Wise Counsel Interview Transcript: An Interview with Alan Rappoport, Ph.D. on Control-Mastery Theory
David: Welcome to Wise Counsel a Podcast interview series sponsored by mentalhelp.net covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show, we will be talking about an approach known as Control Mastery Theory with Dr. Allan Rappoport.
Alan Rappoport, Ph.D. was born and raised in New York City. He graduated from City University with a Bachelor's degree in mechanical engineering in 1963. He worked at Lockheed Missiles and Space Company as an Aerospace Engineer in the 1960's. After leaving Lockheed, he spent several years as a hippie and part-time carpenter.
During this period of self exploration, Dr. Rappoport studied Zen Buddhism, Gestalt therapy and experienced many of the various approaches to group and individual psychotherapy and personal growth that were available in the San Francisco Bay area during the late 1960's and early 1970's.
Following this, he decided to pursue a career in clinical psychology and in 1976 became one of the founding members of the Pacific Graduate School of Psychology. He graduated from there in 1981 and began studying control mastery theory soon afterwards.
He was impressed with the theory of scientific foundation, the spirit of collaboration between patient and therapists. It's clarity about how psycho pathology originates and can be treated and its pragmatism and relative freedom from ideology.
Dr. Rappoport has given numerous workshops and seminars on Control Mastery Theory. He has published several papers on the topic. He is recognized as a knowledgeable and engaging speaker. He maintains a private practice as a psychotherapist in San Francisco and Redwood City California. Now, on to the interview. Dr. Alan Rappoport, welcome to the Wise Counsel Podcast.
Alan Rappoport: Thank you.
David: Let's start out with your background. You know as in where you grew up and how you got into psychology, where you went to school and all of that good stuff.
Alan: I grew up in New York City; I went to school Stuyvesant High School and City College of New York. It is now City University of New York where I studied engineering. Actually, I wasn't sure what to do in those days so I just was trying to find something that would enable me to make a living.
I got a job at Lockheed Missiles and Space Company in Sunnyvale. I moved all the way across the country to a job I never knew much about or a place I never knew anything about.
Alan: I was interested in being close to San Francisco. It looked pretty close on the map but it turned out that it wasn't that close.
David: Yeah, right.
Alan: I worked there for about five years aerospace engineering. I found I had nobody to talk to. Everybody wanted to talk about how they had fixed their car over the weekend. I didn't feel like I was contributing much of what seemed important to me for the world.
I got myself into a layoff and just kind of goofed around for five years or so. I was a hippie for a while and worked as a carpenter in construction. I studied Zen Buddhism and Gestalt therapy and all the personal growth groups that were active in this area at that time.
David: When was that? Was that the late '60's or early '70's?
Alan: That's right. The Bay area was just, every weekend there was some kind of group marathon that you could go to. All kinds of therapies and groups available and stuff like that. I did all of it basically. I worked with Fritz Perls. He used to come through once in a while in people's living rooms and we would go for eight hours a day over the weekend.
David: Oh my goodness. I was in a group once that he walked through but I didn't really have much of a direct experience.
Alan: It was very intense.
David: I remember that period. [laughter]
Alan: Perls made sure those groups were very intense, very powerful.
Alan: Then I decided that if I didn't do something about it that I was going to be a carpenter when I was sixty years old. I considered medicine or psychology and decided on psychology to be a psychotherapist.
There was a group called Psychological Studies Institute in Palo Alto, which I was accepted into and then dissolved. The people from that school, the faculty and students got together and formed a school on their own. Which was an amazing thing in itself; we opened the doors at Pacific Graduate School of Psychology in 1976.
David: It is still going, right?
Alan: It is still going and fully accredited. It is an amazing thing that we created. We used to sweep the floors, hire the faculty and attend classes.
David: That is great.
Alan: I graduated from Pacific in 1981, I believe, licensed as a psychologist in '84 and as a family counselor in 1980 or '81. I worked for a while treating people that had agoraphobia and all kinds of phobias. It was a group in Menlo Park called TERRAP. It is for territorial apprehensiveness. We did all kinds of treatments for people who were afraid of supermarkets and being out on the street in down town or going to movies or driving on the freeway.
I got initiated into doing therapy under all circumstances, which was wonderful. It didn't just have to happen in an office. I would go driving with people on the freeway and try and help them be more comfortable and go into movie theaters and supermarkets and everything. That helped a bit for me to not have a set idea about what psychotherapy is supposed to look like.
David: That is fascinating.
Alan: I worked for a group also called... I don't remember the name of it. It was a group that we provided counseling to people on an emergency basis. People would call in and they were having some problem. We would go out to meet them.
We would meet them in a park or a bar. We would meet them in their living rooms or where ever and talk to them to see if we could be of help. That got me pretty wide open to doing therapy in all kinds of ways.
David: Yeah, plus I would imagine that your experience working in the trades as a carpenter and working in a factory kind of environment. Was it Lockheed did you say?
David: That those kinds of experiences probably... I'm guessing that maybe you weren't quite as much of a stuffed shirt as those people kind of went through academia the whole way.
Alan: [laughing] I suppose so.
David: Yeah, Yeah. After all the eclecticism, you became highly identified with an approach known as Control Mastery Theory.
Alan: That's right.
David: How did that come about?
Alan: When I was in school, at that time. I guess still at this time there are all kinds of theories of therapies floating around. There was analytic certainty and behavior theory were the most established ones along with Carl Rodgers stuff .
Then there was family theory and Gestalt therapy. You know they all come to mind and existential. The problem that I had was that each one of them made sense to some extent.
Alan: I couldn't say: well this is nonsense.
Alan: Each of them made sense, but often they were often mutually contradictory. Each theory seemed to be saying you have to look at it this way you can't look at it that way. This is the right way. I thought they all made some sense. A lot of people were calling themselves eclectic at that time.
I wasn't especially happy with that. It seems like: well you are just going by the seat of your pants and you do whatever you feel like makes sense. There is still no way to get organized like that. That is the quandary that I was in.
The woman I was living with at the time was also a psychology student. She had come across this group at Mt. Zion hospital in San Francisco developing the Control Mastery Theory. Harold Samson and Joe Weiss who founded that were giving case conferences that were open to the public.
She was going, I thought, as part of her internship. Well, she was. I said: gee that sounds great. I wish I could go. She said well you can. It is open to anyone that wants to go. I started attending the case conferences and that was how I got started.
David: That is fascinating. I certainly went through a very similar process, in terms of being open to a lot of different approaches and having difficulty calling any of them absolutely wrong and sort of labeling myself as "eclectic". I didn't take that next step of really becoming strongly identified with a certain school of thought.
Alan: Well, I'll tell you. Oh, go ahead.
David: Well, I can tell you...Go ahead...
David: I can just see the advantage of that. Go ahead, what were you going to say?
Alan: The reason I was able to do it is that this is the first theory I came across that didn't require me to give up any other theory.
Alan: Yes, it was very pragmatic. One thing that impressed me very much about Hal Sampson was people would ask him about interventions they did. "I did this in therapy, what do you think about it, Hal?"
Hal would invariably say, "I don't know. Tell me what happened."
Then the person would say what eventuated from that. He would be able to make some assessments of whether it was a good intervention or not. Not "good" in the absolute sense, but was it helpful? He taught us what to look for to determine if something is helpful or not.
So, they weren't espousing a certain technique. They were trying to be pragmatic. In fact, the title of one of Joe's best books is "How Psychotherapy Works. So, it's not about, do this. This is the way we think about it. It's about: so, what's going on here anyway?
The theory is very pragmatic and it enabled me to use everything that I learned, but also to think about why might something might work. That would be a good thing to try with this person. Then, watch them to see what happen and to decide. In fact, if it's not a good approach, should I try something else?
David: That's great. I want to get deeper into that in just a moment. But first, I notice that the San Francisco area seems to be kind of the hot bed of Control Mastery Theory, if you will. Why is that?
Alan: This is where Hal and Joe and the group that formed around them were located. They were at Mt. Zion Hospital in San Francisco. As part of the psychiatric and psychological training programs they had there, the group grew up around them.
There are some other groups around the country. There's one in Boston, I think, but this is the main group because that's where the founders were.
David: OK. So take us through the basics of Control Mastery Theory.
Alan: Well, let's see. Why don't I talk about the words "control" and "mastery" because they're a bit off-putting. In fact, I tried to have the name theory changed at one point and nobody was especially happy with it.
But, it's the best we came up with and once something's established, it's pretty hard to change. The words, actually, do represent the two most important principles in the theory. Control refers to the notion that people have unconscious control over their defensive system.
That's a highfalutin' way of saying that if we can more likely to be more ourselves, the more relaxed we are. If we have a family that we live in that is accepting and nourishing for us, we can pretty much be ourselves at home. We can relax and be whoever we are without worrying too much about what's going to happen if I act this way or that way?"
If we're in some very formal situation, we're afraid of being judged. If we don't do exactly the right thing, we might be pretty uptight and careful about what we do. So, we may have a social persona or we may kind of automatically fall into it or consciously do it to fit in in that circumstance.
So, we're talking about psychological defensiveness, which means a pattern of behaving that we've learned to adopt in order to be safe. So, if we grew up in a family where a certain psychological dangers, you know, we'll be rejected if we don't have a certain religion or a certain way of speaking or a certain educational level. We're not sure if we're loved or not, we're not athletic or we are athletic or whatever it is. We have to adapt to that in some way, we're affected by it.
It's very important that people feel attached to their family and that they know that the family members are attached to them. If things threaten those attachments, we try and make adjustments so as to preserve them as much as possible.
David: Let me just ask you a question. I understand what you're saying in broad strokes, yet I find just a little bit paradoxical to talk about unconscious control. To me, those two words fight each other. You said the person has unconscious control of their reactions or something like that. So, if I'm unconscious, how can I be in control?
Alan: Let me finish describing...
Alan: ...this and then let me address it. So people develop these mechanism that help them adapt to their family. For example, if they're required to be very high functioning in the family, they may develop that persona and work very hard to get all As in school and be as good a student as they can be. If somebody asks that person, "Is this what you want?"
They would say, yes. It's really important to me. But actually, it's an unconscious decision that: this is what I have to do to be accepted by my parents. That's an example of an unconscious choice. The person realizes, usually, unconsciously that things don't go so well if I'm not a good student. And if I am a good student, I get always praised and acceptance. So that's the way I'm going to go in life.
They make their whole life, they may become an academician without realizing, you know, I never really chose this. This is what the family culture rewarded and so that's what I became. But - maybe through therapy - I'd actually rather be a musician. I'd, actually, rather be whatever it is. Or, actually, this is what I like but I want to choose it for myself rather than have it foisted on me by my family. So, that would be unconscious choice.
David: OK. Unconscious choice.
Alan: In therapy...
David: Yes, I can understand unconscious choices, I don't have a problem with that.
Alan: So, in therapy, one way we see therapy working is if the person comes in, say they're the same person and they come and they're very high achiever but they're not very happy. So, they want to find out if the therapist has the same needs of them as their parents did. They'll be ways of testing out. Do you accept me if I'm not such a high achiever?
So, this process is an unconscious process. The person may not even know they're doing it. But, if they find acceptance, not based on achievement, they'll tend to relax and open up and become less defensive. So, there's an unconscious process going on that a person is trying to assess how safe am I if I'm not such a high achiever?
They'll make unconscious evaluations of well this person seems more accepting of me even though I didn't get an A on this last thing or my boss didn't speak well in my last review or something like that. The therapist says well, they don't get on them and say "you should try harder" or something like that. The person may become more relaxed and more open. We would call that being less defensive.
So our sense of it is that the person is consciously and unconsciously making these evaluations of how safe is it for me to be myself in this relationship? To the extent the person feels safe, they'll be less defensive. So that's what we mean by unconscious control. Unconscious control over how defensive or how open we think it's safe to be.
Alan: Does that answer your question?
David: Yes, yes. Where does the mastery part come in?
Alan: OK. So the mastery part is about people are trying to get better in our understanding. There's a wish to heal psychologically just like the body tries to heal physically, there's a wish to heal psychologically.
Now, sometimes the body is overwhelmed and the person never gets better from some injuries, some sickness they've had and the same psychologically. So not everybody gets healthier and healthier as they get older. But, we recognize an impulse in people to try to do that.
If people are coming in to therapy voluntarily, we presume that that's there and that's what's motivating them. Sometimes, they want their spouse to come in to therapy and the person is not really able to move forward psychologically. So, even though we think there's an inherent motivation to heal, the person is not free to act on it. But, our sense of it is that people who are voluntarily in therapy are trying to get better.
So, the motivation for the healing process comes from the patient, that's what makes it so important, this drive for mastery is the idea. So that, in a lot of other theories, it's the therapist that does the treatment to the patient. The Behavior theory is certainly that way. Analytic theory holds that the patient is going to resist treatment, the old analytic theory, at least. The therapist has to attack the person's defenses, so there the patient and the therapist in adversarial positions in some way.
But, the control mastery view is that we're allies. More than that, the energy for the treatment is coming from the patient, so that's a much easier position for the therapist to be in. They're not carrying the burden of trying to drag the person into health and the person is either resisting or inert. You know?
But our view is that the patient's trying to get better, the therapist's job is to understand what they're trying to get better from and what their goals are and what they're method of getting better is and then to ally ourselves with that to help them along in the process.
David: OK. You touched on something that I was interested in because I gathered that Control-Mastery Theory is a spinoff of psychoanalytic theory and so I wanted to ask, well, in what ways is it similar and in what way is this a different from psychoanalysis. And you just touched on one important way that you don't attack the defenses, I think, is what you said.
Alan: Right. There's no - there's no, because attacking the defenses makes the person feel less safe.
Alan: And so they're going to close up. Their goal, presumably, is to open up, which means to be more free to be themselves. So, you never want to do that, in our understanding.
Alan: And, I wouldn't - I wouldn't say Control-Mastery Theory is a spin-off of analytic theory but, what happened was, Joe was trained, Joe Weiss, was trained as analyst. He went through a year of analysis, which didn't help him. And he felt like - and also, the understandings he got from psychoanalytic training he had, didn't seem to apply to him, to the work that he was trying to do with patients.
And, he was a bright guy and also he was very creative and very free-thinking. He was able to - he didn't feel especially that he had to conform to what other people told him. He was very able to investigate things for himself.
And so, he took very good notes of his cases. He would study them and go over and over the case and try to figure out, well, you know, when is the patient getting better and when aren't they and how can I tell if they're getting better? And, what do I mean by getting better? And when I do this, what happens? And when I do that, what happens? You know?
And so, he put together a theory which really has very little to do with psychoanalytic theory. It's not an outgrowth of it, although a lot of Joe's writings are describing Control Mastery Theory in contrast to analytic theory, because that's what his training was.
David: I see.
Alan: And that's what he - that's the only other approach he had in his mind to compare it to.
Alan: But it's not a continuation. He actually tries to make the case that it's an outgrowth of Freud's later writings, because he was trying to pitch it to the analytic community. So he wanted to cast it in those terms.
But, really, it's something that he created on his own. Then he looked for support in Freud's writings for it. You know? But it's not an analytic theory at all. It looks similar because two people are sitting there in an office talking to each other and there's ideas about the unconscious and defenses and all of that stuff, but it's not really very related at all to analytic thought.
David: Oh, OK, that's interesting. And, from the other side, there's a way in which it reminded me of cognitive behavioral therapy.
Let me read you a little passage that I took off, I think, it was off your website. Saying, "Control-Mastery proposes that in attempting to adapt to unhealthy psychological environments, people develop invalid, negative beliefs about themselves and others that make them unhappy and prevent them from living effective and satisfying lives. It's these beliefs that are the basis of psychopathology."
So that business about taking on beliefs, that then negative beliefs, that are invalid and that cause pain, in some ways, that reminded me of the cognitive behavioral position.
Alan: Absolutely. And that's an example of how this theory is inclusive, you know? It doesn't say any other way of looking at things is wrong. But - so, it's very similar to cognitive theory in that way.
Two of the differences I would state would be, one, is that the patient doesn't fully believe these things. They believe them on a certain level but, if they fully believe, then they wouldn't come to therapy. They're coming to therapy because they have some sense that there's something about how they function that's making them unhappy. And they're thinking of themselves as what needs some help.
So, deeper than the beliefs is, which is why I use the term "pathogenic adaptations" rather than "pathogenic beliefs." Deeper than those beliefs is the belief is there's something wrong with those beliefs, you know? I need to change my beliefs so I need to get some help about this.
Alan: So, cognitive theory, I believe, doesn't assume that the patient is already trying to change their beliefs. They think that it's the therapist that introduces this notion, you know, which the therapist may and the whole process is maybe unconscious for the patient. But our notion is that there's a more deep - that the wish to be healthy is deeper than the beliefs for the people that are coming into therapy and so it's not the most fundamental belief.
But, OK, so, the other difference is that we also talk about unconscious beliefs, not just conscious beliefs. We can't work with a patient who is suffering from an unconscious belief that's making them unhappy if they're unaware of the belief. So, you'll have to help them be aware that they're even thinking that way before you can work on it.
Now, you can work on it in the relationship but you can't work on it in the conversation, if you know what I mean. You can't discuss, for example, suppose somebody - this person who's a high achiever and has this belief that they have to be a high achiever or they're not going to be acceptable and doesn't know that that's what's making them unhappy. If the therapist was to bring this up, the patient wouldn't understand what they're talking about and would argue with him, you know, like, are you saying that it's better for me to be a low achiever than a high achiever?
David: Yeah, yeah.
Alan: You know, they wouldn't make sense of it, so - so, it would be hard to deal with that in cognitive therapy.
David: Yeah. Well, it reminds me of Albert Ellis who, in some ways, was, well, if not the father, one of the forerunners of cognitive therapy. I saw him both on film and in person, work with people, and he would kind of beat them over the head...
David: ...you know, with...
David: ...with, that's a false belief, you know.
Alan: That's right.
David: And that you're saying that it's really not. He would have tried to engage them, I think, at a philosophical, intellectual level, but you're saying it's really important to work with it in the relationship as it manifests itself in the relationship.
Alan: You know, a - yes, I am. And that's an example of trying to work with something on a conscious level that's unconscious for the patient. So then it creates an adversarial relationship between the therapist and the patient. But the patient is actually coming in for treatment so why create an adversarial relationship when they're looking for a collaborative relationship?
So, but also, our sense of it is that the patient is trying to get better. They're coming in with this problem and, with what we consider to be an unconscious plan, some kind of generalized approach that they have towards getting better.
And so, rather than introduce our way, that we want to impose on them that - for them to get better, what we try to do is look what the patient is already up to and work with them in that. So, the person that's suffering from this problem will be trying to work on it.
Now, there may be other things they have to work on first before they can get to that. So, that's fine. Let's work on what you want to work on and we'll eventually get to that other thing. You know? Or they may want to work on it right away and help, but we let the patient set the pace and the agenda.
David: What do you do about the patient who comes in kind of expecting a magic bullet, you know, like they figure, OK, you've got the knowledge and you're going to cure them, and so...
Alan: Well, I would probably think about that as a test, so we haven't talked about tests yet.
Alan: But tests are ways that people use to find out what's the story here. [laughter] So, suppose somebody comes in with, the first possibility that occurs to me is, this person has had people that have told them how to run their lives their whole life. They haven't felt free or accepted for having a sense of autonomy. So, a person like that would come in and probably do exactly what you suggested.
Alan: But, we would think of it as a test to find out is it the same story here, or is it different.
David: I see. Yes.
Alan: And they'll offer to submit to the therapist and say, "I have no idea how to run my life, tell me what to do." And the Control-Mastery therapist would say, more or less, I mean, imply at least, well, that's an interesting idea that you don't think you have any idea how to run you life and that I know how to do it. Tell me more about that. And we'd be off and running.
David: Yeah, you talk about two kinds of tests, transference tests and passive-into-active tests.
David: And maybe you can explain those - that wording of "passive-into-active." I have a little struggle with that but take us through both of those.
Alan: It took me five years [laughter] to understand that...
David: Oh, good.
Alan: ...you know. It made me crazy.
David: I feel reassured.
Alan: Transference testing is what analytic therapy therapists know very well goes on in therapy. A lot of other forms of therapy don't consider it, like behavior therapy or cognitive, I don't think, pay too much attention to the transference, but analytic therapists - psychodynamic therapists pay a lot of attention to it.
All that really is the patient putting the therapist in the same role that their parents had in their lives. The patient may assume that - suppose somebody had a very self-centered parent, the patient may assume that the therapist is self-centered.
And that in order for the relationship to go well, they have to pay close attention to what the therapist needs and approves or disapproves of, or is threatened by or reassured by and accommodate to those needs. Hopefully, the therapist actually doesn't have those needs and isn't imposing them on the patient, but patient will think that they are there anyway.
In analytic theory, it's called analyzing the transference where the therapist would face something like you seem to be very concerned about whether I am approving of you or not. And a fuller interpretation might be, and that reminds me of what you said about your parents that you seem very concerned about whether they approve of you or not. Do you think there is anything going on here that might be reminiscent of what went on in your family? That would be a transference interpretation.
That's what therapists mean when they talk about transference.
Alan: The patient is transferring the relationship they had with their parent on to the therapist.
David: I am sure many listeners would be familiar with that idea. However, this other one passive-into-active test - that terminology is a little confusing.
Alan: It was a lot confusing to me. The passive-into-active is a terrible term that means what somebody experienced passively they are now doing actively. I couldn't make any sense of that. But what it means is that if the parent treated them in a certain way, they are now acting as if they were the parent treating the other person that same way.
For example, if the parent is a bully, it's very common that parents who are bullies require their sons to be bullies. And the way that the kid can be close to the parent is to be like the parent. The parent will want the kid to be tough and to push other kids around and just like me and that's what I do and that's what my kid does and we are a team, and that kind of thing.
The kid is being trained to identify with the parent. Often, of course, the parent who is a bully is bullying his kid. The kid may have experienced being bullied by his father and now goes and bullies other people. That would be an example of passive-into-active.
The p-i-a, passive-into-active, I created a mnemonic for myself which was parents-in-action. That helped every time somebody would say in a case that's an example of passive-into-active, I would have to stop and say, what is that - a parent in action - that's right. They are saying the patient is acting towards, say the therapist, as the parents acted towards them.
It took, as I say, five years before for somebody could say passive-into-active and I would know whether that would end with having to go through that little thing.
David: I don't want us to get hung up on this, but I have to say that sounds a lot like the first one the transference test.
Alan: It isn't at all because the similarity is that the patient is creating in their mind a relationship that doesn't actually exist that's being transferred from the past. That's why they are both forms of transference. But in one case, the patient is in the role of the kid and imagines the therapist is the same as their parent was. In passive-into-active, the patient is in the role of the parent and is treating the therapist as they were treated as a kid.
In our example, the patient may bully the therapist.
David: OK. That helps.
Alan: The patient maybe saying your fees are too high. Where do you get off thinking that you can charge people that way? I don't like the way you have your office set up, and who do you think you are anyway? And the therapist may feel threatened, probably, will feel somewhat threatened.
The patient may bully the therapist, but our understanding is not just for the purpose of bullying the therapist. I mean the patient having to go out of their way in their life to come down to the office to engage in therapy, pay the therapist, do all this disruption, it's not just to beat up on this stranger they haven't even met before.
There is some purpose in it.
Alan: We understand the purpose to be, look here is the problem I have: I have been forced to identify with my parent and I treat people like this. So I was bullied, I am going to bully you. Let's see what you do with being bullied because I can never figure out what to do with it. And I eventually had to identify with it.
You are supposed to be an expert in relationships and understand all this stuff. I'll give it to you. I'll put you in that same position and show me another way of dealing with it. That's what I really need. I don't want to have to be identified with my father like this. This hasn't worked very well for me.
David: They are doing all of that unconsciously, of course.
Alan: Yes. Absolutely.
David: Yes. One thing that really interests me is the degree to which you emphasize the importance of creating a safe environment and also, that's how you also measure the progress of their therapy is their sense of safety.
Alan: That's exactly right. That's the center principle in Control Mastery Theory. It is creating a safe environment because that's the opposite of defensiveness. Defensiveness is a response to unsafe environment. Our sense of it is that the safer we can help the patient feel, the more automatically they will get rid of their defenses and become who they would naturally be.
David: Yes. I was also fascinated by - I was reading one of the papers on your website that you had written. I was interested in the one on the experience of the therapist where you wrote, "for the therapist the most fundamental is whether he or she enjoys the work and derive satisfaction from it. This is a critical issue for the therapist to face and it also has great significance for the patient."
How does that have great significance for the patients?
Alan: The patient is looking for fulfillment and satisfaction in life. The therapist should be able to embody that. If the therapist is kind of depressed and constricted, it's going to be hard for the patient to use the therapist as a model of what they want to accomplish and to understand how one is able to be happy in life.
Also, it's important that the therapist enjoy the patient because the patient usually feels like there is something wrong with them that creates problems for other people. It's important that the patient not be creating a problem for the therapist because the therapist will unconsciously resent it or try to be defensive in some way if that is going on.
It's important for the patient that the therapist enjoy them and enjoy the visits and is also living a fulfilling life. Because the patient wants an example of what does it look like to have a fulfilling life and I'd like to see somebody that feels entitled to do that and I'd like to learn from that person how in the world they feel entitled to do that? I don't feel entitled to do it.
Also, for the therapists not to get burned out or to get rigid in their work, it requires that they find satisfaction in the work. We are not doing this work just to "save the world" or earn a living. If we don't find personal fulfillment in it, we can't be doing a good job at it. And we are doing it for the wrong reason.
You wouldn't want to buy a painting from an artist who is miserable being a painter, right?
David: [laughs] I don't know.
Alan: What's that hanging there in your living room? You want somebody who feels this is his calling and who loves to paint and he's communicating something and expressing himself and it is very meaningful to him.
David: Yes, that makes a lot of sense to me and I suppose that's also where you are coming from when you say it's important for the therapist to give authentic answers to patients' questions.
Alan: That's right. In my own therapy, I often ask my therapist: how do you feel about this? What would you do in a situation like this? Or, how do you feel when I say this and that?
In my case, my parents weren't very forthcoming. I was often guessing or I'd given up on even knowing who are these people and what are their worlds like and why don't they tell me about them and stuff like that.
For me it's very important that the person be able to share themselves with me. So, it's a way for me to investigate that and to see what's it like to be in a relationship with somebody who is open with you and feels free to be open.
Sometimes I might ask her how is it that you feel free to say all that. That's a very conscious form of testing, but it's still testing in the sense of investigating and trying to learn how do relationships work. But most testing goes on unconsciously.
David: Yes. Another thing along that same line that you wrote is, "it's as important for the therapists for the benefit from the encounter as it is that the patient benefit."
Alan: Right. Same thing - if you are in therapy with somebody, you don't want to feel like you are making the therapist unhappy. This is hard work for them. You'd like them to be gladwhen you come in the door and you'd like them to have felt some value in the encounter.
And that goes a long way towards dispelling the patient's idea that they make people unhappy or they don't know how to have relationships or people get tired of them, and that kind of thing.
Just an example of unconscious testing, say, somebody comes in late repeatedly. We think of it as a test. They want to find out what happens when they come in late, and there can be all kinds of things about it. Will the therapist be mad at them? Will the therapist feel like, where were you, I was here and you weren't here?
It's like the therapist feels like they didn't get something and now they have been deprived by the patients. So, is that going on? Or, are they critical of the patient in some way. They had some standards that the patient is supposed to meet and they can be investigating all kinds of things.
But I just wanted - because for the patient they would say, Oh gee, I am sorry I am late. I meant to get there on time but I got a phone call or there was traffic. But if the patient is doing it repeatedly, we would assume there is some unconscious motivation and something being expressed in this behavior.
But, for the patient, they don't have it consciously. And you can't even talk about it with them. You could say, "Well, you come in late every time; don't you think that there is something going on about you with that? No, it was just circumstances. I don't know how it happens but the past five times something has come up." It can't be addressed in the conversation. We would think of that as an example of unconscious testing.
And say it's about being criticized. Suppose the therapist isn't critical, say, "Oh, it's fine; come on sit down, we'll talk." And that goes on for a while. The patient might get the idea that this person isn't really very critical of me. Well, that's nice.
Oh, so I know what I wanted to say, what are signs of progress in therapy? What we look for is physical relaxation. We look for people taking deep breaths rather than small shallow breaths. We look for them sitting back in their chair. We look for relaxed expression. We look for a tone of voice that seems relaxed. We look for the ability to be reflective, to be spontaneous.
I said something to a patient the other day and they said that reminds of a dream I had. And I thought I'd just said a good thing. I said something fit in with this person's plans because now they are giving me more material, and material which they have forgotten about but it evokes a memory and then the dream was right on point.
We look for associations: "that reminds me of this or I had that memory or I had this dream" or whatever. So things that were unconscious become conscious. The person is more interactive and they are more present and they are freer. That's what we look for as a sign of progress in therapy.
I don't care what I did, but if I do something and the person looks like that, I want to be thinking, "What did I just do and how did that help the patient. And vice versa, if the patient looks more defensive and suddenly there are hesitations in their speech and there are speech disruptions and they can't think about anything and they look stiff, I think, "I just did something that scares them." Whatever it was it wasn't a good thing to do.
I want to try and figure out what it was and why it scared them and make sure I don't do that again, figure out what I should rather than that. That's very pragmatic. The idea of what's helpful in this particular case comes out of those kinds of observations about the patients. We build up a formulation based on the patient , not that we have one first that we fit the patient into.
David: Something popped up in my mind as we were talking that I hadn't planned to talk about. I am wondering if you saw the "In Treatment," the HBO series about therapy.
Alan: I saw the last episode of it. That's the only episode... a lot of my patients talked about it.
David: Geez, you got to see that because I really would be interested in your reactions to the therapist Paul.
Alan: What we were you interested in...
David: And the later ones, it got a little bit off the wall as it went on. But the early sessions were very interesting and I thought that - I think that he maybe - I would just be curious to see the extent of which you would feel that he illustrated some of the things that you are talking about in terms of creating a safe environment, being self-disclosing etc.
Maybe we can have that conversation down the line.
Alan: Maybe we could. The self-disclosing - everything in therapy in our view is case specific. It depends on the case. One person being self-disclosing might scare the hell out of them and the last thing you would want to do. Suppose they had a parent who hogged all the time and everything had to be about the parent and they weren't interested in the kid at all.
You probably won't want to be too self-disclosing with that patient. Somebody else whose parent were cold and withdrawn and hard to get to know you might want to be open with. We don't have, in this theory, any specifications of what the therapy should look like. What form it takes. What we are looking for is increased safety on the part of the patient.
That's why I am able to use every theory I ever heard of. One theory may work for this patient very well, not a theory but approach, may work for this patient and another approach may work for somebody else. I feel very free to go back and forth and do anything at all. What I am paying attention to is: is the patient getting defensive or not?
David: Might not some people argue that: geez, having a patient be real comfortable, that's not a good idea. They need to feel anxious in order to be motivated to work on their problems.
Alan: That's right. That's old analytic theory. The patient is going to resist progress. That they are trying to hold on to their defensive system. And it's up to the therapist to create a level of anxiety where they won't be able to maintain their defenses anymore and some authenticity will break through. That's not our idea.
David: OK. [laughs]
Alan: Our idea is to help them feel safe enough so that some authenticity will break through.
David: Yes. I am in your camp. What if some listeners wanted to find out more about this, is there a book that you recommend where they might get more information?
Alan: There are two books, one written recently by George Silberschatz and by the way, you can find all of these either on my website or on the website of the San Francisco Psychotherapy Research Group, sfprg.org. One by George Silberschatz who is a long time proponent of the theory and a researcher that's called Transformative Relationships and then Joe Weiss' book, about 10 or 15 years ago, How Psychotherapy Works are both very accessible.
David: OK. I wished I had more time to talk with you, but I know you've got an appointment coming up and we don't want your patient giving you a hard time about being late. [laughs] So Dr Alan Rappoport, thanks so much for being my guest today on Wise Counsel.
Alan: You're very welcome. I really enjoyed it.
David: I hope you enjoyed this interview with my guest, Dr. Alan Rappoport and that you learn something new. I certainly did. I got the sense that there are a lot of subtleties of the Control Mastery approach that would require more time and study to understand. You can find out more information about Control Mastery Theory on Alan's website at www.alanrappoport.com, and Alan Rappoport is spelt A-L-A-N R-A-P-P-O-P-O-R-T.
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