speech and non-verbal presence of others through psychologically interpreting their belief, intent, emotions and perspective. These specific understandings occur immediately, most of the time, for empathic persons. (The final section below provides a short overview of the experimental research into the on-set of this ability at around three years of age (Perner, 1991, p 82)). The important point to grasp with respect to the intentionality of belief is that there is a major difference between the sense believed and the conscious object (whatever it is, a specific experience, a group of relationships to people, conscious evidence, past or present). The precision of belief is that action, thought and emotion, etcetera, follow in-line with what is believed about the object in question. Empirically, what comes after four years of age (p 88) is the ability to work out if others are telling the truth as they see it, as opposed to joking, lying or due to having made a mistaken belief, or if they are being ironic perhaps. This most basic distinction is being able to explain the difference between a false or inaccurate belief and a more accurate one. The distinction is returned to in a section below because it is key for understanding the process of creating new beliefs and re-interpreting evidence in therapy. Specifically, in social anxiety with low self-esteem, there is an inaccurate anticipative empathising that others are frightening - and self does not have sufficient strength to withstand the onslaught. It is precisely this inaccurate understanding that prevents a more accurate one from occurring. Let us take the case of beliefs about self that are inaccurate. When a belief is inaccurate, the general problem is that “I believe my ability to …” is not the same as the person’s actual ability. In general terms, what a fuller contact with others would produce, for instance, is the understanding that people are usually polite, even when they do not like someone. It is unusual to receive the huge rebuff that people with social anxiety and low self-esteem anticipate. In short, if there was no ability to make meta-representational distinctions, then the account of the intentionalities involved in distress and its therapy would be impossible. Without meta-representation there is no formal ability to account for the circular closed-system evaluation of experiential evidence. The problem with non-meta-representational approaches to evidence is that the problems that are created by beliefs act as evidence to support the beliefs that cause the problems. For instance, when fear-producing beliefs create fear, the fear is evidence for 233

Talk, action and belief further beliefs that the object is genuinely fearful. This is a problem of lack of a comparison to what could be the case. Expressed in brief: Belief ↔ evidence that supports belief. Meta-representation shows its worth in the greater understanding that there are types of beliefs about regions of evidence and that this in itself loosens any connections between a specific belief about a specific portion of evidence. Metarepresentation is not merely cognition about cognition, as in the idea of metacognition (Flavell, 1979, Teasdale, 1999) that concerns reflection, interpretation, monitoring and control of intentionality. Meta-representation is not the appraisal, monitoring or control of intentionalities but refers to a more fundamental aspect of consciousness in being reflectively self-aware as part of being conscious, noted in chapter 9 (Sartre, 1943/1958, pp. xxvii, xxx). Meta-representation involves being able to make the most basic distinctions about intentionalities, in the widest possible sense of how we are aware of any intentionalities whatsoever. For instance, fear and anxiety can prevent people from getting close or making contact with objects that really need their attention. In social phobia, people anticipate that a variety of negative events will occur and that fear, embarrassment or being a burden on others are felt in anticipation of their actual occurrence and because of conditioned responses, the anxiety felt in a social situation impairs social performance, social skills. The consequence is that the socially phobic person has little or no contact with others and so the problems of fear and avoidance are maintained. The interpretation of the intentionality model of the ‘cause’ of this situation is that inaccurate belief and understanding are to blame. The meta-representational distinction applies in knowing when a belief applies well in one context and not another, or when a response is accurate in one context but not in another. The next section maintains the focus on comparing representations and the means of making them. The remaining sections of this chapter concern a progression towards the complex situation of how to understand psychopathology in order to work out how to lessen distress and dysfunction.

Working with meaning and belief Meta-representation differentiates between mere appearance versus a more trustworthy sense of ‘reality’ (Perner, 1991, pp. 82, 189) when it comes to considering meaning and belief, the process of studying representations is one of judging accuracy with respect to a specified represented-object. The simplest way of stating the picture of belief in the meta-representational view is to begin with the distinction that accurate and inaccurate beliefs can co-exist with respect to any believed-object. Part of interpreting belief through meta-representation is to avoid conflating believed-senses with their referent. Inaccurate beliefs provide incorrectly interpreted senses. Accurate beliefs provide 234

Ian Rory Owen PhD more accurate representations due to citing proper evidence and learning across time that enables useful action with respect to the referent. Meta-representation also occurs when distinguishing an accurate sense of an object from an inaccurate one. Accurate and inaccurate beliefs and understandings are technical terms. Inaccurate understanding indicates the narrow range of experience that occurs in insecure forms of relating; as opposed to what could be the case for the same person who could over-come fears and limitations by having much more contact with the object that is currently feared. For example, if dogs are feared generally, it is only getting close to a friendly dog on a safe and regular basis that will undo the generalised fear. If an understanding is accurate or inaccurate, a meta-representational comparison is being made with respect to what it could or should be. On the one hand, accurate belief is self-confirming and congruent with a non-problematic outcome. Inaccurate belief begets its own problems. In short, the more mistakes happen, the worse performance is, the poorer is self-esteem, the greater the anxiety and shame, and the vicious cycle continues. On the other hand, if there are good outcomes, the work done brings satisfaction and a sense of deserved tiredness, plus positive self-esteem and relaxation. In this view, the constitution of psychological problems rests on the generation of faulty outcomes that are created through interpretations from an unhelpful standpoint. Josef Perner states that the mental maps of belief have to be sufficiently accurate for the “organism … to succeed”, (p 232). For instance, meta-representation occurs in distinguishing between an old defensive belief that was formed of a previous social context and its evidence in the past. The defensive belief functioned to fend off an old consequence that was painful or destructive. The psychological problem is that the old belief still exists long after the threat has gone (p 181). Meta-representation makes it clear what needs to happen in therapy. A new belief needs to be drawn up that reflects accurately the current evidence of contemporary social contexts and leads to new, more open and confident consequences in the present. Given that personality and psychological problems are fundamentally experiential, it follows that understanding the problematic experiences begins the process of seeing a way forward. Theoretically, distinctions about intentionalities in relation to their objects concern the “ability to represent the representing relation itself ”, (Pylyshyn, 1978, p 593). One phenomenon that can be explained is that psychological damage to children less than five years old seems to produce long-lasting implicit beliefs in addition to explicit ones. There is no one-to-one correspondence in the type of influence created, but adult survivors of abuse, neglect and trauma in childhood often continue some form of bad treatment of themselves, may have difficulty in knowing their own needs and being able to satisfy them. The cumulative effect of many different types of trauma and disappointment may also produce fixity in the form of an over-reliance on specific defensive ways of dealing with the world. 235

Talk, action and belief Where psychological problems begin is that a wrong estimation of risk begins worry, for instance, that something bad will happen that will have catastrophic consequences. This worry gets repeated, so that anxiety and avoidance build up and the believed event gets confirmed in its credibility, thus driving the problem. This is a meta-representational distinction because types of intentionality are specified in relation to specific senses about the same object - and contexts of previous understanding and belief about different intentional events are mistakenly added to that object. Let us take the example of agoraphobia. Because Peter once had a full-blown panic attack, he decided to limit going out as much as possible to prevent its recurrence. This emphasised Peter’s personal vulnerability (which was over-estimated) and emphasised the external risk involved (which was over-estimated). Because Peter prevented disconfirmation of his beliefs (because he avoided crowded places and felt that he is vulnerable), there was a vicious cycle of maintenance of his inaccurate beliefs. Making self-care interventions clear requires understanding the principles of distinguishing between the forms of intentionality involved, so that Peter could find out experientially that he is stronger than he believed himself to be, and that the extent of risk that he believed was the case, was actually a lot lower than he had anticipated. The meta-representational view of belief is continued in understanding development across the lifespan. Beliefs arise from social contexts. It is generally agreed that children learn to behave in the family, and in the social environments of early care, in ways that promote psychological coping, defence and survival. Accordingly, the preferred hermeneutic stance for understanding is as follows: On leaving the family and attending school, or on leaving home for the first time, the belief-map of the world that helped children survive at home can hinder them, in the new social context. This is a meta-representational view because it compares two situations to bring out their differences. The same situation can be described as “identifying what individuals take into situations with them”. Particularly, identifying an understanding that is inaccurate or false. More evidence for the meta-representational conclusions above comes from Ron Tulloch and Naomi Murphy in their paper, The Forensic Perspective (Tulloch and Murphy, 2002). They comment that ‘personality disordered’ clients often appear developmentally delayed as though adults were stuck at the ages of seven or eight. Their commentary is a personal observation on their work with clients in severe distress. This conclusion can be interpreted from a position that makes sense of the general tendency of clients to be awkward, angry, sometimes manipulative and controlling, and able to stir up strong feelings in therapists: It is as though adult clients were still children who test their carers. This phenomenon indicates that belief, habit and fixity are present, between childhood and the present. Similarly, clients’ problems and styles of relating may begin for one reason, but they are maintained for different reasons. 236

Ian Rory Owen PhD The meta-representational understanding of development is easy to see in the case of traumatised children who get into trouble with the outside world when they leave home. The world outside is not as harsh as home. They get into trouble because the beliefs that derive from their anticipations of their family are successful in that context, and serve to protect them there and get care and attention from parents. But the same beliefs do not fit the world outside their family. It is easy to see what they take from home to the new context because that is where the discrepancy with the actual needs and intentions of current others becomes manifest. Therapeutically, the good news is that most people in the world are less abusive and neglectful than their carers have been. Prior to therapy, people judge their self-worth on what their parents, siblings, peers, teachers and significant others have said and done. After therapy, the appraisal is kinder and more balanced and includes their strengths and potentials, rather than an excessive focus on weaknesses or events misconstrued as inexcusable sin. Explicitly in therapy, a meta-representative hermeneutic stance compares those who are fixed in their ability to interpret the world - and those who can empathise accurately and respond accordingly, in being flexible and adapting to the current psychological environment. The fixity of beliefs across decades can be seen most easily in PTSD, severe neglect, rape, sexual, emotional and physical abuse, death threats, invalidating, incongruence-producing home environments and trauma prior to the age of three. These experiences form influences that last a long time. No wonder children who receive such treatment at the hands of their carers are ‘externalising’ (cannot take responsibility) and potentially are manipulative, sadistic, masochistic and ‘narcissistic’ in the broad senses of these terms. Nor should it be a surprise that children who have been raped, beaten, emotionally abused and threatened with death, or survived murder threats or actual attempts, have the experiences called ego inconstancy (Akhtar, 1994, Tyson, 1996) and death anxiety. In death anxiety people feel vulnerable and have a pervasive belief that they might die any day soon. The problem is that the picture of self is extremely weak and vulnerable when the person is in good health psychologically speaking apart from their fears in one area, say. Nor should it be a surprise that they think of, attempt, or are successful at suicide. The sense of vulnerability to imminent death may be defensively protected by self or not. Dying might become fixated and the topic of rumination and worry. It can be experienced as anxiety or worry and full reflection on these topics and their causes can be avoided and not understood.

Meta-representation and relationships The key distinction that meta-representation provides is the ability to comment on relationships with people, including the relationship of self to self and comparing types of attachment. Emotions between people are forms of representation with 237

Talk, action and belief respect to psychologically important other people who are needed and wanted, for the main part. The same holds for children and infants who can be freer in the expression of what they feel. For instance, the basic cry of a child is a request for caring: The child’s displeasure exists in relation to its innate ability to feel secure and cared for. For adults and older children, the idea of defences within attachment relationships also marks a difference between actual vulnerabilities as opposed to false ones. When there is actual threat from others, there is a genuine need to protect self whereas ‘false threats’ need no protection because there is no possibility of harm. A subtle difference occurs when there is an actual vulnerability in self: then there is a genuine need to protect self. This is different to when there is a false sense of personal vulnerability that needs no protection. What people should do to overcome the sense of vulnerability is assess genuine risks and plan how to respond, should a problematic situation ever arise. But they need to learn to trust themselves and know that they could cope with an emergency. Meta-representational distinctions play a part in attachment in the following way. The permutations of the connection between self and other, in the insecure forms of attachment, share one thing in common. They are all inaccurate understandings of non-threatening other persons. The specific themes of the past of individuals comprise psychological ‘causes’ and beliefs (in addition to biological causes obtained from the past) that can guide current action in a faulty manner. Because fixed over-generalised beliefs are held, they will not always be relevant to the current social context of non-threatening others. Hence, the focus is on identifying intentionalities through comparing and contrasting them. A secure attachment response is born of accurate beliefs about what are genuine threats. Accurate beliefs help people feel anxious in the immediate proximity of threat, in order to flee or fight when necessary. That situation is opposed to inaccurate beliefs that trigger an insecure response when there is no genuine threat: and the person flees or avoids their anticipation. In other words, anxiety in itself has a defensive purpose. Anxiety has the purpose of preparing and potentially protecting the individual for any eventuality (Owen, 2002, p 253). But the direction of cure for excessive inappropriate anxiety requires the person to re-learn what is genuinely safe. Hence, the need for exposure therapy and the practice of social skills. The next section expands the context of relevant factors in order to connect with the views of others across time and how it becomes possible, through discussion in therapy or other means, to re-evaluate topics as they are discussed. The discussion is a conceptual medium for re-arranging psychological and emotional senses: All of which are representations made through representing forms of intentionality.

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Accuracy and inaccuracy of belief in development and the views of others Let us take the example of long-term post-traumatic stress disorder (PTSD) to spell out in detail what meta-representational distinctions are in relation to formulating psychopathology and using the interpretation of intentionality. Let us look at some general aspects of PTSD first, before considering the social and empathic consequences of abuse in the family and social roles. The aim is to explain the type of complex comparisons that occur in understanding any type of disorder or personality syndrome by making comparisons to other types. Let us take one small portion of the conscious experiences of people with longterm PTSD. Early trauma may produce a belief about self as shameful and self may treat itself in a similar way to that in which the perpetrator originally attacked the child. The problem is how to explain how abused children self-harm, become mute, do not seek help from trusted adults and seek fights even with children who are their friends and have never hurt them. The effects include the following, particularly in the case of an “interpersonal stressor”. What can be experienced are: …impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness; shame; despair; hopelessness; feeling permanently damaged; a loss of previously sustained beliefs; hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual’s previous personality characteristics. American Psychiatric Association, 1994, p 425. These are significant effects particularly if they happen in childhood and especially when no treatment occurred at that time. Such experiences could lead to beliefs concerning inaccurate apperception and empathy that may last for decades. However, the list of symptoms above is not cited to focus entirely on the individual but to think about what happens in his or her ability to make important distinctions concerning how to make sense of themselves. This happens by comparing before and after traumatisation and before and after treatment. How PTSD exists as a whole is dependent on the level of development, lifestyle and the social circle of each individual (Pfohl, Jimerson and Lazarus, 2002). Let us take the example of PTSD in order to consider what happens around the individual: Apart from the differences between traumatised and nontraumatised people, and the differences before and after trauma, what also appears for a meta-representational view of trauma occurs in its social habitat (cf Perner, 239

Talk, action and belief 1991, pp. 88, 119, 123). The listing of key aspects by the American Psychiatric Association is introductory to how trauma manifests itself for a child in a physically abusive family, for instance. In the case of violence, ‘breaks’ in empathy are furthered through the frequent occurrence that the survivors’ views of the trauma and its consequences are denied by the perpetrator. It might even be the case that a perpetrator of abuse denies, manipulates or threatens the survivor not to complain or express distress. This is yet another area where meta-representational distinctions are made. When trauma has happened, or there is current conflict for people who have been traumatised, the following can occur with respect to the perspectives of traumatised persons: Their views are refused or argued against. Dominance in the aggressor demands submission in the oppressed. The views of others are understood but not agreed with, in an attempt to suppress complaints. The views of others are devalued or destroyed. Or the views of others are unable to be understood because those listening are not psychologically minded. Or there is a failure to discuss outstanding negative issues that does not help solve the problem and may maintain or increase it. Or there is a failure for two people to see each other’s perspective. This in itself is problematic and needs to be addressed and solved if possible. Altogether, failure to accept differences in lifestyle, values and culture are usually problematic. Psychological life and communication can be understood sufficiently because of the meta-representational understanding of empathy. It can be seen that there are ‘breaks,’ metaphorically speaking between the views of self and others. The usual connection is further broken when traumatised people cease considering new evidence and turn inwards, thus freezing their beliefs and overall experiences, in attempts to become excessively self-reliant. Children learn about the nature of the world during the first 10 years of life. The drama of childhood is intensified in childhood PTSD. Children are generally more anxious than adults. But when there is PTSD in childhood there may well be additional arguments, bullying and exclusions from the peer-group, early shame and low self-esteem, anxiety and depression at a young age and survivors may not receive treatment until adulthood. Diagnostically, there is a good deal of overlap between long-standing PTSD and some of the personality disorders. But in wider view, the term “personality disorder” is inappropriate as a description for the results of PTSD because it is an intersubjectively ‘caused’ problem that has physical and social consequences and leads to problems when clients try to selfcare and problem-solve prior to therapy.

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Ian Rory Owen PhD What the concept of meta-representation enables is a distinction between what is mis-interpreted to occur - as opposed to what can be accurately interpreted to occur or what could occur. Let us take this example of a generalised sense of fear then compare that to a situation where there is less fear. Firstly for Odile, her defended and threatened sense of self operated in relation to tidying objects to control the pervasive fear. Other persons also appeared threatening, in a non-specific way, and Odile mis-empathised others and their intentions. One consequence was avoiding others or otherwise, they needed to be defended. The role of anxiety was to prepare for fight or flight. Her own relation to herself was modelled on traumatic events and past abuse, so sado-masochism, denigration, hate and anger of self appeared as gross intolerance and impatience towards herself. These beliefs, understandings and experiences followed the example of how her father had abused her in childhood. An example of trauma makes the point about sharing perspectives clear. Odile grew up in her family where domestic violence perpetrated by her father on her mother was a daily event. At three years of age she had the realisation (which was accurate) that she could be murdered by her father. What this set in motion was a lifelong sense of vulnerability to attack, fear, illness and anxiety expressed in a wide range of death and health anxieties that inter-acted with chronic obsessive compulsive disorder and anorexia as ways of controlling how she felt. Specifically, when Odile was a child, her father threatened her with physical attack if the family home was not perfectly clean and ordered. The intentional interpretation of Odile as an adult is that the function of the obsessive-compulsive disorder was to control non-specific fear, to prevent anticipated attack and verbal criticism from her father, and act as a distraction away from lifelong health and death anxiety. Odile’s childhood was full of fear to the extent that she shook and vomited on the way home from school as a seven year old. She dreaded going home and had no idea what to expect when she got there. The belief that arose from her family socialisation was that Odile had to be tidy in order to prevent attack. Fear for instance, can create a link between belief and action. However, the intentionalities existing are discernible among these events. Empathically, Odile accepted her father’s views and rules for decades into her adulthood, long after he had forced them on her. Furthermore, as the French saying goes “he who doesn’t speak out consents”. Excessive self-reliance prevents external influence, new experiences and compounds the overall problem. For instance, an original trauma can be denied, negated, discounted and not attended to - and that may perpetuate disturbances in ego constancy, empathised senses and insecurity of attachment. Arguments that do not get resolved might continue because one person does not acknowledge the views of the other and insists that their own view is the only view of what happened. Being able to compare and contrast the views in the family around the traumatised person can help the child get therapy

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Talk, action and belief early on, can deal with family members who do not understand and make it clear how perpetrators can be re-educated to prevent further abuse. The next penultimate section discusses intentionality as the representing power of consciousness to become aware of others, its world and itself.

Discussion Meta-representation is a subtle type of distinction that applies across many specific situations. Meta-representation also occurs in making distinctions between emotions. For instance, excitement is not anxiety. Seeing is not understanding. Empathising another’s distress but choosing to ignore it in favour of getting one’s own message across – is not the same as being unable to empathise anyone’s emotional state. When it comes to empathising others, the impression that anybody can get of the intention of another person may not at all be what that person intended. The only way of getting certainty about what another intended is to know them closely over a period of time and to be able to create conditions where they are relaxed enough to speak what is on their mind and the same for self being able to ask for feedback from others. Meta-representation occurs in making key judgements concerning when to act on thoughts or feelings about the same situation. An outcome of a chosen action can be in-line with thought or feeling. For instance, trusting a feeling is not in doubt when it is a desire for intimacy and making friends with people who are capable of it. However, there can be internal dialogue and worry about rejection that reduces the positive feeling and the desire to be in connection with others. On the other hand, trusting anxiety-provoking thoughts is in doubt when fear closes down intimacy and what happens is acting on feelings of withdrawal and the desire to protect self when the persons are capable of responding positively. If the other people in question are genuinely trustworthy, then thoughts about secure contact with them should win the day. The abstract comparisons above can also be explored with another more concrete example. The meta-representational understanding is that there is an on-going comparative ability: whatever the sense of self felt, it occurs in relation to an empathised sense of what others feel and what self feels emotionally. In the special case of physical aggression on self by self, there is a neglect of one’s own needs (due to a variety of causes). This is the same for the lesser cases of self-criticism, self-doubt and general self-dislike. The felt-sense of self varies and can be the focus of comparisons concerning how others are empathised to be. Of the many senses that people can have about themselves, let us consider those that occur in therapy and compare these specifically to self-hating types. The most general inter-relation is always the same: there is a self in relation to a specific other, within the context of others, more widely known. The senses given to others 242

Ian Rory Owen PhD may be accurate or inaccurate, despite other factors that might promote accuracy (like asking people how they feel). The relations towards self, of excessive love or hate – could co-occur in relation to the sense that specific others are sufficient or insufficient, or that self is useless and should have no contact with those others. When attachment theory is seen through meta-representation, the differences and tensions of attachment are a cornerstone to understand emotions, the influence of the past and identify the influences of current thoughts and feelings. The general process for clients is one of opening out, from a fixed or narrow set of experiences, to a much wider range. This often occurs through the ability to stop and reflect on the nature of what is happening and begin helpful action. Indeed, meta-representational differences are at the heart of governing choices and decisions in psychological change. Similarly, in small children who get beaten, the howls of protest are a statement that they know that they should receive better treatment. But the aggressor is more able to exert influence than the child. The perpetrator, say it is the father, knows that the child knows the abuse is wrong, yet forces the child to pretend not to know. This creates a second need to hide attempts at controlling the child into not complaining. Therefore, there are attempts at preventing the child complaining in addition to hiding the fact of the beatings. In later years, when the child leaves the family and lives outside of it, the damage done is the creation of an implicit emotional reaction or through conscious reflection and interpretation. The survivor of physical abuse believes “you are all the same,” “everybody hates me,” and “other people have better lives than I”, for instance. The tendency of the past in influencing the present and the future is well-known. The difficulty is in being specific about the nature of the negative influence in order to over-come it. Let us explore the meta-representative understanding of social life further. The modes of aggressive relation of self towards others are where there usually may not have been anything in the current relationship that warrants the aggression shown. There are those cases where it is necessary for self to protect against lack of care, antisocial demands and attempts to control and manipulate. The various ways for selves to react to others are comparable. Hence, each specific way becomes known in relation to the other possibilities. Also, forms of leery behaviour towards others, who have not elicited it by their own behaviour, enable it to be understood that envy, jealousy, quarrelsomeness, seduction, generalised anger and contempt are all lesser versions of physical attack – but each has its own style of aggression. These attitudes towards others also make sense in relation to the overall fear and aversion from others in social avoidance. Thus, the different forms of social withdrawal can be teased apart: fear of loss of attachment can prevent attempts at it. Social anxiety and paranoia proper share the commonality of empathising the other as being attacking and view self as being insufficient to deal with it. Ultimately, the actual causes of these senses are biopsychosocial. But 243

Talk, action and belief to understand specific versions, it is necessary to compare and contrast aspects of the overall whole and help people take action to look after themselves and meet their commitments to others. Clients can take up defensive perspectives and hold them tightly for decades. They maintain their beliefs in a semi-permeable manner, often to the exclusion of contrary evidence prior to therapy. The process of change occurs when it becomes possible to hold different perspectives on the same referent. Therapy cannot prevent recollection, of course. But it can help clients gain a new perspective on the same referent. With the attainment of a new perspective, there follows the possibility of change of affect, belief, thought, relating, values in life and the senses of self and others. Meta-representational understanding is important because it implies that being with other people is an opportunity to sample their perspective and see if it fits (and vice versa).

Empirical research in the theory of mind This final section of this chapter makes comments on some empirical research in developmental psychology that employs the meta-representational view. The research has mainly concerned how children go through distinct developmental stages in being able to understand how other people believe. What is asserted is that at a most basic level, the meaning of any object co-occurs with perception of it and the addition of the meanings of others about it, gained from empathic perspective-taking that begins at about three years of age (Perner, 1991, p 87). The outcome of this fundamental level of empathy is that it is possible for children to learn empathically what another person is seeing and experiencing: The one anticipates that the other has a different sense of the object to themselves, according to the position of the other, with respect to the mutual object. The same can occur with respect to more complex perspective-taking, when selves can learn empathic accuracy of the senses that others have. This seems to begin at about two years of age (p 139). Indeed, at two years of age, other persons become generally recognisable as purposeful agents (p 209). What is dawning at this time is the understanding that the perspective taken towards an object is a condition for the existence of the sense that is experienced: for self and for others. What the empirical research by Josef Perner and colleagues means for belief is that being able to make distinctions about false beliefs is a developmental milestone that is usually achieved at five years of age (p 195): Specifically, children are unable to deceive others prior to this age. Most three year olds do not understand the point of lying as a means of providing false beliefs (p 198). But such awareness is not achieved thoroughly and consistently. To make the distinction between belief and lie is to meta-represent. That distinction is allied to other distinctions including the fundamental ability to understand how one’s own beliefs can change, like in the case of Jonathon that was cited at the beginning of chapter 11. To return to the concrete meta-representational differences of positive change for Jonathon, was for him to realise the detail of how he had changed for the better across his lifespan: The ambivalent, socially avoidant teenager gave way to a confident and capable 244

Ian Rory Owen PhD middle-aged adult. His fearfulness decreased step by step. His maturation concerned increases in self-esteem, security of relating, and perhaps most importantly, the ability to appraise the evidence of his own contact with other people in a way that was fair. Such ability is meta-representational because the interpretive positions taken to any understanding of an object may include: •

Identifying inaccurate understanding, values and beliefs that lead to unhelpful outcomes, actions and states of affairs. Inaccurate beliefs are mistaken representations that can be explained with respect to how they began and it can be shown how they are inaccurate about what exists currently. Sometimes unintentional error occurs, leading to a mistaken outcome.

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Purposeful lies may result in people being misled unless they can identify inconsistencies, “holes” in the deceit they are given because liars have to be consistent about the lie and the truth.

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Delusions may continue to exist without any supporting evidence, or even when there is explicit evidence to the contrary. Delusions are distinguished with respect to some idea of what should or could be believed.

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There is the possibility of agreement and conflict between persons of different perspectives. Joint awareness of an object may only be achieved at a low level of agreeing that something has happened. The higher degrees of mutuality of reference, to common points of reference, may not be achieved. Although developmentally, the accuracy of empathising others arrives hand in hand with accuracy of understanding self at around age three (Bischof-Köhler, 1988, cited in Perner, 1991, p 132).

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It is possible to replace poor understanding with an explicit means of interpreting and believing in more accurate ways and to be able to demonstrate how the new beliefs are more accurate. It is a further step to use understanding, interpreting and believing in positive action to solve psychological problems.

The distinctions above require making meta-representational distinctions about the types of intentionality occurring and distinguishing between the senses generated as a result. Whilst it is impossible to be utterly precise in defining what a client’s beliefs are concerning the influence of the past, the lack of precision in this procedure is a matter of fact. It is more concrete to interpret current psychological problems and relationship events in terms of what is problematic when it occurs, and what clients think and feel, rather than concentrating on where the past influences have come from.

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Talk, action and belief

Summary George Botterill and Peter Carruthers conclude on behalf of Josef Perner that “theory of mind development cannot be explained in terms of quasi-scientific theorising, because scientific theorising would be entirely impossible without mind-reading ability”, (1999, p 94). What Botterill and Carruthers mean is that empathy is a condition for science, rationality and experimentation to exist. For instance, it has been shown empirically that children who have more siblings are likely to pass the belief test earlier than those who have fewer siblings. This is taken to mean that empathic ability employs a socially learned transposal into the perspective of others and it is adequately developed through early socialisation (Perner, Ruffman and Leekam, 1994). •

Meta-representation, the “ability to represent the representing relation itself ”, (Pylyshyn, 1978, p 593), is involved in identifying the initial attitude that is taken to a situation, to produce a state of fear, at say a spider – as opposed to being relaxed in the presence of a spider, even if they are disliked. The means of making such distinctions varies but the test of the degree of accuracy is whether it stands the test of time and whether it connects with the world of the perspectives of others. Dependable senses of an object are those that stand out in relation to fear-induced, false, momentary, frozen-in-time and other misleading experiences. Genuine, accurate senses are those that connect with a long-term immersion in all aspects of the object of attention.

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Meta-representation is comparison that occurs in the identification of problems such as what happens in insecure attachment forms, as opposed to the secure type, as the differences in chapters 4 to 7 discussed.

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The means of formulating and discussing phenomena is formally interpreted as meta-representational. It demands understanding relationships through intentionality, belief and making temporal and experiential comparisons between what has been, what is and what could be.

Problematic beliefs are inaccurate or partial representations as opposed to more accurate beliefs about a person, a psychological process, an object, event or situation. Beliefs serve a hermeneutic function in that they interpret a referent in some way. For instance, to be alone could be felt as a release from the constraints of others or the pain of disconnection from them. When beliefs are used they make sense of an object’s nature and its mode of existence and so structure behaviour towards the object. Philosophical terminology is able to account for this phenomenon, not psychology as a science. Meta-representation is at the root of the key distinction for knowing the difference between genuine belief, mere illusion and delusion: What is accurate lasts the test of time and makes contact with the views of others. 246

Part IV The practice of talk, action and belief

PART IV The practice of talk, action and belief

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Talk, action and belief This final part turns to practice to explain through tangible examples the consequences of the prior parts. What follows are chapters on the further details of assessment, formulation, talking and action interventions. Although much has been stated above on practice and theory, there has been no sustained attention on what to do and how to do it. The arguments for attending to social meaning, lived experience, motivation and other matters, will be clearer. The overall aim is to increase striving, effort and commitment towards clear outcomes. And simultaneously, decrease habit and inaccurate ways of believing, acting and feeling. The aim is to make changes in specific problems and this permits change in the personality, ‘from the inside’ of helping people who want to change themselves. This occurs because the personality is comprised of many smaller aspects. It is possible to classify interventions according to the intentional form of the problem. This would lead to noting changes in sense that occur in redeploying different intentionalities, for instance. The intentionality model suggests that the egoic and social aspects of meaningful problems can be understood as consisting of intentionality, sense, object and context in every case. Changes in sense are obtained through altering the type of awareness plus the amount of duration of attention on any one sense of an object. And the objects chosen for attention influence relating, emotion and mood. What is not being proposed is a ‘one-size fits all’ means of trans-diagnostic formulation of the initial on-set and on-going maintenance of psychological problems that includes “co-morbidity,” the co-occurrence of problems, or in relation to originating social contexts. The absence of such a theory is not avoidance. Therapy can be certain of little at this point in the development of the biopsychosocial perspective. This book does not provide tips and theoretical rules of thumb for every aspect of practice. However, theory guides practice. Already existent understanding shapes what can be recognised while there is a major difference between actual events and theory. What this part covers are three core competencies for the practice of assessment, formulation and intervention. Assessment is represented here as an initial phase but in some cases new information can come to light during the therapy phase that means that assessment might be an on-going process. In either case, assessing is a co-operative procedure, like the other two core competencies. The sense of co-operation is to employ a division of labour through having clear roles for client and therapist and for there to be open and honest discussion of any problematic or doubtful aspects. Difficulties for both parties can be mentioned in a way that means that they will be well-received as attempts at problem-solving and not criticism. Chapter 14 presents a semi-structured interviewing procedure. The scene for practice is set by explaining the necessity of assessment and providing the briefest of outlines for practising a talking therapy and how that could be highly specific – or entirely non-specific and left up to the clients to set their own changes. 248

Ian Rory Owen PhD Chapter 15 comments on treatment planning. Chapter 16 presents formulation as a procedure where therapists lead in making sense of specific portions of the experiences of clients in a way that asks them to check the understanding that it made of them. Formulation is the backbone of practice and may require reformulation as changes and new information are found about what happens for clients. Formulation is the meeting place between theory and practice. It provides rationales for interventions that are understandable in terms of the intentionalities that create problems and indicate what needs to happen to create change. The practice of intentional formulation with clients should create mutual understanding towards clear aims, owned, defined and controlled by clients and supported by therapists. The details of how to formulate are covered after providing sufficient background detail about what comprises an adequate understanding of what formulation is and what it does. Formulation is related to the choices, meanings and experiential processes that it is about. The purpose for self-help treatment is to help clients begin to realise how they might be contributing to, and possibly even perpetuating, their own distress. These processes need to be clear, accessible and explained in such a way to begin discussion of the way in which clients are linked to their own beliefs, evidence and emotional distress, plus addressing the complex experiences and relationships that can be involved. This is where the ability to interpret intentionality shows its strength in formulating how people experience any aspect of their lives, whether it is problematic or joyful. Chapter 17 rolls out the links between the intentionalities including belief, and the evidence to which they refer. The fourth and final part of the book covers practice. Chapter 18 explains some details of what it is like to live in a meaningful world. Chapters 19 to 21 present details of interventions and cases and chapter 22 concludes the work. One major task of therapy is encouraging clients to become more effective in using theory to point to what matters. Non-technical discussion should be used to pass on these methods to clients. The purpose of formulating the maintenance of personality and psychological problems is creating a means of shared understanding of the on-going reasons for a psychological problem. Formulation only focuses on the most relevant highlights in preparation for clients taking action. In some cases, merely formulating a current problem can be sufficient for clients to take the necessary action without any further input from therapists.

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14 Assessment Aim: This chapter makes some theoretical distinctions prior to practice by discussing some key necessities of assessment for individual talk and action therapy. Like packing for a long journey, when the destination is known, it is easier to plan to get there. A semi-structured way of assessing is defined and two types of screening subroutine are included in order to recommend whether the identified problems would be helped by talk, action, both or neither. What is being assessed is the suitability of talk or action, and talk and action or no therapy at all, for specific persons, their ability and interest in these approaches. The main assessment tool is clinical reasoning not based on questionnaires and empirical research but based on a detailed consideration of what clients and therapists are capable of achieving together. Right away it has to be noted that only talking about problems cannot help some people. Furthermore, even prior to the assessment phase, those who would not be helped by therapy of any sort should not be invited to discuss their problems in the first place because it raises hope that cannot be satisfied. Below, some pointers are defined in order to make assessment into a procedure that helps clients get the services they need and can use. Assessment estimates risk and danger to self and others and is legally defensible. Often, it can be 251

Talk, action and belief achieved in one 90 minute meeting rather than having two or more meetings. This time allocation does not include any time for the use of measures and questionnaires that could be completed before the meeting begins. This chapter concerns the necessity of starting individual therapy with clients who are properly briefed and able to understand what it is they are committing themselves to – because commitment and effort are required to generate change. In many cases, the end-products of the therapeutic process are based on the mental substances of understanding, insight, understanding one’s own choices, motivations and preferences. It is necessary to act in specific ways to gain and then maintain these hard-won improvements. The sequence of points is that a first section introduces assessment. A second section discusses how to assess for talk and action practice. A third section notes contra-indications for the talk and action approaches. A last section makes closing comments on screening for talk and action.

The purpose of assessment This section begins to tease out some of the priorities of assessment. The assessment phase exists because a recommendation is going to be made. Either some form of help is suitable now, or suitable later, or currently there is no form of psychological help that is suitable for specific reasons. The purpose of assessment is finding out whether specific clients will benefit from what can be offered to them. The most basic purpose is to assess people’s needs and abilities to use help of specific sorts. It recommends what will help them best regardless of who can offer it. It entails rejecting persons who cannot be helped and explaining why that is the case and making some recommendation that will help them. The basic question is to ascertain whether talk or action or both will be helpful and accessible to the specific member of the public being interviewed. Empirical research suggests that the most ethical and effective way of providing care is to do so via the evidence that recommends that action therapy is potentially likely to have the most benefit in the shortest time (Owen, 2003). However, this is a rule of thumb and is open to a great deal of flexibility due to a large number of important variables. Because action interventions have been shown through research to have the greatest likelihood of helping on average, it is most ethical to offer these because they are highly focused on helping with specific disorders. The problems of the actual delivery of care are numerous and practice must take on-board the abilities and wishes of clients who may not want, or be able to participate in action or self-care that is focused on one disorder. What is under discussion is the nature of matching clients and therapeutic processes. Suitability or unsuitability is partly a problem concerning what is being offered in connection with the needs and abilities of the person to whom it is being offered. For the most part, providing understanding to clients by itself is insufficient. 252

Ian Rory Owen PhD Rationales for change should be clearly stated during assessment. Once accepted into therapy, there is the expectation that clients will follow through and apply an intervention to find out if it works. (If they will not do it, or if they try it and it does not work immediately to their full satisfaction, then maybe there are natural causes at play or other unknown psychological ‘causes’ of side-effects that have not yet been identified).

On assessment Assessment is offering a semi-structured interview process that is approximately the same for all persons. People with special needs show themselves in having difficulty in taking part in a standardised process of finding out the nature of their problems and how to provide help to them. What potential clients reveal are mixtures of their personality in their social context, due to their personal development and accumulated choices over time. These influences create problems with mood, the social world and attachment life. They concern specific psychological disorders in inter-action with the long-standing ‘personality’ or ‘character’ functioning. By way of disagreeing with the mainstream tradition, it would be better to strike the word “disorder” out of the psychological lexicon altogether because “personality” and “disorder” are loose syndromes and not tightly definable. But because of widespread usage, below “disorder” is used synonymously with “problem” on the understanding that a good deal of variability exists in these and the classification of ‘personality’. A wide scope for viewing human being is required in order to view these problems from the inside of the client’s view. During the first assessment, 90 minutes is needed to go through the following. A statement concerning what to do in the case of the possibility of serious harm by clients to themselves or others should be made in the first minute of the meeting. It should also be mentioned that it is possible to meet again, and extend the assessment phase to more than one meeting, if that is necessary. It is the task of therapists to explain and get informed consent by clear explanation of assessment and treatment. It is best to explain the following format, mention that note-taking will occur, and explain if there will be any requirement to report to third parties. The easiest format is to state that three major areas will be covered that will probably take about 30 minutes each. The assessment needs to do three things. It needs to work out where clients are; where they can get to and thirdly, how they can get there. Answering “where clients are” occupies the first 60 minutes because there is the current set of psychological problems that clients have and there is the necessity of finding the effect of their personal history, their personality as well. Starting with where clients are means addressing what they want to go towards which is agreeing a focus for the meetings and setting an agenda. The question of how clients can get to where they want to go is in-part where the discernment of

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Talk, action and belief the clinician meets with the needs and wants of clients. The means of making the journey is that it has to be suitable given the abilities of the persons involved. However, the first thing that needs to happen is getting informed consent for the assessment itself. The purpose of the meeting should be stated and that is finding out how to help the person best. This is a way of stating that having an assessment is not a procedure that leads automatically to immediate access to help. Finding what might best help them can only be found after careful questioning. The recommendation will include advice on what approach will help, and if any sort is unsuitable. The local legal requirements of the employer and professional association need to be followed. For persons with trauma, neglect, abuse and complex long-standing problems, it is best to err on the side of caution. If therapy can do no good, then it should surely do no harm and there might even be instances when assessing itself might be hurtful. An explicit statement, preferably on paper should be made that assessment and any potential treatment is being offered on the grounds that there will be confidentiality except when there is the possibility of harm to self and others. So if there is harm to self and others, then confidentiality will be managed but it will be automatically broken according to the demands of the local laws that are in existence. Gaining informed consent to treatment means discussing, explaining and negotiating with clients what will help. Therapists are mandated to ask for, and create explicit informed consent for assessment, for a general treatment strategy and the use of specific interventions. Informed consent and clinical reasoning in sessions form a whole and require therapists to explain themselves and their recommendations for treatment. After having gained informed consent through explanation, it is useful to give clients the opportunity to disagree by asking them explicitly to do so. Thirty minutes each can be spent on the following three major parts of assessing. •

Ask open questions and list all current problems according to the check-list definitions of the Diagnostic Statistical Manual IV (American Psychiatric Association, 1994). If one type of specific problem is found, it is best to ask around and find if there are adjacent problems that commonly occur. For instance, if a person has one anxiety disorder, they may have others. Or to ask if there are clusters of occurring disorders like bipolar disorder with worry, low self-esteem and lack of assertiveness and then ask if there has been childhood trauma, psychosis or abuse. Asking if specific disorders are present is necessary. Asking “is there anything else you would like help with?” might produce a response that adds in the extra detail of what else is currently problematic in a person’s life. The reason for this precision is to facilitate change in the extent and nature of personal development across the lifespan.

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Take a genogram of the family of origin and ask about the personalities of parents, step-parents, partners and children. Interviewers should ask how life 254

Ian Rory Owen PhD has been for clients in periods of decades of their life: The first ten years, teens, twenties, thirties, forties, etcetera. The answer to this procedure shines light on early experiences that might be causative of contemporary ones. •

Finally, a recommendation should be made concerning the type and duration of any therapy. If therapy will help, the type of therapy recommended should be explained and the meetings set up, even if only in brief. If therapy of a specific sort is being recommended, then the reasoning for this choice should be explained in a clear and succinct fashion. Similarly, if therapy is not recommended, then that should also be explained and honest reasons provided as to what will help clients best in its absence.

The ‘cost’ of therapy for clients is the amount of time and effort spent in trying to get the changes that they want. The recommendation concerning how to get to the desired end-point concerns how to employ talk, action or a mixture of both. The combinations of help under consideration are talk or action, both or neither. All therapies consist of some combination of talk and action. Talk can be for the purpose of gaining understanding only. In other circumstances, talk is preparatory to any treatment. In other cases, the function for talk is to pave the way for action. Action therapy includes behavioural experiments and participation in graded exposure programmes of over-coming fear and avoidance through stepped exposure to chosen amounts of these experiences.

Estimating the suitability of therapy One model for assessing is to use the semi-structured format below that asks about problematic experience. Assessing requires thinking through what is necessary for there to be a good outcome, and from that, to work out what is necessary to be in place at the start of meetings. When viewed in this light, the key questions can be stated as: “what is sufficient to make a modality work for this specific person?” And “what is it about what is on offer that is sufficient for this person?” The job of therapy is a practical one. It exists to understand psychopathology and attachment to provide informed professional judgement concerning how to help improve quality of life. Often at assessment, the assessor maintains a wider vista than when therapy has commenced. As potential client and the assessor do not know each other, it may well be useful to set potential clients a task and extend the assessment period, until specific key questions can be answered. Such homework-setting or testing can work towards excluding those who do not have suitable approaches for them and including those who were previously insufficiently interested. Most models of brief therapy work by agreeing a limited focus for the sessions. Even if several assessment 255

Talk, action and belief or initial sessions are used in making this appraisal, then it is worthwhile overall to educate clients as to what will help and for therapists to explain what it is that should be treated, in what order and why. For instance, clients need to be out of danger (if this is the case) and not be excessively depressed or anxious to receive the full benefit of treatment. For instance, if their excessively low mood impedes their emotional, motivational and thinking abilities, then mood should be the first priority for improvement. Practically, two parameters present themselves above others when it comes to assessment. The two parameters combine to create four possibilities that need to be teased apart when clients first ask for help. What is crucial is the ability to reflect on psychological meanings concerning self and others. But sometimes it is a necessity that clients have low resistance, self-disclose and participate in any form of psychological help. It is possible to include by mistake those who are interested in having therapy, but for whom it is unsuitable. Altogether interviewing potential clients can find if referrals fall into one of these four categories. 1. The therapy offered is unsuitable for the psychological needs and abilities of the interviewees and they are uninterested in receiving the type of help that is being offered. If this is so, the prospect of having therapy needs to be called off and tactfully-worded reasons provided. 2. The therapy offered is unsuitable for their needs but the person is interested in having therapy. Interviewees need to be turned away and honest, tactfullystated reasons provided concerning why this is happening. 3. The therapy offered is suitable for their needs and abilities, but ultimately the interviewees are uninterested in having it because they are insufficiently interested or motivated for a variety of reasons. 4. Finally, there is the best case. The therapy offered is suitable for their needs and the potential clients are interested in it to the extent that they are willing and able to participate, despite the effort and drawbacks involved. The meaning of the term “suitable” means that clients are able to use the therapeutic approach being offered and it meets their needs, abilities and situation overall - including how much damage could befall them because of not being able to feel the emotions generated and understand the full consequences of their problem. The distinction concerns judging between someone who is entirely ready to start immediately, or being able to notice when someone is not yet ready to participate, and be able to pinpoint what needs to happen in the meantime. The term “interested” means that a proficient therapist of any orientation can motivate and inform clients to participate in a suitable treatment. To be “interested” is what happens when clients want help on a focus, and are able to provide the effort and bear the negative effects involved. Assessment can be inaccurate in that 256

Ian Rory Owen PhD it can be difficult to exclude those for whom there is no suitable approach, but who are interested in receiving benefit. What makes therapy suitable is a basic ability to become aware of problems, reflect and talk about intentional relations to objects of awareness and be able to employ the sense of what therapists say, in making sense of themselves and their situations. If persons who are unsuited and uninterested are sent by a third party who puts pressure on them to attend, then they are likely to be insufficiently motivated to attend even after assessment and they may not want to have their needs met by therapy. If so this is entirely their choice and their lack of motivation is a major impediment to progress. Key distinctions in being interested but having no suitable help are false beliefs about self, what therapy will entail and how it can help. If there is enough time, such false beliefs can be elicited during assessment, then those who have help suitable for them, but are not sufficiently interested, can be prepared for the therapy and come to want it and be able to work in it with realistic expectations. Persons who are interested, but have no suitable form of help, could have become mistakenly referred or self-referred through a variety of means. Persons can be identified as unsuited to having therapies (category 1, unsuited and uninterested, and category 2, unsuited but interested above) and can be screened to find if they are currently, or even permanently, unsuitable for specific types of help. What could be provided for them is self-help, guided reading or some other means of managing their problems including medication. This exclusion is not problematic, if it is agreed that for some people, therapy of any sort may only increase their distress and not provide them with any understanding, change of meaning or actual help. Therapy may be contra-indicated in cases where it would destabilise clients or involve a level of effort that they cannot sustain. Persons for whom there are suitable therapies, but who are uninterested in having them, by definition are reluctant to seek help. Perhaps, they do not see themselves as being able to have help at all. Such people are the unmet need in the general population who might only appear at assessment after third-party requests. They keep their disability and distress to themselves. The word “disability” is used to compare the varying amounts of impairment of home and work roles, due to psychological problems. For instance, mental health promotion and items in the media on psychological problems might awaken those who can use what is being offered, to the realisation that there is help available. Or they may prefer to continue with their own ways of managing their problems. If they do participate in the referral and assessment process, they may drop out of it by not attending assessment or first therapy sessions. Yet such persons would be capable of participating if they could commit to it as being worthwhile. That would mean their beliefs would have to become sufficiently different for them to see therapy as being something that they could work in. This case highlights the importance of motivational assessment and making increases in motivation and understanding the therapeutic process of 257

Talk, action and belief assessment. Persons who are suitable but uninterested to make the effort, may lack self-esteem or the ability to believe that they could change, and that may keep them from seeking help. The last category, of being capable of entering a suitable therapy and being interested in it includes those who can engage in a therapeutic process, leading to change. Such persons are willing to put in the time and effort and bear the hardship of selfdisclosure and are prepared to work for what they want. In sketching out the four categories of being suited and interested, I am not suggesting that these are clear and easy distinctions to make. Experienced therapists should be able to engage and motivate those who a less experienced worker might turn away. Yet there is the case of false optimism, where workers can take on those who are unsuited to what is being offered and cannot engage in it. There is research of the ability of therapists to assess, infer and use clinical judgement. Most of the papers claim that there are shortcomings and the tendency is to misconstrue the needs of clients in being overly optimistic of what they clients can achieve (Chapman and Chapman, 1969, Wiggins, 1973, Watts, 1980, Faust, 1986, Turk and Salovey, 1988, O’Donohue and Szymanski, 1994). It may only be possible to make the distinctions between the combinations of suitability and interest, according to what actually happens within a number of sessions.

Understanding risk If there is risk, self-harm or potential harm to others, then these matters should be dealt with according to the local legal situation, the rules of one’s employer and professional body. A crisis plan should be made for how to handle crises that might occur outside of the therapy hour. At assessment, it should be asked if clients are ready to begin to give up their self-harm (in the broadest possible sense of this term). In relation to making changes, sometimes it is necessary to have reached rock bottom in order to want to turn things around. “Hate something, change something” is the motto. 1. If there is risk to self and others, including the possibility of self-harm of any sort, or other major psychological crises (extreme emotional states, dissociation, etc), then these need to be addressed as a priority and resolved. For those who work outside of psychiatric and forensic settings, this may mean not starting therapy until these matters have been safely contained and addressed. 2. The aim of psychological therapy is to improve the quality of life of clients. This is enabling clients to be self-determining and become motivated to find their own direction and enjoy life more, no matter what their freedoms and constraints actually are. People who do not self-disclose are easily rejected, 258

Ian Rory Owen PhD and do not understand what sessions entail, are likely to have difficulty in using the opportunities offered them. 3. Clients are part of a wider social context and so aim 2 above means helping a person fulfil their potential by finding a social context (of family, home, friendships, play and work) that they feel they belong to and is right for them. This latter aim is usually part of the end-phase of therapy and may feature as the last stage in providing care to people who self-harm and are in severe and enduring distress. Some current self-harm, even if it is regular cutting and self-injury, can be successfully treated as can severe and enduring eating disorders and obsessivecompulsive disorder. The relational, cognitive and affective impairments that go with excess drug and alcohol usage are treated by agreeing a focus of reducing, or being abstinent from usage, prior to beginning any other focus apart from dealing with suicide and risk. People who have fully recovered from a psychosis may be able to participate in therapy, as even to some extent will some people who have wellmanaged residual psychotic experiences. A number of priorities shape the decision-making process overall. If the physical health of self or others is endangered through attack, self-harm or suicidal intent, then these need to be addressed as a matter of urgency. Self-harm can also be understood in a broad sense that includes the need for maintaining the bodily self and providing caring for self, as that person would care for others. If there is a current psychosis or transient psychotic experiences, then unless specialist cognitive therapy can be offered to deal with these experiences, then the person should be referred elsewhere. For instance, talking therapy should not be offered when clients are seriously suicidal, particularly when their self-harm and low self-esteem are active, and if they have a complex personal history. This is because even if social support is present, therapy is likely to increase temporarily their low self-esteem, regret and selfloathing. This happens by airing their thoughts in sessions which might damage the relationship and bring out their strong belief in their own worthlessness. The following are further factors that may increase the odds against any type of therapy coming to a successful close: where “successful” means being able to increase understanding and quality of life through alterations in understanding and behaviour. On the client side, the following tendencies may contribute towards a contra-indication for any therapy. Some reasons for not assessing include a current refusal to ask for help when feeling actively suicidal. Those who are actively suicidal with no social support and refuse to ask for help when intent is present, become subject to the law and need to be referred to emergency psychiatric services. Also people who are unwilling or unable to tolerate the pressures of ordinary living without drink or drugs, would not be psychologically available for therapy, because whenever they are distressed they will abuse their substance. If a person is using 259

Talk, action and belief drink and drugs to keep away thoughts and feelings, then the substance usage needs to be the first priority before working on any other matters. If clients are not willing to decrease their usage and the usage is defensive, then the possibility of change will be severely hampered to the extent that the side-effects of the substance will mask their thoughts and feelings. This is why substance usage itself needs to be an early priority for therapy before other matters can be addressed.

Personality and problems are a whole What needs to happen is that both personality (“axis II”) and psychological problems (“axis I”) need to be understood as a whole. Self-esteem, self-acceptance and mood need to be good and resistant to minor mishap. The general strategy of help is to lessen psychological pain, gain control over problems and work to eradicate or minimise them, if that is at all possible. If the particular problems concern the preferred patterns of living called the personality, then the aim would be to think more along the lines of the question “how could that person manage their lives given that they do not wish to change how they are?” Some details of the personality can be found by asking about the first 20 to 30 years of life in particular: Questions like “what was it like to grow up in your family?” are useful for eliciting information on childhood and opening up the personal history of clients for discussion. The personality reveals itself in questioning as the answer concerning all those parts and abilities of self that are the most long-standing. A leading assessment question is to ask potential clients to describe themselves. Wordings such as “how would you describe yourself?” Or “what sort of person are you?” would suffice, although others could be used. If there is no answer, difficulty or hesitancy in answering, or the answers elicited are of the sort that indicate the person does not know who they are, what they feel, or will not say who they are, or if they lead lives of chaos and excessively strong emotion, then interviewers should proceed with caution. Personality is shown by the consistent problems and abilities across a person’s lifespan. Given that there is no strict separation between the sense of self and the recurrent disorders that a person has, then answers to questions like “how were your twenties for you?” are telling in being able to spot if the person has been recurrently anxious and depressed, for instance, so much so that being anxious and depressed is a part of their personality because they have experienced it every year of their lives. The presence of any recurrent axis I disorders throughout every decade of the lifespan is sufficient to class these problems as part of personality as well. It is also necessary to tease apart the differences between the social influences of the family as opposed to the biological inheritance. One way of telling if a biological trait is present, when all the siblings have been sexually abused within the same family, is that if some of the siblings have made a recovery and are better 260

Ian Rory Owen PhD functioning than the interviewee, then there is some indication that perhaps a biological predisposition is present in addition to the trauma. If there is no risk of harm, then mental well-being and quality of life can be addressed. The process is to count the psychological disorders that a person has, as a first step in recognising their personality style, then finding out how well they are currently managing. A major distinction is identifying people who can understand their own needs but do nothing to help themselves - as opposed to those who cannot understand their own needs at all. The basic aim of any therapy would be to help people identify and own their needs and so facilitate them gaining satisfaction through their own efforts.

Contra-indications for assessment and therapy The contra-indications to therapy include all those ways that prevent there being clear work towards helpful goals. Some of the client factors that comprise unsuitability for help include the overall inter-action of multiple problems, low social support, the inability to tolerate frustration and distress, having unfeasible expectations about what therapy will entail and being unrealistic about the extent to which it can help. Some of the problems that indicate that therapy is unsuitable are excessive current self-harm and suicide risk without support and refusing it, current drink and drug abuse and being excessively demanding of instant help from therapists. If there have been several previous unproductive therapies, then it becomes more unlikely that any new therapy might be helpful. In this case careful questioning should elicit what happened in the previous attempts and that might decrease the suitability of new therapy. Persons who have fear about self-disclosure itself may not wish to go further when they realise that any type of therapy means telling the truth about what is problematic. Freud’s term “resistance” is accurate in describing those who are anxious in the face of self-disclosure and may have spent decades avoiding the consequences of their own predicament and on-going actions. Potential clients who are very high in resistance will have difficulty in attending assessment at all and might refuse to speak of their personal past, or if they do start speaking about it, what will happen is that their overall mood, functioning and self-esteem may crash and they might also cease attending and revert to self-harm, drink and drugs or some other maladaptive means of coping with how they think and feel about themselves. Another aspect of people who are resistant is that they tangle their helpers because they enter a helping process but prevent or doubt the very possibility of receiving help. With resistant and tangling persons, actual and foreseeable problems must be explored as a way of pre-empting and lessening negative effects. These issues can become an initial focus for assessment itself. People who are in chaos, who cannot bear ordinary negative emotion and frustrations, and who are so hopeless as to be actively suicidal, will not be helped by a further burden that works to expose their negativity before 261

Talk, action and belief it can provide help. Persons who have suicidal intent are excessively isolated, and refuse social support when their mood drops, are in danger and may need in-patient treatment first. Persons with fixed beliefs, who cannot believe that their beliefs will change, are not currently open to change. If they do not agree to work on their beliefs then they cannot be accepted for therapy. The following criteria also contraindicate therapy: •

Impulsive, extreme expression of feeling and actions congruent with strong negative or positive emotion: impulsiveness means an inability to contain the negative feeling, reflect on it, interpret it and choose to act in a helpful way.

•

Psychological mindedness and emotional intelligence are shown in the ability of people to have psychological discussions where intentions, beliefs, desires and the human condition are discussed in detail. This is the opposite of alexithymia. Alexithymia is the inability or refusal to feel emotions and the consequent inability to talk about them. Being alexthymic is shown when people have no ability to name what they feel, think or understand their own motivations and intentions. It excludes them from action therapy in particular and may exclude them from talking approaches also.

•

A haphazard conversational style, resistance, defensiveness, avoidance and alexithymia hinder the simplest expression of problems. People who are verbally unresponsive, those with current psychosis, Aspergers syndrome and autism should be referred to specialists in these areas. Clients need to be sufficiently well-organised to attend on a regular basis. A chaotic lifestyle means they cannot attend regularly and so the regular impetus for change will not be gained.

•

If there are major crises pending, such as redundancy, court appearances, imminent divorce and imminent death of a child or parent, these will make therapy with a specific focus more difficult to achieve through becoming side-tracked away from the agreed focus. It is reasonable to delay the start of sessions whilst any of these events is about to happen. If major negative life change happens during the series of meetings, then it should be dealt with. In either talk or action work, if there are too many crises, then this will detract from the total time to be spent in a fixed-time contract. Whilst crises cannot be avoided, they will disrupt a clear focus for the meetings.

However, some contra-indications for any therapy may include the following: Being unable to see the possibility of change towards a target, lack of commitment and being unwilling to look after self and say decrease inhibitions. Not coming to sessions regularly, not doing homework, not following boundaries for practice, and 262

Ian Rory Owen PhD having an excessively disjointed conversational style may all decrease the ability of a person to use therapy. Clients need to be not too depressed to take part in action interventions, because if they are unmotivated through depression, then the effort involved may be too hard and action therapy is guided self-help. What is required is a whole series of tasks, such as specifying which beliefs apply to which events and why. Some future findings from empirical research into psychopathology could specify how the past influences the present and state how psychological problems are maintained. If there is a history of incomplete previous therapies, a general inertia to change and an entrenched view of self and others, then these features may be contraindications for a successful outcome. Whether these indicators mean turning down any individual client is the responsibility of therapists to decide. To be over-optimistic means that people can be admitted who cannot be helped by what is being provided. This leads to a “no win” situation where clients’ hopes will be dashed and therapists will feel responsible. To be under-optimistic means wrongly turning away persons who could receive help. Those who are accepted and are initially interested, yet are ultimately incapable of using the opportunities offered them, need to be identified and discharged and reasons provided for stopping the treatment. When there is clearly no form of help for someone, that conclusion should be explained, if possible even at the referral stage. When more than one assessment appointment is being offered, then that may also indicate that the ability of therapy to help is limited. The reason for this is simply that if more than 90 minutes is required to understand the current problems, another 90 minutes for understanding the personal history of their intimate life and attachment relationships, and then a third 90 minutes for talking about what might be helpful, then this indicates complexity. Getting side-tracked and catering for clients who have special needs means that something unusual is happening. When therapists get caught in minutiae, forget the obvious, get side-tracked and lose track of what they are trying to do, there are problems that need attention. Dependent on the problems existent, the sort of help that can be provided should be made clear because therapy itself is not social work, financial aid, occupational guidance or a dating agency. People with psychosis and those recovering from it might be at higher risk of suicide and selfharm than other members of the population. It is better to close down the possibility of having therapy during the assessment phase itself, rather than beginning therapy only to abandon it later. The assessment phase should be brought to a close if during it clients become impaired in their functioning due to self-disclosure. This can only be ascertained between assessment appointments. On these occasions, catharsis has not been achieved and may have promoted worry or low self-esteem that lowers mood, for instance, and that is what impairs functioning.

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Talk, action and belief

Screening The term “screening” specifically refers to those situations where a further procedure is required to find out if talk or action is suitable for a particular person. Action therapy requires clients to act in more organised and scheduled ways and to fight their demons. The way that belief is common to talk and action interventions is omitted for the sake of simplicity. Talking and relating are more fundamental and once the therapy relationship has begun, its quality and the needs of clients need to be reviewed at every session, particularly during the first few meetings, to find out how the help provided is being received. Talking therapy has its strong points in being capable of addressing empathic, relationship- and emotion-focused problems. The modality of talk can easily address highly complex problems of family issues, the influences of past persons, identity, trauma and abuse because the largest part of the population can empathise, come to re-interpret themselves and what they think and feel, without other formal techniques. But the weakness of talking only is that it could end up being merely supportive and the opportunity is missed to provide highly specific changes to the maintenance of problems through the type of intervention that taking action can make. Beware of sudden strong feelings of any sort. Impulses to act, emotions towards clients that result in a sudden decision to end or begin meetings, or a decision not to respond to clients in one’s usual way, demand understanding. The way of understanding these feelings is to realise that they are reactions to clients based on their comments in highly-charged meetings. Altogether clients who are “pre-contemplative” (Prochaska and Diclemente, 1992) should be identified and motivated to work with the recommendations offered them, if that is at all possible. If some people are excessively pre-contemplative, that should be found during assessment. If they are too unmotivated and incapable of becoming so, for the uphill tasks that are being proposed, then they should not be offered therapy and turned towards some other form of help like medication or self-help. A contra-indication for talking therapy is not being able to process emotion and thought, and finding that spontaneous changes do not occur, even when the person is fully open and honest. This is an empirical or a posteriori characteristic that might be found between two assessment appointments or in interviewing about the events within previous therapies. One way to test for this is to ask clients to reflect on what they made of the previous therapy, or the previous assessment session, and realise that clients cannot feel helped by verbal expression of their problems and receiving helpful comments. Action therapy is a highly specific way of unpicking individual psychological disorders. If clients are unable to follow the actions for exposure and refuse to do behavioural experiments, then a talking therapy could be considered. If people are 264

Ian Rory Owen PhD very depressed, then encouraging them to be more physically active despite their low motivation is the most helpful intervention except in the case that they are too depressed and unmotivated to do this on a daily basis. If people cannot identify any thought or other triggers that bring on the depressive experience, then a diary will help. A contra-indication for action therapy is that people with a highly discursive style of presenting themselves can only take part with difficulty, as the flow of their speech needs to be halted and turn-taking occur. If action therapy is recommended, consent found and rationales for it given but the homework is not done, then it should be made clear that if the treatment of choice is not being followed, then something else will have to happen. If an action therapy approach is the only one recommended for achieving the focus of the therapy, then the meetings must be reviewed and might decrease or come to a close. In attempting to provide action therapy, those people who are too disorganised and unwilling to put in the effort and face fears over a long period of time, cannot take part in the self-help procedures. This situation needs to be elicited at assessment by asking for commitment or even setting up an early behavioural task during the assessment phase itself, to see what will happen. There is inaccuracy in assessment that can be corrected through extending the assessment process to include some introductory sessions. Assessment without therapy is possible when persons only want a professional opinion concerning the nature of their problems. The willingness to try interventions should be primarily ascertained at assessment, not during the therapy. Refusal to take part in an action therapy is different to an inability to get help from an intervention that has been tried. The motivation to use a therapy and the estimation of the ability of clients to use it, are part of assessing. Action therapy is preferable in most medium to severe cases, to create positive changes in the short-term. Talk therapy is better for complex problems that need a good deal of understanding. In such cases, it may be possible to move from an early use of talk to action interventions in the later meetings.

Turning down prospective clients When turning down prospective clients it should be made clear that it is the therapy that is insufficient to meet the needs of clients, rather than the other way round. Specific reasons should be stated in a face to face meeting and some plan for the future agreed. Turning someone down should be done face to face with some clearly understandable rationale as to why it is going to be unhelpful. The profession must realise its own limits in knowing when it cannot help and not raise unrealistic expectations. The overall aim is to produce a co-operative set of meetings where problems with the therapy are discussible. Brief therapy is potentially more directive than long-term, open-ended work and this is part of the skill of providing brief work. The aim is to resolve or produce a positive, quality of life change in the main focus, 265

Talk, action and belief or possibly in two or three adjacent topics in 16 to 25 sessions. In order to offer any type of help, there has to be some identifiable area that is capable of receiving change. If brief therapy is being offered, then the more specific the target, the better. In open-ended work, then there is more time to work through a client’s problems, one at a time. When listening to the material of the problems and personality style of clients, then it is necessary to think about the possible inter-relation between constellations of problems that come at the same time (and at other times they are not present). How persons progress through assessment phase and the early stage of therapy says a good deal about how well they can use the opportunity offered them. A modality of talk or action should be begun and only when clients respond (or fail to respond) is it possible to know if the modality used has been suitable. The order of addressing a series of problems is important. Because the ego is connected to the occurrence of a great deal of problems, then engaging the person in their own self-care is very helpful. One problem of practising is being incorrectly optimistic towards persons who are incapable of being helped by the techniques on offer. If therapy is begun that will later run aground, it would have been better not to have embarked on that course of action. The strategies for intervening are talk alone, action alone and mixtures of talk and action. The options include not having therapy of any sort. The problem of assessing for talk and action therapy is not the simple matching of a disorder to a type of therapy. To illegitimise Shakespeare’s Hamlet, when it comes to offering talk, action or both: “To cbt or not cbt is not the question”. When choices and tendencies to act have got the person into trouble with the law, or are contrary to commonsense, then they should be approached with interest and curiosity. What should be done is explaining why certain options are unsuitable for explicit reasons. What should happen during the assessment phase is that the boundaries of the meetings should be set including stating the means for cancellation and making it clear that there is room for disagreement. The reviewing of progress should happen in every session, even if very briefly, just to know how clients are at the end of each session. This can be a mini de-briefing at the end of each session. Defining the roles of both persons should be done in a brief way. This means that a lot happens during the assessment phase. One particularly important task is mentioning that the quality of care received by clients will be one of the subjects to be discussed. All these matters should be explained in a clear and concise fashion and possibly made clear in writing also. At assessment, people can be turned down by asking them what they think about the possibility of having help and if they feel that treatment is right for them. If the answer is positive, then one way of exploring how they feel is to ask them to explain how they think it will be helpful to them. If the therapist believes that therapy will be harmful or ineffective they should say so: “I don’t think this is

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Ian Rory Owen PhD right for you…” and state why this is the case, followed by what would be the best form of treatment or other strategy for care. The choice at the end of the assessment phase might be to meet again to continue the assessment if there has not been enough time to complete the procedure. Or to ask clients to think through if they would like to achieve and make a first therapy appointment. Problems with mood and self-esteem can be put back to clients as potential reasons for them to make some changes in their behaviour and re-evaluate how they believe and behave. Explicitly asking if clients are willing to participate in gaining some understanding of their problems and experimenting with new ways of doing things are part of gaining informed consent. If the answer is anything other than a clear “yes,” then the hesitancy should be explored. If the answer is a clear “no,” then therapy has been refused. The decision is whether to end the process after a further discussion of possibilities for therapy or recommend some means by which the person can manage their problem. If people have difficulty in accessing help, then just focusing on that is a topic for the assessment phase. Until that difficulty is clarified. Those persons who have no sufficient approach for them need to reflect on how to proceed with the assessor’s help. Referrers of those who are interested but have no suitable help may have not understood, nor had it explained to them, that taking a focus on problems might make clients feel exposed and vulnerable. If so, such experiences may make clients become uncommitted to working on their problems. Of least importance with regard to turning people down, is financial solvency and well-being for self and loved ones. As long as the person earns sufficiently, to maintain the most basic physical well-being, then there is not a financial problem. But if there are difficulties in keeping employment, running businesses, over-promotion or under-achievement, the financial uncertainty will be a factor concurrent with more serious problems.

Recommending help The skill of making recommendations for care lies in being able to judge what are the one or two most-pressing problems to be tackled first. Either choices are forced because of the danger of death, harm to self and harm to others - or attending the primary problem of low mood and poor self-esteem, or clients can be asked which problem they would like to start on. In cases where there is risk of harm to self or others, then not offering any other focus for the therapy, apart from dealing with risk until it is sufficiently reduced, enables a review to re-open discussion of what the next topic for sessions can be. This obviates the problem of starting on job problems, for instance, when a person is suicidally depressed and self-harming. It should also be noted that even if therapists have explained something of a potential problem that might occur through self-disclosure, such 267

Talk, action and belief as over-turning the trend of decades and working to create a new lifestyle, then that does not mean that it has been properly understood. Clients are not stupid or have poor memories but have fixed beliefs. Agreeing a focus for the meetings has the function of stating what the sessions will be about and makes an estimation of the scope and end-point of the meetings. The end of assessment is marked by therapist and client agreeing explicitly on what the focus of the meetings will be. The therapist should state what clients need to do in order to attain the goals in simple language and state any difficulties that can be envisaged even at this stage, according to recurring difficulties encountered by clients. Even the explicit question can be put, “are you willing try this despite the distress that it might cause you?” Once the first chosen topic has been sufficiently understood and formulated, then that topic is worked on until it is sufficiently achieved or another can be selected. What helps in talk and action is getting an agreed focus for a stated number of sessions. This is achieved by negotiating what the focus will be and then stating, for instance, that “eight sessions will be spent on depression and then we shall discuss our progress on it and see what to do next”. Explaining to clients what may best help them, what that will involve, and involving them in their treatment at the assessment stage, sets the scene for future meetings. If clients want time to think through a personal choice they have made then that is a good idea. It might well be advisable to ask them to think through their recommended type of treatment, so that they can be properly committed to it and its consequences. Otherwise, it is advisable to ask clients for their views on any proposed course of treatment. If they disagree or refuse treatment, then that is their choice and it must be honoured and not disputed. What makes therapy work is when the client’s needs and therapists’ desire to help meet in being able to supply the means of help. When therapists know what they are suggesting, and when specific procedures can be explained in a way that can be understood, so clients understand what interventions will feel like, then therapy makes sense. If clients get too depressed by talking without any other interventions, it is necessary to change to a problem-solving procedure. Part of assessment is case management which is what can be done if no improvements can be found through talk or action, or if there is risk and substance usage. A focus should be found and agreed during the assessment phase. Not having a focus can be over-come by the application of commonsense that begins with making a problem list. Such a list sets a shared agenda for the meetings because each item can be worked through. Whether an outcome is possible for a particular person really can only be estimated if they are fully on-board in wanting the change, are motivated for it and able to achieve it. If clients have reservations about the prospect of getting changes, then this is a fundamental problem that will impair progress and must be inquired into. What wins the day is having some idea of what the next move could be and how to get agreement with clients about how to proceed. Therapy works because therapists know they have something to offer and have confidence in being able to answer almost every personality, problem and novel situation.

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Ian Rory Owen PhD Any potential difficulties concerning treatment should be pre-empted if possible. The means of how to complain, ask questions and review what is happening should be clearly put in place during assessment. Although difficulties in the relationship cannot be entirely avoided, some pitfalls can be pre-empted. Some disappointments for clients can be avoided through careful preparation. Part of assessment should include putting pre-emptive comments in place, in terms of providing some positive motivation and information about some of the gains that can be expected from therapy. But it should also be mentioned that clients need to work on specific problems towards specific ends and apply effort. For instance, describing what it might actually feel like to participate in exposure work will let clients know to what effort and distress they are committing. When there is abuse, neglect and complexity, there should be a note of caution, that in some circumstances, there is little that can change. It is the therapist’s responsibility to lead, pre-empt problems, identify potential difficulties in the therapeutic relationship and even estimate the difficulty with which clients can change. This is to pre-empt problems and begin working with clients to solve those difficulties. It is the responsibility of clients to use what is being offered. Once work has begun it may include re-setting the definition of client and therapist roles and drawing the meetings to a close (if necessary). It is expected that it is possible to increase client motivation and understand blocks to progress. But having therapy can never have a guarantee of satisfaction. It is potentially preferable to pre-empt disappointment, rather than having a series of sessions that end in bitter recriminations. The role of clients needs stating, for talking and action therapies require different things from clients. This needs to be made clear for therapy to work. Primarily, clients need to self-disclose and speak out if anything about the side-effects, or their feelings about their therapist and the implication of his or her speech, manner and actions, need discussion. Assessment ends with some indication being made of the number of sessions that will be provided, be that 15 sessions for a specific problem or three years treatment for highly complex and pervasive problems. The length of sessions should be stated and their frequency. Questions about the treatment should be invited. The assessment phase can be brought to a close by asking clients that are accepted into therapy, if they have any questions and what they thought of the assessment.

Summary It is the purpose of assessment to include those who can use what is being offered and exclude those who are not likely to benefit and provide specific reasons for turning them down. From the first assessment meeting, therapists have a number of duties to provide basic information, set clients at their ease and help them feel safe. Some of the information provision can be done by creating a written handout. At the end of the first assessment meeting, therapists could use the last few minutes to summarise what has been agreed and what has not, and ask for 269

Talk, action and belief feedback and provide some also. The aim is to be a beacon of clarity and openness about the service that is being provided. Therapists should never make promises that cannot or will not be kept. If strategies employed by previous therapists have not worked, there is no point in trying them again unless a thorough interview has found out what went wrong with those previous attempts at help. The agreement on the initial focus for the first session should be a collaborative procedure and might refer to creating a formulation, an explanation of a specific problem of the client. When such a formulation is made, the client’s view of the explanation should be sought. Albert Ellis was right that the consequences of problems need to be born in mind for the connections across time to become more apparent (1962). Otherwise there is a lack of a temporal link between the self-triggered start of a problematic behaviour and the consequences that it brings. If there are unrealistic ambitions and aims, these should be found and put back to clients for self-interpretation. “What do you really think about that?” The most general strategy for therapy is a three-stage model of working out where clients are and where they need to go in order to make it clear how they could get there. Client and therapist roles should be explained on paper, if possible, or such information could be explained as necessary as the meetings progress. Psycho-education can be provided at any point without interfering in a talking therapy or action one. Finally, if no focus has been agreed, then the assessment process should continue until one is agreed or sessions should not be scheduled. Therapy outside of forensic settings should only occur through informed choice and without coercion. Therapy is offered on a provisional basis: clients are permitted treatment only if it is expected that they will benefit from what is offered and that they agree to participate in it. The provision of any therapy assumes that clients will be able to use the opportunity and obey some basic ground-rules. However, it is not a panacea and not everyone can take hold of its opportunities. Despite the above precautions, sometimes the provision of therapy will only be realised to be unsuitable, after it has begun. For some clients, only being in the therapy will help them know what it is like. This is the same for other types of relationship of course. It is a truism that both people have to stay together for them both to find out about the other person and themselves in relation to that other person. Chapter 15 provides an overview of the most basic aspects of treatment planning that will lead directly to accomplishments and successes. It discusses using talk and action interventions and making explicit choices to enjoy the rewards.

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15 Treatment planning Aim: This chapter develops ideas to support the provision of a mixture of talk and action interventions for clients whose needs and abilities are different. This chapter provides guidelines about how to make decisions with clients in providing talk and action interventions. Talking and relating are the media for delivering action therapy. Talking therapy refers to those situations where discussion is the only medium for change and sometimes no behavioural programmes are implemented. Talk is necessary to understand any psychological problem and personality combination. After detailed discussion and formulation, suitable actions become apparent. The treatment of belief and how to work with it is detailed in chapter 16. Working with belief can support talk and action interventions. The sequence below starts with considering the basic necessities of any theory for practice. Treatment planning is discussed before moving through the strengths and weaknesses of action and talk as modes of facilitating change. Therapists lead in recommending choices about treatment but decision-making involves clients. Sometimes the choices below can be thought through at assessment and therapy is not begun until the preparations for it are complete. Hopefully, people who are 271

Talk, action and belief unwilling or unable to work towards positive aims have already been identified at the assessment stage and not offered therapy. The decision-making process might be informed in the light that a previous attempt at one type of therapy (talking or action) had not been successful. Once the reason for this is ascertained, another sort of approach can be tried (action or talking).

Introduction to practice Choice-points are where major decisions are made concerning how to structure meetings: Agreeing the sequence of foci that and the means of addressing them. The major decision facing therapists concerns how to recommend treatment. Choice-points for clients need to be explained and discussed with them so that they understand what is being recommended to them and why. The treatments that are available are (1) talk only, (2) talk then action, and (3), action then talk. The possibility of (4), action only is rarer and there is the problematic situation of (5), that after starting the meetings, it appears that a person cannot be helped by therapy of any sort, either currently or possibly permanently. The progression of activities across the meetings moves from exploring and agreeing the central focus during the assessment phase. However, it is good to begin meetings at the focus as already agreed and to begin work on the first prioritised problem. Generally, once crises, risk and self-harm have been addressed, these enable clients to be in a safe place and be ready to work. The next step is to address specific “axis I” psychological disorders that are circumscribed, but co-influence each other and impair functioning, mood and self-esteem. A general starting point for therapy is to start working on poor functioning and mood, shame and low self-esteem, as these are frequently more accessible to change. The middle phase of therapy is dealing with interpersonal problems. Later phases and the ending phase can then deal with matters that are termed the “axis II” problems of the “personality disorders,” which is a pejorative term shrouded in mystery. The ending phase is always to round up the progress made in a formal way in writing (chapter 19). The shape of most sessions will be spending the first five to ten minutes meeting, checking on homework or changes by asking “how are you?” The answer provided may or may not be about the last session. It is part of the therapist role to motivate clients and help them decrease their ambivalence. But when clients say “no” to an intervention, then that is their answer. The following comments concern how to practice by using talk and action interventions. However, profound immediate changes in meaning and the senses of mood and self can occur when clients take action in their lives to promote or reduce various activities. Action therapy is precise and demands precise inputs from therapists. For some complex psychological problems, its precision does not fit the 272

Ian Rory Owen PhD complexity and inter-action between disorders and the un-clarity of the situations of clients. In other cases, precision of action is required. Action therapy refers to behaviour therapy but seen in a much wider scope. Taking action is part of generating meaning in contexts of various sorts. The overall process of making something positive happen with clients begins with asking about the details of what they want help with and formulating the salient points on a piece of paper, then asking for comments and inviting disagreement with what therapists recommend. After agreeing the formulation, it should be clear to what area it applies. The next step would be to get the aims of clients defined in a behavioural way: By defining what level of achievement they are attempting by specifying outcomes, hours spent and frequency of action. In this way, clients are consulted at every step, so they fully own the target and understand the self-care package. Even in the early days, it should be clear to them that they are working to achieve what they want. The role of therapist is spelling out the entailments of what clients will have to do in order to achieve their focus. Therapists should ask clients to be committed to daily homework and creating a number of targets that enable work towards their clear aims at their own pace. Therapy works by asking for commitment explicitly, and helping people become in-charge of their own recovery by passing on clear principles to them. When insight is achieved but no change is forthcoming, that is the place where the usefulness of talking therapy ends and where the explicit self-care role of the action therapy begins. Action therapy presumes the ability to work within the therapeutic relationship. In this situation, therapists interpret clients and there is even more of an explicit request for clients to be self-caring, in thought and behaviour, and engage in self-care interventions that are structured. Clients need to be committed to an active self-care programme that involves dropping old habits, values and beliefs - and expressing new ones. The nature of the change in action therapy is trying new actions, no matter what thoughts and feelings they have. Through sustained practice and commitment, change can occur: Emotions, thoughts and understanding, catch up later. This produces the on-going experience of progress. Later sessions can feature asking clients to set themselves their own homework or asking clients what it is that they want to work on as the next priority. The next five sections work through the pros and cons of various combinations of talk and action across treatment and within individual sessions.

Talk only Talking therapy is the practice for the speaking and relating skills of therapists, in relation to enabling changes in meaning and action. There are many possible interventions that therapists can make through discussion alone. The time when 273

Talk, action and belief talking only is most helpful is when the problems are very complex and may have never been voiced before. It is likely that talking about them for the first time produces a confused message and it is confusing for therapists to receive it. It may also be the case that those who are ambivalent in looking after themselves may find that through the therapeutic relationship, it is possible to re-evaluate their sense of self, through the respect and time offered them. One outcome gained by talking is “catharsis:” emotional expression and release through speech. The release felt is not of ‘stored unconscious emotion’ but is due to the fact of telling the story in the here and now that may never been told before. Some aspects of the story and its consequences may not have been aired. The previous lack of telling it leads to feeling emotion for the first time and partial understanding, simply because the story has never been properly told. Talk is most suitable for people who have a discursive style of presenting their problems or who may have complex problems of abuse and neglect and they want to discuss the impact of the past. Action therapy would not honour these complex problems because it would have to stop clients in their telling, time and again, to get the details of what was happening in order to help in a more interventionist way. Accordingly, when there are complex and all-pervasive problems that have never been voiced, the first imperative is to listen and understand through speech and relationship skills. The way in which therapists initiate a talking therapy influences how clients speak and receive help. Talking therapy can begin in two major ways. One way is to talk about anything, for any length of time, in free conversation. Another is to talk about a specific topic for a fixed number of sessions. It is best to agree a strategy at the assessment meeting and ask clients to prioritise one area that they want to focus on first. In times of crisis and self-harm, therapists should take the lead. But at other times, it might be clear to clients what they need to explore. Talking therapy means that what will be happening is discussion that has a focus and should lead to changes of understanding that will in due course lead to new action. When strong emotions are ‘caused’ by speaking and listening to conscious meanings and their implications, then just speaking and listening itself can be traumatising for clients and therapists. The process through which talking helps is that Freud’s discovery of the reframing power of speech means that adequate discussion of past events helps to process the meaning of the material afresh (1915e/1957, pp. 201-202). Even repetitive discussions, where clients start each session with the same question: “Why did he do that?” and each session was turned to just this question, can be of benefit. An indication for talking therapy is that complex problems concerning the past, plus interpretative and relational problems, are suitable for its wide scope. However, in order to participate, clients need to possess the ability to tolerate frustration, anxiety and other negative emotions and find worth in speaking

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Ian Rory Owen PhD and self-disclosing. The abilities to be psychologically-minded and emotionally intelligent are presupposed in talking therapy. In the negative, talking therapy may also be useful when clients have started on the path of action therapy but then found they that are insufficiently organised or motivated to take part in it, to achieve self-care and completion of the tasks and experiments. Persons who are unable to focus on a topic in meetings, and those who refuse, or are otherwise unable to do homework tasks, may find talking might be the only possible medium for change if medication is rejected. One case where therapists might ask that a specific topic should be explored is whether to stay or leave a partner in the case of current domestic violence. Another is discussing the developmental influence of childhood and its current effects on being able to understand, think and feel: The aim is to help adult clients protect themselves against harm. Still further conclusions are required on how general and specific speech acts can help, in which situations and why. However, what talking therapy presumes is that clients are willing and able to look after themselves and mend their own self-neglect and low levels of socialisation. This may be precisely the site of the problem for some people. The rewards that socialisation and adequate self-care bring must be sufficiently attractive to overcome the inability to value and think about self and the negative reinforcement of defences that prevent encountering the risk of negative experience. Robbie, a young man who had been taking cocaine remained paranoid many years after being drug-free. Through talking only, he came to realise that there were explanations for his fearfulness and suspicion. But Robbie refused to take part in behavioural experiments that could have further tested his belief that he was being watched and followed. Only through talking did he come to appreciate the reasons why he was paranoid. Robbie was also pervasively disappointed in others and only slowly did he come to feel better about people in general and re-evaluate his own cynicism. Robbie refused to do homework assignments that could have helped him and he would not write down his thoughts and feelings between sessions. But he was willing to discuss them openly in meetings. The conclusion is that some horses can be lead to water but not made to drink. Speech is a privileged medium of influence where clients choose what to say and when to say it. It has the promise of spontaneous changes in meaning that are brought about merely through discussion. Frequently, what happens for clients who are too unorganised, unprepared or unwilling to participate in action, could use talking and might get some benefit from it. The specific type of benefit received from talking is developing new senses of the previously preconscious objects, once these re-enter conscious discussion. Talking therapy can follow Freud’s basic rule to some degree, yet it has to be realised how client and therapist might wish to take the meetings towards their own interests. Talk may change psychological disorders as a by-product of new 275

Talk, action and belief understanding. Action therapies are very specific in comparison to talking therapy. They offer specific means for addressing specific problems. Talking is more suited to understanding the developmental accrual of problems. If a person has a specific problem but is unwilling to work on it practically, then they are unsuited to action therapy.

Talk and action in the same session Let us take an exemplary case of Guy, a middle aged man with generalised anxiety disorder who had a pervasive and enduring mood of anger that is the result of intense and sustained worry. Guy came from a violent and controlling home where his father showed him intolerable cruelty throughout childhood. The overall therapeutic process that unfolded was listening, receiving and honouring the story of his childhood and his current problems. Next, the therapist initiated a rational approach that consisted of breaking up larger problems into smaller, more manageable pieces. The therapist asked Guy to give himself advice on what he should do in order to be self-caring. This engaged Guy’s rational thinking. The intervention concerned the difference between useful problem-solving and planning; as opposed to hurtful and excessive worry that led to suicidal despair. The major intervention on worry was to ask Guy what he thought was a safe limit of worrying per day. He answered that one hour per day of worrying did not overly upset his mood. Guy set a 60 minute maximum of thinking about his problems that now included talking that thinking through to finding an answer. Guy applied this safe limit to himself and found that the pervasive sense of anger and remorse at his actions lessened. Guy was then encouraged to keep on with this intervention that he had designed for himself. In time, Guy forgot to worry and followed some new interests. The point of this example is that action and talk can fit together well in the same session and make good sense. Talk and action interventions were used in the same sessions with no confusion for Guy. He was able to explore his issues in discussion and plan to change his behaviour in the same sessions.

Talk then action across treatment As already noted, talk before action is suitable when there is a good deal of complexity and clients are unclear or may lack motivation to work towards a specific aim. There is the case where the views of clients have never been aired and so their perspectives have never received validation. After validation, there may be the clear motivation to self-care and problem-solve through action because emotions make sense and their influences are understood. 276

Ian Rory Owen PhD For instance, Paula was afraid of showing her needs for friendship for fear of appearing weak and vulnerable. But in meetings she was able to express her problems over the course of 15 weeks. After having adopted talk as the only modality of treatment, to understand her negative anticipations of what she would feel and how others would react, it was then possible for her to begin contacting people to check if her negative anticipations would be upheld. Specifically, talking produced clarity about her beliefs and anticipations. What Paula was sure would happen was that others would reject her request for friendship. She would feel utterly humiliated and hurt because she had showed her neediness. And Paula believed that other people generally did not like her, whatever she did. What happened was that with gentle encouragement only, she decided to meet people who she knew for lunch. This was not a behavioural programme but an activity that Paula wanted to do. It was not formalised in any way but was encouraged by the therapist. The intervention began with getting agreement on the nature of the problem, as noted above. The intervention for Paula was to contact people she knew by email in order to ask them out for lunch and so re-new and maintain the small number of acquaintances and friendships that she had. Further interventions then helped her enter new social arenas on a regular basis. The task was formalised with the therapist suggesting that Paula could carry out these plans and stay in contact with people long-enough to find out that they were generally interested in her. Because of her low self-esteem, it had been the case previously that Paula had left social gatherings early because she had convinced herself that people did not like her and she felt excessively needy and rejected, despite the actual interest that people had showed in her. The order of treatment progresses through talking to explore issues and understand the problems and was then followed by interventions that promoted new choices of behaviour.

Action then talk across treatment Action then talk is most suitable for those situations where thinking and discussing a topic will only increase the distress, anger and de-stabilising distress that a person feels. After some action has been taken, it may then be possible to introduce talking to explore new experiences, insights and changes received. But in the situation of suicidal intent and self-harm then, the talking should only begin once the person is out of danger. In the case of suicide, self-harm or where there is excessive depression and low self-esteem, action interventions have a great deal of effectiveness in raising mood (Dimidjian et al, 2006). Accordingly, action is the first priority when fear, depression, avoidance, suicide and self-harm are current.

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Talk, action and belief The next example concerns a woman in her fifties who had had severe early losses and had never had any prior psychological treatment. Katie came from a family where there was cause to think that there was a biological predisposition toward depression. However, in addition to suicidal thoughts and being severely depressed on starting therapy, Katie was also socially avoidant. She wanted to avoid her friends, family and not start a job she had been given. The intervention agreed was for Katie to make contact with others in necessary areas, no matter what she told herself or how she felt. This was because she told herself very negative things, that people thought badly of her and that she saw herself as completely useless and untalented. When Katie told herself these things she felt worthless and a social misfit. Katie went to her job and spent time with her friends, reluctantly at first. However, being involved with a new job and with people who cared about her had a spectacular effect on her mood and she went from being slowed down in speech, thought and movement, to an eager responsiveness to others in only two months. Once the intervention had worked, so that Katie’s mood rose, it then became possible to discuss her multiple bereavements and what it was like, for her and her family, to have been suicidally depressed. This latter part of the work was achieved through talk alone, where the goal was to explore and consider the perspectives of family members in her childhood. These complex discussions were only possible when her mood was good enough and she was out of danger. Her beliefs changed when she began to contemplate the impact of her childhood and adolescence and appreciate that the multiple losses she had suffered existed in addition to the probable existence of a biological tendency to become depressed.

Action only The key function of experimenting with new behaviours, and the complex changes that can occur through it, is worthy of a broad perspective on what behaviour is and does. The term “action therapy” is used in these pages to suggest a new, wider understanding of the role of taking action. Taking new action is particularly suited for those situations where talking, remembering and feeling the full meaning of what is discussed brings pain that leads to disorientation, loss of functioning and leaves clients over-whelmed by powerful emotion. Such experiences may be why they may have been reluctant to discuss these topics before, because discussion brings to consciousness what they have preferred to ignore. It can be the case that some people elect to have a talking therapy, but once it begins, the experience of it is less appealing than they had thought. In the negative, where the exploration of painful topics would trigger extreme distress and excessive rumination on problems and low mood, the over-coming of conditioning and implicit beliefs (such as breaking through fear and increasing the 278

Ian Rory Owen PhD toleration of impulses, boredom and discomfort) are the best reasons for taking action. Taking action means breaking the maintenance of problems and finding that objects can be experienced and understood in a new sense altogether. For instance, two cases where action only is effective is suicidal depression when there is current risk, and reducing obsessive-compulsive disorder. The reason that action is successful is that the exploration of the thoughts and feelings in both these examples is likely to create further distress in the sessions, without gaining any relief or providing the means of lessening the emotions involved. Let us consider two examples to make this tangible. Action therapy requires a change of understanding that produces a consequent change in behaviour that can be achieved through talking and deciding on the actions that produce change. Overall, the process of action therapy means knowing the same objects with a greater fluidity of sense, rather than just problematic senses. For instance, once it is really understood for clients that self is worth looking after, physically and psychologically, then there is no resistance to helping clients address their own self-care. (However, in the most severe cases of abuse and neglect, feeling good enough can take decades of the lifespan before it becomes manifest through therapy or life experience). The problem of being unable or unwilling to look after self can be explained metaphorically, as being prejudiced towards self. Or like being an extension of cleaning teeth and washing clothes. Like cleaning one’s teeth, people refuse extra problems and prevent ‘psychological tooth decay’ by doing something helpful for their mood on a daily basis. A series of choices arise concerning how to choose new intentional relations to objects of attention. For instance, once it is understood that there is a need to avoid creating a limited future for self, other matters such as a reduction in the use of tobacco and alcohol may also feature in a turn to health. Action therapy assumes the ability to feel, speak and discuss the same painful topic for a period of time, although the focus is not so heavily on the past. If clients refuse to think of the past, not only will they be unsuited for talk but they will also be unsuited for action. Action therapy means that the ego needs to take specific action. However, the types of action vary from choosing acceptance and mindfulness (Teasdale, 1999), acceptance and commitment therapy (Twohig and Hayes, 2008), and the radical acceptance of personal history (Linehan, 1993). Overall, the broad church of cognitive behavioural therapy urges understanding, problem-solving and self-help. The role of therapists is to help clients decide what action needs to be taken. They assist clients in gaining the skills necessary for their desired outcomes. Let us consider two more examples. Carl, a talented young man, is suicidal to the extent that he took a carving knife out of its drawer and placed it in front of himself while he considered whether to kill himself with it. This expression of how he felt about himself ignored the fact he had achieved enormously well in a number of artistic activities. The therapist 279

Talk, action and belief did not put his achievements back to him because Carl was convinced of his utter worthlessness. The intervention that was begun was increasing his physical activity in order to better his mood, and creating a means of decreasing his self-criticism, which provided some temporary relief from internalised voices of criticism and his habit of being overtly hostile to others. His hostile behaviour had become a part of him due to his upbringing that had been chaotic. When Carl was angry he was copying the model of his parents. It was standard behaviour inside his family to protest by shouting, smashing things and being violent. But such behaviour was unacceptable outside of it. When it was possible to interrupt self-criticism and enable him to focus on physical activities that made him feel good, then his mood began to shift. It was only then that he became properly able to engage in a written treatment plan to look after himself and break away from the disruptive influence of his childhood. Obsessive-compulsive disorder can be helped a great deal if clients fully adopt basic behavioural principles through fully understanding how they work. This may or may not require effort on the part of clients. Some cases of action therapy for obsessive-compulsive disorder gain rapid progress, whilst in other cases, the rewards gained only ever amount to slow progress. But problems of this type of worry and fear can be greatly reduced through listing the repetitive behaviours and working to reduce or extinguish them, one at a time, starting with the easiest. However, taking action demands that clients are fully on-board in their self-care because nobody else can make the changes for them. An indication for action therapy is that when classical conditioning and negative reinforcement are present, then clients should become sufficiently skilled in being able to self-treat. Accordingly, for successful action therapy, clients need to employ the precise principles that are necessary to gain benefit. As a contraindication, those who cannot or will not commit themselves to try out a new belief, and the behavioural targets that would bring positive change, will not find that the effort will be worth success. New thoughts and behaviours have to be enacted. A first step to act differently has to be made. Action therapy works only after action has been achieved, not in the absence of behavioural change.

Summary The therapeutic relationship begins when clients first contact the service, or the individual practitioner, and it ends when they leave for the last time. For many people, there is difficulty in being able to reflect and conceptualise themselves and this does not indicate gross pathology. The way forward is to understand self with respect to the social whole and the genuine peer group. Talk and action progress by having a clear agreed focus, clarity of roles and a basic responsiveness to client needs. Contrary to what some therapists think, 280

Ian Rory Owen PhD it is not confusing for clients to move from talking to action within the same meeting or across a series of meetings. Contrary to the ideal of free association in psychodynamics, it is sometimes more useful to have talks about something and towards the purpose of understanding something that is explicitly agreed and to have a number of sessions allocated for the task. In talking therapy, discussing a specific topic for an agreed length of time can help to structure the sessions. But it can be more difficult to specify and achieve change in talk only, than in action-focused meetings. Talking therapy is aided by having an agreed focus for discussions even though the topic of the discussion may change as it unfolds. Action therapy is helpful where there are suicidal thoughts and feelings, selfharm, anorexia, depression, poor functioning and low self-esteem. Action therapy works by having specific targets that are achievable in a sufficient amount of time. One strength of action therapy is its precision. The aims of the most general procedures of therapy can be stated simply. Therapists should help clients be motivated to take part in the work. A certain amount of self-control is part of good psychological health and this includes rational thinking in a way that soothes self; rather than adding to a panicky mood with uncontrolled impulses and catastrophic thinking that make the panic worse. Therapists should be unendingly patient, consistent, supportive, validatory and open to feedback. They should work tirelessly to support clients in knowing themselves and helping them make their own major decisions in life. “Ego integration” is one of the aims of the mid- to end-phase provision of care. It is most helpful in that it identifies the need to promote integration of disparate senses of self and others, and increase the sense of object-constancy and the meaningful cohesiveness of objects of attention.

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16 How to formulate and work with belief Aim: This chapter defines the bedrock of creating agreed formulations with clients so that awareness of the causes of problems is increased. Formulation helps design interventions that work towards desired goals and contribute towards perseverance in achieving them. The aim is to be precise about understanding the personalities and problems of clients in order to create suitable interventions. Accurate formulation lowers the risk of damage and dissatisfaction for clients. The focus for the intentionality model is on theory that relates to the experiences of clients. Bad theory and practice work entirely from preconceptions and disregard the experiences of individual clients. This is a dogmatic horror and means there is no point in asking clients anything because the answer is already known. Dogmatism comes in a number of forms. Some are entirely in favour of the evidence base, some for theory, some for grand ideas and values, and some for the idiosyncrasies of personal experience and preference.

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Talk, action and belief Here it is proposed that good practice has a wide base for justifying its actions. What the intentionality model espouses is a focus on work with individual clients through the exclusion of mis-information and mis-guidance. The aim is understanding the world as clients’ see it from their perspective (Husserl, 1962/1977b, §45, p 174). The role of theory is to map their problems and personalities accurately, with respect to their experiences. Any understandings gained by therapists are passed back to clients for them to comment on the understanding gained. The sequence for this chapter begins with how to understand psychopathology, followed by a further deepening attention to personality and problems, followed by a deeper look at the ideas of defence and functioning, then biopsychosocial causes are recapped. After this pre-amble, it is then possible to discuss formulation of the intentionalities in personality and psychological problems. For all personality and psychological problem constellations, there is uncertain or even unknown multifactorial biopsychosocial causality responsible. However, responsibility for selfcare and self-motivation towards the desired aims of clients is the core concern of the provision of therapy.

Introduction to interpreting psychopathology, defences and the primary mental health problem A number of writers have commented that the mainstream way of thinking about development and psychopathology is to include the possibilities of equifinality and multifinality for understanding developmental pathways (Institute of Medicine, 1989, National Advisory Mental Health Council, 1990, Richters, 1997). Since Gordon Allport (1960) there has been a tendency to eschew assumptions of a single, fixed occurrence in childhood that is responsible for the problems of adults. Currently, the terms “equifinality” and “multifinality” are used to express opposite possibilities. Equifinality is when many pathways lead to one developmental position. John Richters cautions that there is uncertainty as to how some pathways develop over the lifespan. Richters supports the view that there is no one-to-one causality in the development of psychological disorders. Multifinality occurs when many pathways lead away from a developmental position. Developmental psychology tends to prefer qualitative interviewing and other methods that view the individual in their context. Currently, there is no consensus on psychological cause. Nor indeed is there any consensus on the nature of psychopathology. So despite the lack of agreement in these areas, what is provided below is a means of focusing on belief in a pragmatic way. In short, psychological problems concern people jumping to conclusions about what to believe. For example, adults tell themselves “I am unlovable” because their parents 284

Ian Rory Owen PhD were unable to provide love when the person was a child. Although the belief that self is unlovable may not be true from the perspective of others. The consequences of the belief, when it is held for a long time, can determine large aspects of the lifespan and quality of life. Let us pick up the problems of assessment once more in the light of the lack of certainty in the profession. The remarks on belief so far do not provide a set of guidelines for good practice. The focus on belief needs to be set in an understanding of psychopathology. The discussion of “suitability” and “interest” in therapy in chapter 14, teases apart the differences among clients whose abilities and difficulties are different. Suitability for, and interest in therapy, is further compounded by the different abilities of clients to use different types of therapy, at different points in the lifespan. One writer on psychopathology is Joseph Zubin (1977) who provides an uncompromisingly bleak analysis: Persons either increase in the security of their relationships and their sense of ego constancy across the lifespan - or they do not. No matter what their early life trauma may have been, some people are able to increase their functioning and decrease their disability and distress, while others only deteriorate. Zubin goes further in postulating some factors that he thinks are at play. He makes the following four relevant distinctions: •

Axis I psychological disorders are episodic. They have an on/off quality in that they are triggered by certain circumstances and operate for a while, then go into abeyance without any professional intervention. Axis II problems of the personality are much more constant and enduring.

•

When under stress, a disorder or a number of disorders are triggered. The ego has an increased vulnerability during these episodes. The stress-vulnerability interpretation of psychopathology includes endogamous and exogamous factors in the biopsychosocial interpretation of cause and effect.

•

Clients with a high threshold for withstanding stressors are relatively securely attaching and self-regulating in their ego constancy. Even if these persons are not given therapy, after an episode of distress they are likely to return to a level of positive functioning, when the external trigger or stressor has gone.

•

But clients with a low threshold for withstanding stressors are insecurely attaching, have low ego constancy and have difficulty self-regulating. They exhibit a “hysteresis” effect because they may not return to being selfregulating after having been exposed to stress. They do not return to their previous level of higher functioning and deteriorate in their ability to cope with ordinary living. When people with psychological hysteresis are exposed to stress and disorders are triggered, one interpretation is that they maintain anxiety and the psychological problem as a way of coping with the stressor, 285

Talk, action and belief even after the threat has gone. When the “hysteresis” changes are permanent across the lifespan, it means that the person’s ability to cope with everyday life decreases and the good functioning of their personality also decreases. The term “hysteresis” arises in physics where certain materials and properties of materials irreversibly change after having been heated or otherwise altered. What I am referring to by using the term for understanding human development is that the accumulation of psychological disability in the personality can be irreversible and unresponsive to psychological help, and might be unresponsive to medication also. Or for people with hysteresis, therapy may even act as an extra stressor that promotes deterioration and prolongs their distress and disability. Zubin recommends “rehabilitation” for such persons (p 341) by which he means that therapy should be aimed at increasing their baseline ability to cope with life stress and the processes of psychological ageing. This is the management of psychological problems rather than their cure. What Zubin is claiming is that relapse, the recurrence of a new episode of the psychological disorder, is not the most salient factor. What he is postulating is that increases in hysteresis across the lifespan need to be identified as a major hazard to overall good functioning as part of personality. If persons are increasingly deteriorating in their functioning across the decades, then the focus for treatment is their primary mental health of their baseline ability to apply understanding, self-care and cope with everyday life: Their mood causes impairment in the role performance of carrying out everyday activities of the most basic sort. Because Zubin postulates personality factors as being at work, what he means is that a focus on cure and prevention of the recurrence of the problem is misplaced for those whose developmental pathway shows increasingly poor overall functioning. Zubin thinks the answer is self-care interventions that need to be practised to cope with the hysteresis effect (p 343). Zubin’s comments are accepted by the intentionality model and understood as the positing of a primary mental health problem: Regardless of personality disorder, trauma and brain damage, and once risk is taken care of in suicidal intent, self-harm and anorexia, if a person is functioning poorly due to low self-esteem, low mood and lack of self-acceptance, then these matters must be treated as a pragmatic priority before turning attention to any other topics. In this light, and to invent a new verb the current way that people ‘personality themselves’ and employ their axis I psychological problems are attempts to defend, protect, and gain relief and control. But the resulting personality and its problems, as well as providing benefit, provides negative consequences. Problems operate through inaccurate beliefs about how the psychological world exists. Clients make solutions that are overly-influenced by previous psychological situations. Their current attempts at solutions provide unwanted consequences as well as wanted satisfactions (such as the reduction of anxiety, the prevention of fear, 286

Ian Rory Owen PhD or avoidance of expected ridicule from others, etcetera etcetera). Free will and the ability to act show themselves when people reflect on the options open to them, consider their alternatives and maintain their unhappiness. Self-reflection demands interpretation that requires understanding self, one’s unmet needs, and estimating the ability to gain satisfactions, and the practicalities of achieving such satisfactions. Such costs add up. Overall, the expenditure of effort required exists in comparison to whether it is better to stay the same. Clients frequently overestimate the ‘cost’ of changing and so opt for staying the same with all the negative consequences that it brings them. Most often, psychological problems occur because there is a clash between short-term needs to manage anxiety or protect self - that are in opposition to longterm needs. For instance, if people choose a short-term means of getting relaxation through alcohol consumption (that actually incurs longer-term problems of increases in anxiety, lower mood, poor sleep and other knock-on effects), then there is a clash between short-term and long-term aims. When people are distressed, it feels to them that they are at the beck and call of their own emotions and exhaustion. But that focus discounts their own activity in having chosen a lifestyle and a means of coping defensively that makes their mood out of balance and genuine satisfactions out of reach. The types of risks that people defend against are sometimes called “internal” or “external,” although this distinction is false in the wider view of the intentionality model. External risks are about other people, externally ‘caused’ psychological disappointments and frustrations. Internal risks are all forms of worry and self-generated bad feelings, thoughts and visual images that have strong negative emotions associated with them. If risks were acted on without understanding, they might well have negative consequences for self and others. So there is a connection between internal psychological processes and the estimation of external risk. The general function of defences is that an actual or potential threatening experience is blocked and replaced with an immediately less threatening one that provides short-term relief. The pattern is that one type of intentional relation to one type of object of attention is replaced with another. Thus, internal threat, a negative mood or negative emotion could be distracted by work, busy action, dissociation, repression or other means. Anticipated or actual decreases in selfesteem could be blocked this way. Or self-esteem and angry pre-emptive attacks could arise to manipulate, accuse or otherwise attack mis-attributions of the cause of the sensitivity in self. The consequences might be actions towards others that are unwarranted, or avoidance because of what is anticipated to be about to happen, or interpreted to be happening. The extent of the defensive beliefs that operate explicitly or implicitly is such that they can be as strong as delusions and perceptual illusions concerning what is or has happened in that the experiences

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Talk, action and belief of the defensive person might bear no relation to that of others who are in direct contact with that person and their situation. There is an anonymous saying that “coping is wisdom”. In terms of believing, feeling and acting, one’s beliefs should reflect psychological reality and permit the gaining of proper satisfactions. But beliefs should reflect when and how there might be real dangers that need to be avoided or dealt with when they actually occur. The ego is the place of choice and control and needs to provide monitoring and flexible feedback on the way towards clear personal and mutual goals. In everyday living, goals are things like staying in work, looking after children, seeing friends, and staying satisfied and happy with one’s partner. What this means is that when troubles arise, there is than an on-going ability to adjust one’s own course, soothe self and others, and take sufficient rest in order to be able to function properly, no matter what has happened in childhood and no matter what is about to happen currently. The evidence of what works and what does not is social in that it is able to be mutually experienced and that the views and experience of those around self are relevant in working out how to proceed. Ordinary living entails problems of roles, personal and shared responsibilities, conflict, social obligations, plus lack of agreement and discussion. Self-care and care to others is possible through understanding and over-coming temporary distress. Psychological absence, lack of self-care and abdication of responsibility - all worsen current problems. The received wisdom of what are probable and improbable causes of specific effects for clients will continue to alter before the human genome project has reached a conclusion on the biological nature of the basis for personality. ‘Causes’ are psychologically interpreted. They are not observed in a value-free way. How choices and events lead to a developmental position for clients is a matter of weighing the evidence for and against possibilities. In other cases of movement into the future, there can be diversity, change and growth. These are the vexed questions of equifinality and multifinality in psychopathology and understand the personality (Richters, 1997, pp. 205-207) and they need further certainty.

Understanding personality and problems as a whole In order to understand what the personality is, and become able to help with longstanding problems of personality or self, there is the necessity of understanding that the ego is involved in its own self-care and the production of its own quality of life, whether it knows it or not. If the ego does no work on its own self-care and rejects the positive influences around itself, and fails to recognise itself as the source of its own achievements and its on-going ability to achieve, then there will be difficulty experiencing quality of life. The circular nature of cause and effect exists in difficulty in acting and being motivated to look after self that connects 288

Ian Rory Owen PhD with what is produced through that difficulty - be that worry, rumination or poor personality functioning. Formulation on paper is a formal way of discussing and understanding cause and effect reasoning, so that people can reflect on their own actions and choices and take the opportunity to regain balance, because the ego may be an actor in its own down-fall. The low mood produced, for instance, may be a further difficulty in becoming motivated. So in order to understand personality problems and their psychological consequences, it is necessary to focus on what enables clients to understand and change themselves rather than anything else. Personality problems include those aspects where there are inaccurate beliefs about self and others that have been mistakenly accepted and generalised, long after they should have been abandoned. For the intentionality model, any whole experience about an object is comprised of many senses. These individual senses are in-part emotional and may concern internal dialogue and the relationships with self and others. In the same way that changes for the worse have multiple effects – changes for the better have multiple knock-on effects across a number of areas – not just the first occurrence of an idea and an immediate change in emotion. Increases in liveliness and the return of humour, the ability to tolerate discomfort and temporary low self-esteem go hand in hand with decreases in worry and anxiety. In order to get leverage, there is the necessity of clients being willing to examine their own choices in personality-ing themselves, then making a leap into the unknown at some point. Increasing awareness of the problem can be achieved in a number of ways. For instance, one way is to ask clients to time themselves each time a problem occurs, to find out for how long it happens. This leads to choosing to reduce the length of the problem, through interrupting it midway or at its outset. Given that the total causes of emotional distress are biopsychosocial, despite this, personality problems can be treated as defences that make an unhelpful equilibrium. Like all problems, the overly-defended personality attempts to re-create solutions from the past. But in the present, there are both positive and negative consequences. Let us take a specific type of personality problem. Amanda is ashamed of herself. She has continual low self-esteem and she feels empty despite being in a job she likes and with her husband and baby son whom she loves. The low self-esteem and emptiness have lasted for decades despite there being many significant achievements including raising a family and becoming qualified and proficient in a highly demanding and skilled profession. The problem of the on-going emptiness of the self is that there is a lack of contact between the sense of self and the abundant evidence of its achievements. The answer is reflection on achievements to date and the proper interpretation of them as significant, valued and belonging to self as the just rewards for actions, decisions and reflecting the positive qualities of self. Once this lack was over289

Talk, action and belief turned through forced contemplation through a week’s retreat, Amanda’s sense of self became revitalised as fulfilled, active and engaged. Amanda then understood herself as the source of her own accomplishments in terms of a life of struggling with adversity without proper support. The problem of her low self-esteem and emptiness was then seen as persistence from her childhood of the senses where she had never been able to feel good about her own achievements. When there has been no solution to personality problems, what can help are life management and the ability to maintain mood, self-acceptance and selfesteem, if nothing else. In conclusion of this section, the self-care necessary for helping with the problems of personality are no different to any other technique to deal with axis I disorders. Some of the key points are: 1. Attending to the primary mental health problem of poor overall functioning, poor mood and low self-esteem is a priority. Increasing self-acceptance at an emotional level improves self-esteem and mood. Sometimes this can be best achieved indirectly through wholly logical, rational and behavioural changes at first and then emotional changes follow suit. 2. Enabling clients to express themselves and find their niche in life, whether that is in a social context or in the active choice to be alone and become a hermit. 3. Helping clients be co-operative and be neither excessively submissive nor dominant. 4. Helping clients get sufficient contact with other people, where self-esteem can be experienced through social contact. 5. Whatever the long-standing problem, the first task is to achieve a neutral selfesteem. The ability to rate self accurately with others is useful and necessary. A minimum requirement of the relationship to self is to understand how the self is with itself. This can be done by taking a time where there has been an enforced isolation such as being stuck in a foreign airport with no money, a week alone in a strange town, or some such, and asking open questions about what it was like for the client to be with self.

On functioning: From defence to coping Functional analysis, the form of functioning and the level of the capability to cope with ordinary living, concern defences that have both positive intentions and consequences (in terms of self-defence and protection) - but because of their overuse they inevitably limit the person and entail problems and negative consequences. Most often, the positive intent is to stave off fear, prevent disappointment or some other ‘failure’. Defensive coping is an attempt at wisdom. It is important to note that precisely the same behaviour in one person can have a completely different 290

Ian Rory Owen PhD meaning and function in another, according to what is happening overall for each person. Understanding psychological functioning means understanding specific cases of defence, coping and managing anxiety - or other strong negative emotion and experience. But it has to be understood that there are different types of function and different types of anxiety, in the overall relation of maintaining a specific psychosocial status quo. In these pages, defensive anxiety has the purpose of preparing for any threat or eventuality. However, a vicious circle arises when the anxiety that is part of being ready for any eventuality, becomes a reason for limiting one’s exposure to the feared object or situation. What this means is that there are different roles that anxiety plays with respect to attachment relationships and situations of specific sorts. The topic of psychological functioning really refers to the alteration of strong negative emotion and unpleasant anxiety-provoking experiences and situations, in an attempt to reduce or avoid the feelings. But often these negative reinforcement attempts only produce short-term relief and lead to further negative consequences. Let us take a sexual example to show the differences. Specific actions have different functions according to what role an action has in managing emotions, identity, mood and other aspects of the conditions of possibility for any given state of affairs. For instance, masturbation can have a number of functions depending on how it is used and in what context it arises with respect to the person’s aims. Given that a person wants a partner and they are single, but is defensively avoidant, then if masturbation is the exclusive form of sexual expression in the absence of attachment relationships, then it is problematic because chances to become attached and find sexual satisfaction with another are wasted. Masturbation is dysfunctional in this case because it is incongruent with having a sexual attachment relationship and because self-satisfaction is chosen as the only means of sexual expression. Masturbation and being single or in a relationship is not functionally bad. As long as the person is clear that he or she does not wish to be in a relationship then masturbation is not functionally bad. If the motivating force to masturbate is unnecessary fear at getting hurt through intimacy, then it functions as an attempt to create personal satisfaction without ever engaging in mutual satisfaction as part of a loving relationship, where positive emotions and the ability to enjoy another person’s company can occur. Masturbation is self-pleasure within or outside of an attachment relationship, and a part of bodily pleasure. If it is part of a paraphilia within an attachment relationship, then it is also acceptable. But if masturbation is the only means of sexual expression within loving and sexual relationships, then it is problematic because it is a fixed manner of expression. Masturbation could have a number of different functions and be used defensively and pathologically, as well as being part of relating, depending on the 291

Talk, action and belief overall context in which it occurs. A defensive function of masturbation would be masturbating over the self ’s own image of being loved and adored and that would be narcissistic, specifically in the context of re-living anxiety and distress, or as a means of uniting the sense of self around a repetitive negative reinforcement, a masturbatory ritual of some kind. If masturbation is used to decrease anxiety, increase the value of the sense of self and self-soothe, then it may not be functional. Because taking action to decrease the source of anxiety, increase the sense of self and strengthen self-identity through some other means might be more effective. However, the realm of sexual pleasure includes a wide range of fantasy and the imaginative self-pleasure of merely thinking about possible sexual escapades (Kahr, 2007). So masturbation to orgasm as part of sexual fantasy can be an ordinary part of sexuality and personality or it could serve an unnecessarily defensive function and prevent the formation of attachment relationships and the proper satisfaction that they would bring. Let us consider the example of PTSD in childhood. The problem with PTSD is that the ability of traumatised children to seek help is poor, particularly if their verbal skills are not fully developed. If they are too young to express themselves and understand their feelings, then there will be the non-verbal expression of distress, rather than the beginnings of making sense of it through speech. Also, the future developmental pathway for traumatised children will be different to their peers who may react towards them in uncharitable ways. For instance, psychological function is clear in the following example. Odile was traumatised as a child and sweated a great deal through fear. The other children at school called her “smelly” and refused to sit next to her. The developmental pathway for anyone with PTSD is altered in the direction of having multiple anxiety disorders. This is the case for adults and children. Yet for children there are further problematic consequences from having obsessive compulsive disorder, phobias, attachment difficulties and health anxiety because of the damage that these problems cause in restricting the lifestyle at an early age - as opposed to sufficient socialisation where children develop through turn-taking, co-operation, competition and play. Strongly anxious, insecure and avoidant children will not experience the joys and frustrations of everyday living. So by the time they enter their twenties, they will be missing preparatory experiences that would help them deal with the stresses of ordinary adult life. However, all of Odile’s problems were so long-lasting and engrained in her, that by herself, she was unable to separate herself from these attempts at solutions about how she believed and anticipated the emotional world would be. It was not until her mid-forties that she realised what had been happening for her. Her whole life had been a struggle for her. Her marriages were born of low self-esteem. Her drug taking and alcoholism were attempts at selfmedication in order to have some brief respite. Her personality and psychological problems were forms of coping that had a price. 292

Ian Rory Owen PhD Before going to the major topic of this chapter of formulating personality and problems as a whole, what the next three sections provide is a clarification of cause.

Recap: The differences between natural cause and psychological ‘cause’ When it comes to understanding what happens when anyone understands a psychological situation, it has to be understood that making sense psychologically melds with natural cause. The two are not the same. Therapists can keep separate the theoretical beliefs that they hold about how they make sense of clients and ask open questions about which intentionalities create which aspects of personality and its problems. The method of doing this is to ask open questions about the order of events that clients experience (details below). Depending on what influences are existent in any case, the most basic way of making sense is to add sense to what is experientially present. This is the most basic connection between a psychological meaning and an identifiable perception in consciousness as current, remembered or anticipated, for instance. On the other hand, the ‘causes’ or functions of a defence, for instance, might be multiple. There might be a current deficit of some sort where the personality and psychological problems function in such a way to maintain the fear of others, for instance. There might be a developmental deficit that might be influential in that a person who never experienced frustration as a child has no means of containing such feelings as an adult. There might be conflict between different parts of self, in that there are short- and long-term needs in opposition. Thus, to pick up and answer the research question broached at the top of the chapter, the difference between meaning and cause is that the perspective of meaning is more fundamental, whereas psychosocial ‘cause’ is higher and dependent on the more fundamental. Or phrased differently, people do things because of conscious meanings that have a personal and social, on-set and maintenance. Trying to promote change and reduce suffering is complex because the interpretation of psychological ‘cause’ overlaps with the hermeneutic stance taken: Psychological events cannot be ‘caused’ by a single universal occurrence in the past. (This is not the same as stating that meanings exist on their own without ‘causes’). The point is that generalised beliefs about ‘causes’ in childhood can never have explicit evidence, but can only be an interpretation that concludes on the evidence. In some cases, the evidence of memory may be false. Similarly, causal hypotheses concerning the traumatisation of adults can never be tested empirically. There are two further influences to be taken into account. There is egoic ‘cause’ as habit, mixed with intersubjective ‘cause’ as a further influence on 293

Talk, action and belief meaning. These two aspects are mixed together in a way that makes it difficult to tease them apart. When it is acknowledged that cause and ‘cause’ co-occur, there are no clear distinctions and there is reversibility in some instances, mutual influence within the reciprocal whole of ‘cause’ and effect. However, it is untrue to claim that emotions and relationships are wholly ‘caused’ by belief because of the on-going inter-actions between the three parts of the biopsychosocial whole. Indeed, even if there is substantial natural cause occurring for a specific person that produces personal psychological effects that in-turn influences the creation a social context of a specific sort.

Natural cause The biopsychosocial perspective reminds us that the talking and action therapies are not grounded entirely within the scope of natural cause. Natural cause is irreversible specific cause. The effect of natural cause has no counter-effect on itself. There is irreversibility of effect. This is not the case for most types of personality and psychological problem. Psychological ‘causes’ concern reversible non-specific ‘causes,’ meaningful influences and motivations. But psychological effects can increase causes and sometimes effects can be undone through a variety of means including choice, action and new understanding. Natural cause is the irreversible biological cause of genetic inheritance that appears in physical tendencies to have a specific sort of personality and specific sorts of psychological problem. Natural cause can be seen when people become depressed for no identifiable psychological ‘cause’ in their lives. If a person becomes depressed when there is no self-generated sense of loss, and no loss in the current context, then it is likely that the person has an inherited tendency to depression. Particularly, if the person has many blood relatives who also have had similar depressions in similar psychosocially unexplained circumstances. Biological traits are an entirely natural inherited tendency to be conscientious (for instance) or to have a sexual orientation or gender identity. Psychological problems might arise as the consequence of material damage to the brain or the physical structure of the body in the physiological ability to deal with stress, for example. In the sphere of nurture, there are the meaningful events within smaller and wider spheres of influence. Starting with the smallest sphere of personal choice and action, there is the sphere of family attachment figures. Wider still, there is the culture of persons who are known, then the wider sphere of persons who may not be known but who are still influential. Finally, there are the widest spheres of society, international life and history. Habits exist due to complex mixtures of causes from biological traits that connect with repetitions and rewards, so that any inertia to change is motivated by the ease of repetition of what is already known and ‘mastered’ – as opposed to taking the risk to change 294

Ian Rory Owen PhD and do something new. The difficulty in embarking on the new arouses fear. The fear is ‘successfully’ avoided by choosing to stay the same and over-estimating the difficulty involved in changing.

Psychological ‘cause’ ‘Cause’ or motivation is a learned association by pairing that persists across time and has a current influence. This is a psychological explanation concerning ideas of motivation (Husserl, 1952/1989, §§54-61) or “allure,” a translation of the German word Reiz (Husserl, 1966/2001, §32, p 196). Without the distinction between psychological and natural causality, there is conflation and inability to judge where one sort of cause applies rather than another. Natural causality in the psychological region refers to inferences about natural or material being (Husserl, 1962/1977b, §1, pp. 4-5). Meaningfulness concerns making sense due to being in a meaningful context and understanding a part within its relevant whole. Psychological ‘causes’ are weak and not natural causes by irreversible necessity of the current material conditions like heat, pressure, temperature or chemicals. Human beings are sentient creatures and can choose to act in a number of ways, at any given juncture, because of the beliefs, meanings and values that they interpret. For some, linguistic thought seems to drive emotion, in that specific painful emotions arise because clients have been ruminating on some topic for three or four hours without pause. For others, if they feel one way, then that is the truth about them as a person: their emotion is the sole evidence required to conclude that they are unacceptable to others, for instance. Others still, create visual images then tell themselves something that creates emotion. Or they see an external object then feel emotion. There are other combinations. Psychological cause concerns associations of meaning across time and social context. The psychosocial aspects of personality and its management are defensive and might be due to trauma or the pre-emptive ability to fend off anticipated problems, or due to a lack of sense of self – thus becoming excessively specialised in one area of living and abandoning other aspects and needs of self. When persons are considered as a whole, what is most pertinent is how to re-establish good outcomes for positive functioning, self-esteem and mood expressed in congruent action. Good quality of life can only be achieved by the ego taking full responsibility for its own well-being, giving up unhelpful choices and finding sources of genuine satisfaction. Having recapped the co-occurrence of the two types of cause that are open to intervention, it is now possible to begin the detail of formulating the intentionalities involved in a variety of basic situations of practice.

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Formulation is interpretation Formulation has the purpose of identifying a small number of key psychological processes, causes and meanings in a way that is understood by clients and provides a rationale for meetings. Formulation need not identify every possible cause and meaning but should identify those that are crucial to get change. Formulation is creating a simple hypothesis about ‘causative’ meanings and processes that act to produce specific portions of problematic experience. Let us start with a concrete example right away. For Odile, gathering the details of the different types of experience and checking the progression through them, showed the series of events were anger at self, then the expression of the deeply held conviction “I cannot cope,” and the forthcoming action was an attempt at suicide. In her case there was a movement from emotion to belief to action. It is only when the overall process is interpreted and clearly stated back to clients that it is possible to design interventions. Formulation has its worth as the key for organising the mutual work of client and therapist roles and creating positive value for both persons. Formulations that concern intentionality require a flexible system that makes key distinctions and understands its own assumptions without being dogmatic. Such a system should attend to the unique occurrence, whilst employing general interpretative rules for understanding psychological problems. But it is important not to confuse theory with what is happening for clients. Particularly, it is better to be confused or unclear about what is happening for them, as opposed to being certain that a favourite view applies in a situation where it does not. The best way to maintain accuracy is for therapists to explain how they make sense of situations, and invite clients to disagree and respond, or to invite them to speak about their own explanation of their problems. Interpretation of the problem prior to action itself alters the meaning of the problem, to make it something that clients can feel able to alter. The interpretation of explaining operant conditioning and negative reinforcement is that it makes problems amenable to change. It supplies hope and puts the problem into a completely different perspective. When the new actions are carried out, and changes in emotion are experienced, then what is discovered are more dependable, open relations to new senses of the same referent. Because beliefs can be simply phrased, they can form a general statement of aims that clients can easily remember. Changing belief can usher in new events into people’s lives. Treating beliefs as causative is a way of helping clients act in their own favour. Stating explicit beliefs and their consequences enlists clients in their own self-care, when it is clear that they are being encouraged to fight these beliefs and see them as the problem. The guiding principle is that once clients’ experiences have been grasped ‘as they exist for clients’ and put back to them and discussed, can it be concluded 296

Ian Rory Owen PhD that the formulation is anywhere near what they experience. Accordingly, the only legitimate formulations in the intentionality model are idiosyncratic ones. However, because they also serve a pragmatic function of highlighting a small number of specific aspects of a problem, then the way they are presented, on paper or verbally, should bear in mind the order of what needs to change first. Some examples of written formulations are presented below. The general aim would be to formulate important problems such as suicidal thoughts, self-harm or starvation in anorexia as a priority and ask clients to be committed to working against these problems at assessment. Therapists can formulate first and ask clients to disagree if they wish. In the case of behaviours that seem to have no current positive purpose, it might be the case that when the behaviours began, they did serve a positive purpose at that time.

Original on-set In general, the lived sense of self co-exists between the anticipated future, the current context, the current behaviours and the influence of the past. There are possible biological causes and traits acting on the whole of the personality and the problems. Because it is impossible to currently identify the precise amount of influence in any particular case, apart from noting that personality disorders and psychoses can sometimes be genetically inherited, then the felt-sense of self can be understood as being in a dynamic interplay between the shadowy forces of the biological, the psychological and the social. Let us bring together what has already been noted about the biopsychosocial view and produce a first minimalistic formulation diagram. Beliefs in early life are likely to be implicit non-verbal conditioned senses due to early socialisation plus the effects of biological traits. ↓ ↑ Inaccurate beliefs are first produced by the child’s interpretation plus the influence of adults. These lead to inaccurate interpretations, assumptions and attempts at coping that contribute to forming the personality and psychological problems. ↓ ↑ Maintenance of the forming personality style and psychosocial problems of inaccurate experience in the current adult psychosocial context, promote further reflection and negative interpretation after the fact. Figure 15 - A biopsychosocial interpretation of the relation between an originating context and the current context.

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Talk, action and belief What figure 15 explains are the links between the important aspects of the biological, the psychological and the social, in a developmental perspective. Although there are biological factors involved, those may be more influential in childhood (Plomin et al, 2000). The early psychosocial situation is that the child is dependent on the actions of its carers. Research shows that the actions towards the child are influential in producing childish reflection and the type of nonverbal understanding of specific attachment relationships with its carers (Pfohl, Jimerson and Lazarus, 2002). The child’s reflections and experiences can be taken forward unchallenged and can become explicit beliefs about themselves, if they are old enough to speak. It is also the case that implicit valuing may happen at non-verbal levels for those children who self-harm and are aggressive towards other children, for instance. Formulation diagrams are a means of discussing and agreeing cause and effect, so that both parties are singing from the same song-sheet. The diagrams are initiated by therapists and handed to clients for them to check and agree or disagree. The tasks of thinking and understanding problems can be begun in sessions and carried on by clients when they go home or in discussion with their partner or close friends, if possible. In the above, the arrows signify influence from one aspect to another. The therapists’ manner of interpretation co-influences clients who are interpreted as responding to therapists’ influences on them - and vice versa – in an inter-action that is going on.

Developmental formulation Overall, developmental cause means the biopsychosocial perspective: The multifactorial total of causes is an inter-action between the natural-material, the ego and the social environment that moves across the lifespan. Let us stay close to the phenomena concerning damage to children, before moving to theoretical considerations. Below figure 16 is a second general formulation diagram that can be used to structure detailed discussions concerning what have been the influences on the current sense of self and current problems. Early experience ↓ Conditions of cause for being good and bad, accepted or imposed by others ↓ (Repeat the step above as necessary for infancy, childhood, adolescence, early adulthood and mid-life etcetera). Current triggers for current problems 298

Ian Rory Owen PhD ↓ Resulting problematic experiences and explicit beliefs about self, others and world ↓ Positive and negative consequences and attempts at coping Figure 16 – Developmental formulation to explain that the personality and psychological problems are attempts at solutions that have negative consequences as well as positive. The child’s nascent interpretation of self, other and world is such that problematic senses are born in early life and usually these senses are frightening. Often, the emotions felt were accurate with respect to the real damage that was being done at that time. The child makes assumptions that are pertinent to its social context and such assumptions can be both explicit in language and implicit in emotions, relating and behaviour. The child’s wisdom is to cope as best they can. The practical intentionalities of behaving and empathic relating are attempts at producing solutions of the defensive sort of anticipatory self-protection and avoidance of risk. Thus, insecure attachments are forms of defence. Avoidance and ambivalence are attempts at compromise in trying to get attached or maintaining an insecure form of attachment that exists currently as a solution to the problem. However, for adults the current situation may be very different to the previous contexts of cause. Defences are established at an earlier time at a key moment of transition and kept on long after the transition is over. Sometimes the defence may not have been fully functional at the time but if kept for decades they are obviously dysfunctional. This is particularly problematic if the defences begin in infancy or childhood as they wipe out the possibility of development at these times. If they can be identified at any point in adulthood though, it is useful to bring them under egoic choice and control. Developmentally, what happens first sets the scene for later phases. In terms of the beginnings of psychopathology as a learned experience, some of the earliest experiences of managing fear, loss, hurt and pain will be to get control over the current generalization and expression of those emotions. What is under the infant’s control though is his or her physical body. The genesis of problems in childhood and adolescence are more likely to be about the alteration of sensation that goes with emotion, frustration, loss and tensions, because that is under the child’s control. It is through bodily physicality that pleasure can be created and so the sensations of strong negative emotion can be reduced through bodily pleasure like over-eating. The next section focuses on belief as a central ‘cause’ of current experience.

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On maintenance formulation The general form of the maintenance of the personality and psychological problems is that inaccurate beliefs constitute inaccurate negative senses and produce defensive action with respect to innocuous objects (Adler, 1931, Ellis, 1962, Salkovskis, 1991). To provide a definition, psychological belief concerns complex judging acts that take portions of evidence, in explicit or implied contexts, as being indicative of a real state of affairs. Consequently, such beliefs create emotion, relating, avoidances, actions and thoughts. The believed evidence can be comprised of various sorts: Sometimes vague, sometimes highly specific. Let us consider the full experience of what happens in maintaining a psychological problem. For instance, someone with agoraphobia avoids leaving the house. At first glance that seems self-defeating. But as a purposeful behaviour, agoraphobia makes sense when it is clear that it is worth staying in the house (with all the problems that are entailed), when it is understood and believed how awful it would be to have a panic attack in the street and possibly die there of a heart attack. Short-term benefit is preferred to long-term benefit. When people interpret the nature of personality and psychological problems with an eye to cause, formulating belief as the link across time is an expedient way of summing up complex situations that have many causative factors. What appears is what therapists are told about the current observable behaviour of what clients’ describe, interpreted in some way. What appears could be seen through the idea of attachment, the biopsychosocial whole and other relevant ideas like classical conditioning and negative reinforcement. An interpretative decision is made when making sense of the psychological problems and the personality style that appears through interviewing. When the spot light is on belief: Believing is an intentionality that takes a whole and interprets it. The intentionality of belief is shared between people in a variety of ways (Kern and Marbach, 2001). The following diagram links development of the personality and problems to their maintenance in the current context. Initial ‘causes’ of beliefs in childhood or earlier times ↑ ↑ Inaccurate beliefs leading to inaccurate interpretations ↓ ↑ Maintenance of the personality style and the psychosocial problems of inaccurate experiences Figure 17 - A minimalist, decontextualised interpretation of the relation between an originating context and the current context.

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Ian Rory Owen PhD Figure 17 brings together the influence of the past on the present in a way that places belief at the centre of driving personality functioning and psychological problems. Problems are maintained through some of the following means that involve lacks of feedback and understanding. •

Lacks of complaint and feedback from others can permit a person to continue causing offence.

•

Lacks of effort, commitment to achieve, aims and a sufficient time-scale in which to achieve aims, and self-control to do something helpful, will disrupt positive movement.

•

Lack of negative feedback from self in understanding one’s own situation sufficiently will mean that the negative consequences will be accepted. What this means is that there is a lack of reflection and interpretation of one’s own situation and no links are made between negative consequences of one’s own unhelpful decisions and unmet needs.

In adolescence, adulthood, the maintenance of inaccurate experience continues. In the adult situation outside of the family home, the current thoughts, feelings and images about self, or about self in relation to others, are distorted in specific ways. For instance, failure to attach or the problems of maintaining attachment and the ‘costs’ involved can promote further inaccurate interpretation of the situation and distorted relating. The current emotions, relationships, beliefs and interpretations are recognisably related to earlier incidents across the lifespan. In order to formulate in an accurate way, the statements and diagrams made need to be clear and simple. Clients should be asked to comment on what they think has been causative of their problems and should be explicitly asked for their comments. Accordingly, formulation occurs through interventions to find the genuine problem, personality style or groups of problems, and understand how they inter-act. A formulation should take into account how a problem began, how it developed across time and how it functions in the present. The next section develops the theme of formulation as a means of structuring treatment of long-standing personality and more sporadic short-term psychological problems.

Formulating the primary mental health problem What needs spelling out are some priorities about what to formulate and why. Practically, there is such a thing as a primary mental health problem and that is the combination of mood and self-esteem in an experiential way that creates a primary state of poor coping and negative mood at a non-verbal level concerning 301

Talk, action and belief the sense of self and its objects. A problematic mood could be anger, lack of trust, anxiety, shame or depression. Practically, this is the singly most important aspect of mental health because if the self does not feel at least neutral at an experiential level, then it will not function properly in daily living. What frequently co-exists when there is severe depression, anxiety and depression, or low self-esteem (in all its varieties) then the self will be dysfunctional and potentially unable to look after its own needs due to incapacitation. There is co-morbidity between the basic ability to cope with ordinary living as it co-exists with mood and selfesteem. Therefore, the priority when a person is not in danger through suicide or self-harm, is to formulate and treat mood and self-esteem in the first few sessions, regardless of any other problems. What also needs to be recognised is that the proper meaning of the term “co-morbid” is co-‘causative’ because there is a circular relation between those intentionalities that produce anxiety, say, and those that serve to quell it. And it is also important to realise that self-esteem, for instance, as part of apperception, has several facets to it such as self-doubt, selfcriticism, self-directed anger, catastrophising, worry and lack of self-acceptance. These species of problem belong to the genus mood, like shame and strong low self-esteem. The mood relates to a general ability to feel competent and to have achieved something, in the broadest possible sense of “achieve”. The most basic formulations of functioning, mood and self-esteem are as follows. Protective beliefs and biological inheritance ↔ Personality and problems of Impaired mood, inaccurate self-esteem and basic role performance Figure 18 – Primary problem. Figure 18 has the pragmatic function of targeting only two major aspects of the overall current experience. The purpose of such a strategy is to motivate self-care of the mood and self-esteem and provide a minimalistic explanation of how they stay the same. Figure 18 states the most general case. The next maintenance formulation is more complex and can be used to highlight the same factors as above but in a way that refers to the order of events experienced. Fixed negative beliefs ↔ Impaired mood Ľ Ľ Inaccurate self-esteem Figure 19 – Primary problem. 302

Ian Rory Owen PhD Figure 19 focuses on three major inter-related aspects and accounts for the circular occurrence between ‘causative’ beliefs, the designated outcome of depression and the secondary outcome of the beliefs concerning low self-esteem, due to the inability and unwillingness to tackle things in ordinary living because of the depression. Figure 19 focuses on the psychological beliefs and omits any inclusion of biological cause. The next maintenance diagram is more complex still and refers to the case when there is mental or practical avoidance. Poor mood and self-esteem ↔ Inability to function and cope Ľ Ľ Avoidance of necessary self-care, pleasure-bringing activities and social support Ľ Temporary relief from anticipated sense of burden and difficulty Figure 20 – Primary problem. This third formulation in figure 20 includes more factors and notes the presence of operant conditioning concerning the reward of relief gained by avoidance and defensiveness of basic aspects of psychological self-care. Thus, self-neglect might have a short-term reward, but long-term it will bring a greater burden due to the erosion of the duty for self to do what is necessary to make its satisfactions and happiness. The aim is to increase motivation for the clients’ own effort to self-care and when they achieve activities then they feel the benefit of relaxation and a sense of achievement.

How to formulate In more complex and serious cases, it is advisable to select a small number of key problems in any one session and spend at least, the last 20 minutes of an interpretative and formulating session focusing on antidotes to negative beliefs. The type of beliefs that are most negative are ones where there is a risk of death through suicide, self-harm through cutting, or death through starvation in anorexia. The major strategy in formulating belief is to explain the difference of what it means to believe that something is the case as opposed to not believing. If it is believed that the world will end next Tuesday, there will be fear. If it is possible to reflect on this belief and see it as unlikely or mistaken, then the emotional response will be different. The problem of belief is that clients stay in the belief. They are unable to reflect on it and accept it as a proper representation of the truth of affairs 303

Talk, action and belief in the world. The first change is to help them understand that what they believe is an inaccurate, false or unhelpful belief that is potentially open to change and renewal in the light of more evidence, which often will already be known to them. Instead of therapists interpreting all the beliefs, it is useful to encourage clients to interpret themselves. This can be done through asking questions or otherwise asking what function they think self-harm, for instance, currently plays in their lives. The answer could be, for instance, “I need my self-harm in order to go to sleep”. Or “my selfharm is pointless and only makes me feel worse about myself ”. It can be a defensive behaviour but is used without it working and providing and positive outcome. Formulations of the intentional processes of clients are begun by asking them open questions about the order and detail of their experiences. It is best to assume nothing about the content of thoughts, feelings and the meaning and function of behaviour. The way to investigate an individual occurrence is to ask open questions about what happens. Then ask about the order in which events occur. For instance, comments like “I am really interested to know what happens for you” are sufficient to find the information to help people understand what is going on. Questions like “what happens after that?” And “what happens before that?” Are sufficient to find the order in which experiences occur. For instance, if a person complains of being anxious and depressed, it is best to ask how that happens or “what happens to trigger that?” Or “what happens as that builds up?” Other questions ask about the links between types of intentionality such as “what leads you to feel depressed?” Or “when you have a visual anticipation that you will be made bankrupt, how do you feel?” These types of questions find the links between the end-products of anticipations, emotions and behaviours, plus other types of intentional relations to conscious senses. The means of encouraging people to encounter difficulty and go past the borders of their self-imposed safety, is to understand how they construct their fears and not just focus on what they fear. Let us consider Joan who has agoraphobia. What she expects is that a panic attack will occur and she will fall on the floor in a busy shopping precinct and that people passing by will think she is stupid, feeble and out of control. What happens on this occasion is that visual anticipations are strong and accompanied in Joan’s self-dialogue with the anticipatory empathised dialogue and intentions of others towards her. For Joan, the sequence is that the visual and auditory anticipations come first, followed by the empathised dialogue of others. For Joan, agoraphobia arises because anticipatory shame gets added to anticipatory fear. And because she creates an anticipatory ‘film’ of what she believes would happen, the visual element is foremost in her anticipations. Armed with this information, it was then possible to create a new visual scene for anticipation, new internal dialogue and new problem-solving actions, even in the worst possibility that these fears might actually come true.

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Ian Rory Owen PhD Time and careful attention are required to persist with creating new, helpful beliefs and make sure that old ones are understood in terms of their original purpose and current negative effect. Emotions and behaviours that do not make sense currently, and do not have any positive purpose for clients in their own evaluation, may be easier to over-come than those where there is a fixation on something remaining the same. The worth of clients interpreting themselves through belief is that this focus steps around resistance and helps clients make their own realisations about the psychological functions that their beliefs, emotions, actions, relationships and thoughts play, in creating a whole. In good psychological health, there is a balance between emotion, belief and outcome. When there is a psychological problem, there is an imbalance. For instance in dating, waiting for a perfect partner could be a belief that drives a solitary lifestyle. The loneliness felt is due to the solitary lifestyle. As long as the person remains solitary and never begins dating someone who is not perfect, they will never get a partner. Whether in talk and relating only, or through a mixture of both, one intervention is to take a piece of paper, and as clients are speaking, to conclude on a belief that they have and state its consequence. For instance: Belief: Something unknown and bad will happen. Consequence: I refuse to try new things and stay anxious. Belief: I do not deserve good things. Consequence: If I expect nothing good, then I won’t be disappointed. Belief: I would be lonely whatever I did or wherever I went. Consequence: I stay depressed, single and introverted. Some questions to determine a maintenance formulation include the following: “What happens when ____ gets worse?” “What happens when ____ decreases?” “Do you think your choices are worth it overall?” “Are there things that you currently choose, that in balance, you would rather not do?” “Do you think that your mood of ____ is related to ____ ?” If clients are happy with how they are and unwilling to change themselves, then that is their choice. However, if there is understanding and commitment towards making change, then the mountains of personality and its entrenched lifestyle can be moved, one piece at a time. In order to provide more detail of how these ideas apply in practice, the next two sections are examples of formulating. An example of formulating in writing at a first session is provided below.

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Written example: Binge eating Bea has a problem with binge eating. Bingeing has a psychological function in that it creates depression in the long-term but manages anxiety and boredom in the short-term. A recent experience of bingeing is analysed. Bea chooses a time when binge-eating began when she heard some bad news. Her negative emotion motivated a binge that was enjoyed at the time but afterwards Bea felt sick. When Bea went home from the restaurant where she had been eating, she felt disappointed in herself. She felt physically sick and began to worry about a number of things including what other people might think of her, about her weight and attractiveness to men and women. Through discussion with her, the maintenance formulation diagram was agreed to be as follows in figure 21: Feel overwhelmed ↓ Want reward and comfort ↓ Binge/reward ↓ Feel sick ↓ Low self-esteem: “What am I doing?” Figure 21 – An idiosyncratic behavioural formulation. Bea was clearly asking for help to stop her bingeing and said that she wanted to eat normally, which from discussion with her, meant that she wanted to stop dealing with psychological problems through the false means of using food to act as a distraction away from unpleasant emotions that Bea would prefer not to feel. Through discussion what came to light was that Bea began to worry. Through further discussion that assessed the intentionalities involved, a procedure was found for dealing with the fearful possibilities she faced. Bea began to not leave possibilities hanging as problems, but took them further forward in time to their possible resolution and management. Problem-solving her anticipatory worry was achieved by asking Bea what she would do if these possibilities were to happen. “What would she do?” “Is it likely that these things will happen?” “Have they ever happened?” When Bea returned from behavioural experiments, belief-testing and exposure, then further de-briefing was carried out in finding out what happened and what she had learned. Eventually Bea could spell out precisely what happened and compare that in detail to what she anticipated would happen.

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Ian Rory Owen PhD Clients can be asked to draw graphs of their anxiety against time after an event and this information works in helping prepare the way for future action. The next section makes some short statements on how to work with belief without making a written formulation diagram. The next example will make the process clearer.

Verbal example: Challenging inaccurate beliefs Steve, a middle-aged businessman and expert in his field, is very nervous prior to meetings. Steve is claustrophobic in meetings and prefers to sit near the door or close to an open window to help him reduce the sensation of heat and panic that he feels when he is socially anxious. He is acutely sensitive to how his body feels at these times. In the three hours prior to a meeting, Steve ruminated on what might happen and that is called performance anxiety. Steve anticipated himself being exposed as a fraud and that he might make a mistake or that he might be seen as incompetent. At the start of treatment he did not like speaking in public, which was a problem as he was about to become more senior in his company and that would entail taking a lead role. His therapist interpreted his problem to him as being that he was more competent than he believed. This interpretation was voiced after careful checking that revealed that no one had ever belittled, criticised or otherwise unnecessarily questioned Steve’s judgement in important business meetings. Therapy proceeded by encouraging him to remind himself of his competence before and during meetings and to practice public speaking. In four sessions, all the problems were resolved to his satisfaction. This case is an exemplar of the meta-representational theory of belief in practice. Let us consider the details. Steve’s original belief was that he was incompetent generally. This began at a specific age in the context of his schooldays where Steve was bullied and lacked confidence to ask or answer questions in class. The belief arose from this specific body of evidence, at that formative time. However, what happened in the classroom still appeared in his thoughts, feelings and behaviours as an adult 40 years later. The interpretative stance of the therapist acknowledged that his beliefs were a response to his schooldays. The major restorative distinction came through asking Steve about his actual competence in more recent years. It was found that there was nothing during the last 30 years that supported, in any shape or form, the belief in his incompetence at work and business meetings. Consequently, the nature of the problem was summarised by interpreting that Steve held the belief that he was more incompetent in his role than he actually was: A distinction was made between his abilities as he believed them to be; as opposed to his abilities as they actually were. It was then possible to devise a means of checking the accuracy of his beliefs in such a way that allowed him to be more relaxed before and during meetings.

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Talk, action and belief In order to offset 30 years of social anxiety, performance anxiety and claustrophobia, Steve was further encouraged to create situations where he could test his own ability to speak in public situations. The rationale for this task was explained as helping him have more practice so that he might feel more confident about his ability to handle meetings. Theoretically, the key distinctions were that there is a difference between what had happened in the past; what he anticipated might happen in a fearful manner, before and during meetings – and how he came to be able to remind himself that his fears had never materialised. The next section is the penultimate one for this chapter.

Discussion of working with belief Something needs to be said about negative reinforcement and the one-person interpretation and formulation of psychological problems. If the psychological forces for one person are considered, then that is a decontextualisation of the larger picture, particularly if there is the omission of public meaning. One-person interpretations are not full explanations and ignore the other and the processes through which culture and society create meaning. This is acceptable as long as it is explicit that this is done for pragmatic purposes. Negative reinforcement is a useful hypothesis but only a part of the whole. The psychological function of negative reinforcement is the means of ridding oneself of negative emotion or other negative experience, or pre-empting such feelings and thoughts through physical action or mental distractions. By way of wrapping up the above, it should be noted that the ego and what is private is always public to some degree. What belongs to the ego is the overuse of some abilities, intentionalities and the amount of attention given to one thing as opposed to others. In the negative however, if a therapeutic stance cannot identify psychological objects, or its understanding of them is inaccurate, then there cannot be the possibility of offering help. Simple questions like “I am going to start a sentence and I would like you to finish it...” are sufficient to get people thinking about what they do believe. For instance, “I believe that others are...” and “I believe that I am...” are two immediate ways of asking clients to formulate their own beliefs about highly complex situations. What a biopsychosocial perspective means is that nature and nurture interact in a dynamic way. Personality is the sum total of defences and attachment style. It is long-lasting and taken everywhere and enacted. Personality refers to the semi-constant way that one person engages others. There may be occasional interactions that are out of style. However, “personality” includes the most frequently used means of dealing with self and others: family, partners, close friends, work colleagues and neighbours. Contrary to the usual idea that there are clear definitions of disorders and personality disorders, here the conclusion is that such occurrences 308

Ian Rory Owen PhD are biopsychosocial syndromes in an on-going biopsychosocial inter-action. This is not to say that there are no norms and that there is no distress or inability. Rather, personality style and concurrent psychological disorders are the result of complex inter-actions. When it comes to practising, tolerance, generosity and an accepting way of meeting clients help the general public. No special techniques are necessary over and above the use of good practice that has already been made known (Owen, 2007a). There may be further more complex inter-actions between the areas of biopsychosocial influence on a person and their current psychological problems. Only the biological inheritance is inevitable, natural cause that has ramifications, personally and socially. In a sense, free will is constrained by cultural conditions (as meaningful inheritance) and material conditions (natural inheritance). Whilst free will and choice between meanings are genuine phenomena, they only form one part of the whole. What can be chosen is tempered by its inter-action with the intersubjective (cultural, societal and historical ‘cause’ - mediated through the family and the influence of others across the lifespan). Simultaneously, what can be chosen is also tempered by heritability (the genetic predisposition and biologically conditioned states of the physical body). Furthermore, what is social also concerns how heritability influences the material aspect of the social: Perhaps some genes are more likely to promote anger, for instance, but it is untrue to claim that heritability is the only cause. Agreeing with the common sense phrase that “the first thing to do to get out of a hole is to stop digging,” it follows that how to undo personality and psychological problems is to stop maintaining them through the self changing its decisions and actions. Something new needs to happen. Work needs to be done. Particularly concerning the need for self-care to increase mood, self-esteem and decrease excessive self-reliance. However, it is much more difficult to understand self than another. Insight without change is insufficient when problems repeat. In the same way that people clean their teeth and wash their clothes, some type of self- and other-care is required to improve the overall psychological environment and participation in it. Negative feedback is required to decrease the problem and bring it under control. Or otherwise, the need is to recover from a problem gracefully and minimise it. For instance, an emotion may or may not appear in an identifiable context. Sometimes, the thoughts that the person has are clear expressions of belief. At other times, it is difficult for clients to reflect on their experiences and interpret how they are acting and feeling. In the latter case, it is best to surmise that their beliefs are tacit or implicit, in that we can assume that beliefs ‘cause’ how they feel and act the way they do, as though they explicitly did believe something. In other cases, there may be an over-reliance on one type of intentionality at the exclusion of other forms.

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Talk, action and belief Assessment for belief work should be around formulating a key belief, explaining its hypothesised role and tying together key problems and explaining what might be required in terms of the effort to over-come them. When there is credibility to an old negative belief, one strategy is to ask clients to be committed to working against it. Some people can make no such commitment though and this should be found at assessment. It contra-indicates working with belief because the person cannot yet reflect on themselves and their purposes and commit to change. The target beliefs for a session, or a series of meetings, can be identified as the commonality between the past and the present problem. For instance, for Anjula there is neglect in childhood, a lack of current socialisation and the current problem of low self-esteem, for which Anjula originally asked for help. The therapist directly asked Anjula to be committed to making changes. A small number of assessment sessions were offered and early progress was reviewed to find out whether Anjula could benefit from this approach or not. In belief work, like any other aspect of providing care, a rationale must be specified and informed consent obtained before starting the intervention. Focusing on belief helps to create clear aims. Belief work side-steps excessive complexity and a slavish adherence to textbook definitions of psychological disorders. The benefits of this style of belief work are that it is flexible and selects key aims for the sessions and applies principles that clients can continue to use, after the meetings cease. In a wide view of belief, there is the role of therapists themselves, who verbally and non-verbally express their confidence in being able to help (or not). A congruent and convincing expression of one’s ability to help may in itself build a helpful positive anticipation that positive change is attainable and will be forthcoming. This is the place where the sense of belief, elides into a faith that something positive can take place. The role of explicit beliefs, as specific expressions that things exist one way or another, has direct consequences that are expressed in relationships, behaviour, emotion, physiological arousal and internalised speech. The anticipation that something good can happen may produce a positive effect at a material level, as well as at the level of conscious meaning. There are literatures on the placebo effect and its opposite, the nocebo effect. This area of research shows that healing follows after positive expectation, in the absence of any material causative agent. The opposite is true in the case of the nocebo effect in voodoo death, where a believed-curse is the sole stimulus for death (Cannon, 1957). On the positive side, attentiveness to the plight of clients, and the inter-action with them, are beneficial in themselves, even if only in a very non-specific way. A great deal of therapy is done by helping clients to help themselves. However to do this, it is necessary for therapists to have a clear understanding of what they are suggesting as the means of providing help. Therapists should know experientially what having therapy and doing homework feel like. The necessity 310

Ian Rory Owen PhD of making reference to experiential aspects is to make any suggestions for possible behavioural experiments or other homework, understandable in simple concrete terms. Minimally, therapists do suggest what, how and why. Minimally, therapists suggest a means of creating change, even though this might be as non-specific as “open-ended talking” and “I think problem-solving would help”. Because the relation between intentionality and the sense of an object in a context is a ubiquitous one, it is brought to therapy relationships and psychological life to structure understanding of psychological problems and indicate their possible minimisation, management or even eradication. The principle for formulation is to ask open questions about client experiences, their order and the duration of any senses of any objects. The answers are interpreted according to the intentionalities as the motivational and meaningful ‘cause’ of the maintenance of current problems and aspects of personality as a semi-permanent manner of relating and its overall consequences. What is argued for is a collaborative and negotiated approach. For instance, rather than the view of therapists predominating in sessions, it is helpful to ask clients if they disagree. After having explained a rationale or formulation, therapists can ask clients to think about what has been said and invite discussion on their comments. This can include asking them to recap what they think are the causes of their problems. After an experiment or homework has been done, this is another opportunity to have clients demonstrate how they are interpreting themselves and acting in new ways. Some specific ways of working with the perspectives of others are explicitly to acknowledge their viewpoint and then add one’s own. This validates their perspective and provides a counter-point with one’s own. Wordings such as “it seems that you feel ____ . I can see why you fear I might ____” would achieve this aim. It does so by asking questions like “let’s find out about what happens for you. What happens when _____ ?” And “what happens before that happens?” Connecting with clients and stating or re-stating a formulation would be to use open questions to find out what happens for them. If impasses occur and there is a continuing inability to see each other’s position, that in itself needs to become the subject of the meetings themselves. It is also possible to encourage clients to interpret themselves by asking them open questions. Particularly useful are questions that elicit people’s advice to themselves. Causality in the broadest sense includes the psychosocial ‘causes’ of influence, choice and motivation plus natural cause proper. Cause proper is the necessary and inevitable force of change in inanimate material. Soft psychological ‘causes’ concern meaning, attraction and aversion. The will of the ego includes its ability to manage the consequences of biological cause. If this were not the case, there would be no possibility of mood management in the case of bipolar disorder, for instance. Although there is irreversibility in the lifespan about the order of events across it, what hysteresis refers to, in a psychological sense, is the on-going decrease 311

Talk, action and belief in personality functioning and mood that is irreversible. Joseph Zubin (1977) has given the gloomy opinion that some people, with personality disorders and severe psychological problems, the focus should only be on basic coping and increasing functioning. He is asserting that here are people whose mental health will only deteriorate across the lifespan. Psychological hysteresis occurs when people do not ‘bounce back’ to where they had been in terms of their functioning, after a stressor has been lifted. Persons who exhibit psychological hysteresis deteriorate in the ability to cope across the lifespan despite having had therapy that may have had some positive effect for them. Sometimes such deterioration is irreversible and cannot be halted, if clients refuse to self-care and their self-neglect decreases their functioning. Accordingly, the intentionality model posits a primary mental health problem of low mood, low self-esteem and poor functioning in everyday living that leads to exhaustion and poor decision-making often called “the nervous breakdown,” a non-psychotic collapse.

Summary In total, the starting point is what appears for clients in their conscious experience and only that should be interpreted. There are two major types of interpretation that therapists make. The first concerns what is happening in the current moment with clients and is clarified through verbal discussion. The other concerns how to make sense of what clients are saying in a wider, more formal sense concerning what causes their negative behaviours, emotions and sense of self. The overall process is to help clients question their own beliefs because they no longer fit the situation that they are being used to represent. Both of these matters take something that perceptually appears and work towards understanding what is signified or depicted in what appears. Through speech, the empathic sense of generalised other persons can be clarified in the here and now relationship with them. Other important factors can be included through formulating and coming to understand how key aspects of problems coincide. What is required to develop the biopsychosocial approach is a greater attention to the psychological and social aspects, and becoming clear about what the ego can choose. Formulating is prior to encouraging clients to achieve their aims. There is the need for the ego to choose to look after itself. That could begin with considering looking after self for a trial period, to see if it is possible, and if the effort is worth it. For the intentionality model, what formulation means is that when clients are interviewed about their worst possible anticipations, then it is possible to find out what intentionalities are involved and in what order they operate. The empathic psychological meaning is a quasi-appearance through the speech, non-verbal 312

Ian Rory Owen PhD presence and the psychological pre-requisites that we take with us through life. Some basic ideas of how to order the sessions and the asking of open questions is sufficient to capture the causes of the problems of clients and promote self-guided work on them and their sense of self.

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17 Intentionality and evidence Aim: This chapter makes some brief notes to aid re-interpretation of beliefs and help clients understand themselves in a new light, decide on new aims and motivate them to change themselves. The chapter lists a number of situations where types of intentionality can present selected regions of evidence and provide conclusions about the meaning of it. The teaching point of the chapter is how to recognise the way the evidence is being looked at in order to rectify the beliefs drawn from it. This chapter continues the theme of showing how intentionality and belief actually identify portions of experience as evidence for some meaningful conclusion. This chapter makes explicit the detail of how beliefs are interpreted from regions of evidence. As will become apparent, any type of intentionality can be turned toward any region of evidence. The overall conclusion gained from interpretative activity is believing in the manner of existence of the evidence. However, it is also possible to have transitory thoughts in internal dialogue and discussion with another about the same evidence. There could be emotion, value or practical activities or mere imagination, anticipation or remembering of the evidence. Further more complex nested versions of intentional awareness, about the same evidence are possible. 315

Talk, action and belief The worth of the intentionality model is to appreciate how an experience or series of experiences can be selected and stand iconically as representing some psychological conclusion. A psychological belief is such a conclusion. Belief is pervasive understanding about existence that guides feeling, relating, thinking and behaving. For instance, one view of self, others and world is that self is worthless, the world is a desperate place and good others are out of reach; whilst those who are in reach have bad intentions. The order of approach is to discuss evidence and its interpretation, then the temporal focus for portions of evidence. A discussion and conclusion follow. What follows below is not a detailed overview or critique of leading contributions from cognitive behavioural therapists on evidence and belief. What are presented are comments on the nature of evidence, belief and how it is interpreted. The precise details of what to say and how to elicit aims are omitted at this stage. The model for understanding is Wilhelm Dilthey’s metaphor of parts and wholes made contemporary by Peter Simons (1987) Parts: A Study in Ontology. Psychological problems are in-part about role impairment and the failure to achieve needs and aims in specific social contexts.

Evidence and its interpretation Beliefs, actions and experiences make sense in a full understanding of the present situation and the histories of the persons concerned. The same action can have radically different meanings, according to different histories and contexts and the perspective from which it is viewed. It is only when tradition or function demands a particular performance, and a person cannot deliver it, that there is a problem of the impairment of the individual and the anticipations of the social context. There is also the matter of determining what a proper region of evidence is and rejecting any set of experiences that have mistakenly accepted as representative of an ability or personal quality when they are not. Sometimes the first quest is to find the proper region of evidence. Some comments can now be made about specific ways of interpreting experiences. An abstract terminology is used because the comments below refer to any aspect of life. The hermeneutic rule is that inaccurate understanding and beliefs and their consequent experiences exist with respect to a fuller, more adequate experience and its appraisal, within the relevant region of experience. To interpret evidence sufficiently, means considering and re-considering it in a manner that is as fair to self as it is to others. The terms “knowledge” and “representation” are interchangeable below: both words refer to lived experiences, plus thought and speech about those experiences. Where interpretation plays its role is in internal dialogue that can alter the meaning of emotions or create emotional evidence. And hence, there could be avoidance of actualities and possibilities through 316

Ian Rory Owen PhD fear. All manner of situations can be re-interpreted, so the abstract terms below can refer to emotions, thoughts, past and future anticipated relationships and events. The purpose is to be precise about how evidence is being interpreted. The processes cited are common in various types of psychological problems. Some of the negative interpretations that occur can be understood through Dilthey’s metaphor of the part and the whole, the hermeneutic circle. It also has to be noted that some situations are ambiguous for a while or there can be insufficient evidence to decide at all. Furthermore, theoretical conclusions should not be confused with the actual meanings that clients have and live. There are a number of constitutive intentionalities involved in any problem for any person. The ego strives, decides, chooses, avoids and interprets amongst other activities. From the standpoint of only considering problematic outcomes, belief occupies an interesting position amongst the intentionalities: It is close to the ego’s ability to choose and its more passive, non-egoic abilities to emote. The active and passive processes that create emotion sit close to socially acquired influences of habit and the most fundamental intentionalities of bodily sensation, perception, association and temporality. However, belief concerning psychological problems is not understood or initially capable of control by the ego. If they were, there would be no need for therapy. People would be able to reflect and correct themselves accordingly. The possibilities below are currently called “cognitive distortions” by cognitive behavioural therapy. This is problematic because obviously they are not all cognitive in the sense of them being merely linguistic in the manner of their distortion. And the stuff that is distorted (or better, mis-represented) is often not cognitive either. “Cognitive distortion” as a term is inaccurate particularly when what happens may only be felt and not reflected-on at all but avoided through anticipatory fear. What is really being referred to as “cognitive dissonance” is psychological hermeneutics. The 21 cases below are not a complete listing but illustrate the point of hermeneutics in understanding psychological problems for practice. The term “whole” means an adequately known whole, not an ideal, perfectly known one. A ‘well known’ whole is a representation of the referent that is sufficiently accurate, given the limitations of time. There are further possibilities that are omitted such as the case of delusions. In delusions, for the deluded persons, there is no evidence to support beliefs and that the beliefs are inaccessible to reason. Let us take a specific example. John has spontaneous visual flashback of being beaten by a teacher that may evoke his anger at being attacked. The flashback is a snapshot about the client’s relationship with the abuser. In self-understanding, John interprets himself as a “fool” for not reporting the abuse to the police at the time. Through discussion, it is possible to explore and re-evaluate the relationship with the abuser. The intentional relationship remains the same. There is the inter317

Talk, action and belief relation between John and the abuser and the memory of the attack. Through discussions or other interventions, the changes that can occur are changes in meaning and affect about the memory. How it is thought about and discussed (the relation of conceptual intentionality to these objects) will also change. The process of understanding qualitative experience in its own terms means that what appears of its inherent nature are a number of key aspects that are united as a whole. This is why the hermeneutic circle of the German tradition is called upon to explain how taking different attitudes towards the same situation makes it appear so differently. For instance, for understanding self, what appears are the links between the initial understanding of self in relation to the lived experiences of the sense of self at any instant. There is no specific end-product but rather a co-relation, an inter-action: The initial understanding creates a certain sort of emotion about an object. And the emotion created influences the understanding of self in return. The next three sections consider evidence and how it is concluded on between the past, the present and the future.

Interpreting the past Some forms of interpretation concern the past. The past is gone and beyond the reach of making changes to it in terms of what actually happened: All that can be changed about the past is one’s relationship to it, what one understands about it as its meaning and influence on self and what one has learned because of it. Some interpretations of the past guide current behaviour and promote specific experiences in the present. Usually, the experiences and fixed interpretations began in the past at a time of trauma, ridicule at school, or are responses to some past upset. However, the form of these problems in temporal terms is the same: A past influence governs present events. Ten examples are as follows. A single experience or a number of negative or ambiguous past experiences are interpreted as being a permanent view of the whole. This iconic view of the past is carried forward and is used to structure life today. For instance, Paula had one major argument with her mother and this was evidence to believe that her mother had completely betrayed Paula. The consequence was that Paula dismissed her mother with cold anger. The anger lasted for twenty five years and it was only when her mother died, was it clear what Paula’s relationship had been with her mother since the argument. It took some years for this realisation to be fully grasped. Negative recollections exist (in connection with anticipations) and currently influence the person generally believes that they will be left with emotions that are unbearable, cannot be coped with or tolerated. This is a faulty interpretation of the self ’s ability to cope. Furthermore, it becomes a generalised belief that self is 318

Ian Rory Owen PhD utterly worthless in all situations at home, in love and at work and will never amount to anything worthwhile. This is the case of on-going loss, depression and pre-occupied attachment Fear about a part that is known inhibits a more accurate knowledge of the whole. Because maintenance of a fear leads to avoidance of any experience of an object, people come to interpret themselves, for instance, as socially inept and unlovable. The belief and the manner of its maintenance go hand in hand. Let us take the example of social anxiety. Because of recent problems of being anxious and angry at self, a young man leaves a social group and never returns to it, although he has no other friends and he is living in a new city. Mistaking part of a region for the whole of that region. One mistake at work for a young graduate manager, in his first job after university, is enough evidence for him to tell himself that he must resign and change career to something where he will never fail again. Corrective measures are put in place to alter the young man’s expectations of his role, his progress and what the company is offering him. He stays with the company and through its appraisal system, he is able to re-negotiate his role each year in a positive way, gain feedback on his progress and gain the sense of on-going competence and progression. Martin is a heterosexual young man who finds himself nervous from time to time in social situations. As a consequence he tells himself that he is incapable of dating. Because of his nervousness generally, not only does he not ask out women that he finds attractive, but he also turns down invitations from women who ask him out. This is a problem because Martin values getting married and staring a family. Thus, a problem in one area is assumed to apply to another. In general the problem is accepting a part of a different region as representative of the whole of the region in question. He has generalised his social anxiety to prevent himself getting to know single women in potentially romantic one-to-one situations. Martin prefers loneliness to risk. Inaccurate empathy with a lack of checking assumptions about other persons concerned, can lead to grossly inaccurate beliefs about the experiences and intentions of others. One version of this problem is that inaccurate empathy is generated and never checked, so a faulty part comes to be accepted for the whole. On occasion this mis-understanding is based entirely on non-verbal presence and gestures, and may explicitly refuse to take into account the spoken comments of others. For instance, Annie tells herself that people dislike her and do not want to know her. Annie does this by looking at others and attending to the emotions that she anticipates they might have. This maintains Annie’s belief that people dislike her and that she is unable to get in close contact in friendship or marriage. If Annie were to check out what people did show of their feelings towards her, she would revise her inaccurate empathy and stay closer to others, as she desires.

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Talk, action and belief Negative, inaccurate interpretations of self and other create a false impression of the whole. For instance, “nobody loves me” is the conclusion drawn when a person feels intensely sad for an hour. “You are completely unacceptable” is the conclusion drawn when a loved one makes a mistake. In some cases, the role of the orientation in time is more complex such as when current evidence is not taken into account. However, the perceptual present is an openness into which past and future appear and the sense of the past can be connected to the future. Let us take a general case: Interpretations of self and other fail to include the positive evidence that does exist, contrary to the fixed belief of the person. For instance, a young woman who is depressed has been successful in her work life but finds herself completely without merit when the company loses money and downsizes and she is made redundant. She cannot carry forward her worth and capability from her previous success. The nature of the problem is that she cuts herself off from her past success and tells herself she will never be successful again. It is as though her self-esteem only lasted as long as she was in work. As soon as she lost her job, her self-esteem went with it and did not return, nor was there the possibility of finding it again, she believed. There are forms of vacillation. The first example below is vacillation at a more intellectual level and the second concerns two types of evidence that fail to be unified. Some people vacillate between two positions. For instance, either they interpret themselves wholly positively or wholly negatively. Each outcome is temporarily accepted as a permanent view of the whole. This produces vacillation between the two opposing views. For a few days, one wholly negative sense of worthlessness, fear and low self-esteem exists, then for a while, pride, expansiveness and hilarity. The problem is that there is no overall integration of the two means of interpretation in order to experience more days of an even mood. There are effectively two selves, two senses of others and two experiences of the world. These experiences coexist without amalgamation and movement occurs from one to the other. The vacillation is all-embracing. When one pole is embraced, the other is lost. Overcoming the problem requires using the intellect to understand the changes and striving to lessen the difference. The situation of cognitive dissonance is where two separate regions of evidence are kept apart and not brought together. For instance, Jack is a heavy smoker, drinks heavily, overeats and has a fear of death. This seems to be linked to being beaten as a small infant and child. These experiences co-exist and are mutually contradictory. There is a belief that death will happen in the near future and he does not want to die but he maintains his unhealthy lifestyle that helps him gain what he feels as pleasure and works to blot out negative emotion. A tension exists between the two positions without movement. The vacillation is subtler. Within the same day 320

Ian Rory Owen PhD and at the same time, Jack eats, drink, smokes and worries. The same person holds completely different beliefs. Over-indulgence co-exists with the fear of imminent death through a variety of means and the emotional conflict remains the same.

Interpreting the perceptual present The next series of three cases concern empathy in relation to time in the present. There is no such thing as the here and now, pure and simple. The temporality of the present moment is a mixture of the immediate past and future, plus the influence of the longer-term past and future. In psychological problems, what sense is made of the present often shows how the past has been and how selves are defending themselves against those events happening again. Six examples follow. Inaccurate interpretations of the extent of responsibility (of self or other) are made in relation to the actual amount of responsibility (of self or other). For instance, Steve has obsessive compulsive disorder. He tells himself that he may have dropped a piece of paper in a bin that was one metre away from him. Steve believes that this might have happened and feels acutely anxious because he believes that it would be awful if it had happened. So he goes back to check whether he did lose something in the bin. Steve checks and finds nothing. Half an hour later the process repeats. Whenever he has checked, he has never found something that he has lost. But each success does not act as evidence to stop the checking. Steve continues checking because it is driven by worry, “what if that a disaster has happened?” Or “what if it is about to happen?” Steve believes that problems are extremely likely and the negative consequence is out of proportion to what would actually happen. His sense of responsibility and capability of making a mistake are inaccurate with respect to the evidence. Inaccurate interpretations of the extent of ‘cause’ from others exist in relation to the actual amount of ‘cause’ or culpability of self. For instance, the responses of other people towards self are all that count as evidence to conclude that Andy feels lack of support in a love affair. However, Andy fails to mention any of his own contributions that lead to the lack of support from his lover. This problem is one of attempting to ‘break intersubjectivity,’ metaphorically speaking. The cause of the problematic inter-action is placed entirely in the hands of the other person and the contributions of self are ignored. The problem is not understanding the inter-action as a whole comprised of two parts in a linear sequence. Like partner dancing, a small change in the position of one person will cause changes in the position of the other. This is not to wipe out the actuality of specific contributions from one person, but is a way of emphasising the inter-active quality to which intersubjectivity refers. Interpreting self or others according to excessively high, ‘unfair,’ harsh and perfectionistic, standards. A depressed man enters cognitive behavioural therapy 321

Talk, action and belief but sets himself targets that he could achieve only when he is not depressed. As a consequence of his depression and high standards, he does not meet his targets and becomes more depressed and angry with himself. The following problems concern apperception and empathy as comprising a whole. Justine was a lonely only child and made very few friends at school. As an adult she worked as a prostitute and opened her own brothel but was caught and sent to prison for 5 years. On release from jail she saw no point in making friends. Justine told herself that people will not want to know her, so she continued a life of social isolation despite her need to be with people. Justine was unable to put the past behind her. The inaccurate interpretation of self and others contributed to an inhibition of action in the present: A form of mistaking a false part for the whole. Some people assume that emotions are genuine representations of situations and that specific actions must follow, because of the strength and type of emotion: This is a problem of mistaking an emotional representation of a single type for the whole experience of it. The mistake in this example is primarily experiential. The person is governed by ‘the truth’ of what they feel. There is a false belief in the value and accuracy of emotions in all cases and at all times. Emotional evidence can be preferred over logical reasoning and other types of evidence. This is problematic if there is no comprehension that fear, for instance, can be unnecessary and that it might be possible to over-come fear and be confident instead. The following problem is more about the preference for the short-term effects of negative reinforcement than the long-term problems that follow as consequences. A very wide set of events can be classified as “self harm,” such as risk-taking, self-punishing and other behaviours that serve no current positive function in maintaining psychological and physical health. Such behaviours may have had a defensive function when they first began in that they produced some positive consequence (possibly in addition to some negative consequence). However, people can interpret themselves entirely according to their self-harming behaviour and see themselves as useless. This is another version of mistaking the part for the whole. The self-harm can be connected to the belief that bad deeds must be punished. This rule is applied to self in the creation of a means of managing negative emotions in relation only to short-term goals like reducing distress and not long-term ones like taking the effort to create long-lasting satisfactions. It is clear for persons who self-harm that they want their self-harm and need it because it is a fast and reliable remedy that provides relief.

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Interpreting the future Some interpretations of belief concern anticipation of the future. It is quite impossible to anticipate what life will bring with certainty - which is not the same as saying that striving towards a goal has no benefit. The future is that which has not yet happened in actuality, and it remains inactual, unreal. Strictly, the future is not a region of evidence but concerns potential and possibility that is construed in a specific way when it is anticipated with belief that anticipated experiences will come true. In a way, the future is a blank space where people try to guess how it will be based on the past. Human experience is turned toward the future, particularly in trying to aim for specific satisfactions and create strong relationships with mutual satisfaction. Five examples are provided. Negative anticipations may lead to fear, avoidance and inhibition - even if no anticipations have ever come true. Again, the problem of interpretation is that a faulty part is mistaken for the whole: the future is certainly something to be protected against. What is believed to be coming is dangerous and uncertain. Accordingly, a constricted life is valued as better than engaging with a ‘vicious’ world. Inaccurate anticipations about self and others concerning idealisations, preferences and assumptions are due to what is believed “should be the case”. Thus, ideals and ‘shoulds’ are accepted - instead of attending to the whole as it actually exists. This is another case of mistaking an inaccurate part for the whole. Over-valued ideals about what should be the case in a perfect world are used to guide actions, emotions and relationships in the real world where people change their mind, surprises happen and things go wrong. The actions of self and others may be further interpreted as to what this means about the nature of self or others. For instance, “I should ____ and if I don’t, then I am bad”. The problem is that an excessive valuation of ideals comes to govern current events and future planning rather than going with the flow of actual events. What is realistic and feasible does not come into play. When disappointment arises, it has to be removed and further unrealistic assertions made in order to maintain the ideal beliefs. Negative anticipation can produce fear or be part of rumination that is not held in check by creating an effective means of dealing with the situation at hand. The fear generated through expecting a disaster is a false part that may act as an inhibition to reality-testing. The causative anticipations are of the sort “what if something catastrophic happened?” Although “what if ” thinking is partly focused on the future, it also influences the choices being made in the present. Such a manner of interpretation is present in obsessive-compulsive disorder, health anxiety, social anxiety and generalised anxiety disorder (worry). People can create their own anxieties, initially perhaps as a form of protection concerning what feasibly might

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Talk, action and belief happen. But through action and avoidance – or their absence – anxiety increases overall. One form of worry concerns repetitious visualisations and self-talk that is anticipatory and produces fear before an actual event. Another form is uninhibited imagining of a catastrophic event. The intentionalities involved can concern visual anticipation that creates a feeling related to auditory and conceptual objects, visual imagination, auditory imagination and conceptual imagination in internal speech - about what might be said or thought. Usually, the object anticipatorily seen is catastrophic or highly problematic. The anticipation or imagining is repeated and may well be so for days, from precisely the same perspective and in precisely the same way. Sometimes different versions of the ‘disaster film,’ longer or shorter, are made and shown to self. Usually the action stops when the problem is at its worst and the visual scene is not taken further forward into prevention, planning or other types of problem-solving, in advance of the problem’s actual occurrence. The remedy for worry is self-awareness and self-understanding permitting an egoic choice to catch self and stop over-using the same intentionalities and objects that create anxiety, depression and constitute further problems. The selfcare action diverts attention into another non-catastrophic, neutral or reassuring object of attention. If it is not possible to change the topic of one’s thoughts, then the next best thing to do would be to alter the physical surroundings or occupy self with something that demanded a good deal of immediate here and now attention, like playing a team sport or some other activity that was physical and released physical tension. During worry, the sense of self was that it was small, defenceless, under attack: Self feel easily capable of being threatened and problems that were going to be encountered would be insurmountable. When worry stops, the new sense of self is one that is more adult and more resourceful in looking after its assets and interests. The coping self works to solve its problems. Two problems of evidence and its interpretation remain concerning the future. Negative anticipations, assumptions, beliefs and thoughts can predominate entirely contrary to the evidence. This is a problem of mistaking one’s own beliefs for the whole and failing to reappraise them with respect to current evidence. There are circumstances where people have fear-inducing false beliefs, but point-blank refuse to consider how accurate they are with respect to the evidence. This is the situation of delusional beliefs. It maybe insightful to consider what role delusion plays in protecting the person. For instance, what are clients anticipating might happen? If they did not hold these delusions, what would they be able to do which they currently cannot? If they did admit another belief, what would they have to accept to themselves? What would have to happen to help them over-come their delusional defence?

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Ian Rory Owen PhD Finally, the present can influence the future in the following case. Negative mis-interpretation occurs according to arbitrary, irrelevant or unrealistic standards: There is a failure to accept and understand the whole. For instance, anorexia is when people convince themselves that they are over-weight when they are underweight. Body dysmorphic disorder is the false belief that a part of the body is exceptionally mis-shapen and ugly, when it is what they were born with and it may not appear mis-shapen to anyone else. This is a problem of believing that looks are more important than personality, spirit and actions. The problem of not understanding the whole in this case is an excessive focus on a specific type of look that is deemed desirable, and a loss of what people are like in terms of what it is to be in contact with others. The visual aspect of a person exceeds all else. This is probably influenced by the parade of pretty faces that appear through the mass media. However, handsome is as handsome does. Beauty comes from within and is demonstrable in behaviour toward others. The aesthetics of the human body is a matter of personal taste as it is influenced by the mores of culture and history. A full discussion of the aesthetics of the human body lies outside of the present discussion except to say that “every one is beautiful in their own way” and to leave the matter at that. The consequences of swallowing contemporary prejudices on the matter is that people get to think badly of themselves and others and it prevents contact and connection with one’s own abilities or with the potential inherent worth of being with other persons. The problems are those concerning the ability to value self and others according to their personality and credentials in society, rather than only by the current fashion for how a human body should look.

Discussion Some of the advantages of understanding and interpreting belief in the way outlined above are that it should become clearer to therapists what they are doing when they focus on beliefs in relation to the complex details of peoples’ lives. For instance, merely to state that beliefs always occur in the form that “others are _____” is forcing clients to accept or reject a generalised statement about the true intentions of other people. As a psychological statement “others are _____” is always wrong. Specific people might be one way or the other but the population as a whole cannot be described in these terms. Similarly, highly negative and generalised statements about self are wrong. The ability of anyone to be one way or another depends on the context, prior events and the history of their relationships and what has recently happened. A standard way of working with belief in the cognitive behavioural tradition is to test beliefs. What this requires is being open to the possibility that beliefs are false. This is part of a manoeuvre to check the type of evidence and the manner 325

Talk, action and belief of its interpretation. Once this is realised, it takes behavioural experiments away from scientific experimentation with its true-false distinction and further towards philosophy with its if…then reasoning (Husserl, 1956/1970b, §47, p 161). Still, there is similarity between the two. In a longer-term view, what is being asked of clients is that they are being requested to think through their beliefs, values and lifestyle and choose to maintain a commitment to new more adaptive beliefs. This is an explicit procedure. It will involve effort and feel strange at first. To only consider the positive short- and long-term benefits ignores effort and the downside to making the necessary changes. Once the change to a more positive way of life is achieved, clients may wonder why it took so long and why they could not make the changes unaided. So it is genuinely untrue to claim that changes can be effortlessly achieved. Let us make these terms more tangible. Even if problems are reflectedon and the emotions felt can be understood, still there might not be change in the slightest. For instance, clients can think positively about themselves, can understand what therapists say to them and agree that they deserve better. But still for some clients, little or no change occurs. Even after a full explanation, the emotions of some clients are so credible and strong that they feel depressed and tell themselves that “life is going wrong and that they will never amount to anything”. And that in itself is sufficient to demand cutting and suicide attempts as a form of physiological release from the feelings. For instance, Claire holds a senior position in her company and has an excellent performance in her complex and demanding job. But Claire completely rules out her excellence at work in favour of focusing on her interpretation of herself as grossly inadequate when she does not know what to say to her friends. In a social situation, such as a bar or night-club, where her friends move around, when someone she has been talking to moves away, it is interpreted as that person disliking and rejecting her. Claire interprets the movement away from her as rejection and that ‘causes’ feelings of worthlessness, powerlessness and despair so strong that rational thinking about her self-worth and competence in her job cannot possibly redress the balance at that time. When in a calmer mood, the work experiences Claire has are perfectly intellectually credible as evidence for positive self-esteem. The problem is that although she is with friends, she interprets her situation insecurely and believes she is rejected with the full force of feeling utterly dejected and ostracised. An implied belief is one that drives relating, feeling or behaviour. For example, it is implied because it has not yet been expressed, reflected on, considered and accepted as being true for the believer. It is implied that the person believes that the situation is _____ because they immediately feel ____ about it. How to explain this to clients is to say that explicit beliefs are ‘caused’ by what they say to themselves: repetitious internal dialogue produces painful emotions. Implicit

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Ian Rory Owen PhD beliefs cause the immediate physiology of fear, for instance, that gets made sense of in language only after the fact of feeling the fear. New explicit beliefs about one’s own, or another’s abilities, are created through interpreting evidence that is relevant. New implicit beliefs about abilities will be more accurate and most often will reflect calmness, security and greater confidence in the abilities to handle the same situations that used to be problematic. For instance, people need to have had enough self-harm and enough low quality of life, for them to want to strive for something more positive. They need to reject being at rock bottom, rather than accepting the negative consequences of their own actions and intentionalities.

Summary Belief work is a commonality between the talk and action traditions. Beliefs are abstract and interpretations are made of specific parts of a person’s overall enmeshment with others in the communal life. Beliefs can be interpreted as ‘causative’ of the problematic experiences, relationships, emotions and other aspects of clients’ lives. But even people who are intelligent and empathic can fail to understand themselves, their beliefs and reasons for acting and feeling the way they do. This means that the problematic beliefs of clients become manifest in problematic emotions, thoughts and relationships. For instance, living with the after-effects of psychological trauma means adopting a position with respect to the whole of one’s personal past. The way to understand specific experiences is in the context of intersubjectivity. Clients can be encouraged to adopt new beliefs that are more helpful and less limiting than the old ones through which they have run their lives so far. Just this may increase hope and set in motion a placebo response concerning the faith that something can be better (Owen, 1992). Each psychological disorder occurs in specific forms. Each presentation may combine features of other sorts that are dependent on the personal history, severity of dysfunction and idiosyncratic occurrences in the lives of clients. One interpretative rule can be explained. The view below is general and an attempt to sum up. The interpretative rule is distinguishing the differences between: •

A psychological disorder as defined by a checklist in a textbook.

•

The general forms of intentionality that may constitute a textbook definition.

•

There is the entirely unique presentation of a specific client.

The difference between these three distinctions is that they move from the most general to the unique. What appears are actual clients who, through 327

Talk, action and belief meetings with therapists, can be interpreted as having forms of intentionality that create their experiences. To an extent, the nature of psychological problems is the over-use of intentionalities of specific sorts, to the exclusion of others. The assumption is that for any specific disorder there may be several versions of it. But that does not prevent co-morbidity and further idiosyncratic complexity and development that need to be represented and shared with clients. What is being demonstrated is how hermeneutics and intentional implication between persons account for meaning. In order to cut the tangled knot of the relation between the presence of the past and its current influence, beliefs have been chosen as responsible for making sense of the phenomena of psychological problems. Beliefs are capable of showing the congruence between aim and outcome in the psychosocial component of any biopsychosocial problem. Let us first consider one person. In abstraction, where the contexts of influence have made their mark in that the formulation of belief is an answer to the questions “where is control of the problem situated?” And “how do you get access to it?” The answers to these questions are that the ego has the ability to choose, decide, interpret and select its beliefs and behaviours. At first, clients may interpret themselves as not being able to do these things. Beliefs are maintained in the present moment but there can be access to changing them.

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18 Six meaningful worldviews Aim: This chapter explores six examples of psychological worldviews that are problematic. This is not listing new overviews of psychological problems but a means of showing how any worldview of sense and belief can be understood. Intentionality is illustrated as part of psychological problems in a complex, world-whole of sense. This chapter focuses on wholes of meaningful experience with the purpose of emphasising that a change in one area promotes change in another. It is with this principle that hope can be passed on. Six problematic worldviews are considered. The idea of world (horizon or context) is that instead of the full totality of the world being considered for all people, what actually appears is the limited view of how any one person lives in their part of the world. Being ‘in one’s own world’ is a re-statement of human nature as situated culturally, socially and historically. This chapter interprets belief, similarly to the last three chapters. However for the sake of complexity, the previous comments on belief fall into the background in order to devote more attention to how a person makes sense of specific aspects of themselves, others and publicly accessible cultural objects. The focus is on how people make sense of themselves and how thoughts, feelings and beliefs about self are made. 329

Talk, action and belief

Background This chapter presents a number of examples that show how to understand clients in how they have made sense of the world. The view of psychological problems below balances textbook definitions of problems with the unique set of experiences that they are about. The view of the intentionality model is that selves interact with social contexts to produce a world of shared meanings. Self creates its own social contexts across the years. In return, the contexts created influence self. What makes up a world is shared and does not belong to one person. Whether people co-operate or conflict – what they share are the same cultural objects but they have different senses of them. This chapter and the next three show how hermeneutics makes sense of portions of evidence that are intended by a specific type or types of intentionality. People use their own belief-map of the world to navigate their lives. The intentionality model highlights the difference between the sense made and how a part of the world is understood and experienced. The case where therapy has begun, but clients do not wish to continue at an early stage, also merits attention. The foci are the relations of self to self - and between self and other. Meta-representation appears as a way of distinguishing the differences in how believed senses inaccurately express other ways of believing and hence experiencing the same person or situation. The ways of making sense of situations are provided by the psychosocial whole, comprised of social contexts across the lifespan, where the major variables are meaningful and psychosocial. The guiding thought is that personalities and psychological problems are the result of beliefs, contexts and ‘causes’ initiated in the past. Such ‘causes’ appear in explicit thoughts in language, in emotion and the avoidance of emotion. Beliefs, and a focus on an aspect of evidence, are maintained in the present. Beliefs come from the past and are used in anticipating how the future will be. The sense of another person’s world can be empathised from meeting them in discussion and being with them non-verbally. Definitions of psychological disorders in Diagnostic and Statistical Manual of Mental Disorders IV (American Psychiatric Association, 1994) have a justificatory purpose in defining psychological disorders and personalities for the community of mental health workers. The strength of texts like the Diagnostic and Statistical Manual is that they play a role as a lingua franca for the mental health professions in being able to co-ordinate care around specific definitions. When the definitions are used well, they become a genuine opportunity to understand and explain back to clients the nature and inter-relationship between their problems. But the problem with Diagnostic and Statistical Manual is its minimalist checklist quality. The official definitions are static and do not show the numerous developmental

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Ian Rory Owen PhD pathways that happen for those who have suffered earlier and later psychological trauma, for instance. The cases below are anonymous amalgams of real and typical presentations. A view of the composite intentionalities known as classical conditioning and negative reinforcement are inter-woven with the intentionality view. The basic idea is that people live out their worldviews with others. The sum total of a human life is indicated by the footprints in the sand of creating a worldview and being in it. Living a life is not about single people living alone but consideration extends to the whole effect of what people contribute to the greater communal life. The sum total of a life is comprised in the traces left behind on the lives of others with whom we come into contact. The accumulated effect of one’s contributions to others, in the widest possible sense of the word “contribution,” of influence of all kinds, indicates a life of giving and receiving contact with others. What follows below are six types of psychological worldview. There are a large number of other ones identifiable. The six types mentioned here are illustrations. With these remarks in place, let us turn to specific examples.

Shame and low self-esteem in relation to others What the lay public calls “lack of self-confidence,” psychology and therapy call “low self-esteem”. The phenomenon of good self-esteem is to approve of self, believe that the actions, thoughts, feelings and experiences of self are generally socially acceptable and includes knowing that one has always tried one’s best. The phenomenon of low self-esteem is the result of complex comparisons of self with others, where self comes out worst. The term “self-esteem” is a good description of an important aspect of the relation to self. The relationship to self is influenced by the views of others. When one’s own value to self is accurate and positive, the selfrelationship feels like being glad to be oneself. When the value of self is excessive, it might result in boasting and grandiosity. When low self-esteem occurs, persons may be capable and have potential to offer, but all they can see is their faults. Low self-esteem can be explained as the opposite of boasting. Self-esteem is one aspect of experiencing and understanding oneself (“insight”) in relation to other people. The treatment that selves with shame and low self-esteem give themselves would be unacceptable if it came from another person. But because it comes from self, it is accepted and not identified as a problem. The consequence is that clients become their own worst enemies. As noted in chapter 9, “apperception” is how people have a relationship with themselves similarly as they might have a relationship with others. Low selfesteem co-exists with mis-empathy about what others think and feel about self. The tendency is to believe that others see self negatively and this can occur without evidence to support the belief. The relationship of selves to themselves can be 331

Talk, action and belief seen ‘from the outside’ through making sense of how people treat themselves in being self-punishing and self-denying, for instance, and through other physical signifiers such as clothing and hairstyle, or through how people are non-verbally, how they spend their lives, what they want, fear and avoid. The self-relation covers how a person looks after their own psychological needs, as they do their needs for sleep, good food, clean clothing and personal hygiene. Frequently, what is seen are relationships to self that are masochistic, self-punishing and excessively cruel. Or people may abandon their own needs for rest and an adequate social life. These trends are seen more easily by others than by the self who lives them, who can completely fail to understand themselves as others see them, even when challenged to re-think themselves in a forceful way. Similarly, the relation to others appears in the type of meanings that are shared: in terms of mutual grooming, shopping together, the sharing of interests and the creation of mutual satisfactions or conflicts. People who have problems of low inaccurate self-esteem express their low worth in their experience. The straightforward variety of low self-esteem occurs through biased interpretations of self in relation to others. Others are thought of and empathised as privileged – and evidence to the contrary is discarded. Others are viewed as having worth to society whilst self does not. Self-esteem is part of apperception that can be accurate or inaccurate with respect to the valuation of the achievements of self and others in the widest possible use of the term “achievement”. The core intentionality is a loss of the sense of value of one’s own actions and an overfocusing on negative value and interpreted lacks, short-comings, bad deeds and abilities. There is the inability to accept good things and the inability to accept the love and attention of close friends and family. The problem with low self-esteem is that the self sells itself short. Its actual potential is under-represented and not made manifest. Opportunities that it could achieve are missed in turning down opportunities, people and turning away positive possibilities that later produces regret. In order to make low self-esteem clear, a comparison is made between loving another and narcissism and this will make low self-esteem clearer. To love someone is to have their perspective on one’s own mind and to want the best for them. Nothing is too much bother to help someone who is loved. But at the heart of narcissism is the image that the narcissist creates of him or herself as clever, important, amazing and adorable in their own head. This comes across in stories of triumphs, name-dropping and boasting that might sound exciting for a while. But even when adoration is provided, it is never enough to meet the high ideals held. So the narcissist ends up feeling disappointed, humiliated and insulted because others get tired of their demands for adoration. Metaphorically, narcissism is the problem of over-selling and then not being able to deliver the goods as sold. 332

Ian Rory Owen PhD Excessively high and low self-esteem can be seen in the world of work. Some talented people under-achieve whereas some untalented people get to the top by sheer bravado and self-publicity. The problem of narcissists who get over-promoted at work is that once the person is at the top, they cannot deliver. Narcissism is excessively high self-esteem that is inappropriate by definition. The problem is excessively high self-worth in relation to one’s capabilities. For instance, if self worth is too high, not only is there boasting but by definition role-performance is poor. On the other hand, if self appraisal is inaccurate on the side of being too low, there is self-denigration, the opposite of boasting, but role-performance is good. (Similarly, the other can be inaccurately valued with respect to the whole of their actions. If the other is at first over-valued, then self will be disappointed later. If the other is under-valued, then the other will know and feel unloved and possibly retreat). When self-esteem is accurate it gives rise to thoughts like “I like being me,” “I approve of myself and my choices” and “I have the same rights to love and attention as others”. The matters that are central to low self-esteem for Melanie Fennell are core beliefs about self (1999, p 6). Specifically, she identifies verbal and non-verbal products as due to core beliefs that entail, in the terminology used here, a negative apperception and a negative empathy of other persons’ views. Furthermore, she explains that the source of these negative beliefs about self and others is due to internalised speech from the family of origin. One form of low self-esteem is to interpret self as damaged and incapable, when self is not. There is an overestimation of vulnerability and inadequacy. The consequences of shame and low self-esteem that Fennell claims includes a phenomenon of self-fulfilling prophecy where negative core beliefs are confirmed through an interpretation and selection of evidence leading to self-condemnation. For instance, crises of self-hatred are explained by the idea of a “bottom line” of worst-case events that are repeatedly supported by clients’ negative readings of their lives and events around them (p 61). The bottom line is the apparent confirmation of a global belief like “I always knew that I would amount to nothing”. The consequences of low self-esteem are many. One aspect of low self-esteem is feeling un-entitled to things in life that are legal and accessible to other persons within one’s peer group. These are things that are pro-social and life-affirming. Yet through general life experiences, these relationships, roles and the ability to ask - are experienced as out of reach for self. There is an inhibition to ask for these things and dis-belief that one could ever attain them. In short, low self-esteem is not being able to appraise self and hence feel worthy of the good that more secure and confident people rightly assume is theirs for the asking. A further consequence is that if something good is given to people with low self-esteem, the immediate reaction is to feel that it is too good for self and that it has to be rejected, or in some other way, distanced: a gift is cause for anxiety 333

Talk, action and belief not satisfaction at a job well done. So, to right the wrong of low self-esteem is to provide equal opportunities for self. What this means is helping people who exclude themselves and make sure that the rights that are given to others are given to self. Equal opportunities must also apply to people with self-esteem problems, even if this process is entirely driven by logic at first. Techniques of raising selfesteem start by enforcing the idea that self can have a second slice of pie when it is offered. And when people show a positive interest to someone with low selfesteem, the interest was not made out of mere politeness, or that there was some ulterior motive to the request: When people ask for someone’s company, they did mean what they said. But on the contrary, there may be evidence to conclude that self is liked. However, suspicions about the motives of others need to be overcome - and distinguished from false requests and the belief that what is present is a sense of politeness that was never genuinely meant but only stated to obey social niceties. The types of things that people with low self-esteem feel they are not allowed to have are good feelings, the clear rights that are afforded to others at large, that enjoyment is possible and praise can be accepted when it is offered. Alternatively, when criticism is offered that is untrue, it should be identified and rejected as false, even if that does not happen immediately. If techniques to explore and improve self-esteem are rejected, then there will be no improvement. There are techniques that seek to make explicit what the sense of self is, but these can be refused in practice. Without intervention, the baseline is that people with low self-esteem will continue what they began in their youth. This is problematic specifically because self-esteem is particularly suitable for re-evaluation and improvement. The difficulty with the inertia of any belief is that clients can refuse to believe that they are worthy of the most minimal of human rights. On occasion, when asked to be fairer and less prejudiced towards themselves, they will not accept a choice that indicates a possible solution. What this means is that they are unable to defend themselves and begin to cope with strong emotion that makes them feel out of control. One general method of working with belief is to create neutral, opposite beliefs to the toxic ones that have been identified. Statements about belief should be simply phrased. When there is inertia to be over-come, some less toxic belief can be agreed as an interim goal on the way to something more accurate. For instance, a belief like “I am OK” can be substituted for “I am a failure,” on the way to “I am basically a good person but with some faults like anybody else”. Part of asking clients to create new beliefs and helping them to live according to them, is asking clients to be committed to living in the new way, for six months say, and to define the frequency and extent of how the new beliefs will be expressed during this time. Although there is an aspect of low self-esteem that is a type of self-obsession, and the consequent need to protect self against the anticipated consequences 334

Ian Rory Owen PhD caused by beliefs of personal vulnerability and inadequacy, low self-esteem includes guilt, shame, self-pity and unworthiness about self as a result of the loss of affective intentionality in relation to how other people express love and appreciation. How people show the value they have for others is through the following types of behaviours: smiling, touch, wanting to spend time with the other, saying “thank you” and expressing appreciation. Appreciation may have happened, but for the person with low self-esteem, that did not register as people showing respect, interest or care. Despite there being real experiences of positivity that have been expressed, these do not sink in. The belief derived from and maintained by this ‘self-distancing’ contact with others is the empathic understanding that self is worthless for others. Others are guaranteed the rights that are denied to self. In low self-esteem, guilt can be produced by worry about falling short of ideals of performance that are easy for others. Clients with low self-esteem are sensitive to specific events. They choose inappropriate partners and stay with them when the relationship should have come to an end. People with low self-esteem misinterpret others in specific ways. Clients see themselves as being at fault and insufficient with respect to the flawless other and the demands of their context. This may lead to fearfulness in therapy meetings also. The distinctions inherent in low self-esteem can be furthered when the matter of temporality is brought into consideration. The person with low self-esteem holds anticipated, idealised cultural objects as their goal. For instance, he or she does not own a sports car and in reality will never afford one. The desire for the car is unrealistic. But the car can become a measure by which they see themselves as incompetent. The object of value is wanted but has not yet been achieved. The generality of the term “cultural object” is useful in that it refers to any unmet expectations that both dictate the achievement of satisfaction and happiness and act as the measure of that inability to attain the ideal, the perfection (be that bodiliness, a relationship of some sort, or a state of mind). The cultural objects sought-after might include being liked by everyone or never showing anxiety. Persons with low self-esteem do not believe that they are ever capable of attaining their aims. Accordingly, selves with low esteem interpret valued cultural objects as the standard for how poor their own qualities and abilities are. The enabling cultural conditions for low self-esteem are the general breakup of the family, the community and the mass media that focus on highly talented performers, sports people and educators. The dissatisfaction with self is perpetuated through competition and the general tendency of capitalism to promote need and a sense of inadequacy in connection with a lack of goods as a way of promoting sales of the goods. (People cannot have a ring of confidence without a specific brand of toothpaste). The industries that thrive on the creation of low self-esteem are clothing, drink, drugs and dieting that tell people that they are out of fashion and unattractive as they are. The atomised individual has to take 335

Talk, action and belief responsibility for their own future by buying products that will remedy the problem of their lack of esteem. Low self-esteem is a type of internalised snobbery turned against self. And whilst some degree of pride and vanity are helpful and protective, an excessive desire for self-improvement can become a defensive narcissism. Selfesteem can become connected to fashionable products rather than the sense of achievement and satisfaction based on having always tried one’s best and having made the best decisions possible, based on the information received at the time. The way around this problem is to have definitions of good self-esteem that are more all-inclusive and robust so that they can include temporary emotional upset, dissatisfaction and tolerate lack and frustration. Inevitably there will be times of waiting for something to happen in the social world, where nothing can be done. Mistakes will be made and the consequences will have to be born. When it comes to relations with others, then due to past significant experiences, there is faulty empathising of the current other, due to learned sensitivities born of past experience. Low self-esteem can mean that people choose inappropriate partners and can raise a family with people to whom they are unsuited and this has major negative consequences. Past experience colours comparisons with others in the present social context, to mis-empathise others as flawless. A telling distinction is to note that if another person came along and treated the person with low self-esteem in the same way that he or she treats himself, then that would clearly be seen as discriminatory. But as it is self who does this to self, then the connection is not made to understanding how bad self treats itself. It is easier to help other people because it is easier to see their problems and how they fit together. In order to know oneself, it is necessary to know how other people do things, but this type of information is not readily on display. The apperception of self by self is such that the treatment from others towards self in the past, leads to unfair self-treatment in the present. Self is discriminated against, oppressed and treated unfairly by self, without proper attention to basic and social needs. The self treats itself badly in the absence of actual ‘crime’ and ‘sin’. This happens most often because of the treatment that clients received when they were children or adolescents. Specifically, other people have treated them as worthless and without basic rights and abilities. In later life, the influence is so strong that they still model themselves on the image of self that they saw in the other’s actions towards themselves. Low self-esteem means that people are unable to look after their own interests, yet would gladly expect that other people can have what they cannot. The reason for this is interpreted as a ubiquitous belief that the oppressive others were correct: ‘I am a fool. I do not deserve better. I will never be ordinary like other people’. The beliefs of low self-esteem focus on the central “I am no good” but most likely include a belief concerning the empathised sense that other people have

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Ian Rory Owen PhD about self, that are usually of the sort “they think I am no good”. Other beliefs are such as: “I am unworthy”. “I am unlovable”. “I am inadequate and unacceptable to others. I have not got enough ____ to do ___”. “I am less than others. I am third rate”. “I am physically and sexually unattractive”. “My perspective and contributions are useless”. “I cannot do ____ until I have done ____”. This means I am not good enough to begin ___ and I will not be good enough until I have achieved ___”. Frequently, in the developmental histories of people with low self-esteem, there may have been bullying, criticism, a previous failure to meet the standards of parents or peer group pressure from other adolescents. People with low selfesteem show their unfair treatment of themselves. The rights and respect they gladly show to others are not accorded to themselves. Low self-esteem beliefs are maintained in the present through interpreting events with others as a justification to not assert one’s rights. The attainable levels of self-esteem are as follows. Listing four levels of the attainment of self-esteem, from the best to the worst: •

Excellent accuracy of self-understanding is achieved by making reference to good and bad experiences of self in relation to others and interpreting self fairly. Accurate self-esteem continues even in conditions of adversity and self can judge when criticism is warranted or unwarranted.

•

Good accuracy and ability to maintain self-esteem are usually the case, except in adversity.

•

Basic vulnerability and limitations to self-esteem operate across social contexts and are part of the personality due to mis-interpretation and excessive focus on unhelpful evidence and the exclusion of relevant evidence.

•

There is an absence of accuracy of self-esteem most of the time with respect to many regions of experience for the reasons of fixed belief and faulty selfinterpretation that are impervious to relevant evidence.

The general way of working with self-esteem is to identify those regions of past and current experience where the person is doing well. One quick way of doing this is to set homework where clients are asked to list three decisions that they are really glad that they have made across the course of their life. This sows the seed of re-evaluating their worth. In some cases, the regions of evidence to be re-appraised are ones of potential and notes attempts made, even if they 337

Talk, action and belief have not come to fruition. Self-esteem cannot be based on future occurrences but on the valuation of deeds and abilities. The process of re-evaluation of explicit and implicit beliefs about the value of self is towards the general aims of positive emotions, abilities and secure attachment. Specific contexts can be selected to test if self-esteem has been fully altered to be more accurate. For instance, in the context of dating the test is being able to walk up to attractive people in a public place without fear and speak to them and even to be turned away without feelings of rejection or hurt.

Suicide and self-harm There are various strengths of suicidal intent. The mildest form is wishing that death would bring an end to psychological pain, without any intent to kill self. In stronger versions of suicidal intent, support may be rejected and clients become convinced of their worthlessness and lack of a viable future. Similarly to the simple case of shame and low self-esteem above, suicidal thoughts, attempts at self-murder, self-harm and low self-esteem concern being undefended against the forces that exist in social reality and are close to self-neglect and self-valuation. Suicidal thoughts concern a style of rule-bound, inflexible, under-entitled and self-hating interpretation. This view is inaccurate because it ignores the potential and actual positive contributions of the suicidally-depressed person or self-harmer. Suicide and self-harm are motivated by forms of interpretation that express a masochistic attitude towards self. At worst, the negative attitude concerns the fact of being alive. Suicide and self-harm share the interpretation that life is over-whelmingly negative. Life is not a gift or an opportunity for the suicidally depressed. There is nothing good about being alive in the present moment. There is nothing to look forward to and the past is full of painful reminders of ‘gross inadequacy’. If the quality of life were good, then people would be fearful or reluctant in their attitude towards their own death. But for those who suffer in this way, the possibility of release through death or pain is an attractive proposition rather than a fearful one. In suicide, too many ‘faults’ and ‘disgraces’ have occurred to permit self to continue. The anger at self rises and mixes with despair that self can never be good enough. The burden of past failures is so heavy that it wipes out the possibility of future redemption. From this viewpoint suicide is bringing to a close the future and the past. When life is not worth living, the ‘everything’ that has happened (the inaccurate interpreted-sense that is felt) is an immense burden and torture of being alive. Opting for suicide argues that the burden needs to be put down through death. In this context, when a person fails to attend to their own needs and wants, through fear and avoidance, the short-term benefit of avoiding unpleasant emotions 338

Ian Rory Owen PhD and thoughts outweigh the commitment to the person’s long-term benefits and needs. The needs of the future are abandoned in favour of short-term relief. The provision of short-term relief for Burrhus Skinner is called negative reinforcement (Walker, 1984, 1987). The reward is the avoidance of unpleasantness. Inhibition and its consequences maintain the problem, rather than bringing it to a close. Self-harm and suicide are placed together because there can be a progression from self-harm to inadvertent death. This is for the reason that self-harm can be used as a sufficient punishment or replacement for death. The commonality of self-harm and suicidal intent is that they are advanced states of shame and low self-esteem. In connection with specific sequences of emotion, belief and action, negative reinforcement brings wanted and unwanted outcomes. The commonalities of self-harm and suicidal intent are self-directed anger and hate that are obtained through a comparison to some current cultural object that is believed to be unachievable. The role of the ‘unachievable’ cultural object (of staying married, remaining in control or ‘being normal’) is currently ‘unobtainable’ for complex reasons. Such reasons may concern there not being enough time, effort or preparation in being able to attain a desired goal. However, a desired goal that cannot be achieved is interpreted as a measure of failure. A tension exists where the person empathises others as being normal, wholly successful and without disappointments and frustrations of their own. This is due to the strength of the false belief that others, the world and cultural objects are perfect and unobtainable. There is an inflexible and rule-bound quality to the beliefs about self as bad. The time for self-execution can be stated as an “if… then” belief that if something bad happens then it is the time to die. Self-harm can vary a great deal in frequency, type and severity. The most basic form is hitting or cutting. The physical pain creates a temporary relief from a prior state of emotional pain, a complex of belief, thought, emotion, behaviour and relating to others that are altogether unbearable and of a specific character. If there ever were an exemplary case for the existence of negative reinforcement, then it is where the action of self-induced physical pain successfully wipes out prior psychological distress and brings the reward of short-term relief by physiological means. The pain temporarily erases psychological anguish. Another way of interpreting the same situation is to write that clients distract themselves from states of consciousness that are unbearable. This is an avoidance of self-generated emotion and action that are due to belief. Avoidance wipes out consciousness through pain (although similar relief could be achieved through drink, drugs, over-eating and vomiting, gambling, masturbation or sex). The rules that are being followed at this time are similar to the following: “Because of my unbearable emotions and actions, I am unable to function. Only a material solution to my psychological distress will work in the short-term. Therefore, I need pain to alter my consciousness and it is justified because I am bad and deserve to be punished”. 339

Talk, action and belief The beliefs “I am bad” and “I must have my self-harm,” need to be challenged by pouring some scepticism on them. I do not mean in a confrontational way, but in a co-operative one with respect to the evidence that is available. In serious self-harm, there are connections between the three aspects of emotion, actions and thoughts in internal dialogue. Self-harm works as a tool to decrease powerful negative affect. It is usual that the self-talk immediately before self-harm acts as catastrophic justifications (conceptual mis-representations) that are sometimes barely coherent, panic-stricken states that are temporary and concern self-loathing. Other forms of self-loathing are longer-lasting. Sometimes the immediate precursors to self-harm are transient psychosis, paranoia and dissociation (Grinker, Werble and Drye, 1968, p 83). If people are perpetually unable to think and remain distressed, then short-term admissions to an inpatient unit may be the key for creating a sense of safety. If clients are selfharming but not at major risk and are being seen for psychological work, then the grid intervention (chapter 20) is helpful, plus the adoption of delaying self-harm and increasing self-understanding. The therapeutic focus should then be how to understand, tolerate and contain strong affect, and reject impulses to act on them. One way of doing this is to reflect back the emotion concerning what is happening (Rogers, 1986). Verbally, the aim is to indicate that therapists understand what is happening rather than somehow pretend that nothing is occurring or provide a blank response. Simply inquiring into what clients are experiencing at the end session is good to find out what they think of the meeting and provides the opportunity to express and work on any dissatisfaction in the sessions. Other ways of working with strong affect include using distractions from self-harm altogether. The substitution of less harmful and symbolically painful self-destructive acts might be possible as an interim manoeuvre (Rosen and Thomas, 1984). But better still is the avoidance of self-harm altogether and working to help clients see self-harm as a problem to be over-come. Rather than preferring it as a means of immediate relief to toxic thoughts, feelings and impulses. The process of therapy requires re-framing the meaning of self-harm as belonging to a sado-masochistic influence from the past. Full self-observation and mindfulness may also help clients gain a better view of what they are doing to themselves (Kabat-Zinn, 2007). Something like reminiscence therapy may help though employing flashcards, mottoes, new thoughts or calming mental images that soothe rather than add to the flames. It is the role of inaccurate belief and emotion about emotion producing negative self-talk that is the negative feedback that drives the initial problem and promotes a fixation on it. The matter is out of proportion and ends in a secondary emotion because is linguistically-created through negative self-talk and may be about the emotional consequences of the self ’s own emotions.

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Ian Rory Owen PhD From Marsha Linehan (1993), there arises the worth of intentionality once more in understanding how troubled selves can soothe themselves. One means is creating a shift in attention which is a conscious choice to distract self from powerful negative emotion. Others use attentional control in fixating on good and calming objects of attention. Relaxation techniques are also useful (Rossi, 1986). The view of the intentionality model is that the fundamental lived experiences of the relationship of self to self, and between self and other, is that mis-representation exists and plays a role in reifying the sense of self in a negative way. Specifically, there is control and choice of one’s own forms of intentionality (thoughts, feelings, memories, anticipations, beliefs). It is the exercise of choice that is the major weapon in the battle for self-esteem, good mood and functioning. One way is to create a neutral, interim appraisal of self, in self-knowledge and understanding, free of the need to torture and destroy self. Consequently, suicide can be interpreted as an over-reaction to stressors. Suicide can occur in conjunction with an inability to ask for help, to express feelings, an excessive focus on personal responsibility and excessive self-reliance. An example will help. Steven takes the emotion of depression that he feels as properly representative of the worth of himself to others. His excessive focus on it obscured other emotions. Excessive belief in the current sense of loss becomes the experience of the whole of focus in life. This exclusive belief prevented the potential for an object to be unfolded and properly known in detail. His wife Melanie came home to find Steven had hung himself in the garage. There was a note that explained how he felt shame at not being able to cope with stress at work. He felt that he had made certain mistakes that were unpardonable. He had not asked for help at home or at work. He had not expressed depressed in his behaviour. He had prepared for his death in various ways by clearing his desk at work and paying bills at home. Melanie was devastated and told herself that she should have known. But literally, there were no clues. Varying degrees of suicidal intent are noted below. The worst cases are where there is imminent risk. The ability to judge suicidal intent is notoriously difficult. Those at greatest risk may have lifestyles that include the following factors. •

There is a concrete plan stating the conditions for the self-imposed death sentence, plus how and where to die.

•

Recurrent major depression may be occurring. There can be the sense of loss of what should have been, or a loss that is linked with personal shame and gross low self-esteem and impulsivity and low tolerance of distress and disappointment. The tendencies to being impulsive and having a low tolerance of distress and disappointment may also be conducive towards suicide attempts.

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Talk, action and belief •

There has been a recent failed but serious attempt at suicide.

•

There may be chronic pain or a terminal medical condition.

•

There is lack of social support with current drink and drug usage.

•

There may have been psychiatric admissions or outpatient treatment for a major psychological problem.

On taking a vantage point between self-harm and suicidal intent, some further commonalities appear. In both cases, there is a loss of future potential. But on the contrary, no one knows what the future actually holds. In self-harm, the possibility of finding psychological solutions to psychological problems is not entertained. The past and present are interpreted as failure in one or more regions of life. Often, the self is apperceived in all regions of life as being unacceptably poor with respect to others, having permanently failed and never being capable of achieving valued cultural objects. Also, for self-harm and suicidal intent, the future is interpreted as an unbearable burden: “I cannot go on living because of what I have done and not achieved”. The presence of unbearable complexes of experience, belief, emotion, thought and relationships are interpreted as evidence that the person is bad. This creates an obsessional and delusional, self-deceiving quality in the type of depression that may be present. Persons who physically harm themselves or want to commit suicide may well have had a number of failures that stand as evidence of their unacceptability to themselves and others. Once a person knows that cutting will create a sense of safety, there might be the explicit belief that “I need self-harm in order to get release”. The pain wipes away the immediate sense of failure. But this does nothing to alter the on-going standards by which there are ‘failures’ nor does it do anything to bring the repeating pattern into focus for understanding and change. Self-harm beliefs justify self-punishment whereas suicide is the logical conclusion of self-execution. Some successful suicides are impulsive expressions of selfdirected anger and loathing. Other suicides have been considered as possibilities for decades. In the latter case, metaphorically, the person sits on ‘death row’ and finally decides their fate when the ‘circumstances dictate its necessity’. The danger zone is comprised of fixed beliefs of the following sorts. “I am bad, worthless and unacceptable to others. I cannot change. I will never ____ and achieve my ideal. I cannot ____ so I do not function adequately. My situation cannot change. I have brought shame on my family and others and I deserve the ultimate punishment”. The self-loathing of clients can be interpreted to reveal the following sorts of ultimatum beliefs and relational rules, such as: “Unless I am listened to then I am worthless”. “Unless I am understood then I am not normal”. 342

Ian Rory Owen PhD “Unless I cope then I must kill myself ”. “I am so bad that I have to die”. What can help in self-harm and suicidal thoughts are talking more and not staying alone, physically and psychologically. Behavioural interventions are often most useful in raising mood. It is also worthwhile asking people to talk about their feelings, rather than acting on them. Reflecting on beliefs and re-interpreting them in the light of negative reinforcement can change the meaning of self-harm: the belief that drives self-harm permits an action that certainly works in reducing anxiety and self-hatred. But the self-harm action also maintains the low selfesteem that drives the beliefs in the first place. The therapy of self-harm needs to reverse this process, so clients can tolerate, distract or ignore the self-hatred and cease wiping away negative emotion by self-harm.

Eating disorders Eating disorders can be understood as the result of beliefs and intersubjective rules set by socialisation in culture, society and the family, and, as attempted solutions of problems powered by the beliefs held. The sense made of eating disorders is that they are forms of low self-esteem of specific sorts plus an excessively harsh set of ideal cultural objects built around ‘the beauty myth’ that lead to a tension between how the self is apperceived - in relation to a tightly-held belief in the ideal. The beauty myth is the belief that thinness is a guarantee of social acceptability and that everything will be perfect if self is sufficiently thin. The beauty myth is the spurious anticipation that when clients will be sufficiently thin, then she or he will be loved and accepted by others and that happiness will be guaranteed forever. The mythic belief promises its holder that thin people achieve guarantees of acceptability that will defend them from criticism and is an answer to negative emotions. However, the myth never delivers its promise, as well as it being very difficult to achieve. A central facet of this worldview is that clients believe that their acceptability to others is solely based on their physical attractiveness. And that physical attractiveness is inversely proportional to their weight. Trouble arises because these beliefs are tightly held. Further problems arise if any interpersonal conflict or lack of satisfaction occurs because it can trigger further starvation. Anorexia and binge-eating concern the emotional functioning of eating. Anorexia is linked to rejection and refusal of other people. Binge eating has its psychological function in providing short-term relief from distress. But binge eating as part of bulimia has the price of lowering self-esteem after vomiting, laxative abuse or excessive exercising and can increase conflict and emotional distress. In the case of bulimia, there is both dieting and binge eating. Whereas in anorexia, if there is a problem of any sort, the person seeks to re-double their efforts to be thin. 343

Talk, action and belief Anorexia, bulimia, binge eating and long-lasting dieting, or dieting and normal eating due to hunger, each have a psychological role in creating material solutions for psychological problems. Most often, the events that lead to dieting or binge eating begin with increasing psychological distress due to false and inaccurate beliefs that lead to the self-induced withholding or over-indulging in food, as an attempted solution. This is an answer of a physical sort for a psychological problem. But the attempted solution entails unwanted consequences of a different psychological kind altogether. Specifically, persons hate themselves for being out of control and having acted on the desire to over-eat and vomit, thereby punishing themselves and wiping away the temporary relief from prior negative emotion. Whatever the specifics of an individual case, food plays a psychological role in altering emotions. The major aspects of anorexia concern having a thin body that is believed to guarantee social acceptability, no matter what. This is partly for the reason that the belief is held that people judge others on their appearance and that this belief must be obeyed. Depression in anorexia occurs if eating is indulged, or the person has not yet attained the anticipated and idealised bodily self of sufficient thinness. The ideal bodily self is out of reach yet desired. The ideal fuels starvation that can lead to death. Others are mis-empathised according to their body size. The anorexic view of self co-exists with the empathising of what others think self should be. For instance, the ‘horror’ of a fat body is interpreted as a lack of self-control. A thin body is interpreted as moral superiority, self-control and the model for social acceptability. For the anorexic self, self-control is interpreted as part of the solution to attain the desired state of thinness and acceptability to others. There may be a great interpersonal sensitivity to criticism and judgement from others about the anorexic’s body. The body of the anorexic person may well elicit non-verbal communications of shock from others, because anorexic people are obviously starved. Such non-verbal responses from others can act as a signifier for further interpretation of their unacceptability that requires more starvation in order to achieve the sought-after acceptability. The general nature of apperception at play is one of self-criticism and non-acceptance of the bodily self. One’s own body is apperceived as a sign for the worth of the whole personality and their personal history. In anorexia, empathy is inaccurate because it is believed that others will think badly of self in a general sense in the absence of any bad behaviour. One way into this system of evidence and belief is to help anorexic people step out of their beliefs and help them come to realise that it is they who think badly of themselves and they donate their mis-empathy and beliefs to others. In bulimia there is a more ambivalent situation where the defining characteristics of composite intentionality are an oscillation between eating and dieting. The time taken for the changes can be within a day, across a week 344

Ian Rory Owen PhD or between months. Two sets of beliefs are in opposition. One justifies eating, its sensual pleasure and the physiological sense of satisfaction that promotes psychological relief instead of distress. Another set of beliefs, more characteristic of anorexia also exist, where a thin body is valued but has not yet been attained. These beliefs form ambivalent unobtainable goals and act as an anticipated idealisation that become a measure of failure, worry and self-criticism and can confirm low self-esteem and depression. When vomiting is present, it connects to the sense of self-control, in that vomiting can be used to try and stop self feeling depression, anger or other strong emotions. However, the relief is only temporary and the sense of it may lessen as persons return to interpret themselves in a critical way and tell themselves that they have no control over their lives, their actions or emotions. This apperception of lack of control lowers their self-esteem. Vomiting is negative reinforcement that maintains the low self-esteem and inability to tolerate negative emotion and frustration. Binge eating without vomiting or dieting also qualifies as an eating disorder that may have a psychological function as a replacement for bad feelings, lack of self-esteem, or as both a reward and a comfort. In binge eating, the overeating can be a defence against negative frustrations (and a reward for successes achieved). Thus, eating functions like alcohol or drug abuse. If something good or bad happens, either is a justification for over-indulgence. The following example of bulimia and depression should make these general comments clearer. Developmentally, because of chronic marital conflict between her parents, Carol, an only daughter, took on a sense of responsibility for her parents’ happiness. This began a need to please others and win her parents’ approval as she did not feel deserving of their love or attention. On the death of her father, and whilst feeling lonely and away from home for the first time, Carol found that vomiting helped reduce the sense of loneliness. What also occurred from her teenage years onwards, was a long-standing depression and inability to separate herself from her parents, particularly her mother. However, the inability to achieve happiness and the inability to be separate from her mother continued hand-inhand with the role that vomiting had as a method of erasing specific emotions. What happened in this situation is low self-esteem in connection with low mood and high ideals that were unattainable were kept tightly in focus as ideals for achievement. These factors inter-acted with the occurrence of chronic depression, the inability to feel self-worth, great difficulty in giving up the vomiting and beginning to choose a better future. In therapy, although Carol was unable to feel good about herself during the first 30 sessions, she was eventually able to begin to look after herself and did work to improve her mood. Her depressions became shorter and less intense. Hope returned, as did some positive anticipation of the future. Carol broadened her interests away from her previous fixation on negative emotions. It was then that her quality of life began to increase. 345

Talk, action and belief The types of beliefs in bulimia are more complex than anorexia. In anorexia, the beauty myth predominates and is the only answer. The beliefs common to anorexia and bulimia are of the sort: “I must be acceptable to others”. “I must be thin to be beautiful”. “When I am thin I will be acceptable”. “Only people who are thin are acceptable”. The person must be thin and the thinner the better. People are valued on their physical attractiveness. Those who are ‘fat’ and ‘ugly’ are bad people and are not in self-control. They are over-indulgent which is morally repugnant. In bulimia, there are two opposing sets of beliefs. “I must be thin” and “I hate food;” co-exists with “I need to get rid of bad emotions now, so I will eat in order to vomit and gain self-control”. In bulimia there can be the desire to vomit and purge self through laxatives or enemas. This is a form of self-harm that feels good because it provides temporary relief from worry induced emotion. Yet sometime after the relief is over, there is likely to be an increase in low self-esteem. The vomiting also acts as a temporary release from depression due to pervasive low self-esteem. There are different versions of bulimia and some show a slow cycling from one set of beliefs (that permit over-eating, at one time) to demanding its tight control at another.

Neglect in the family of origin Neglect in the family of origin can be due to a number of ‘causes’ such as divorce of parents, re-marriage or poverty, workaholism in one or both parents and enmeshment between a child and parent (where the child cannot become separate whatever their age). Or there being a lack of attention to the child for any reason including depression, absence of the carers, self-interested carers or there being a large number of siblings. The lack of attention promotes a version of low selfesteem that may co-occur with insecure relating. In order to understand this type of problem, it is necessary to begin with understanding child development. One problem of the abuse and neglect of children is one where purposeful behaviour has existed to exclude, ignore, berate or scold children for expressing their genuine requests for assistance. How this can happen is through a variety of means from the clearly sadistic to merely being over-looked, as though the child was never eligible, or somehow, there was never time for being loved. When this happens, it is frequently the case that children who have been abused and neglected have great difficulty in anything other than seeing themselves as bad or useless and have difficulty in looking after themselves. Because of early psychological damage, the perpetrators ‘knock the survivors off-course’ for decades afterwards. The forthcoming ‘personality’ defences need to be recognised for them 346

Ian Rory Owen PhD to be clearly seen as unhelpful and unnecessary and to enlist the full potential to make adjustment for them to be over-come. The phenomenon to be honoured is the plain fact that early child abuse and neglect are pervasive in casting their shadow forty and more years after their occurrence. The effects can be a deep and pervasive inability to relax, distrust and a tendency to avoidant and or ambivalent attachment that can be seen in numerous failed close personal relationships. If abuse has been sexual, then being sexual can be a way of maintaining identity and function positively as a defence against unwanted feelings. Or, there can be fear of sexual intercourse and attachment relationships. According to the intentionality model, what is most important is not that people who are neglected or abused are unable to reflect on themselves and have difficulty in feeling and understanding their emotions (alexithymia). The problem concerns the senses that are produced are insufficiently clear, to be capable of providing guidance. (A person who is unable to reflect on themselves and their own actions would be unusual indeed). The difficulty in not knowing one’s sense of self is due to being unable to relate self to the probable senses that others have. There is no such thing as self-empathy but there is such a thing as imagining self through the eyes of others and being able to grasp the intent and nature of specific other people and empathise the value and image they have of self in their actions and speech. The difficulty in interpreting self, for people who are neglected and abused, is that the experiences they have arise for no wrongdoing of theirs. The ordinary world never discusses experiences about the neglect and destruction of childhood and adolescence, the foundation or ‘first direction’ of the personality. Therapy is different in that it is an attempt to talk about things that are not part of the everyday culture. The meetings have the purpose of being a cultural brokerage for those who are lost and mis-guided by their false beliefs from childhood. However, if there is a pervasive absence of the sense of self, it means there is an inability to take direction in life and know what suits and what does not. The reporting of the difficulty in “representing” self means that the feelings of enjoying self either do not get connected with memory or that positive feelings do not appear in the present. The lack of representations of self means that there is no connection between thoughts, feelings and the immediate feedback that one is doing something worthwhile. (This might be because it is not worthwhile). Affective communication exists in a rudimentary form for children. They may be correct in understanding what their parents feel. But they are usually unable to realise why their parents feel as they do, even if they have had it explained to them. For instance, a father is angry at home and criticises the rest of the family. The children may be apprehensive generally and fear criticism whilst they are small. Once they are larger they may well fight back, verbally and physically. For children, a basic understanding of the angry parent is achieved but they are not able 347

Talk, action and belief to empathise the present in a more wholistic way. Through repeated experience, the children become sensitive to the emotional state of their father and anticipate criticism and attack. They need to be sensitive to his moods in order to know how to act around him. They become used to wanting positive caring attention but get rebuffed time and again. The situation continues for the teenager and young adult. Once the child leaves home, the set of expectations do not get forgotten but persist and interfere with other relationships. Neglect-induced low self-esteem can arise in a variety of specific forms and is representative of attachment phenomena in the lives of adults within family, friendship and work. The senses of others are ambivalent. There is an anxious relation in an insecure attachment style with a partner, parents, siblings, colleagues or friends. The apperception includes self-directed anger and self-criticism. What may also occur is a region in life that is developmentally delayed due to some sensitivity, trauma or multiple traumas in earlier life. It is not just the case that there are deficiencies in the attachment figures and relationships with parents, step-parents, abusers, bullies and other children. Neglect is not about the type of damage that has been done either. What is recognisable in childhood neglect that leads to adult self-neglect is an impoverishment in the overall psychological life of the individual. This can be present in a number of ways. These ways include flattened affect, poor overall functioning, preoccupied attachment and lack of assertiveness in intimate relationships. There may well be on-going dissatisfaction in the family, particularly in the cases of estrangement, divorce, step-families and when there has been abuse. When there is an impasse, there is a place where the person and those around them are stuck in conflict and unable to empathise each other’s position. What is entailed is fixity, a default or defensive position, a fallback belief. For instance, a fixed belief concerning the past is mis-applied and recurs in the present. Because the impasse is not comprised merely of belief, but is a whole of various parts, there will not be a single area of delayed development and relationship (in a broad sense of relationship). But there may also be an atrophy of social skills, an adherence to phobic fear, a conflict with parents, siblings or others that are on-going and not resolved. This type of distress can appear as depression, lack of assertiveness, or pervasive anger at a step-parent with timidity and fear in other areas, for instance. These are all ‘caused’ because current relations are out of balance. The type of dis-harmony in the past is related to the type of dis-harmony in the present. It is possible to take the end-products in the present and interpret them as being due to identifiable factors in the past, in active discussion with clients. On some occasions, mere discussion and trying to encourage reflection and thinking about what has happened may be sufficient for some clients to grasp the reins of their lives and make necessary changes. In other cases, the person is unable 348

Ian Rory Owen PhD to attend to themselves, in neglect-induced low self-esteem. In cases of neglect, the person has no experience of being valued or comfortable in being the centre of loving attention from others. In some cases, there is no sense of themselves as an actor with a future. Nor is there any way of judging what they like or dislike, should search out or avoid. In such situations, “anything will do” because no option is any better or worse than any other. The adult-self perpetuates the neglect of the needs of the child-self: They are undefended, in that they do not give themselves sufficient care and attention so that problems arise. When problems concerning themselves, self-care and personal needs arise, they find it difficult to take action for their own benefit because they have never done it before. The effects of the original neglect are deep-seated and corrosive of the ability of clients to know themselves and others, identify outcomes and work towards them. If this is the case, then what appears is a pervasive inability to bring about genuine satisfaction from life and so aimless depression occurs. Because a prior means of dealing with these difficulties has lasted a long time, it means that forms of coping have been over-used and re-invented in the present. However, there may have been an initial event and an attempted solution that began in childhood, that is being reinvented in the present for different reasons in a more severe or complex form. If client and therapist can agree and discuss some key aspects of it, the painful senses and the current situation can be managed, then that may be sufficient. Clients who have been neglected as children may have great difficulty in identifying their own beliefs as much of the problems they face exist at a level of emotion and constricted lifestyle that require being made explicit in order to know how to act. There may well be problems with motivation to change that need to be addressed at assessment so that explicit commitment towards a goal is asked for and received, prior to commencing work on a focus. This helps reduce the problem of ambivalence in having clients who claim they want to achieve a goal but are not adequately motivated to make changes towards it.

Attempts at security in talking therapy Clients with a variety of complex problems may want a relationship with their therapist in the sense that they want to be close, be given attention and speak honestly about what is really troubling them. This might be because they believe that therapy is a confessional or that they wish to disclose and discuss something for the first time. But wanting to tell the truth about oneself and one’s problems may be an ambivalently held wish. What is being asked of therapists is to bear witness to some aspect of clients’ lives. The understandings that clients have made of the therapeutic relationship imply that therapists should respond in a way that is helpful, emotionally and otherwise, corrective (Alexander and French, 1946, 349

Talk, action and belief p 22). This may entail therapists supplying new contexts for understanding to replace the harsh conclusions that clients have told themselves. The medium for help with this type of problem is most likely talk rather than action because what needs to be discussed are complex situations. Rather than seeing people with these characteristics as inappropriately demanding, it is more helpful to see them as trying to establish attachment security. The Freudian techniques of free association and free-floating attention are useful to let clients speak their minds and for expressing their intentions and experiences without fore-closure. However, the technique of the basic rule that demands free association from clients and free-floating attention from therapists is an ideal. The ideal of free association is to speak thoughts and feelings immediately as they are experienced. But it is forever defeated by the prior understanding of both parties (Reich, 1933/1970, p 4, p 40). The power of listening and being transparent to clients through checking out empathies of them should not be under-estimated in its curative potential. Free association and free-floating attention have promise in allowing clients with complex family backgrounds and numerous psychological disorders to explain themselves and set an agenda with their therapists. Free conversation is where no topic needs to be set to explore issues with clients who want to speak freely and where the free flow of ideas is sufficient to create change. It is my observation that people who want to self-disclose and relate with therapists are those who want security generally and are ‘relationship hungry’. They may not want to take part in specific action-oriented interventions, problem-solve or participate in a structured therapy. These clients may want to engage in an intense relationship and want to connect with therapists and have them bear witness to their life. Such clients ascertain, in an oblique manner, if the therapist approves of them, their choices and lifestyle. Perhaps they have a specific question to answer like “finding out what life should be about”. This case is one where clients should be assessed for their ability to use speech and make use of free discussion without any agenda in order to clarify their thoughts, feelings and beliefs and make their own decisions about how to act differently. In my practice I find attempts at security-seeking and self-disclosure a spontaneous phenomenon. Of the aetiology of this attempt at a secure relationship, I can say nothing at this stage. I can speculate that there has been some security of attachment in the past and that this has not been too damaged so that it spontaneously re-appears in the therapeutic relationship. However, the free conversation of topics crucial to clients is closest to the free association and freefloating attention model of Freud’s psycho-analysis of speech and relating. Clients who aim at security use the opportunity of the therapeutic relationship as a restorative experience for exploration. When this spontaneously occurs, it means that these persons are ideally suited for talking therapy. The 350

Ian Rory Owen PhD ability to achieve security and self-disclosure with therapists is usually attained after guilty or fearful expression of past and current events. Most clients are capable of discussing psychological matters. (Those people who are incapable of such discussions may not be offered therapy). Emotional intelligence is the ability to reflect and re-interpret self in the light of the evidence and discussion. Spontaneous changes and re-frames of meaning occur when telling a life story. What often occurs, with little addition from therapists, are improvements in selfesteem, self-acceptance and the greater acceptance of others plus other increases in psychological understanding. There also seems to be a sufficiently accurate empathising of therapists, despite anticipatory fear, desire for wanted reactions and fear of unwanted reactions. The recollections of lost attachment figures in the past, some of whom may have been major influences, can be part of delayed grieving that is both painful and necessary, in order to move on. The beliefs within the heterogeneous group of people who want security cannot be summed up. They have not lost all faith in human nature and are trying to make sense of themselves and their world. Some ambivalent beliefs are of the sort “I want reassurance” but the person might be unable to feel reassured immediately when it is offered. This is because there are two sets of beliefs operating concerning the desire to be secure and the fear of the same, because they fear losing control or cannot, or will not believe that they can be helped by the therapist, or get what they want in their lives.

Spoken or unspoken dissatisfaction The last example of this chapter comprises those who are “hard to help”. Those who despite having had an assessment interview, and the process of therapy explained to them, and have explicitly agreed to participate in what therapy demands, may meet a series of events in the meetings that do not tally with their previous inaccurate anticipations of what would occur. Those who have been assessed as capable of taking part in a specific type of therapy, but who then leave therapy early, are a special case where more learning can be achieved about how to set up therapy for others. What can happen, if the therapist does not realise that something is amiss, is that clients do not return to a planned session and cease to respond to letters asking them to return or discuss what has happened. What might have happened in this situation is that there may have been one of a number of mis-matches probably due to client expectations that have not been met. This final case is put forward for pre-emptive action at assessment or during the first few sessions. What usually happens is that some negative emotion or occurrence for clients means that they cease attending after assessment or early on, and may never voice their reasons for doing so. If clients are dis-satisfied with 351

Talk, action and belief the therapeutic relationship they “sack” therapists by not attending. Clients may also not respond to letters or phone calls asking them to attend. Therefore, the tales of absent clients need more elicitation and interpretation than the other sorts of psychological problem noted above. In this case, multiple factors result in the same end-product: needy clients who might be able to receive help prematurely fail to return to sessions, usually within the first two or three visits. Often therapists have no idea that clients will not return and the absence is a surprise to them. But in other cases, there could be a range of factors that lead to what is clearly an unsatisfactory state of affairs for persons. Yet therapists may never have the views of these clients directly expressed to them even if they have asked for feedback. In this circumstance, therapy can come to a halt for some of the following reasons. •

Clients maybe unable to understand a secure therapist offering a time-limited opportunity for secure relating within the confines of confidentiality, time and place. The secure person is mis-empathised as smug, all-knowing, glib or in other ways as unhelpful.

•

Clients may feel exposed after self-disclosing. If so, the shame felt in speaking the truth for the first time can bring the treatment to an end.

•

Clients may dislike focusing on suppressed thoughts, emotions and relations and feel that the consequences of speaking about such feelings and events lower their self-esteem. For some, all that matters is fixing the problem without trying to remember, feel and understand it in any detail. If this is the case, they may need to accept the necessity of some experience of distress.

•

The communication of non-attendance at a planned session can be an inhibited complaint or communication in relation to a question or distress that was never voiced: The absence is an unspoken, imprecise communication and relation to therapists. Possibly, there is some negative interpretation of the therapeutic relationship: It has missed or is expected to miss something that the client cannot voice. Perhaps it is anticipated that the therapist will not understand what needs to be said. Or the anticipation that expressing their distress will result in rejection.

The forces that clients might struggle with include an unwillingness to tell the truth for fear of shame and disapproval. Clients can incorrectly predict the concomitants of having therapy. Clients may obliquely talk around what they might want to say. Or express their fear and negative anticipation through the inexplicit action of failing to attend an appointment. For instance, Rob says that he would like to live in Thailand but does not say why. When comments come out of the blue, as non sequituurs, they might be self-disclosure. If therapists do not 352

Ian Rory Owen PhD pick up on such clues in the moment, the opportunity to explore their material and engage them is lost. Further still, there may be beliefs that talking cannot change anything or the inability to believe that self can be different or that change can occur. These possibilities contra-indicate having therapy and show that clients are in the “pre-contemplative” phase of not yet being prepared to do the necessary work (Prochaska and DiClemente, 1992). Other possibilities include some magical idea that visiting a therapist once will solve everything or there are other unrealistic assumptions that some magical change to the past or present will occur. Therapists cannot comply with such expectations and there may be disappointment leading to absence. Some clients may not feel helped by talking and reflecting on their problems. They may feel strong negative emotion, exposure, shame and embarrassment. If this continues, they may feel that the effects of focusing on their problems in speech alone only upset them without problem-solving occurring. So they find that what is meant to be helpful turns out to be de-stabilising. On this occasion, talking should help people know what they feel and help them think it through, by themselves or with the therapist, in a spirit of throwing off low self-esteem and finding greater self-acceptance and self-worth. For those who cannot tolerate strong negative emotion, or emotions of specific sorts, there is the possibility that making-conscious suppressed memories, thoughts and feelings ‘cannot be accepted’ as part of self or worked through: Thus, clients are left with unbearable feelings. For them, perhaps action therapy and pragmatic problem-solving are the only way forward without medication. The beliefs that this group hold might include the interpretation that they are beyond help or that their therapists are useless and do not or cannot understand. But this is potentially part of their lack of understanding and inability to trust in the process of psychological change even within a secure relationship. Some typical beliefs are of the sort “it is pointless to try” that may co-exist with seeking out help. Despite completing assessment and clearly stating that they will be fully active in the therapy, people can change their minds after beginning sessions due to their own negative ways of interpreting and their ability to be insecure.

Summary In summary of this overview of six views of the psychological world, a handful of psychological problems have been discussed in order to show how the concepts of belief and intentionality fit the experiences of clients. Clearly, there are many other possibilities.

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19 Interventions concerning talk and relating Aim: This chapter makes talking and relating interventions understandable by emphasising the role of using intentionalities of different sorts, altering the objects chosen and the contexts for understanding. This chapter outlines some key points for the talking and relating aspect of any therapy in addition to its previous treatment in chapters 4 to 7. The sequence of topics in this chapter begins with empathy, non-verbal communication and emotion before going on to the details of how to work with the therapeutic relationship. The aim is to respond with honesty and tact in conversations that are either completely without an agenda or form a series of meetings where a minimal agenda has been agreed, like discussing the effects of childhood on the present. Because a potentially infinite amount of novel relationship events can occur, the approach below is to explain the basics of how two-person relationships make sense, between self and other. The ability to think and interpret feelings about self and other people is required for both parties in 355

Talk, action and belief therapy. A general strategy is not to be hasty but to be considered and thoughtful, and inquire into what is happening for the other person and self. The sense of the other person is an accumulated sense of one’s thoughts, feelings and empathies about them. Beginning, maintaining and ending the therapy relationship are three crucial aspects of practice. The responsibilities of therapists are to lead in a number of ways. For instance, therapists should set boundaries for meeting times, frequency, cancellation and payment. What follows are comments on the most basic interventions of talking and relating.

Returning to empathy The matter of how to express self non-verbally in every possible situation is too detailed for this introductory account except to say that therapists should be attentive to the slightest changes in the voice and posture of clients that might indicate that clients are changing emotionally in the moment. Empathy is the received sense of the whole meaning of another person’s current conversation and non-verbal presence. If the content of the logical meaning of the communication were taken away, what would be left is the non-verbal visual messages of eye movements, facial expressions and the overall non-verbal sense that co-occurs. Empathy enables meanings to be public (Husserl, 1950/1977a, §55, p 120). If there was no empathy, there could be no communication because logical sense is public and predicated on the existence of empathic non-verbal communication and understanding. The way that empathy works is that it presents an immediate emotional sense of the other and their situation. If we consider the case where the therapist expresses him or herself congruently, verbally and non-verbally, then to cut a long story short, then either clients catch the meaning accurately as it was sent – or they mis-empathise and confuse the general tendencies and worries that they have with the message that is actually being sent. On the side of therapists, it is part of their role to be clear and congruent communicators, most of the time, and to exemplify the role of carer. If clients do not check out and are permitted to build up faulty understandings of the intentions and aims of therapists and their meetings, then unchecked, assumed and wrongly anticipated complementary responses will come from clients and be concerned with their fears and worries and other negativities. To sum up, the theoretical conclusions that enable this discussion are the realisations that: •

Empathy connects people together in living in the same world, with a broadly similar set of cultural objects, desired conventions and taboo relations to objects.

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Ian Rory Owen PhD •

Empathy adds the profiles and perspectives of different persons to those of self. This creates the socially and temporally distributed understanding of the same referent by people in family, culture and society. The overall accumulation and integration of manifold experiences, that comprise the distribution of views on the same referent, could be understood by an empirical study of how such decisions to believe and disbelieve are made. To be more concrete, the understanding of anorexia for the person who has it is first hand, for their family, their understanding is second-hand. The understanding for mental health professionals is second-hand but different again.

Through empathic intentionality, there are intentional achievements of higher sorts concerning all kinds of social meanings, values, rules and practices. Reflection on personal experience, a self-interpretation, can lead to accurate knowing and understanding of what is happening. Higher still, there can be the achievement of satisfaction and desired outcomes, through accurate beliefs, desires and intentions that hit their mark. The highest form of reflection on meaning occurs when it is possible to understand that there may be differences in the accuracy of some beliefs because of the perspective taken and that explains the outcome obtained. The empathic awareness of clients occurs through the life experiences of therapists that have been re-considered in their training therapy. A wide set of life experiences, confidence in the ability to help and knowledge of the nature of the therapeutic process, enable therapists to engage clients from a wide range of backgrounds. The body of psychological knowledge that is employed is a mix of the emotional and the intellectual, the specific and the general. How therapists appear to clients is communicated non-verbally in the facial expressions and the content of the shared discussion. If a therapist is persistently non-verbally blank, it is a real communication of dis-interest and lack of support. The best way to aid practice is to return to the theoretical understanding of empathy, so that by interpreting it, formulating it, it becomes possible to understand where error and mis-understanding can arise. The social learning that is the basis of empathy makes a link between how people appear visually and auditorially. When there are problems with empathy, for instance, they are of the sort that an inaccurate feeling can be held as accurate when it is not. One example for therapists where this can be problematic is when the feeling that therapists can help gets over-valued far in excess of the actual ability to help. This is a problem of being over-optimistic in judging the ability to help. •

What empathy does is take a small amount of speech, in the context of the non-verbal expression of emotion of another person, and turn it into a visceral understanding of what happened almost as if it happened to oneself. Thus, empathy is at the centre of the human capacity to co-operate and share 357

Talk, action and belief information. The phenomenon of empathy is the gateway to social experience and public meaning. Persons who have a severely damaged ability to grasp the social world are unable to function in it as properly social beings. •

It is a direct consequence of this definition of empathy to realise that the entirety of human civilization, is given through empathy with others. Empathy provides the universe of meaning in a manner that can be theoretically specified, in advance of any practice or research. Empathy is the root connection between people producing meaning, social practices and being social creatures.

With these points in mind, let us recap the experiences of insecure clients. Their mis-empathy of a securely-relating therapist is the re-creation of negative feeling and action, related to their own history that is retained in involuntary memory. The experience of danger and threat serves the purpose of warning against further mishap. Sometimes this is highly complex accumulations of infancy, childhood and adolescence, and sometimes the problems can spring from adult experience. The relationship is mediated through each person making sense of the other’s verbal and non-verbal communications. When clients mis-empathise therapists, it is due to the implicit belief (that creates “primary emotion,” explained below). Thus, strong negative emotion can be entirely due to false understanding that mistakenly guides relating and interpreting inter-actions with the therapist. Persons who have attachment disorders have strong tendencies to mis-understand others on a regular basis, and whilst the content is different, the style of misempathising is regular and identifiable. Emotion and empathising are general terms for practising talking, relating and taking action about the current social context. For instance, people can have homicidal rage and imagine attacking the perpetrator of abuse but that does not make them a murderer. Indeed, the rage is understandable. The term for over-coming strong emotion is “dis-identification”. For instance, “I am not my feelings. I do not have to act on my feelings” is one way of counter-acting fixed beliefs and strong negative emotion. Empathy provides psychological meanings that can only be rightfully apprehended by going beyond perception in the five senses, in order to catch what others mean. To understand a situation psychologically is to grasp what others mean and be able to think through what they are saying and its possible connections, in the heat of the moment of being with them. At heart, the experience of empathy is the immediate provision of a whole of what it is like to be another person, and be in the world as they are, with the people they know. Specifically, it involves a learned appreciation of what it is to be like other persons and understand different walks of life. The learning is never explicitly taught but rather comes with time through living in a wide set of general life experiences.

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Ian Rory Owen PhD The “first gear” of therapy is to provide the core conditions of empathy, positive regard and congruence as Carl Rogers discussed (1957). But for the intentionality model, these conditions are not the whole extent of therapy. “First gear” is being empathic generally and being able to understand the viewpoint of others’ at the same time as one’s own view, and being able to flit back and forth between the two. Empathy is the quasi-presence of the perspectives of others. Only secondarily is it communicated through supportive comments that promote understanding. In addition to what the person-centred tradition has written on the matter, helping clients trust their own experience, accept it and understand it, and the provision of understanding are part of the process of opening up material for understanding. Sometimes therapists might get this approximately right first time. Or more likely, they may provide explanations of the functions of problems that are novel and surprising at first and may take discussion and contemplation before clients accept them. Dogmatic assertions that are closed to discussion have no place in therapy.

On non-verbal communication Attention to the non-verbal presence of clients is an attention to how they are emotionally in the moment. With expressive non-verbal communicators who are congruent in showing what they feel, these people ‘speak non-verbally’ before they have opened their mouths. Their stance and demeanour says their message first and then they say it in speech. The non-verbal sense they express physically can be compared to the verbal content and the overall predominant non-verbal presence. However, it can be noted that sometimes the sender makes discrepancies between the verbal content and the non-verbal manner. This is not to claim that there must always be congruence within the overall communication. For instance, that is how some jokes work. The non-verbal seriousness for light matters conveys a sense of the pretentiousness of what is being said. Or an excessive constriction in the throat makes the speaker sound like he or she is putting on a false voice and does not mean what is said. Non-verbal expressiveness is the basis of how to understand emotions on both sides of the relationship: there is a certain type of immediacy taking place. If clients do not like what they are hearing, or balk at the idea of some remark or interpretation, then they are immediately responsive and express that non-verbally, even if not verbally. If it is possible to be aware of the non-verbal communication as it is happening, then that needs to be used through checking any non-verbal senses gained, as it is possible to mis-understand even highly congruent other people. What happens is that a facial look or a verbal or physical withdrawal happens. These are non-verbal signs of tension, disagreement, conflict or potential or actual rupture of the relationship. These events may include a change in facial expression 359

Talk, action and belief or the absence of expressed thoughts and feelings about the consequences of what therapists have said, or clients mis-interpret what is being said. For clients there is a withdrawal: A lack of verbal responsiveness, a felt-distance and silence might show hesitancy and irritation at what is happening. This is a time to have a minireview and ask clients to express verbally what is happening for them. From the point of view of clients, how therapists compose themselves is important. For how the practitioners act, sets the tone of how clients empathise how they are being received. Generally, the business of providing therapy is a serious one. It would be highly inappropriate to smile in the middle of being told of trauma and matters of concern and cruelty. Yet there will be lighter moments when it would be out of place not to laugh with clients. In a different sense to verbal self-disclosure, there will inevitably be two-way non-verbal self-disclosure in the moment-to-moment, non-verbal responsiveness of any two persons. In the light of attention to the non-verbal aspect in human communication generally, people non-verbally ‘speak’ to each other without saying a word. Non-verbal expressiveness can either contradict or support what is being said verbally. When the non-verbal message is congruent with the spoken one, people effectively ‘say’ the same thing twice. The role of non-verbal communication in meeting with people is a meaning-oriented, imprecise affair. For people who are resistant and unassertive, it is sometimes the case that they show what they feel but ‘cannot’ say. How they express themselves through their bodies is unclear in comparison to speech and it provides a background sense to what is said. Sometimes, non-verbal communication is not properly conscious for both parties. For instance, Malik, a paranoid client, creates wariness in his therapist through body posture, tone of voice and repeated requests for explanations about confidentiality. This sets a frame for further logical content to be understood as potentially false and capable of some other meaning, so producing an un-trusting response. If the reasons concerning how others communicate can be understood, then it will be possible to separate their un-intentional communication from the intended one. For instance, Roger is deeply depressed. His face is fixed and expresses anguish without any flicker of responsiveness. It is not until his mood picks up does his face begin to express any liveliness. At first his therapist feels hopeless but is able to understand why this is the case. In future meetings, when the two people have got to know each other better, then it is possible to respond to Roger according to an accurate understanding of his mood. What is sent and received can be clarified. Occasionally, it is possible to pre-empt what clients are saying or implying. For instance, the way forward is to point out how something they are suggesting might interfere negatively with the aim of therapy. Some persons transmit indecipherable messages because of the way they hold themselves, use their facial muscles and tone of voice. Other persons do not transmit non-verbally and appear blank and lifeless. This might be because 360

Ian Rory Owen PhD they are tense and their faces freeze up. Others still may transmit non-verbal congruence with the content of their speech to produce the overall message “I am speaking the truth as I see it”. However, because of the medium and the immediate means of understanding it, what is transmitted may not be what those others consciously intended to transmit. Indeed, they might not realise they are transmitting the particular non-verbal sense that is received by others. But what comes through - due to a tight throat, for instance – is a voice tone that sounds like sarcasm, for instance, and the overall message is disturbed because of the nonverbal tone of speech. The sense received is that the speaker never says what he actually means and that makes the hearer’s flesh creep.

The consequences of an attention to non-verbal communication Being open to non-verbal communication is being able to pick up the feelings of others or a group, but the sense received is vague. For instance, just by being in a room and looking around, it is possible to feel if a group is tense, angry, in dispute, bored or happy. Picking up a single person’s emotional state is open to inaccuracy even for the most experienced empathiser. In empathy, what appears perceptually is the speech and actions of oneself and others. But none of what appears perceptually is the psychological meaning of the intentions of the other. Good actions from others do not mean that the other has good intentions. And the verbally expressed good intentions of others do not mean that their actions will always be good. Others can have hidden, bad intentions and employ deceit. The attitudes that they express may provide no clue as to what their actual intentions are. Understanding communication means understanding that how something is said is a meta-message that can override the logical content of the verbal communication (Bateson, 1972, pp. 177178). The many styles of communication attest to this. These include sarcasm, irony, and flirtatiousness. Through the non-verbal component a double message is created. Literally there is a logical content spoken but the non-verbal metamessage may well set a context for a second message altogether. For instance, “hello” said in a cheery manner is a greeting. “Hello” said in a seductive manner initiates a flirtatious conversation. Problems arise because the alleged intentions of others as expressed may not tally with what the other person interprets those observable behaviours to them. The other person may conclude that the actor has different intentions altogether, to those that have been expressed. Intentions are opaque. A lie is when a person expresses false intentions with the sought-after result of mis-leading others away from their true intentions. So whilst a person’s speech and actions are public, 361

Talk, action and belief their intentions are not. It is impossible to see another person’s motivations from the outside of looking at them. It is possible to judge their behaviours that are observable, or discuss with them their intentions in order to see what their track record has been so far. Similarly, behaviour can be carried out for different reasons. Why one person chooses an action can be different to another person choosing to do the same thing. One way of understanding congruent and incongruent verbal and non-verbal communication is to make a comparison with the case of lying. Lying can be defined as the explicit intention to speak a falsehood in order to obscure the truth of actions, intentions, thought and feelings. Part of lying is for liars to cover their tracks by stating they had a positive intention in their behaviour, when it appears clearly destructive or exploitative to others. The liar needs to hold both the truth and the lie, and not confuse them. Providing false intentions to explain behaviour is an attempt to explain it as a reasonable response. For other persons, the same behaviour is understandable as being part of a different intention altogether. For instance, when politicians say that cutting taxes is good for the economy - that might be plausible under certain conditions. However, the same proposed action of cutting taxes might actually be fired by the hope of winning the next election. If this is true, then a cynical intent becomes clear. The observable proposal of cutting taxes has been connected to a false intent. The government has no plans to improve the economy and only hopes to become re-elected. The same principle is true on the smaller scale of stating that beating children is good for them. The claim of intending to help children by beating them can be challenged. To meet with another person and fail to see that person in their world, in an emotional and experiential way, is a failure to empathise. Similar failures to apperceive self in relation to others can also occur in being unable to understand the needs, strengths and weaknesses of self in relation to others. It concerns the failure to know self as a person. Emotions in relation to others are not involuntary and come from tensions between the heart and the head, the private and the social, the past, present and future. For instance, anxiety within social relationships of any sort does not follow the rules of logic, or generally known social rules, yet can still be found understandable through motivations that are social, or as the result of what can happen when anxiety becomes high across decades of the lifespan. One step for therapists is to be aware of their emotions in trying to help. The key is knowing how they feel and how that has arisen, if that is at all possible in the session, but sometimes that understanding is gained, shortly thereafter. If an emotional response to a client is anything other than business-like, then it should not be ignored and over-ridden. The blasé response of immediately assuming that therapists correctly understand what is going on for clients is unacceptable.

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On emotion What the brief reminder on empathy in relation to non-verbal communication means is that there are a number of ways in which emotions signify and that provides clues concerning what they signify. Generally, emotions are about here and now occurrences, but they could be about past or future influences and bear little relation to the present. The difference between a sense about an object arises: A feeling, relationship or thought, when transient and problematic (due to abuse, neglect or false beliefs), should not be taken as being representative of the whole of a referent. The ego receives the outcome of perceptual intentionality, for instance, when we look at the sky, and see that it is blue. If we imagine it as yellow, then the ego is directly involved in making that imaginary experience through choice. Where there is choice and decision-making, the ego is at work. When the ego is involved, what that means is that the self can choose to become aware of its contributions to the maintenance of its problems. The ego refers to the lived sense of self, “who I feel myself to be,” “how I interpret myself ”. The ego includes the experience of personality and identity. Non-egoic intentional processes are involuntary, passive and descriptively unconscious in the sense that they operate automatically. But the outcome is always conscious, however fleeting or weak the senses that are produced. The difference between emotion (as a general perhaps unclear or inexplicit hunch) and thought about a situation is worthy of some attention in order to make the two clear. Thought expressed in internal dialogue is explicit (but still it might be inaccurate). Emotion is more visceral and basic: it is a felt-sense that comes from the immediate social situation, plus the effects of pre-existing mood and the attitude of being turned towards someone or something, plus the nature of the object of attention being turned toward and the influence of past and immediately future events. It may not always be possible to eradicate fearfulness from the lives of clients. But it may be possible to help them understand and tolerate fearfulness, without it destroying their self-esteem or narrowing their lives through false belief and the avoidance of what might happen. The terms “neurosis” and “psychosis” both refer to distortions of the reality that could be available. Reality would become less frightening if clients were to give themselves a sufficient chance to be in contact with it. Psychological problems are contagious in that each person influences others around themselves. One common part of several psychological problems (such as depression, anorexia, bulimia, social anxiety, low self-esteem and neglect) is producing an impoverished, inaccurate sense of self, often in relation to an impoverished inaccurate sense of others. As part of a form of relating, these senses are inaccurate. For instance, depressed persons with low self-esteem see themselves 363

Talk, action and belief as consistently bad. One outcome is to lose contact with others generally. For instance, depression may also incur active avoidance of others and specific situations, and may include suicidal thoughts with or without actual intent. The sense of self occurs in relation to its object of attention. The connection between the self (who acts, thinks, feels) and what is acted on, thought about or felt, is part of a much greater whole. Emotions can be misleading with respect to what the relationship has been or can be, in a longer-term view. For instance, emotions could involve misrepresentation through over-influence because a single distressing event becomes representative of all prior and future experiences, for instance. With respect to the future, emotions can be inaccurate anticipations about situations that may never come to pass. With respect to the past, emotions can be inaccurate recollections about situations that may never happen again. Where intentionality shows its worth is that emotions can be present with respect to others in their presence or absence. There are many cases when emotion occurs in the absence of a person or social situation. This is the way in which intentionality shows its worth in the explanation of phenomena such as anticipatory anxiety and its related cousins of worry, mind-reading and the catastrophic attributions of fearful thinking. For either party in a two-person relationship though, when emotional responses are inaccurate they might not be related to the actual situation. Four possibilities arise. There are (1) accurate representations of self and other, or (2), inaccurate representations of a relationship between the two people due to poor social learning. The emotions felt can be created by chosen intellectual stances and the use of intentionalities. There is either (3) accurate emotions that promote security of relating, or (4) are inaccurate and decrease security. For many, the pain of insecurity in one area of life co-exists with an innate understanding of what security is and how it could be. This categorisation of four types of emotion does not mean that the types occur singly but that it is possible for them to co-exist. Emotions might be strong and clear - or vague and confused. However, emotions as experienced are non-verbal and connected to the perception of one’s own bodily feeling. Emotions are more transitory than moods that stay for a long time. Problematic moods can last for months or decades. Moods can lift and return. The major problematic moods in the psychological disorders are anxiety, depression, anxiety and depression, anger, anxiety and anger, fear, shame and guilt, boredom and emptiness. But emotions are not always accurate representations of their object and should not be trusted as such. Emotions and moods can mis-represent the overall relationship with a person for a variety of reasons. It is easier to understand emotion in comparison to the conceptual intentionality of verbalised thought. Emotion that is conscious yet is at first glance not about any specific person or situation, is best understood as related to an as yet unidentified context and 364

Ian Rory Owen PhD ‘cause’. Often on further discussion, there are valid and current problems that the person faces that may not be linked with the affect that is felt. Emotions can become adequately understood and related to thought and their proper object. Emotion can be the conscious object of attention and are most-often felt in relation to specific persons, situations or objects of attention. But the intentionality of thought, and specifically the speech of other people, never provides the object perceptually unless the form of language used is evocative. The therapist has to do interpretative work to understand the object of an emotion. The interpretive work referred to is discussion and formulation that leads to helping clients find out how things can be different through them experimenting with their beliefs and behaviour. What needs to happen is the basic ability to raise experiences to awareness, and look at the same experience from more than one perspective, in order to understand it through comparing various views on the same thing. The ‘causes’ of emotion happen when self becomes motivated to feel, think and act in response to the interpreted meaning of commonly understood objects and situations. Such ‘causes’ only ever exist between people. The words that best describe emotional ‘cause’ are terms like psychological ‘function,’ when an action may change one emotion to another, or lessen the strength of emotion. The overall nature of the association or motivation that is experienced and responded to is understandable, but cannot be exactly predicted or defined. Nor indeed is it replicable in its link between cause and psychological outcome, because free will and learning can intervene and create a chosen outcome. Emotions are not causal in the natural sense of the inevitability of the same ‘cause’ always creating the same effect. Consciousness and the lived body are moved in subtle and nuanced ways by the presence of the meaningful past and anticipation. Social conditions, past and present, produce felt-links to tendencies to feel and believe something. The conditions for the possibility for emotion are complex and involve the interactions of person, time, meaning and the holding of differences between what was, what is and what should be. The origins of emotional ‘cause’ are many.

Primary and secondary emotions However, the ego is able to understand itself and therapists can help in this respect thanks to the consideration of intentionality in relation to senses of objects in contexts. Because the ego is able to choose and direct the forms of its attention, its intentionalities, then negative emotion is the outcome of what appears, at first glance, to be entirely the result of passive processes. However, the ego is involved in emotion and belief, in relation to many types of experience. Let us use these thoughts to consider the connection with other people.

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Figure 22 - A descriptive account of the ego, active and passive processes. There are “preconscious” objects that, from time to time, are not in awareness. Preconscious objects can be brought to consciousness either through egoic choice and effort, or they appear in consciousness through “passive processes” that work at a remove from the involvement of the ego (Husserl, 1950/1977a, §38). How figure 22 can be understood is that sometimes there could be immediate emotional understanding, correct interpretation of the relevant evidence that the emotion is about, and the ability to make helpful actions immediately. This is an ideal and does not happen often. Depending on the context, if the link between awareness of the emotion of the other person, and concluding on some helpful actions towards them happens during a conversation with them within a few minutes, then that would be good. If the understanding and helpful actions happen at the next meeting, then so be it. The ideal possibility that there could be immediate emotional understanding and correct interpretation of the immediate situation 366

Ian Rory Owen PhD between clients and therapists is an issue that must never be prejudged and be fully open to discussion by both parties. The overall series of events is that either primary “passive” involuntary, spontaneous emotion arises immediately on apprehending the object of attention - or consciousness could sometimes be met with “secondary” active emotion generated by the ego that chooses its intentionalities and its objects. The ego is involved in being aware of emotion in the moment of it happening. It can permit itself to feel and it is possible to choose not to feel. Further reflection by the ego and proper interpretation, can lead to conscious control of the emotion or permission to feel it. But the context and events at hand are important in this respect. It is also possible for the ego to respond with internal dialogue that produces secondary emotion and consequent behaviour of the sort called “earned security”. These same principles apply to understanding the emotions of self as they do for understanding the emotions of others. Emotions whether they are positive or negative, are classified into two types. Primary emotions occur immediately through learned associations or other means. For instance, remembering a previous relationship event without linguistic mediation. But secondary emotions are induced through explicit thoughts, beliefs or self-talk in language or some other intentionality that is directly connected to the ego. For instance, emotions can arise in connection to the visual imagination or anticipation (but that is not a case that is explored in this section). Feeling states are there for reasons that need to be understood. On the one hand, primary emotions are ‘caused’ non-verbally, through conditioning or implicit belief. On the other hand, linguistically expressed beliefs ‘cause’ secondary emotions. Specifically, if a person were to imagine their death, they might feel frightened and understand the effect it would have on their family. However, the root ‘cause’ of these feelings and other consequences is actively chosen by self, so a person who thinks this way is choosing to have a fearful experience. Primary emotion is affective intentionality where the bodily sensation about something is a direct representation of what the relationship is or was, with respect to the object of emotion. Emotions are primary when they appear immediately and without any linguistic ‘cause’ of internal dialogue or discussion. They might be part of classical conditioning or possibly due to memory or pairing by association in social learning. Particularly when emotions arise without internal dialogue and through some comparative event such as the difference between an anticipation and an actuality, then people may feel that their emotions happen to them and so it is more difficult to own their emotions as their own creations and this may lead to situations where people feel that they ‘cannot’ change their emotions. Secondary emotion is where belief or thoughts about an object create the emotion about it, through some further intentional relation to it, such as anticipating its next occurrence. Secondary emotions are due to explicit rumination on topics 367

Talk, action and belief in internal dialogue and explicit beliefs in language. Secondary emotions are due to creating a horror film in the head and playing and re-playing it repetitively. When the choices of the ego are clearer to itself, then thinking about a specific topic repetitiously is the sort of experience where the ego does itself no favours. If clients refuse or find difficulty in changing these emotional responses then it is more the case that they choose not to interrupt their or sequences of thinking and feeling. Primary and secondary emotions can also be understood in the following. The object of attention when spoken about co-occurs with an emotional tone. On the one hand, where the influence of the past appears is that in most cases there has been mis-representation (forced or encouraged by circumstances, either traumatic or social) so that clients have been repressed and unable to express their experience, because it is generally taboo to speak about what it is like to be anally raped as a child, for instance. Nor do family and friends know how to begin discussing or coping with the consequences of such experiences. On the other hand, accurate representation occurs when topics and their accompanying emotions are socially acceptable and are capable of proper expression. The difference for the linguistic ‘cause’ is that representation is accurate when full discussions have taken place that permit adequate exploration of the emotions and the object of attention. Inaccurate representation of emotion and its discussion are enforced when repression, taboos and other matters operate, that prohibit feeling and its exploration through speech. Freud was right when he asked clients to feel free to speak about anything (1915e/1957, p 210). The other half of the bargain is that when they do, it has to be honoured by listening properly to what is being said. Let us consider a commonly occurring situation to bring the terminology alive. Let us consider clients when they speak about what they can remember. The intentionality of speech is turned toward the experience of remembering, say, the first time when Paul was beaten as a child. The conscious object of the memory (and hence of their speech) is that the person re-lives or replays the memory in the usual form of seeing and feeling it. As Paul remembers pieces of the memory as he discusses it, the memory re-forms over the course of time during which he brings it back into consciousness. What happens is that speaking about how he feels helps him understand himself in the here and now, in relation to the specific past event he is talking about and in relation to aspects of his own identity and personality. Given that the base experience for clients of talking and relating is primary and secondary emotion, and that requires them to understand themselves and their relation to themselves and others, within the confines of the therapeutic relationship, then comments from therapists are headed towards pre-empting any potential to mis-understand by explaining the current situation. Particularly, explanation is required in the case of dissatisfaction and anger when clients have mis-understood the tight roles and confined situation that they are in. 368

Ian Rory Owen PhD What therapists can help clients with is differentiating and recognising their emotions and helping them achieve increases in co-operation and earned security, in-line with the necessities of the type of help that they need. This is a very abstract definition of what therapy does. The senses of the objects of attention, others and self, are living, changing senses. By taking up a different position towards others and self, it is possible to gain entirely different senses about the same person, or events between people, whilst everything else stays the same. This principle of flexibility is central to practice and for clients who re-evaluate their own beliefs and behaviour. Through having better contact with other persons and public cultural objects, a broader and deeper understanding is gained. The remainder of the chapter considers specific aspects of the talking and relating components of all types of therapy.

Structuring sessions The first 10 minutes of a session will most likely be spent finding out what happened, if there are any matters outstanding from the last session and finding how the previous homework progressed. Once this is completed there should be a negotiation with clients concerning what the focus of the current session will be. Therapists may suggest their view if they think that a specific topic is a priority but usually they will let clients suggest what the focus of the session will be. It might be possible to split the amount of time available between two topics, with the most important one being dealt with first. If clients jump subject, half-way through a session, then they can be asked if they wish to stay focused on the originally agreed topic for the day’s work or if they wish to abandon it and move to the new topic. It is probably better if the new topic can be noted and an agreement made to return to it at the next meeting in order to do it justice. Saying that a topic is important and “can be looked at in the detail in the next session” is a way of honouring it and treating it with the respect that it deserves. It is good practice to agree to discuss an important topic another week, unless it is so important that the agenda should be abandoned and the new matter is dealt with in the current meeting. These types of decisions should be made with clients. Structuring treatment revolves around making links backwards and forwards at the beginning and end of sessions. This can be useful in providing a sense of continuity and progression. For instance, asking what happened in a homework assignment, right at the beginning of a session, links back to where the last session ended. Recapping at the end of sessions re-states what clients will do for homework and summarises what has been discussed. Referring back to what has happened in the previous session, the last few sessions or in the current one, is good practice. Planning ahead to the next and future sessions is also good because it uses the time between sessions to prepare. A mini-review should happen in every session. 369

Talk, action and belief This could be achieved in any wording. Perhaps by recapping “what we have been doing today was to ____ ”. Or by making comments on what has transpired in the current meeting: “When we discussed ____, you noticed that ____”. Other wordings that ask about specific key points can be expressed like “what do you think about ___ ?”. Or “do you think that ___ will help?”. The aim is to focus on the experiential learning that has happened in sessions and create mutuality and use the current mutuality that is happening to good effect. If there have been any louche non-verbal messages expressed such as a sudden raising of the voice, consternation, puzzlement or any disapproval or irritation expressed non-verbally, then there should be the opportunity to discuss any negative connotation. It has to be noted that even when the opportunity is provided, there is no guarantee that clients will express what they feel even if that is so detrimental that they may cease to attend. Some people are unable to express negative feelings even though they are sufficiently strong to motivate them to stop attending and they have clearly been asked to express the non-verbal communication of negativity. The processes of creating change are understanding the problem and then helping clients commit to actual change. The aim is to encourage experiments and prepare for change in each session. Interventions on intentionalities build and reinforce motivation to enable clients to be on-goingly improving their own quality of life. Many interventions require clients to translate the formulation of a problem into action by themselves, with support from therapists. This requires clients to become aware of what they are doing and help them stop themselves in mid-feeling and mid-thought and create new actions. Some consequences of fixed beliefs are worth avoiding such as ambivalence. It is possible to act and enjoy the action and not complain. Or one can avoid doing something damaging and so avoid the negative consequences that it would bring, such as guilt and regret. To do something then regret it and feel guilty is illogical when the guilt and regret involved are well-known consequences of taking the action. Such thinking is particularly pertinent to helping clients with their motivation to struggle with their fears, doubts and fixed beliefs. For those clients who are making good progress, it is possible to focus more on the talking and relating skills. But this can only be addressed at the right time, when clients are sufficiently in control of themselves and able to have given up self-harm, excessive drinking and drug-taking and are able to be open about themselves and their history.

Structuring a first session After having gained informed consent at the assessment phase, sessions should be focused on some agreed item of business relevant to client’s targets for understanding and change. It is worthwhile mentioning some of the most basic 370

Ian Rory Owen PhD aspects of how to handle sessions, in order to create negotiation and agreement of what each session is about. If homework has been set, like a behavioural experiment or a writing task at the last meeting, it should be honoured by an early discussion of what happened. Note-taking by therapists in sessions can be unobtrusive and should be abandoned if something important is being discussed that demands full attention. Otherwise, having a clipboard and pen in hand is acceptable when the material being discussed is complex and could easily be forgotten. The point of writing notes in sessions is to make a written record of the content of the session that can be photocopied and taken away by clients so that they have a record of what was discussed to which they can refer. Moving towards the positive begins with small steps like making a problem list. This is not trite but highly effective in getting some understanding of what is going on and what the priorities may be. When there are specific problems and modes of help that are of likely benefit, then the type of help, what it involves and what it might feel like to participate in it, should be explained. Clients should be asked to be committed to working on their problems. Potential solutions should be identified with clients, through creative thinking or other means, and specific solutions should be practised until they get easier and are achieved. A sufficient amount of time and effort is also required for practice. If there are completing commitments, then the effort required to achieve therapy goals need to be protected. Therapy works because therapists know they have something to offer and know what they are doing. Clients, on the other hand, know that the meetings are of value and are clear that the solutions that are being sought will be helpful. Achievable roles and tasks should be discussed. Therapists should provide a full range of help towards identified targets. Through flexibility of approach, clients will get the service that they came for and therapists get to enjoy their work when they see improvements from week to week. Other aspects that provide focus, purpose and direction to the therapeutic relationship are frequent short reviews of clients’ thoughts and experiences of getting help. A statement concerning the overall model of therapy could be made to help clients know what to expect of the sessions. Stating something like “what will happen at first will be an attempt to understand, followed by some sort of action or experiment from you, as the sessions progress” may be enough to explain that clients are expected to experiment with their thoughts, beliefs and actions - in order to find what sorts of change to their emotions, relationships and meanings might be forthcoming. Five key points for talking therapy are: Set an agenda for today’s meeting even if only by handing it over to clients to state what they would like to discuss. Discussion to understand the problem. Summarise what has been explored and found out, and use that towards some future positive ends. 371

Talk, action and belief Ask what clients have made of the session to elicit any unspoken dissatisfaction or puzzlement about it. Homework may or may not be set. Finally, the first session should repeat that informed consent applies to treatment. For instance, “I am not going to put pressure on you to make you change your mind or force you to do anything. What I am going to do is put an explanation to you and let you choose whether you want to act on it or not. If you choose to follow these ideas with action, is entirely your choice. If you choose to keep the problems that we have been talking about, then that is fine by me. However, it will mean that you have chosen not to take the opportunity to work on them and we would then need to work out what to do next, in that case”. Some helpful questions are “if you could change, how do you think you would benefit?” “Can you empathise their position?” (Meaning can you empathise another person’s position). And “who do you have as role models for ____?” These latter two interventions are well-established means of gathering information from neuro-linguistic programming (Andreas and Faulkner, 1996, p 200).

Agenda setting It is necessary to agree an agenda for the session to gain clarity and create an explicit purpose for the meeting. Setting an agenda in talk only need not necessarily be written down in a formal way but might be agreeing a starting point for discussion. The general purpose of an agenda is focusing on the needs of clients. The agenda can only really focus on one or two tasks, lasting 30 to 40 minutes, and that includes setting homework. The closing of the session will also take about five to ten minutes. The last five to ten minutes can usefully feature a round-up of the day’s discussions and should invite clients to speak about what they found useful and what they think, generally or specifically, about anything that is going well or poorly. This is a chance for therapists to say what clients have done well and gives an opportunity for feedback from therapists on what clients have found difficult, troublesome or worrying. The last few minutes are a good opportunity to de-brief, summarise the homework set and solicit the experiences of clients about the session.

Improving empathic understanding Even the best empathisers get it wrong from time to time. Because empathising clients is the medium of psychological contact, then it is worthwhile to stop and really focus on how empathising their personalities and psychological problems can be improved. 372

Ian Rory Owen PhD Empathising can be turned into a specific technique by making it more under the control of the ego, its free will and rational decision-making by harnessing the power of the ability to intuit, to know emotionally. Whether through imagination, the intellect, or by memory or spontaneous understanding, it is worth focusing on what clients are reporting in a deliberate way: Imagine what it is like to be the client. For instance, try to feel their ambivalence and hesitancy around wanting change and fearing the means of getting changes. For instance, being torn between wanting to over-come the problem yet wanting to stay the same. If this means that therapists pause in mid-conversation, then so be it. Some explanation may help if it takes a few seconds to understand these feelings. “I am trying to work out how that feels for you ...”. “I imagine that you ...”. “If that were me I would feel …”. Again, even the best empathisers sometimes get it wrong and can make the mistake of accepting their mis-empathy over the actual perspective of the other person. This is why reflection and asking for feedback exist because it is necessary to elicit and check that therapists have understood the actual perspectives of clients. Communication is comprised of verbal and non-verbal aspects and it can be understood in various contexts. Psychology, particularly of the quantitative sort, has always been shy of coming to the world of psychological meanings in anything but the most rudimentary manner. The intentionality model takes the opposite view though. There is no excuse for not attending to experience as it is lived. But it is not as though the problems of attending to meaning have suddenly been solved. Clearly, when the subject matter to deal with is meaning as it is lived, then there is no means of removing error, differences of perspective and no guarantee of uniformity of meaning for readers of the same manual, for instance. There is no means of creating uniformity of meaning concerning any specific observable event, any set of events or for any group of interpreters. In the world of psychological meaning there is not, and can never be, any guarantee concerning the meaning of the same event. The world of signifying objects (of speech, behaviour, series of meaningful happenings in the past, present or future) indicates no specific or constant meaning. The problem with meanings as they are meant, through speech or any other medium for that matter, is that what appears is meant by the speaker and that meaning is empathised by those who listen. People respond to what they believe are the psychological meanings that are indicated by ‘the same’ observable event. What this situation concerns is something general indeed. The fact of the matter is that empathy reveals what is social, and that has meaning that varies according to the perspective taken. When meaning is approached like this, the aim is to ascertain the nature of meaning in its social habitat through discussion with those other persons who have the experiences in question. The power of meaning is that people live the invisible senses of what they believe is happening around them, in the psychological sense 373

Talk, action and belief of what they think, feel and how they inter-act with others. The power of meaning is that it can be believed - the experiences that follow on from this simple starting point are enormous. What appears through speech and vision of the here and now is interpreted as the meaning of what exists. However, what exists and what is responded to are invisible meanings, understood in one of a potentially infinite set of contexts. Psychological meaning is comprised of a large number of parts concerning what is remembered, imagined, anticipated, thought and felt. However, the whole cannot be cut with a knife nor it can it be partitioned by decree. Ambiguity about an object can exist with consequent ambivalent actions towards it.

Problems in talking and relating If there are serious problems of mis-understanding due to tangles when an intervention is offered then refused, such matters need to be explicitly addressed (McCluskey, 2005). Other ways of phrasing and commenting on problems can be: “Just a minute. Perhaps I am not explaining myself properly ...” Or, “you have got the wrong end of the stick. What I am trying to achieve with you is that ...”. Or, “let me make myself clear. I cannot and will not force you to do anything. What I want to achieve is ...”. The social skill is assertion in the aim of identifying relevant impasses and working to understand and pre-empt further problems. Bill O’Hanlon (O’Hanlon and Wilk, 1987) has promoted the idea of focusing on small positive changes in order to make explicit to clients how they have managed something well. Following Carl Rogers (1942, pp. 95-108), there should be the establishment of an explicit frame of ground-rules that cover the most basic aspects of meeting, cancellation and what will happen if clients do not attend or respond to letters to ask them if they are still attending. In addition to what has already been stated, when it comes to working with the relationship, any strong emotions, unusual events and unusual requests are telling and need consideration. What is to be avoided is acting hastily on strong emotion because it is likely to end in actions that are unhelpful for clients and a quality service will not be provided.

Speech acts When it comes to asking questions, sessions should not be a grand inquisition. But the use of questions is helpful. If what is being inquired about is taboo or potentially upsetting, then it is only polite to ask permission to ask a question. And if the answer is “no,” not to pry any further.

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Ian Rory Owen PhD Firstly, any preparation for new behaviour or problem-solving is an opportunity to ask questions in a way that clients can state how they will act in the situation that they fear the most. For instance, Jack is frightened of motorway driving and is asked how he would respond if he might have a panic attack whilst driving. This serves the purpose of taking the nightmare scenario and not leaving it like that, but taking it further forward. Some open questions are the following: “I think it’s like this ___. What do you think?” “I don’t want to put words into your mouth. I am curious to know how it is for you. Is it fair to say that when you ____?” “Well, what do you think you should do when that happens?” It is interesting to ask “what do you say to yourself when you_____?” As a way of finding out about internal dialogue. Statements about belief can be discussed with clients in the following way: “I am going to start a sentence with the phrase “I believe” in it and I would like you to finish it”. Once a context about a specific topic has been created through prior discussion, the therapist states “I believe …” The answer supplied could be “I will have a panic attack”. Or “I will make a fool of myself ”. Reflections are the type of phrases that wrap up a previous section of discussion and put the sense received back to clients for the purpose of checking the understanding gained. “I will put that back to you slightly differently ...” “I am going to say what I think and I invite you to disagree with me if I have got it wrong.” “The way I see it is ____ .” “If I understand you correctly, what is happening is that …”. “From my perspective, it seems to be that ___ is what causes you to ___. Do you think that is right? Please tell me if you disagree.” “What do you think is the problem with that?” is one way of asking people to reflect and interpret their own problems. Making a comment that supports change can be done by saying “I cannot predict the future, but I am fairly certain that if that continues then the problems of ____ will continue to ____.” Explanations of the rationales for treatment need to be made where there is always the opportunity for clients to refuse the intervention and inquire about it to make sure they are full participants in it. Some wordings to set up a developmental formulation can be: “We are having this discussion so that you can understand the influences on you from the past and exercise choice over how you react in the present”. “The aim you wanted to achieve is to understand why you ____. So what we are doing is discussing it to further move you away from its influences”.

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Reviews Asking for feedback on the quality of the help received and beginning an open discussion of the therapeutic relationship are ways of pre-empting and correcting problems in it. The purpose of reviews is for each party to show the other their intentions, to the extent of therapists explaining their reasoning and techniques in brief. Asking for and providing feedback can be begun during assessment, to set the scene. This makes a precedent for discussing the therapeutic relationship and invites clients to participate in it, by discussing their view of what is going on. Reviews serve a pre-emptive function in being able to find and meet any problems, uncertainties and disappointments that clients might have. It asks them to speak directly about any problems, rather than letting them go unmentioned which might lead them to drop out. Asking clients what they thought of each meeting during the last few minutes can begin reviews of progress at the end of each session. This is also a chance for therapists to provide some feedback, to let clients know how they have faired: This is of the sort that “I think we have made a constructive start this morning” or whatever the case may be. After five or six sessions have gone by, there could be further reviews about how clients are fairing. Therapists can contribute their view of the progress so far. One way of creating clarity and openness about the process is to provide time for two-way feedback and discussion of what has happened in each session at the beginning and end of every meeting. Therapists need to ask for feedback from clients and monitor their view of interventions and progress. If interventions of any sort do not work, then it is necessary to know why this is the case in order to modify the approach taken. Part of quality assurance of the meetings is to ask for feedback and to contain any mis-understandings or disagreements within the therapy relationship rather than to have the sessions end and there are still outstanding disagreements or complaints that have not been fully addressed. If there have been any prickly interchanges and nuances of non-verbal communication from clients that seem out of place, even if they are very slight, even when they are alongside smiling and cheeriness, then there might still be dissatisfaction that needs to be expressed verbally for it to be dealt with. The problem is that some clients feel uncomfortable with expressing their dissatisfaction. If therapists think that there might be unexpressed dissatisfaction, then clients should be asked to speak their minds about how they are finding the meetings. It is a truism that for some clients, having therapy may not make them feel better in the short-term and if they leave early in treatment, that they will never receive the benefits that they had desired on entering it.

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How to fore-close There are cases where clients have been accepted for therapy after having agreed that they would like to challenge their demons, and stating that they will work to reduce their fears. But when it comes to taking action, either they are reluctant to do so, or in other ways, there are problems of commitment and difficulties arise. This is not a matter for blame. But if the problems cannot be solved, it means the therapy must come to a close as the treatment of choice cannot be tolerated and the wishes of clients must be respected. For example, if there is no possibility of using talk or action, then there is no choice but to bring the sessions to a close. In this situation, there are a variety of ways of explaining one’s decision and making the meetings a positive source of learning for both persons. The ending of the meetings is an opportunity for a formal appraisal of what has occurred. It should include making written notes of what has happened, so clients have a written record of what went right and are able to remember how that was the case. Even when explanations and the greatest care and sensitivity have been provided, it does not mean that clients will understand or remember what has been said to them. People with trauma and neglect may not want to continue and may decide to bring the meetings to a close. Therapists need to be congruent with what they have said previously, particularly when therapists have promised not to put pressure on clients to change or alter their behaviour in one way or another. What this means however, is that if clients choose not to follow a treatment of choice, then the meetings may come to a close and this should be stated at assessment or at the beginning of treatment. Finally, if therapy has commenced but an impasse has been reached, then it is probably better to state that “I don’t think this is right for you” and tell clients why the sessions should stop and provide guidance on how to bring them to a close and gain some positive learning from what has happened so far. Feedback can be phrased by saying “I want to be honest with you”. And “it is my professional opinion that what will help you best is ____”. And “I am on your side when I say that ____” are ways of stating feedback. The possibility of insurmountable impasses should be pre-empted. This gives reluctant or excessively defended clients a positive way out, so that ending the sessions is a positive choice that they have made and they realise they are not being dismissed.

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Planned endings Sometimes the most insightful understandings of clients are not voiced during treatment and only appear in the last debriefing session. In order to prevent relapse, the relation between understanding and the events of the session, should be that clients understand that what is currently happening is helping them, that co-operation and security are felt, and that agreement about the nature of problems are shared by both persons, through the previous processes of formulation and discussion. What could be helpful is a written self-interpretation achieved at the end-point of therapy. This could entail a statement of progress made and noting how it was achieved. In order to maintain the gains made during the meetings, some further will-power, skills and ideas need to be employed to maintain a commitment to self-care and progress and not relapse into old ways and return to previous attempts at coping by repeating previous problems. What can help is a written plan that makes it clear how to proceed and what pre-empts relapse. The timescale of the plan is that it should be for six to 12 months after therapy has ceased. The basic principles for the plan are that it should be for the long-term good, promote self-care and quality of life, and promote relationship security and the personal aims of clients. The plan could include aims such as returning to work or starting some new education. The plan should be about the basic self-care required to look after self and provide care and attention to others. Some key questions for drawing up this plan are as follows. It is up to clients to provide the answers with support from therapists (Latham, 2003). 1. What results have been achieved so far, entirely as a result of having therapy? 2. What ideas and skills have been attained through having therapy? 3. My action plan to maintain and further my progress in the next six months is that I will… 4. I anticipate that I might have the following difficulties in carrying out my plan… 5. If I encounter such difficulties, I would over-come them by… 6. Where things might go wrong during the timescale of this plan are that… If this were so, then my early warning signs that problems are returning would be that … 7. If I had an early warning sign, or found my problem (or problems) returning, then I would… It should be made clear that it is not expected that there will be an immediate answer to these questions and it is better to think them through in detail even if that takes a month.

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Summary Therapists should supply general directions because therapy is a practical discipline that helps its clientele go from somewhere to somewhere else by a specific route. The type of direction supplied is agreeing some focus for specific sessions and a series of sessions. Talking therapy works by creating an explicit focus for each session through asking clients what they want to work on and agreeing what to work on first and in what order to approach complex problems. The sorts of problems dealt with by talking are those where there is no precise goal to aim towards apart from opening up topics for discussion and working towards a possible conclusion. The end-point is getting some clarification or resolution on a matter. The way to respond is complex. The understandings of emotions and nonverbal communication underpin the verbal discussions. Because therapy concerns leading clients away from distress and towards new satisfactions of various sorts, it is often the case that therapists have to disagree with clients in a tactful, nonchallenging, co-operative manner. The overall therapeutic process is gaining informed consent for explorations and actions that lead clients to a better place, through making the self-responsibility for self-care known and motivating them to change themselves. This leading involves setting an agenda with clients in each session, even if that is to state that they have prepared nothing and are asking the client to set the agenda. It is an effective use of time to ask clients to prepare for the next meeting by planning to work on a particular topic. The last task of each session and the meetings altogether is to debrief and ask for questions. Therapists should be open enough to empathise the non-verbal sense of being-with others. Being attentive to the non-verbal expressions of clients can help in picking up clues that support progress by attending to non-verbal bodiliness that sets the tone for the content of what they say. It is not as though the nonverbal manner of communication says the whole story, but what it does provide is a major sense of what something means. The visual aspect of how a person moves their face and body creates tangible, lasting impressions that persist long-after the meeting is over. To sum up, the consequence of accurate knowledge of self and accurate empathising of others is that there is no need to be overly-defended or under-defended. Through sufficient social contact it becomes possible to appraise and appreciate self, evaluate and incorporate negative feedback, as long as it is well-delivered. Previously dreaded praise is no longer a source of fear or suspicion when self-esteem is accurate about one’s own strengths and weaknesses. From the perspective of self, the image that the other has of self can be interpreted from their speech and actions. Empathy is not visual, auditory or tactile perceptual manners of referring to the here and now presence of other people, but the outcome of what they are feeling and talking about as their experience, their perspective, their intentions, their feelings. Empathy is a 379

Talk, action and belief particular sort of learned meaning about other people that is added to what is perceptually present to conscious attention. Emotions can either be primary, nonegoically-mediated, or secondary and egoically-mediated or mediated through other forms of intentionality driven by egoic choice: Emotions can be mediated through intentionalities such as the imagination about events generally, or more specific anticipations that things will happen at specific times in the future. Therapeutic tasks that need hermeneutic answers are ubiquitous in therapy and everyday life. Part of problem-solving is reconsidering one’s own position with respect to others, understanding tangles and impasses in therapy, and reconciling self to the abilities of clients. From the therapeutic perspective, the latter could be called “knowing how to place oneself with respect to clients”. There are many ways in which psychological disorders can accrue, be tolerated or dissipated. These need psychological hermeneutics to explain how people make sense of themselves and others, and how to select a relevant set of experiences for interpretation. In addition to all else, what therapists do is: •

Praise and reassure clients for over-coming resistance and mentioning the details of their embarrassing and shameful problems. Talking about what it might be like to talk about something can help begin discussions. For example, “what might it be like to discuss ____?”

•

Prepare clients to make sustained commitment and effort during therapy. After the treatment has come to a close, further preparation is useful to support the achievement of future aims that have been agreed whilst the meetings were coming to a close.

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Support clients and provide tactful feedback. Not moralising, cajoling, manipulating or using force to make them do anything.

One way of working with motivation is to ask questions that bring the extent of the problem into focus. Questions such as “is that enough self-limitation?” “Have you punished yourself enough?” Or “is that enough damage to your marriage?” might be enough to increase clarity about the bad consequences of problems and how they impact on others. The basic point of this intervention is to suggest that there is such a thing as a sufficient amount of punishment for a ‘crime’ and once that due has been paid, then the period of atonement should come to an end. The problem of how to value self is compounded by the relative ease of being able to value the actions of others. This is because other people are clear objects of attention in ways that the apperceived self can never be an object of attention to itself. Empathy is what selves feel of their own living bodily presence that is connected, through social learning, automatically to the visual look of the human body from the outside, as one can see it in ordinary experience. 380

20 Interventions concerning action and meaning Aim: The purpose of this chapter is to make clear what it means to have an emphasis on facilitating change in action and meaning. This chapter itemises a number of interventions that focus on problematic senses created by intentionalities and states a number of ways of providing help by applying choice over the types of intentionality used. The sequence below progresses through the basics of choice and the most general outline of how action interventions can be structured then focuses on a number of specific interventions that attend to meaning and conscious experience.

Criteria concerning choice, motivation and planning The following points are necessary in any session as a way of ordering the activities of the session in a minimal way. The activities of the session should mostly be achievable in that session. If homework is set, then it should be possible in the 381

Talk, action and belief time-frame available during the next week and therapists should check to make sure that it is attainable and that it fits with what clients are doing during that time. For both talking and action, it is only on the basis that clients are aware of the experiential basis of their problem, that it becomes possible for them to influence it or choose to stop creating it. This is what it means for the ego to be involved. Understanding leads to wanting to change and that leads to practising the changes and accepting the consequences of having changed. For instance, if people act confidently, then they become more likely to feel confident and reap the rewards when others act differently. The two-step model of therapy as understanding followed by action actually broadens out to understanding, planning, effort and skill to get the pay off of the action. Understanding the nature of the problem is in order to find a solution of some sort. Even if that solution is only accepting that something is the case. For instance, accepting a change of attitude from self-criticism to self-acceptance might all that is attainable in some situations. Planning is necessary to put the new understanding into action. Effort and Skill are necessary and need to be applied over a sufficient amount of time and a sufficient number of repetitions, to achieve the desired aims. Pay off arrives when the benefit gained is worth the time spent and effort applied. The following remarks translate these general aims into a more concrete structure for sessions of action therapy. The following remarks concern the flow of sessions and how to make links between them. The homework should be explored to find out what can be learned from it. Attend to homework results from the previous week. Set agenda for today’s meeting. Understand the problem. Formulate on paper. Give a rationale and get informed consent for homework. Set homework by negotiating achievable and worthwhile goals. Summarise and ask for feedback on the session. ↓ Client attempts homework. On returning to the next session, if the homework learning is not apparently useful, then it still provides information about what might need to happen. However, if the homework was useful, the next session can progress onto a new issue or stay with the treatment plan for the previous one. Attend to homework results and find out the detail of what happened. Set agenda for today’s meeting.

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Ian Rory Owen PhD Go up to a new level of difficulty, if doing exposure work. Formulate and understand the next problem. Formulate on paper. Give a rationale and get informed consent for homework. Set homework by negotiating achievable and worthwhile goals. Summarise and ask for feedback on the session. For action therapy, the major work is going back and forth between formulation and making clear the learning gained from homework. The most effective way of providing help is to encourage clients to experiment with their behaviour, no matter how small the changes that are made. The evident truth on which action therapy rests is that if the problematic behaviours are maintained and repeated, then there will be no change. If clients do not want to change, then they should not seek help that is oriented towards it. Accordingly, to enter a form of help that leads towards change but not to change is to be resistant, incongruent and self-contradictory. What needs to happen is to find out what the nature of the blocks are to change and find what level of motivation exists for clients to get the changes that they had previously said that they wanted and were going to work towards. If they have changed their minds about over-coming their problems, then it may be necessary to agree to stop the meetings. The responsibilities in action therapy should be clear. Clients are asking for help and therapists are providing it by encouraging careful consideration of what will help and asking clients to be self-caring in their treatment. In order for an immediate start, it is better for people to have over-come their ambivalence towards change itself during assessment. There are cases where it is possible to work with someone who is able and willing to take the risk to change. If people change their minds to the commitment that they had given earlier, then so be it. Some change through talking therapy or action towards an object needs to be made. On the one hand, people refuse to tackle problems that have strong negative emotional meaning. There can be major negative consequences of this type of resistance and procrastination. On the other hand, if people are invigorated by the changes they have made, then they will feel the benefit of working towards their goals. The general nature of the psychological problem can be seen in its function to create short-term respite and self-given gratification, rather than work towards longerterm benefit with others. Negative reinforcement is the road to hell. Stoicism, facing up to problems and tolerating temporary discomfort often lead to genuine satisfaction and the benefit of increasing the capacity to tolerate distress.

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Working on the primary problem of functioning and mood If it is the case that people have major problems with their functioning and mood, then potentially as soon as the first session, it can be a priority to take stock of their recurrent problems and begin to find what happens when they become unable to function and how they return to their usual level of functioning. The following procedure of asking six leading questions can be used to make discussions, write notes and problem-solve with clients about how they can catch themselves when their mood alters for the worse and learn from past experiences of poor functioning to pre-empt, manage or minimise it. 1. When I am well, what am I like? 2. What must I do every week to stay well and for how long should I do these things? 3. What are the triggers for impairment of my functioning and mood? 4. What are the early warnings signs of poor functioning when my mood changes for the worse? 5. What must I do to help myself when my mood and functioning change for the worse? 6. How do I know that I have recovered from poor mood and functioning? The answers to these questions form a research project for people to look after themselves and maintain their quality of life.

Self-esteem In order for clients to self-care, they have to understand themselves and their needs clearly and value their own well-being. One recurrent problem is not valuing self sufficiently in order to make the necessary actions and experience the feelings that are the rewards of their abilities and good qualities. Accordingly, in order to help clients with low self-esteem, it requires therapists to lead in order to make key interpretations of the extent of the problem and its nature, before being able to remedy it. What lurks in the background is the idea of how a person should be able to act and how they feel and respond in various situations. Clearly, the interpretation of self always occurs in relation to others. Excessively negative appraisals of self occur when there is an excessive negative fixation on self as bad. The case under consideration is the one where there have been no crimes committed and clients need to understand how they persistently rate themselves so badly. The comparison between low self-esteem and sufficient self-esteem concerns the amount of self-anger, self-criticism and the nature of the inability encountered. People with low self-esteem are impaired in their functioning due to their negativity about themselves that is out of proportion to their actual deficits. 384

Ian Rory Owen PhD If similar self-criticisms were expressed by friends, they would be the first to offer help. But they treat themselves unfairly, as the rights and privileges of others are not afforded to self. Self gets the ‘make do and mend’ policy. Low self-esteem is a form of limitation that is placed on self by self. What is aimed for is an accurate understanding and responding with respect to others (peers, colleagues, family, cultural group and the needs of self ). What needs to be identified are precisely how senses occur that are inaccurate, temporarily or in the long-term. These creations are unrepresentative of the true potential and actuality of self with respect to others. For instance, for some people, it is possible to help them increase their own selfesteem by applying the logical thought that they are no better or worse than anybody else and they have the same rights and privileges as others. The basic principle is that clients must be able to reflect and understand their own experiences and know how to intervene on them. A direct check for good self-esteem is to ask clients to ask themselves “am I OK?” and if they cannot feel it, then the intervention and the principle of believing self as acceptable and as privileged as anybody else, needs to used. Behaving in-line with the belief that self is OK needs to be practised until the thoughts and feelings about self are positive. The key distinction is understanding that conceptual intentionality can drive low self-esteem as well as good self-esteem. If clients logically agree that they are the equal of anyone else, then this is a good thought with which to gain leverage in order to further strengthen self-esteem. One general intervention is to ask people to put a question mark after the own selfdamning remarks. For instance, “I am ugly” becomes “am I ugly?” The answer to low self-esteem is to become able to know the self ’s abilities in a more dependable and open way. Similarly, the genuine estimation of self ’s inabilities is knowing weaknesses but not being worried or threatened by them. This also employs accurate interpretation of self with respect to others. There are other ways of helping people with self-esteem. If it is genuinely agreed that self should have better self-esteem, then it might be possible to have clients accept the challenge of treating themselves well for two weeks as an experiment, in order to find out what happens, and if they can make any improvements on how they feel. One way of doing this is to model a colleague at work, for instance, who has good self-esteem, is assertive and able to act in situations where the client feels un-entitled. The intervention would be to treat self like the colleague treats themselves, and for instance, to ask for what one wants. Or otherwise, learn to treat self as though one expected to be treated neutrally or even be liked and accepted by others. Another way of helping clients with low self-esteem is to define the concept itself and then ask clients to interpret the extent of its negative influence on themselves. What is sought is helping clients understand the extent of the influence of their low self-esteem. For instance, Joe, a young man, uses public 385

Talk, action and belief transport but felt “unable” to press the bell to stop a bus when he wanted to get off. The intervention was to ask Joe to remind himself that he does have permission to press the bell in order to get off the bus. This was done by asking him to repeat the phrase “I need to get off here not elsewhere”. The action was to press the bell and stand up on a crowded bus and ignore how he felt. After two weeks of daily practice he could do this without distress although he still had some of the previous thoughts and feelings. Whatever the specific low self-esteem beliefs, self-limiting and inaccurate self-understanding of your abilities, then there should be re-appraisal and work through exposure therapy and social contact to work towards specific goals. Frequencies of practice should be set for each week and done irrespective of actual outcome. This requires a suspension of belief concerning guilt and shame about self prior to its methodical re-evaluation in-line with contemporary conditions and standards that lead to personal and shared happiness and satisfaction. Part of the work is taking on-board the positive meta-belief that believing in new accurate beliefs is possible. If self-doubt and self-criticism lead to sustained negative internal dialogue in the form of worry, then one way forward is to understand the positive function of these types of intentionality. Generally, there is a positive function in terms of the ability of a self-critical internal voice attempting to problem-solve and fend off problems before they occur. However, the effect of negative internal dialogue can be profound when its consequences get out of hand. If self-criticism does not achieve its aim of preventing the recurrence of problems or preventing new problems, then it is acceptable. If self-criticism is repetitious and lowers mood, then it is likely to be excessive. For people with low self-esteem, it is necessary for therapists to stay with the topic and not give up in finding a place, at any point in the past or current, where clients did actually feel good about themselves and their efforts. The aim is finding an area in which clients realise that they are capable in some way, such as being good at art when they were a child, or that they are a good parent or friend. Finding exceptions to the belief that “I am no good” requires being open to the relevant experiential evidence. Once a positive experience is found, questions like “what does that say about you?” and “what do your friends see in you?” can be used to get positive reflections and interpretations about self. Negative responses should be inquired into to understand the context in which they arose. In the case that there are no positive feelings, the next step would be to move to what clients think intellectually about themselves. The aim throughout is to emphasise the positive role and abilities of self, and offset the excessive tendency to under-value self, because of having perfectionistic standards or through internal self-criticism or other means. When something positive happens, clients can be encouraged to stay with it and reflect on it, through therapists asking them questions that promote self-disclosure. The aim of finding and appreciating the positive can be 386

Ian Rory Owen PhD furthered through emphasising evidence and changes, with respect to a highly negative past event, where the person has survived. Internal dialogue can be brought to a close once the person knows that they are engaging in verbal worry, verbal rumination or self-criticism. Whilst it is not possible to silence the internal discussion forever, it is possible to interrupt negative self-talk and replace it with new more positive commentary. In some cases it might be necessary for people to invent a wholly new way of talking to themselves even if it seems false at first. Thought stopping is a useful technique to ban all unwarranted, excessive self-criticism and self-doubt that does not contribute to problem-solving but is really a part of self-directed anger and self-contempt. A whole new style of internal dialogue can be created by helping people understand that what they say to themselves contributes to their poor mood. What can make a difference is asking people to speak to themselves in a different tone of voice with a lighter and more playful internal voice. The type of empathic ability at the root of the co-occurrence of low selfesteem and social anxiety is being able to see self through the eyes of others. In the case of the sense of good self-esteem and social competency, the self feels wanted and valued and feels that they have something to give that is appreciated. However, when the mis-empathy is to see the self as merely tolerated by others then a psychological distance can open where self wants to retreat from contact with others. If self sees itself as an outsider, the person alienates themselves from others. The emotions felt follow the beliefs and experiences felt and social actions follow like not joining in activities even if there has been an explicit invitation to do so. The solution in re-appraising self-esteem is to seek out regions of positive relevant evidence, for instance, where self has and is performing well socially. There are frequently blocks to finding this positive self-experience even though it might be extensive – somehow it gets forgotten and remains inaccessible. Self-criticism and self-critical worrying without evidence can exist and these tendencies need to be disconnected. Actions that are motivated by low self-esteem, impatience and self-criticism, for instance, may need to be held in check until evidence can be found that supports them. Evie wants to find a boyfriend who is into the arts so she attends a meeting in a bar where a poetry group gather. However, on entering the bar at the starting time she sees nobody. She waits 30 minutes but no one good-looking shows up so she leaves with mixed emotions: anger, disappointment, regret and feeling lonely. On discussion with her therapist she realises that it was unreasonable to leave so early and that her massively high expectation was that she was about to meet The One could not possibly happen at her first attempt at going to the poetry group. She determined to bear the feeling of being alone, were it to happen again and not to act on it, and to stay where she was and return to the same bar and attend the poetry group again until she got to make friends there and find out if there might be any single people who she found attractive. 387

Talk, action and belief Another way of helping clients reflect on themselves is to inquire what their ‘crimes’ or ‘sins’ have been, in order to find out if there has been anything significant that has happened in order to justify the low self-esteem. One way of helping people with low-self esteem is to ask people to re-consider their struggles and achievements as follows. “Please could you write down on paper some comments like I accept myself when I ...” Or “when I am fair to myself I ...” Another topic for writing notes as homework is “now that I have found accurate self-esteem I can…”. Evidence to support the re-appraisal of self-esteem can be found through asking what people like about themselves and what others have said in praise of them. The answers to these questions can form written homework exercises. The outcome is producing comments like “I like to be me.” “I chose this lifestyle in my twenties and I see no reason for giving it up now”. “I am confident in meeting new people generally” and “I have always tried my best”. Another topic for reflection is to ask people who understand what low self-esteem is to make some notes under the heading of “I have had low self-esteem” and ask them to think about it during the following week and bring the notes along for discussion.

How to do functional analysis A weekly grid can be used to begin to analyse what has happened in any week. This is one way of checking the formulation. A seven by eighteen grid of boxes can be made on a word processing package and headed with the days of the week. The purpose is to find the defences as they appear in the week, where a problem can be seen occurring before the defensive behaviour. One word for mood and one word for an activity can be put in a box for each waking hour, each day of the week. Such an analysis shows clients what happens before and after psychological problems. This is particularly suitable for self-harm, eating disorders, depression and anxiety, anger outbursts and substance abuse. It is also useful for weighing up the whole of a person’s week to highlight times of coping, promote reflection and recognition of current events and work out how that has happened. When the grids are kept, week after week, they show how progress has been maintained and if there are any repeating problems. What comes out of this intervention is a record of the links between activities, mood and self-esteem. The weekly grid shows evidence of positive coping and those things that remain problematic. The grid intervention is making a weekly diary at a glance that shows precisely what clients do and feel. It leads to asking about any lacks of necessary behaviours and activities towards the expressed aims that clients have. If there are lacks of behaviours, then the motivations for this should be inquired into. For instance, John, a shy and nervous young man, says he wants a girlfriend. After filling out the grids for three weeks, it becomes apparent that he does nothing to go to places or participate in any activities that could put him in contact with single women in 388

Ian Rory Owen PhD his age group with the interests that he has.

Three steps for problem-solving It is pragmatic to define abstract aims and let clients fill in the detail in their home lives. Tasks involving other people are notoriously unreliable. However, problemsolving that leads to action can be promoted through the following procedure. 1. Analyse the problematic thoughts in internal dialogue and emotions by listing the content of recent experiences relevant to the problem. List out key phrases and relate them to their consequent emotions. Thoughts → Emotions Restless, unable to concentrate anxiety 2. Get the aims of clients for themselves concerning what should happen, plus the desires and wishes of others if any other persons are involved. The answers to questions 1 and 2 are written down on two sheets of paper. The two sheets can be placed in front of clients with a gap between them. Clients are then interviewed concerning what actions they can do that will get them from 1, the problem, to 2, their aims. The therapist writes down behavioural outcomes that will achieve their aims on a third piece of paper. 3. The final stage is to ask clients to act accordingly, as per the third sheet of paper. Or if the course of action is not clear, for them to continue thinking about what actions to take. Other matters should be decided entirely by clients, particularly when the meetings have been progressing well and there is no leeway for danger. Phrases like “what would you like to change this week?” and “for how long would you like to ____ ?” can be used to good effect to create a sense of curiosity about what clients would like to do with their energy.

One day at a time It is a basic achievement to be able to structure any day. For problems like worry or negative anticipations, eating disorders and substance usage, just structuring a day can be helpful. What clients need to do is make an agreement with themselves that what they want is worthwhile and that means experimenting with their behaviour in trying to attain it. In the case of worry, for instance, having a safe limit on painful remembering and negative anticipation of one hour per day (their choice) in total might be one way of staying in the present. The use of distractions that fully occupy consciousness, such as playing football or something 389

Talk, action and belief that demands concentration and full involvement, is a way of diverting attention away from what brings pain and regret. Other ways of putting a safe limit on linguistic repetition or repetitious visual imagining, might be to write down a worry at once, in order to problem-solve it at another time. The intervention is a way of dealing with one day at a time and to stay with the issues of what is most important each day, in such a way to balance up necessities and have some fun and pleasure, rest and relaxation in the short-term. This is an answer to the problem of there being an excessive preoccupation with the past or future that brings pain and poor functioning. Any kind of action requires sufficient time for its completion and sufficient effort, skill and practice for its accomplishment. In terms of looking after selfworth and providing care to others, any positive action is classed as an achievement in the broad sense. When a minimally sufficient amount of care is provided to self and others, then the wisdom of coping is achieved. If the care provided to others and self is insufficient, then its lack will be felt in the low self-esteem that accompanies self-neglect. People need care and attention in the same way that plants need water and sunlight to thrive.

Workshop approach It is possible to ask questions in such a way to get clients to provide themselves with their own advice. Similarly to being in a group setting of a workshop, where a number of people work in small teams to pool ideas and problem-solve creative, the same can be done with two persons. To ‘workshop’ a topic of common sense can be done to check definitions and begin creative problem-solving. When questions that promote re-interpretation for clients are asked from a position it is a means of inquiring about commonsense. For instance, what would it be like for anybody to be “arrogant as opposed to confident?” could be the question of someone who is moving from low self-esteem to a fairer appraisal of themselves, yet fears becoming arrogant. The workshop approach refers to creative problemsolving where notes are made by the therapist who puts questions to clients who answer their own dilemmas. For instance, another topic might be to explore what it means for someone to be confident socially. What would such a person do and feel? How would they behave? How would others behave in return?

Decreasing impulsivity and increasing self-control When there is a problem with impulsive behaviour leading to negative outcomes, or the threat of them, an intervention can be started by asking clients to think about what they want to achieve. The example below is one of dealing with road 390

Ian Rory Owen PhD rage in a person who had verbally challenged other drivers after forcing them to stop on busy roads. 1. Make a clear written statement of the impulse to be curbed. For instance, “I will be less impulsive when I am driving and remain in control of how I drive, should I get the desire to drive aggressively or provocatively”. 2. List some of the major positive consequences of staying impulse-free. Lack of damage to cars. Lack of insurance claims. Lack of court appearances. Lack of risk to self and others. Keeping the ease of mobility through having a car and not losing one’s licence. 3. List some of the major negative consequences of staying the same. Getting injured or possibly killing self and others including innocent third parties. Damaging cars. Getting into fist fights with other drivers. Getting extremely angry and driving recklessly. On this occasion, the client in question realised that being offended by other drivers’ lack of thoughtlessness and common courtesy was insufficient reason to repay them by being a bad driver.

Distractions Distractions can be helpful in some specific situations. For instance, when it is realised that impulses, thoughts, memories and feelings, if they were followed to their emotional conclusion, would motivate extreme and drastic consequences. Distractions can be useful to help reduce anxiety, but they are not necessary for change to occur. Distractions are unnecessary and help people stay exposed. It is the exposing that counts. What really helps are the principles for reducing fear stated in chapter 8.

Time management One way of helping clients manage their time, tasks and priorities is to provide a simple means of helping them classify what their priorities are. This can be done by writing the following classifications on a single sheet of paper to make 391

Talk, action and belief columns. Then asking clients to think through what lies ahead for them. Once this has been done in a session, clients can repeat the same classification concerning what are their most important tasks when present the classification below into columns, the question is “what is the most important task for you? Classify your current tasks, in their order of decreasing importance”. Next task Today’s tasks Tomorrow’s tasks This week Next week This month

Irrational thoughts Irrational thoughts occur for a large proportion of the public (De Silva and Rachman, 1996). Some people see no significance in the full range of their thoughts and the contemplation of possibilities that will never be. Others however, are excessively troubled by having thoughts and imaginings, just in itself, even if there is no possibility of ever acting on them. The means of working with irrational thoughts are to alter, reduce, prevent and exercise choice and help people anchor themselves in good current experiences. Depending on the intentionalities involved in the irrational thoughts, it is possible to help clients make their own interventions on how they react to them and maintain self-esteem. The sort of thoughts that I am referring to are the sort that people think things that are contrary to their personality and sense of self. Irrational thoughts are classifiable as “ego dystonic”. For instance, a married man with children of his own fears being seen as too physically close to his children or too close to the children of others and fears being accused of being a paedophile. On questioning, it becomes apparent that he has no sexual intentions towards any children. However, what he can imagine is being accused of being a paedophile in the street and beaten up and then he would appear in court. Visual images about these possibilities come very quickly for him and hover, like they are on a small TV screen, about one metre in front of him. The intervention is to imagine that the images can be turned into black and white, folded up, shrunk down and thrown away (Bandler, 1985, p 21). He is able to do this whenever they occur. Then he feels a sense of control and gains some understanding. The images are irrational and are not about his genuine intentions towards children.

Parallel paths This is an intervention that increases people’s abilities to stay on-course towards their own explicitly elected aims and targets. The guiding idea is to imagine that there are two parallel paths. One path is that of the desired behaviour, such as not smoking, staying on a reducing diet or being substance-free. The bad path is what happens when the person does the undesired behaviour. ‘Walking off the good path’ 392

Ian Rory Owen PhD might occur at some point. If difficulty in learning the good path is expected, it can be pre-emptively defined as a hiccup and not a permanent disaster. If a person ‘walks off the good path’ then a number of means need to be in place to help them rejoin it as soon as possible. 1. It needs to be clear how to stay on the good path and not fall off it. If it is possible to enjoy the good behaviour in the short-term, then that makes the new good behaviour immediately worthwhile and self-rewarding. The good behaviour also has the promise of long-term satisfaction and is by definition worth having and working for. 2. If the person falls off the good path, one positive response is recovering quickly and rejoining it in a short space of time. Hiccups are only to be expected, particularly if the behaviour is new, such as abstinence of a problematic behaviour, after a lifetime of over-indulgence in it. 3. If it is possible, then the “distance” between the good and the bad could be increased to make a number of changes: by introducing varieties of success and degrees of failure. Rather than there just being either total success or complete failure. This functions to ensure more probability of success.

Death anxiety Death anxiety is not just the realisation of one’s own mortality and a fear of it, in physically healthy people. This anxiety about the possibility of death is a pervasive belief in the immediacy of death in the short-term, without any evidence to support the belief. The belief in vulnerability to death may come after a lifethreatening event or after psychological trauma such as physical and sexual abuse, or be part of worry in health anxiety. However, the belief in imminent death is really expressive of a sense of vulnerability and shows emotional dys-regulation and ego inconstancy. Cases where there are real threats to safety are not included. For instance, living in a violent neighbourhood, smoking, heavy drinking, bad driving and being seriously overweight are real threats. The way forward is to keep a tighter grasp on the possibility of a healthy future, so to decrease the sense of vulnerability. Looking for evidence of good health and physical strength and focusing on them, lessen the fear of death. Another way of reducing the fear of death is to help people persevere with their ordinary lives so that they reduce the amount of time spent focusing on their death and so get the direct experience of what it is like to live a better quality of life, due to less worry. The evidence of living a less worried existence is sufficient to tip the balance in favour of finding themselves stronger and more able to cope.

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Survey of understandings about social situations Empathic abilities can be checked and explored by therapists thinking up some scenes prior to a meeting or putting back to clients their own nightmarish fears, but from a different point of view. For instance, for someone who was paranoid, the following scenes might be relevant to gauge how they are able to think about them from another point of view. This can be done by explaining the scenes to other people and recording their answers. The explanations and surveys of others’ views can be done in the first person, to help people think of each scene from the inside. For instance: “If I saw a person who was brusque, who suddenly changed their attitude, was angry and tried to hide it, then they withdrew from me for two weeks and did not return phone calls or initiate any contact, what would you think they are feeling?” The phrasing can be stated in the second person in a way that invites people to step into what others might be experiencing: “If you saw a person who asked you how you were, then as you responded, they talked about what they were interested in and showed no further interest in you, what would think of that person?” The ‘third-person’ is of use in creating a sense of distance from the problem, ‘first-hand’: “A group of people meet regularly and all but one of them shares their sense of humour. The majority of the group of middle aged adults talk in baby language and think that farting is funny. But the one who does not think farting is funny, worries that the others are less fun to be with than they think they are. What do you make of that situation overall?” The answers to these questions generate evidence concerning a variety of positions on these topics. There are no absolutely right or wrong answers.

Summary What appears of practice is a competent whole of actions, choices and decisions that fit together. However, intellectual concepts in thought and language point to competencies and the good performance of social skills in the work: Therapists work to enable things to happen for clients. Therapists should have some clear idea of what is trying to be achieved. However, it is not necessary or possible for therapists to have all the answers. Clients can give themselves their own advice with questions like “if there was one thing you would like to change this week, what would that be?” Practice concerns making a short-term series of meetings with people who have explicit choices to make, so they actively participate in the treatment. Practice is a whole. The pieces of the whole can be re-learned as stand-alone pieces that get fitted together. The identification of its constituent parts can only be done from the vantage point of competent practice. Practically speaking, it is better to 394

Ian Rory Owen PhD make changes in the mood and self-esteem in the short-term before embarking on a journey into the past. Personality is linked to the direct sense of the lived bodily self, in that positive benefits for the bodily self can bring positive changes in mood and self-esteem. A personality and lifestyle are comprised of an intricate patchwork quilt of inter-locking pieces. Once they are established, it becomes difficult to change the pieces. There is no practical help gained in launching into an exploration of a distressing childhood when clients can barely function in the present. In this case, to suggest such a strategy is practically damaging and ethically wrong. Spending a long time looking at childhood problems is pointless, if there is no connection to here and now needs. It is unnecessary to dig into people’s childhoods unless they need to revisit them in order to understand their present situation. •

Human beings are very complex and not every combination of personality style, in conjunction with every psychological syndrome can be specified in advance. Therefore, what is required is further attention to the detail of how the life-course can be altered and how redemption can occur through acts of free will.

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For clients and therapists, intellectual knowledge of explicit preferences come into play in the face of strong emotion to over-come an impasse, or be able to deal with a key question or concern. Like learning a musical instrument, effort is required to learn the technicalities of playing someone else’s music so that improvisation can occur.

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Some sort of recap at the end of each session about homework, or asking clients to set themselves their own homework, are particularly good when a regular pattern of events has been laid down across sessions.

Knowing how key behaviours are maintained in the here and now is more important than knowing how they started because it is often the case that small changes in the here and now occurrence of problems can have large effects on mood and the sense of self. If mood and functioning are problematic, it is possible to specify various levels of activity and agree the activities that help promote functioning and mood. If a person is fully on-board in their own self-care, then what will happen is that it will be possible to work out with them in detail what sort of self-care actions can be employed to create which positive effects. The programme of self-care should be carried out no matter what the person feels in the moment because behavioural action is first required in order to feel the benefit of it. If there is no self-care action, there will be no benefit.

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21 Some cases showing the role of intentionality Aim: This chapter details some cases where the skills of therapists show themselves in good practice in helping clients develop their own aptitudes and potential. The basic point to grasp is that good understanding produces good outcomes, despite personal, social and other contextual limits.

Opening remarks This section makes a number of non-specific remarks before more detailed comments below. The aim of the intentionality model is to be more precise about the nature of psychological problems and how therapists can specify interventions and encourage self-care through this more precise understanding of the nature of the problem. Both the nature of psychological problems, generally and individually, can be mapped by connections between intentionalities, senses, objects and 397

Talk, action and belief contexts to make practical solutions and experiments that clients can try. In some cases open discussion just by itself might also lead to clients changing their own behaviours. The base material of meetings is to set up experiments and find out what can happen and to what degree clients are able to make changes. If they have not made changes or tried the experiment, it is necessary to explore what happened and discover what it means. Clients are supported in making the sorts of changes that might help. It is never necessary or acceptable to apply force. A preparatory step is evaluating all possibilities, including the one of making no changes. But retrospectively, any positive change frees the sense of self and is invigorating because it breathes some excitement back into a stale life of habit and insufficient self-knowledge and self-care. Before therapy, clients have their own interpretative stance with respect to their beliefs about themselves and others. The usual stance is that clients judge themselves as bad, useless and unworthy of respect and believe that others are against self, out of reach or entirely perfect creatures without problems of their own. A good quality therapeutic relationship is one where clients can use what is being offered and may either begin to adopt some of the intellectual content of the interpretations provided or they are encouraged to think of their own. When clients attend therapy, what is being asked of them can be described metaphorically as ‘stepping out’ of their beliefs. In a more technical sense, what they are being requested to do is occupy a new interpretive stance, in order to reflect on how their explicit or implicit beliefs are playing a role in creating problematic situations. It is always possible that clients can step back into their old beliefs, to believe them once more.

Talk only Instead of presenting a straightforward case where excellent progress is made, the following brief overview is stated to show how impasses can occur in talking and relating. Meanings concerning any state of affairs connect to the whole of any situation, are comprised of a number of parts. Specifically, most psychological situations are understood by listening to the account of other people and (through a culturally-taught capability) being able to grasp what happened for the speaker, those around him or her, are able to guess with a good degree of certainty what the reactions and intentions were of that speaker and those other people. When discussion and relating are the major forms of intentionality used, what is produced is a form of intervention that is easily accessible to most of the public but is more non-specific in comparison to action therapy. The strength of action therapy is that it can be highly focused on the maintenance and the individual structure of problems. Rather than staying at a level of abstraction though, let us attend to the case of Justine, a single woman in her forties who had been abused and neglected 398

Ian Rory Owen PhD as a small child and had grown up in poverty. At the beginning of the meetings, Justine wanted answers in order to understand herself and her motivations. Specifically, she wanted answers to what the effects of her abuse were on her and she wanted a diagnosis and specific instructions about how to lead her life. From the receipt of the referral letter, it was clear that there might not be a good outcome for her and that her needs were great in comparison to the limitations of the service that she was entering. It was stated at the outset of meetings that there was a limit of 20 meetings for therapy in total. What transpired in the early sessions was that abuse and neglect appeared as having robbed her of being self-determining. Her lifestyle appeared as an aimless existence devoid of any thought of the future. Her day to day living was without any regular pattern. Justine had little contact with other people. She had no job, no qualifications and no pastimes of any sort. What was clarified entirely through discussion was her belief that other people did not care for her and the fact that she stayed alone and had minimal contact with others. There was “no point” in seeking out others, for the satisfaction of mutual interests of any sort. In the early part of the therapy, Justine appeared to be very fixed on finding out the truth of what had happened in her family of origin, concerning being locked in a cupboard by her mother and step-father. In fact what was notable was her ability to look after herself as a small child. Justine had run away from home to stay with an aunt and an uncle who were non-abusive. She had had the insight as a seven year old, that her mother and step-father were incompetent in caring for her, so she snuck onto a train without a ticket for a 400 kilometre journey to where her aunt and uncle lived. This was discussed as a positive event in her ability to look after herself. However, where the ideas of empathy and the ease of discussion show themselves is in how the inter-action between Justine and her therapist can be understood. Justine’s problems were that she was neglected and physically abused. She found all social contact to be stressful, so she avoided it. But by the age of 45 she realised that something was missing from her life but she did not know what is was. After 10 sessions of open talking, it became clear to her therapist that enough talking had been done. The therapist wanted to change to make some more specific interventions along the lines of helping Justine gets some ideas about her future, in order to over-come the aimlessness that kept her depressed, anxious and socially avoidant. However, when this aim was expressed Justine reacted strongly saying the therapist had not understood her at all. She had “no identity” and she “could not possibly think of the future without having some sense of herself ”. Justine complained bitterly that she was not getting enough out of the sessions. The problems of her sense of self can be grasped as being an empty self that is disconnected from contact with others. Despite Justine having no structure to any 399

Talk, action and belief of her days she sought nothing and wanted nothing and no one. She was aimless but never complained of depression. What this felt like to the therapist was that he wanted to help, but felt unable to discuss with Justine what was going on because Justine fended off his intervention. Although the therapist had explained the reason for taking a new direction had been approach. His reaction was to back away from re-stating the need to help her move on from the aimlessness that he felt was at the heart of her predicament. The overall inter-action was that she tangled up the therapist when he was trying to help her and discuss with her what her needs were for help. But because he stood back from further discussing with Justine her needs for help, what was produced was an impasse that began to use up the ending sessions. Justine herself did not realise the effects of her strong refusal to accept the therapist’s suggestions for progress. For Justine, she wanted to focus on what she felt was her own lack of self-identity. Justine did not realise how she had pushed the therapist away and she began to complain that she was not getting enough sessions. Despite the limit of 20 sessions having been stated at the outset, it was now becoming the case that the remaining time was being spent on discussing the relationship dynamic of the therapy meetings themselves. This was not a satisfactory state of affairs. At the end of the meetings, it became clearer that the therapist felt that he had always tried to help, but that there had been an incompletely expressed disagreement about what the focus of the meetings should be. For the therapist, he felt that his interventions of taking stock of where Justine had got to in life, and moving to a more behavioural way of beginning changes, was still the right thing to do. For Justine though, she felt disillusioned about her ability to be helped. To some degree, this was probably on the cards right from the referral letter. What was learned for the therapist was the importance of setting up meetings with clarity. And despite the explanations provided, that it would be a good idea to ask clients to explain back what they have understood about what is being offered and the extent of the help that will be provided, to make sure that clients have understood important limitations about the nature of the help that has been agreed. This example emphasises the role and importance of the conceptual intentionality of discussion and the sharing of different views through empathy on each side of the therapeutic relationship.

Action: Working with obsessive-compulsive disorder This section provides some specific details of how the intentionality model helps with the specific problem of obsessive-compulsive disorder (OCD). Let us take the problem of people who check electrical appliances unnecessarily for 40 minutes or more, before they go to bed at night. Anne has had OCD since childhood. Now 400

Ian Rory Owen PhD that she is 50, she is still troubled by unwanted thoughts and images of disastrous events that might happen, for which she alone would be entirely to blame. Anne believes that if she was not to turn off and unplug all electrical appliances in her home, then there would be a fire. What would happen is that her home would be burned out plus all the other flats in her block. She would then be taken to court because she was responsible for the fire. The problem is that although Anne takes the plugs out of their sockets, she does not adequately trust her visual perception that they are out. What comes to mind are strong images of her home on fire. The formulation of the problem is intentional in the following way. There is a learned association between the anticipation of fire and the emotions that are congruent with that scenario: terror and an excessive sense of responsibility for being at fault. The intervention in intentional terms is as follows. In progressive steps, Anne is encouraged to take out a plug and time how long she is permitted to observe that it is disconnected. A list of new thoughts and images are made with the help of the therapist. The new helpful thoughts and images are found, discussed and practised in sessions. However, a reducing limit is placed on the amount of time that Anne can stay at a wall socket and check that a plug is out. This is discussed and the outcome is that Anne decides not to look at the wall socket and to leave the room immediately that she unplugs all electrical appliances. When Anne leaves the room, she employs distractions to make sure that she does not return to check the socket again. The specific steps are as follows. Anne takes the plugs out and leaves the room as quickly as possible. The intentionalities of thought in internal speech, visual imagination and the practical activities of watching TV, reading and cuddling her cats are employed to distract Anne away from her tendency to worry and return to the socket and check it a number of times over. What are being substituted are new objects and new intentionalities that create new conscious senses - in opposition to those that are the OCD. Specifically, the new thoughts are the use of explanation about the visual image of the house burning down but after discussing its meaning, Anne could remind herself that “it is only a visual image,” and “that fire is not going to happen when the plug is disconnected”. Further thoughts like “I am very careful,” “stop it,” “I can over-come the checking,” and “it’s not going to happen” are practised in sessions. Comforting visual scenes are found with Anne. These include being with friends, walking down the street and having lunch with a close friend. These scenarios are practised in the sessions, in relation to actively choosing what it is that Anne will be focussing on, rather than becoming obsessed that her home will burn down and that she will be thrown into prison for her lack of attention to safety. Practical activities are used as distractions to promote her ability to stay out of the room when the plugs have been disconnected. In conjunction with her therapist, some experiments were 401

Talk, action and belief discussed that might provide further help. Anne could try telling herself that she is beating her OCD before taking the plug out. Anne imagined kicking a monster because she feels that her OCD is an oppressor that makes her frightened. Anne could try taking the plug out of its socket and picking up her cat immediately and cuddling it as a distraction. Other phrases that were worked out and practised were comments like “it’s off,” “leave the room,” “I have turned it off,” and “out now” as ways of breaking the habit of staring at the empty wall socket and touching it to find out if it is warm, for up to 40 minutes. The first attempts at walking away were negotiated in therapy. The first target set by Anne was to stay for only 15 minutes at the wall socket (not 40) and to make notes about what happened, to note the level of her anxiety and record any thoughts, images and emotions that she had. Because the problem was daily, its treatment was also daily. Notes were made on how progress was being made towards her goal of not checking. What was explained to Anne was the major difference between having a visual image of a house fire and the event itself. The problem was further interpreted back to her as being an overactive visual imagination and a lack of trust in herself. The realisation came from Anne that she over-estimated the extent to which she anticipated that things would go wrong and that it would be her fault. The other parts of the treatment were to help Anne see that she needed a wider vista in life, in terms of her educational and occupational goals. Her mood lifted throughout treatment and she found that her confidence in her abilities was coming back to the extent that for the first time in her life she could look forward to ordinary events in the near future, rather than be worried that non-specific things would go wrong and that it would be her fault.

Action: Binge eating The following example of using the intentionality model is to help Elaine understand her bulimia. The process was a two-step procedure. Elaine was interviewed around her reason for over-eating and what advantages and disadvantages it gave. It was found that over-eating had a number of specific functions in altering her mood. Secondly, Elaine was asked to problem-solve by repeatedly asking her how she could over-come each part of the problem. At the end of each session, Elaine was asked to take action everyday during her week and report back at the next session what had happened. What came through in close questioning about the order of events around over-eating were as follows. The reasons for over-eating were that Elaine felt bored and depressed on getting home in the evening and that she felt self-contained in that she told herself that she could not talk to anybody about what was bothering her. It then became clear what the psychological function of the over-eating 402

Ian Rory Owen PhD was about. Namely, it served the purpose of acting as a distraction from feeling dissatisfied. At the time of bingeing, she did not care about its effects because the eating made her high. Elaine also realised that she got relief from her mood through the joy of eating. But that binge-eating had negative consequences. About two hours after stopping eating, because she had filled herself to bursting, her reflections at that point decreased her self-esteem, and increased her immediate feelings of loss and dissatisfaction. Elaine had a further insight into her eating when she realised that bingeing was the result of acting on impulse. When she did binge eat, any attempt at dieting was over. Apart from the insights into the motivation for eating already noted, it was the case that Elaine could find no sufficient reason for eating a whole packet of biscuits at one sitting. Obeying the impulse to binge produced two emotional reactions. First, she enjoyed the food but a little while later, Elaine felt sick and was angry with herself for having done it. In order to make a contrast with the problems of binge-eating, a time in Elaine’s life was found when she had been well and there had been no problems with binge-eating, self-esteem and her well-being. This time was discussed in sessions and used as a set of clues to work out what happened when things went right in her life. The sessions were summed up with a written account that was made with Elaine, photocopied and given to her. It was discovered that even at the best of times, Elaine felt a little depressed and that talking to people was good for her mood. Binge-eating was not a solution but a problem that further hurt Elaine. Because of these insights into Elaine’s specific situation and personal history, it became possible to work out what would help Elaine with her mood that did not employ the false solution of bingeing. Elaine realised that she needed to control her impulses to binge. Once she found how to do that, she was motivated to change her own behaviour and quickly she brought binge-eating to an end and decided to have more contact with her friends, family and husband instead.

Talk and action: A case of excessive alcohol intake The way that therapy can help is to make clear what the reasons are for drinking, for each individual. Because alcohol abuse has a cost, it is interesting to phrase questions whereby clients can show where they are in their recovery. For instance, the simple question “what does drinking get you?” can reveal that a client might be hanging on tightly to the benefits of alcoholic inebriation or that they are focused on the guilty after-effects of being hung-over and not being fully capable of their normal functioning. Usually, the reason for alcohol abuse is that the value of temporary escapism and pleasure in the short-term, exceeds the value given to positive success in the long-term. For instance, headache, lethargy, perceptual sensitivity and the sensation of heat comprise the hang-over experience. But the 403

Talk, action and belief repetition of inebriation and hang-over across decades of heavy drinking, and the refusal to face problems and work to reduce them, contribute to an increasing risk of psychological then physical addiction. If a person is drinking heavily and is anxious and depressed, then the resulting mood could be the result of the drinking alone. Or it could be that a pre-existing problem is exacerbated by excess alcohol. Generally, it is necessary to formulate the psychological reasons for drinking heavily, to understand the role that drinking has. Often its function is negative reinforcement. From the point of view of the therapist, heavy consumption means that the edge of psychological addiction is being touched. One aspect of self-harm in this situation is that to persist with heavy drinking means a certain amount of masochism must be present in order to not change in the face of daily hang-overs. In order to interrupt the link from desire to the practical intentionality involved for drinking to stop, the damage done by drinking has to be cognisant at the time of buying, being offered or considering drinking - in order to prevent and minimise consumption. For drinking to continue, the release and “enjoyment of irresponsibility” gained from drunkenness has to be worth the cost of having painful hang-overs, broken blood vessels, tiredness, guilt, anxiety and low self-esteem. Drinking heavily has its costs in terms of the headache, nausea and difficulty in concentrating caused by hang-overs. What, if anything, is gained by daily heavy drinking? It is a few hours of inebriation and a sense of relief from anxiety or other unpleasantness, during that time only. There is a repetitive cycle of events that happens on a daily basis. The cycle begins when a short-lived feeling of minor unpleasantness (such as anxiety, boredom, irritation, frustration, or the low blood sugar sensation) became connected to an impulse to buy alcohol, expressed in internal dialogue of the sort “I need a drink,” or as a reward for things done well or as a comforter for feeling bad. We shall start with some general pointers. Interventions to help people who mis-use alcohol can be based around exploring the personal motivations for and against drinking, and strengthening maintenance of contact with their personal reasons to lower alcohol consumption. The maximum safe daily intake for a woman is three units per day (and for a man it is four). The decision to drink more after the first drink can be made on the basis of a sense of self-indulgence and reward for jobs well-done or other more impulsive behaviours to want to obliterate consciousness. If there is difficulty in gaining control between the desire to be drunk and the physical action of consuming the alcohol, then people who only binge drink might need to consider becoming abstinent. The definition of negative motivation is to avoid a problem for the genuine need to avoid damage and similarly positive motivation is to go towards more positive rewards. The way to do this is to increase the negative and positive motivations as follows: 404

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Positive motivation is wanting sobriety and enjoying it for the reasons, say, of waking up in the morning without a headache and feeling good throughout the day. These are the powerful immediate gratifications of abstinence and low usage. Aim: remain hang-over free. Action: if moderate drinking cannot be achieved then abstinence is the only answer.

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Negative motivation is increasing the dislike of hang-over sensations rather than accepting them. Merely feeling sorry for self and repeated over-drinking day after day, without behavioural change, is to experience the problem and do nothing about it. Aim: stop collusion with one’s own self-destruction and the creation of a low quality life. Action: explore and over-come justifications for excessive drinking.

Real change comes when clients work to make their lives better and increase self-caring and caring for others. Thus, the reality of practising action therapy concerns raising and maintaining the motivation to achieve in clients. It must be clear that it is clients who want this type of help and it is they who need to be motivated. If this is not clear after a discussion at assessment, then action therapy cannot begin, as informed choice has not been obtained. In the view of the intentionality model, a behavioural programme is a decision to alter one’s meaningful world. This translates into increasing some actions and decreasing others. An example will help to explain this. Let us consider the specific example of Stephanie. The story behind Stephanie’s five years of excessive alcohol intake was that she had moved to a new town and focused her energy on work in order to promote her relationship with her employer and establish herself occupationally. However, due to a recent relationship break up, she focused far too much on work and began to drink heavily everyday. Stephanie felt that drinking was her “little luxury”. Because of buying a house and fitting it out, the homemaking activity took up most of her weekends and evenings. Stephanie abused alcohol but was neither physically addicted nor impaired in her work role, even though her consumption was frequently as high as 10 to 15 units, seven days a week. This intake was sufficient to give her a hang-over that lasted until five p.m. the next day. Before entering therapy, Stephanie had taken a liver function test and the result was normal. Stephanie sought help when, after five years of heavy drinking, she admitted to herself that alcohol was causing her harm. In therapy, Stephanie at first described her drinking as her “only luxury” and said that she drank as a means of praising herself for a day’s work done well. She admitted that drinking was something she did on other occasions where she felt that she needed commiseration for things going wrong. When drinking was daily and heavy, although an unpleasant sense of irritation might bring the impulse to drink, it only lasted a few seconds, but it was a sufficient justification for Stephanie to drink 10 to 15 units. When the 405

Talk, action and belief drinking was over, the next morning there was regret and recriminations of the sort that “I will never do that again”. And “this isn’t helping me. It’s hurting me”. However before therapy, the regret at the impulsive action to drink too much, did not lead to a change in behaviour. The hang-over experience (comprised of headache, heat, tiredness, depression and anxiety) was not connected to the need for self-preservation and self-control. This is where the problem lay for her because excessive drinking, when repeated for years, seven days a week, is damaging to physical and mental health and the general good functioning of the individual. It also decreases responsiveness in social life. During therapy there was a long up-hill struggle towards sobriety with many setbacks along the way. Although Stephanie wrote in her diary that “drinking is not worth the brief release in comparison to the effects of being hung-over” and “the decision lies with me to not buy alcohol and not drink it”. It took her almost two years before she was able to reduce her intake. The main reasons that she could find for stopping were the negative effects of alcohol on the quality of her sleep, being hot and tired, grumpy, resentful, impulsive and angry after drinking. However, it took a long time for this to be felt as motivation that leads to action. The direction towards alcoholism was clear to her though. To persist with hangovers and begin to fail to cope with ordinary living would lead to role impairment at home and work. Yet for two years after seeking help, she would still not give up the high of inebriation. But it was clear to her that if she continued drinking her fate would be sealed. One intervention that increased negative motivation to decrease her intake was to look at the bottle and say “this will give me a headache and make me feel exhausted tomorrow”. This was followed by looking at a drink in a glass and remembering very well what it felt like to have a hang-over. The idea was to look carefully at the bottle and want to save the brain, liver, kidneys and heart from damage. A positive motivation was the mantra to be repeated: “I have enough problems already without making myself hung-over, anxious and have bad sleep”. Another intervention in therapy was to rate Stephanie’s hang-overs by way of increasing the focus on the damage done, rather than on the brief euphoria and the ‘devil may care’ feeling of release and inebriation. One rating made and recorded was of the amount of usefulness of the pleasure gained from being drunk. A second rating was to put a number on the amount of pain felt, how long it lasted and the overall consequences of it. Such ratings were made in comparison to sober days, when fully recovered and having no hang-over. On entering therapy, the understanding of her imbalance between work, rest and play needed to be re-set as follows. The therapist elicited her aims: Aims in the positive: Get more friends with similar interests. Ring current friends more often. 406

Ian Rory Owen PhD Invite people to spend time with self and engage in social activities without alcohol. Aims in the negative (avoid, choose not to, minimise): Stop drinking excessively. Reduce getting excessively angry with self. Stop keeping problems to self and start talking about them with friends. When there is the most minimal choice available, there is a dilemma – take it or leave it. When there is proper choice about how much and when to drink, there can be confusion because of thinking through consequences, negative and positive, rewards and costs. As an experiment, a period of sobriety was chosen to find out what life was like without alcohol. The outcome of four weeks of abstinence was as follows for Stephanie: First week – more vitality, more energy, greater stamina. Second week – felt more alive and in the moment, better mood. Third week – felt loneliness at home due to the real reasons of not having a partner but wanting one. Fourth week – begun to feel a success at work, began to feel more confident about the prospect of dating again. The topics that Stephanie brought to therapy were her pervasive sense of shame and not having children and not being married, social anxiety, worry and guilt about masturbation. These topics were hampered by her difficulty in speaking about them. Eighteen months into therapy, what Stephanie decided was that hang-overs and broken blood vessels on her face, arms, legs, feet and stomach were unacceptable. Despite many attempts, the maximum amount of alcohol that could be consumed without bingeing, even on a weekend, could never be more than two units per day. The reason for this was once she had more than two units, she wanted more and more. Often her hang-overs began whilst drinking even a small amount. If she had more than three units, that would almost certainly lead to a binge which could be as high as 20 units. Whilst one or two units could be drunk without a binge, there was still the possibility of bingeing. So overall, Stephanie chose to be abstinent of alcohol. In discussion with her therapist, Stephanie realised that there was an “on” button to start drinking, but no “off ” button to stop it, until unconsciousness had been gained. Even when Stephanie was six months without alcohol she still felt like drinking to oblivion in reaction to mild anxiety, disappointment, boredom or loneliness. Eventually Stephanie decided that even occasional binge drinking of eight units a night was unacceptable even though it did give her short-lived sense of exhilaration and luxury. It was unacceptable specifically because of the hang-over produced. Therapeutically speaking, Stephanie felt she had gathered 407

Talk, action and belief enough evidence to realise that she did not want to drink any longer. The negative clearly outweighed the positive for the first time. For instance, Stephanie found evidence that it was better to keep a poor mood prior to drinking, and take action to deal with her mood rather than by some means other than the substanceinduced euphoria provided by alcohol. Two new thoughts that were made with Stephanie were to enforce her choice to be abstinent of alcohol by asking herself a new question. The old internal dialogue of “do I want a drink?” Was replaced with a new question “Do I want a hang-over?” which was the inevitable result of binge drinking. Abstinence from alcohol produced evidence of a better mood, better self-esteem, less worry and better all-round social functioning. Stephanie also began dating and took part in activities where there would be eligible men. The differences that she also noted were a greater sense of joy in merely being alive and a greater tolerance of negative emotions. When she had relapsed after being abstinent, the old problems of increased impulsivity, anger, self-pity and self-neglect returned at the time of drinking itself and in the 48 hours after consuming alcohol. To recap: the practice of talk and action therapy noted above is to emphasise the roles of free will, choice and motivation in helping people to want their aims more and not want the problem anymore. If people understand the nature of the problem clearly, in terms of the negative influence it is, and the negative consequences it has, the consequence is to act congruently in accord with what is wanted. If people do not want to change, then that is their choice and therapy meetings should either come to an end or a new focus needs to be agreed such as exploring why they do not want to change.

Using supervision Let us turn to an example of how problems arise for therapists. Rather than discussing research or theory, let us start with a practical example of how decisionmaking can be difficult in practice. One problem of practising is being caught between dilemmas and unknowns. Practising involves having to deal with emotional currents that pull in different ways. For instance, Kate, a cognitive behavioural therapist has been seeing Natalie who was becoming more demanding right at the end of the agreed set of sessions. But Kate only provides brief therapy for agreed issues, for a fixed number of sessions. Right at the start, Kate specified the number of meetings required. On this occasion, the end of the meetings is looming and Kate did not know how to proceed. Recently, Natalie, who was sexually abused as a child, has been asking for more help in the area of assertiveness and how to deal with a number of problematic relationships with demanding and exploitative men: including her critical father, her exploitative and bullying boss and her manipulative live-in boyfriend. Should 408

Ian Rory Owen PhD Kate make a special case of Natalie and keep her on? Should Kate prepare Natalie for the end that was agreed at the outset of the meetings? Should Kate tell Natalie how she feels in complete honesty? That Kate is feeling excessively pressurised by Natalie’s neediness and feels unfairly criticised because Kate has been doing her best, despite withering criticism from Natalie. These questions spin round and round for Kate. So she takes the case to her supervisor, Paul. Supervision is part of the general way in which quality assurance and professional development exist in therapy. Therapists take problematic cases to supervision to explore the dynamics of therapeutic relationships and gain a new perspective on their work. Supervision provides new perspectives on how therapists are conducting themselves through understanding their work. Kate’s supervisor Paul, a very experienced cognitive behavioural therapist, says that what needs to happen is that the therapy contract (to complete 20 sessions on the original focus) should be enforced as agreed at the outset, no matter what Kate feels about her client’s needs. This opinion is given in the manner of a recommendation from a respected senior colleague. Yet it does not rest well with Kate. She is torn between sets of contradictory thoughts and feelings. On the one hand, she agrees that the therapy was agreed to last 20 sessions only. On the other hand, she can see that with a little more time, some of Kate’s requests for more help in the new area, if successful, would leave Natalie in a much better place than she is currently. Intentionality is a key in understanding the dilemma and working out how to proceed. Because what is believed and what is entertained as possible has emotional consequences, what Kate tells herself creates an emotional pull that influences her decision-making ability. Whatever way Kate construes the problem in her internal dialogue, so it follows that her emotions and experience as a whole follow suit and provide her with self-generated emotion about what is happening. The problem is that Kate is ambivalent and she can see more than one side of the story concerning how she should progress. In reflection, opposing lines of understanding and action pull Kate in several directions. The following things are simultaneously true about this situation. Natalie’s needs are greater than Kate had first estimated them at the initial assessment. As the sessions were progressing, the full extent of Natalie’s difficulties in a whole series of areas became apparent. These had not been mentioned by Natalie at assessment nor inquired into by Kate. Paul is logically right to emphasise that the therapy should come to a close at the twentieth session or close to that, because that was the agreement made by Kate. For Paul, the fact that Natalie is asking for new issues to be taken into consideration at this late stage, is something that cannot be achieved in the therapy. For him, these new topics could be taken forward by Natalie in her own time after the sessions have ended.

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Talk, action and belief Kate appreciates Natalie’s viewpoint that with a little extra time, what could be achieved for her, on the new topic of assertiveness with the three male figures in her life, would be of great benefit. The nature of the problem above is multi-faceted. The intentionality model focuses on how each person is aware of the same events in different ways. In this case, neither Kate nor Paul has ever learned a relationship-oriented model. Although cognitive behavioural therapy has models of the inter-relation of emotions, thoughts and actions, currently it has no theory to understand how client, therapist and supervisor perspectives inter-connect in the way that Kate became confused in the scene above. For instance, how empathy appears in the above is that there are two relationships. Kate is in the middle between Natalie and Paul. Kate needs to reconcile her views of her client and supervisor. Paul can only work with Kate’s view of Natalie. Kate only works with Natalie. To say it again, this problematic situation is ‘caused’ by three congruent lines between empathic understanding, feeling and action. These are three forms of intentionality. Kate’s fuller empathic understanding of Natalie’s needs overall, gained towards the end of the meetings means that the range of psychological problems that Natalie faces are much wider than Kate had first thought. It is Kate’s responsibility to have grasped this at the first assessment. Yet despite her best efforts, this understanding was not gained at that time. This realisation leads Kate to feel guilty, culpable and want to do right by Natalie and extend the number of meetings. These feelings sway her toward doing what Natalie is asking for. Kate logically agrees with Paul that it was clear from the start what the focus of the work would be and the therapy should finish at 20 sessions. Kate agrees that to extend treatment at this point is really like starting a new therapy altogether, when the therapy contract agreed should be coming to a close. When Kate agrees with Paul’s line of argument, she gets to feel that Natalie is asking for something that she cannot have and was never being offered in the first place. Consequently, in the light of Natalie’s withering sarcasm towards Kate on a number of occasions, Kate resents Natalie asking for more sessions. These feelings sway her toward rejecting Natalie’s request. Kate can take a different view of what should happen at this juncture. If she were to turn a blind eye to the rules of her employer, and not take the advice of Paul, her supervisor, further sessions could be provided and Natalie could be given a chance to aim at what she is asking for. The point of this example is that with the idea of intentionality, and a clear focus on the quality of the therapeutic relationship, what can be gained is understanding how each person has their perspective. This helps to make decisions in confusing and complex areas. In this case, Kate ultimately accepted Paul’s recommendation, the sessions were brought to a close with Kate re-capping what had been achieved and advising on some self-help books for Natalie. 410

Ian Rory Owen PhD Kate also suggested that Natalie could ask her employer if her company could offer assertiveness training classes or perhaps Natalie could find some through the Internet. Natalie was asked to see how she could cope for a year, and if she could not assert herself through her own efforts, then she would be able to see Kate again. The theoretical impact is that the problems and dilemmas above are experiential at base and inter-relate. Intentionality shows that choosing one portion of the whole situation and focusing on it in a specific way is the means of creating specific thoughts and feelings that may lead to choices and actions that have further repercussions.

Summary One consequence of the intentionality model is the focus on conscious meanings and egoic control of psychosocial ‘causes’ and naturally-caused tendencies. In some instances, a good deal of what is ordinarily classed as part of personality is learned. The re-learning process begins with awareness and interpretation, leading to new choices. However, when natural cause predominates, the ability to change is much more limited. The intentional explanation of inter-locking client and therapist emotions is that there is the presence of the past and future, in intersubjectivity. Objectivity of the psychological sort is the public accessibility to the manifold of sense concerning differing perspectives about the same cultural object. This accessibility, and ability to appreciate the perspectives of others, is what occurs in emotional intelligence and psychological rationality. At the end of therapy, or when clients have dropped out, it is useful to reflect on the work done and elicit more information on how clients have been unsuitable and how therapists were unable to help them. It is useful to know what factors make people unsuitable for psychological help of any sort, as well as for specific sorts. Interpretation is what happens in taking experience as evidence for a belief. What this means in everyday contact with people and in sessions, is that the theoretical belief systems of therapists creates practice. Theory becomes manifest in how therapists respond to clients. Their ideas meet the lay beliefs of clients and usually the latter get changed. To the extent that a shared world of mutual understanding can be created, therapy will be successful. To the extent that one person’s view predominates over the other in a forceful way, it is likely that clients will not get the help they came for.

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22 Conclusion This work has provided explanation and understanding for practice where talking and relating are the basic media for changing belief and experience and promoting self-managed choices. It has been argued that a comprehensive qualitative understanding brings clarity and thoroughness of explanation to create tailored interventions. What has been delivered is an explicit understanding of intentionality and its type of hermeneutics. Clear understanding of the intentionalities creates dexterity in facilitating change. However, people in general expect that they will be happy and are disappointed if they are not. When this expectation becomes accepted as a rule for living, the next question is “how do you attain happiness?” What therapy offers is the ability to reduce unhappiness. This book has made its contribution towards the goals of promoting happiness by identifying, in a precise way, how unhappiness exists. However, it is the personal view of this author that the work of therapy should be satisfying for its workers. Practice requires a vocation, a calling, plus the experience of personal recovery from psychological problems, a ‘redemption’ from the long-standing influence of childhood. The training therapy should be the means of delivering this increase in quality of life through the process of self413

Talk, action and belief understanding. If it does not, then each practitioner still carries the responsibility to create and maintain their own psychological well-being. If a practitioner has not achieved redemption, then the concepts that he or she uses have no personal meaning and a type of hypocrisy is committed. In order for there to be congruence, concepts must be personally meaningful and therapists must know what it is like to turn their own life around. Nothing less will do. For both clients and therapists, theory defines how to practice.Theory identifies relevant distinctions and indicates specific aims. As therapists generally have no means of diagnosing or providing material changes in the brain, for instance, they lack the means of providing physical remedies to psychological matters. Even if material cause predominates in any specific case, certainty about it would not help practitioners of the psychological therapies. This is because practice concerns how to create psychosocial outcomes with people (given their limitations, those of therapists and the situation as a whole). Practice employs social skills and encourages specific things to happen for clients, the general public. Practice is not technical know-how by itself. The main processes of practice are semi-structured assessment, followed by semi-structured talking or semi-structured action-oriented treatment.

Intentionality is the key When intentionality is understood, it becomes possible to focus on precisely what happens for clients and make clear what needs to happen to make problems less frequent and more manageable. This outcome is achieved through clear understanding that can be justified and agreed, concerning how to manage functioning, mood and the meanings that are created through mental and practical activities.Understanding intentionality can be used to change attachment processes, relationship style, the personality functioning of clients and the therapeutic relationship. Therapy is not limited to making changes through talk, action and belief but really addresses the whole of the inter-connections in intentionality in living. Practice that attends to the intentionalities is able to understand, in a selfreflexive way, how it assesses psychopathology and turns that into a formulation then into interventions for self-care. What therapists do is employ understanding to create speech acts and relate in a secure manner. The ability to practice effectively is the responsibility of each therapist. When intentionality is understood it enables discussion of the links between distress and its alleviation. This is because human beings are self-reflexively aware of how they are aware. This includes directing attention and having choice over beliefs, actions and emotions. The end-products of intentionality are experiences. Intentionality is the link of consciousness to objects that are, can be, have been or will be conscious. What drives the attention to intentionality is the realisation that therapies work by altering the type and duration of an intentionality towards any object of attention. As the length of time spent and type 414

Ian Rory Owen PhD of awareness change, the senses experienced also change. The lives of clients and practice with them are part of the same whole. The viewpoint is that a specific sort of wholism exists concerning complex inter-relations between intentionalities and objects of attention. What exist are wholes of meaning and relationship, of self to self, and between selves. Conscious meanings are part of emotion and bodily sensation, in relation to what is present, past and future. Selves live in relation to others, the specific and the non-specific. When psychological problems and personalities are understood together, within a context of making sense of them, it is seen how the intentionality model supports an understanding of human being as comprised of biological, psychological and social aspects, in which a great many contexts of parts and wholes could be identified. What this means for therapy is that discussions properly occur in relation to commenting on conscious experiences and situations, actual or possible. Decisions to act are not solely due to one type of cause nor are their consequences only of one sort either. (Although it would be tidy to find accurate understandings and weigh-up the causal influences). In a way, finding the truthful cause of problems does not matter. What matters is helping people understand, accept themselves, become comfortable with their past and present and choose a good quality of life. The intentionality model brings together the psychosocial skills necessary to handle the therapeutic relationship. The model uses Edmund Husserl’s philosophy to provide a cohesive argument to bind together the disparate traditions of attachment-oriented psychodynamic and cognitive behavioural therapy. Theory must be about the conscious experience of providing and receiving therapy or it is not fit for the purpose of guiding practice. Attending to meaning lessens the role of quantitative psychology as the sole means for guiding therapy research and increases the importance of the qualitative understanding of the psychological life. Formulation through understanding intentionality helps clients and therapists agree the nature of the problem and its potential answer. Intentionality is a central concept that promotes accountability and the explanation of techniques to the public and colleagues. The intentionality model is a theory about conscious experience that is both individual and social and can unite psychodynamic relationship-factors with the detail of thought, emotion and behaviour. One purpose of the intentionality model is to structure practice around the ways in which intentionalities are the creators of meaningful conscious experience. What counts for therapy practice is the experience of practising. When practice is understood from the inside of what it feels like to provide and receive care, then its experiential basis is properly understood. To work experientially is working with how people are aware. Generally, the objects of attention that clients have are, at first, held in a negative regard. But through new understanding and behavioural change, these same objects re-appear for consciousness more positively. There is a 415

Talk, action and belief scepticism towards the idea that experimentalism is the only means of justifying practice (Cohen, Sargent and Sechrest, 1986, Morrow-Bradley and Elliott, 1986, Stiles and Shapiro, 1989, Dar, Serlin and Omer, 1994). The intentionality model understands that interventions make changes in the following aspects of here and now experience. The interventions that the intentionality model supports are of the sort where there is a precise problem and the strategy is self-care concerning alterations on what, for how long and how clients are aware. There can be changes in the following sequence of the four parts of experience. There can be changes in intentionalities, senses, objects and contexts. Any interventions can be used to achieve these changes. There can be choices in the type of intentionality used in order to produce different senses of the same object. For instance, the sense of an object could be remembered, acted on, thought about, felt or drawn by hand. Specific overloads of attention on one area of life may be detrimental to other areas and may cause problems, for instance, when workaholism leads to a poor relationship with partner and family. Re-evaluating the amount of attention provided to any object can be helpful plus considering the amount of time spent on something over the course of a week or a month. There are choices between possible objects of attention. There can be alterations in the context of understanding that can be brought to frame any one topic. These contexts of understanding are psychological explanations. The distinctions between intentionality, sense, object and context provide the basic information for working out how to intervene.The enemy of the intentionality model is bad theory that leads to bad practice. The problem with bad theory is that it has no accurate representation of the lived experiences that it purports to be about. It is bad because it is resistant to the qualitative and meaningful experiences of people in relation to each other and the shared meaningful world around them. The application of a theory of intentionality opens the door to greater clarity about the role of psychological processes in explaining psychological problems and the development of the personality. When there is clarity about the links between intentionalities, it enables precise interventions. However, conscious experience is an unscientific object, so far resistant to scientific study, so consciousness could be neglected. The most basic form of understanding people is experiential lived meaning. Science applies to material facts. It does not apply to meaning, relating, values and emotions as they are lived. The remainder of this conclusion comments on belief and the future of therapy theory and practice.

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Belief Observable talk and action express belief about what is psychologically real. The belief in the usefulness of intentionality is driven by the conclusion that intentionality refers to the many ways in which consciousness is aware about what is judged to be psychologically real. For instance, the intentionality of belief concerns what exists or not and that has important consequences for affect and behaviour. Working with belief is a simple means of summing up complexity. By definition, inaccurate beliefs mis-represent a referent. The point is that people behave according to their understanding and beliefs. Old inaccurate beliefs may have had a useful defensive function when they began. But new accurate beliefs can express a clear commitment for clients to take care of themselves and meet others in new, more positive ways. Just the possibility of interpreting beliefs and stating them clearly can promote the possibility of self-understanding and change. Belief cannot be considered alone because it is part of a biopsychosocial whole. Belief operates in connection to the sense made of various portions of experience. Hermeneutics is related to belief because it is the study of how intentionality makes conscious senses of objects in contexts. The hermeneutic circle applies to understanding and belief when working out which intentionalities people use. It means working out “where people are coming from” when they approach some object of attention and experience it in a telling way. One version of the hermeneutic circle is where what is known intellectually and practically shapes the immediate sense found. For instance, prior understanding shapes how clients are being understood in the immediate moment. The hermeneutic circle refers to current understanding born of the past, as it meets a current phenomenon that people are interpreting. One case of this is how people present themselves to others in meetings: if the meeting is feared then they may try to protect themselves. Another is how people anticipate how a new event will be: What they anticipate will happen gets super-imposed on the meeting to such an extent that they have little or no contact with what other persons actually think, feel or intend. Beliefs are the products of hermeneutics in that they can be explicitly interpreted as ‘causative’ of psychological problems. Believing interprets what exists and represents a psychological experience in a specific way. Believing is characterising an object in an identifiable way, representing it. Beliefs express the relation to the believed. Beliefs begin in a specific time and context. They can be reassessed as accurate or inaccurate concerning a current psychological cultural object in a context. Discussions with clients about making the therapeutic relationship secure can encourage clients in becoming more active in their self-care and self-disclosure, in order to get help and feel relaxed during treatment. Analysis of causes in discussion and written formulation diagrams are models that interpret the 417

Talk, action and belief forms of intentionality in personalities and problems. Formulations are created with an eye to motivating self-care and change. Cognitive behavioural therapy has to be congratulated for getting close to understanding some core aspects of intentionality in its relation to what is interpreted to exist as believed, avoided and desired. People choose beliefs and may under-estimate the consequences that a chosen belief entails. Belief has a link to temporality because it dictates the present and the future although it arises from the past. The effects of belief come to be accepted as evidence for reasoning and can promote or decrease distress and satisfying living. •

Beliefs are about conscious relationships, feelings, thoughts and events.

•

Accurate understanding reveals what exists, whereas inaccurate understanding hides it.

•

One problem with explaining observable and describable experiences is that someone else, who takes another perspective, might disagree. Their beliefs and experiences about precisely the same situation can be entirely different.

In a sense, beliefs are like decisions that have been made at some past moment. Human beings are sentient creatures and can choose to act in a number of ways, at any given juncture. For some, belief drives behaviour, thought and emotion - in that specific painful emotions arise because clients have been ruminating on some topic for three or four hours without pause. For others, how they feel is the truth about the other, their situation and themselves. For them, whatever emotion is felt is accepted as a true picture of the object in question. What is felt is the sole evidence required to conclude that self is unacceptable to others, for instance, and the speech and actions of others are ignored.

Looking to the future It would be agreeable to have a body of consensually-agreed empirical evidence about key factors in psychopathology and psychological change from qualitative research. But including the model presented above, there is no consensus concerning a biopsychosocial wholism that could unite talk, action and belieforiented interventions. Consensus does not exist and a great deal is not known about how some people recover from early trauma without professional help, whilst others develop personality problems and psychological disorders. Once disorders have begun, they can be compounded in severity, produce other disorders and have effects on mood, lifestyle and occupational competency. Sometimes disorders multiply across the lifespan. The areas of human inquiry are open to 418

Ian Rory Owen PhD empirical research and differing views. What theory means in this context is supplying conclusions that appraise opposing claims and findings. A consensual empirically-based biopsychosocial position needs to be established concerning: •

A theory of consciousness, the personality and relations to others.

•

A theory of the on-set and development of personality and psychological disorders and the conditions for their on-set.

•

A theory of the development of personality and the increase of disorders, their maintenance and increase or decrease in severity over the lifespan.

•

Consensus about the principles of psychological inertia and change.

•

A clinical reasoning, a set of justifications, should be found with respect to conscious senses about how to create change. Such reasoning is an understanding of which interventions work in which conditions and why.

In order to be precise about the nature of the problem and the answer created required adequate accounts about experience through intentionality, empathy and common psychological sense. There has been an argument for attention to observable inter-actions between persons and creating an explicit means for interpreting. This work has been written in the belief that the good life is adopting beliefs that help people get around the meaningful world without too much personal distress and harm to others. The role of theory is like a map about a country. But the map of practice is not the territory of practising. “The outline of England as drawn in the map, may indeed represent the form of the land itself, but the pictorial image of the map … does not mean England itself … [but] England after the manner of a mere sign”, (Husserl, 1901/1970a, VI, §20, p 727). It has been argued that intentionality is a useful map to understand lived experience. One criterion for accurate belief-maps is that they should be sufficient to enable persons to move around the same territory with ease. Accordingly, in map-making some aspects of the territory are omitted for the reason of creating a useable representation with respect to the actual territory. The map itself is a simplified and generalised sketch, only showing key features.

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