James Tobin, Ph.D. argues that the goals of problem-solving, progression, and resolution have been over-emphasized in current views of psychotherapy. Instead, he argues that a significant aim of clinical treatment should be the expansion of the ego's contact with reality, which leads to an enhanced capacity for joy and tolerance of loss and mourning. Such a view also emphasizes accountability and reckoning as important aims in therapy; they are progressive in that the patient gradually comes to evaluate more accurately how his or her motives and actions led to consequences.

1. Promoting the Patient’s Capacity to Suffer:
A Revision of Contemporary Notions of
Psychotherapeutic Aim
James Tobin, Ph.D.
Licensed Psychologist PSY 22074
220 Newport Center Drive, Suite 1
Newport Beach, CA 92660
949-338-4388
Assistant Professor of Clinical Psychology
601 South Lewis Street
Argosy University
Orange, CA 92868
714-620-3804
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2. Case VignetteSupervision Vignette
# 1
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3. Evidence-Based Practice
• Evidenced-based practice and managed care.
• Symptom reduction and progress: “the standard
of care.”
• If progress doesn’t occur, something is wrong with
the psychotherapist’s abilities or the treatment
provided or both.
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4. Enormous Pressures on Therapists-in-Training
• Not only to diagnose, intervene, and help, but
to cure (the helping profession has become
the curing profession).
• Traditional notions of “abstinence” have
practically been forgotten.
• The proliferation of pantheoretical notions of
the working alliance/relational theory often
don’t correspond to treatment outcomes.
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5. The Helping Profession, the Curing Profession
• Therapist in training place enormous
expectations on themselves, many of which are
misguided (see xxx’s paper “Mistaken Beliefs of
Beginning Psychotherapists”), and many of which
come from unresolved historical issues re:
“treating/healing” a pathological caregiving figure.
• These characterological predispositions fit nicely
with the current environment of symptom
reduction and positive outcomes.
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6. The Therapist’s Role:
To Help Relieve the Patient’s Suffering
• Assumptions and beliefs about therapeutic action
and the therapist’s role: coping and resilience.
• Relieving the patient of his/her “suffering”– we
want to help the patient feel better and do better.
• This is a narcissistic need, both personally and
professionally (we have a vision for the patient).
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7. What are the Liabilities of This Way of Thinking
about the Therapist’s Role?
?
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8. Case VignetteSupervision Vignette
#2
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9. What are the Liabilities of This Way of Thinking
about the Therapist’s Role?
1. Affirming the patient’s subjective.
2. Avoiding CT and identifications (neutrality is a
hyper-focus).
3. The therapy space is ordinary, not extraordinary,
highly restricting what the therapist does with
the patient and feels about the patient
(featured in Stanley Kubrick’s films “The
Shining” and “2001: A Space Odyssey”).
4. The therapist is largely inhibited and the patient
is objectified!
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10. The Curative Mindset = Inhibition
Chad Kelland’s recent quote:
“You mean we can tell the
patient what we really
think?”
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11. The Curative Mindset Often Causes
a “Collusion of Resistance”
• These are “interactional resistances [that make
the] psychotherapeutic work [revolve]s around
noninsightful symptom relief, inappropriately
shared defenses, enactments and gratifications”
(Karlsson, 2004, p. 570).
• Karlsson (2004, p. 569) elaborates: “ … both [therapist
and patient] unconsciously avoid understanding
because they fear the understanding will create too
much psychological pain.”
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12. Role Assignments in the Therapeutic Dyad
• Collusions of resistance not only have to do with
avoidance of pain, but also with pressure to stay in
accordance with role expectations.
• Therapist (omnipotent healer) and patient
(healing/healed).
• The illusion each holds can be viewed as really one in
the same: the role assignments will continue to be
maintained and compatible.
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13. “Two-ness” and Disillusionment
• The inevitable reality of the “two-ness” of the
human condition (puts pressure on the role
assignments).
• Both clinical vignettes feature the emergence of
two-ness – disillusionment begins.
• The anxiety leads to the need to keep things
ordinary (inhibitions about the extraordinary).
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14. Ordinary vs. Extraordinary
• The therapeutic dyad colludes in resistance vs. the
extraordinary (roles are maintained; illusion is
upheld).
• The need to keep things ordinary is very strong
and present even in more subtle clinical
interactions and intrapsychic experiences (what is
“intuited”).
• The phenomena are largely dissociative in quality.
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15. Paralleling Dissociations in the First Vignette
• The patient dissociated from the full reality of his
experience (he did not see his own accountability).
• If he did not dissociate, his suffering would be
immense.
• The therapist dissociated from the obvious comment
emerging within her (out of her “two-ness”) to
maintain a role (to prevent the patient’s suffering).
• Full contact with experience is not possible
(illusions are maintained).
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16. Given This All, What is the Therapist’s Role?
Here are My Recommendations:
1. The therapist must help the patient come into full
contact with the reality of his or her experience and
learn from it.
2. This will likely cause the patient (as well as the
therapist) incredible suffering both must bear.
3. The main therapeutic activity is to detect dissociated
material (internally and relationally) as it occurs and
offer it to the patient in the form of what Renik calls
“logical thinking” or alternative constructions of reality –
the patient compares/contrasts the therapist’s
constructions with his/her own.
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17. Given This All, What is the Therapist’s Role?
Here are My Recommendations:
4. The art of therapy involves the therapist learning how
to move seamlessly back and forth between
empathizing with the patient’s narrative (their
illusive appraisal of reality) and proposing
alternative perspectives and areas of inquiry
(potential for disillusionment); how to do this
delicately so that learning is not traumatic!
5. This involves role flexibility, i.e, shifting between the
ordinary and the extraordinary, always being a “two”
and knowing when and how to reveal your two-
ness (C.K.)
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18. Therapists in Training:
Problems of Exhibition and Inhibition
• Some novice therapists claim their “two-ness” too
aggressively: a problem of “exhibition” (too little
neutrality/poor tact/overly permissive role-playing).
• Others are reluctant to embody their two-ness and to
use it as Renik advises: a problem of inhibition (hyper-
neutrality/overly heightened tact; overly restricted
role-playing).
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19. If the Extraordinary Can Be Entered Into….
• There will emerge “the gradual and nontraumatic
accumulation of knowledge facilitated by a ‘good
enough’ mother and the ‘holding environment’ she
provides” (#4).
• This is Winnicott’s notion of therapy being a
“transitional play space,” a safe arena of exploration in
which illusion/fantasy (what is dissociated) is gently
and delicately replaced by the reality of experience
(the therapist works to move the patient from
dissociation to a more realistic appraisal and
acceptance of experience). 19

20. Shame is Gradually Replaced by Regret
• Gradually increasing the patient’s (non-dissociated)
contact with experience alters shame-based defenses,
replacing them with regret (“learning/suffering”)
(theme of the film “Magnolia”).
• What patients most need is “location of the intuitions
about reality that have not received adequate
confirmation or support from others” (#4, p. 365).
• Shame is nothing more than the patient’s dissociated
intuitions about what actually happened that were
also avoided or denied by others.
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21. An Essential Paradox
• Our patients need to suffer what they have dissociated and
not yet learned (the therapist detects dissociated material);
paradoxically, the therapist cures by helping the patient
suffer.
• For Freud, the goal of therapy is “determin[ing] the role
we play in our unhappiness and the role assigned to
fate” (Thompson, p. 149).**
• “… hysterical misery into common unhappiness” (Breuer &
Freud, 1893-1895/1955, p. 305).
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22. Supervision as Suffering
• The supervisee avoids multiple contacts with
experience in therapeutic interactions with
patients (including traumatic identifications),
frequently colluding and dissociating.
• The supervisor is in conflict vis-à-vis the
supervisee: he wants her to learn but not to
suffer.
• This leads to an ongoing battle over staying in the
ordinary (Kubrick) vs. moving into the
extraordinary that exists throughout the course of
supervision.
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23. Supervision as Suffering
• To the extent to which the supervisee can tolerate
holding/containing the supervisee, and does not
remain too rigidly attached to a role vis-à-vis the
supervisee, he will capitalize on extraordinary
moments as they emerge (not collude in
resistance or dissociate from them) and non-
traumatically offer them to the supervisee for
exploration.
• This involves enormous sensitivity to the
supervisee’s shame-based defenses.
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24. Supervision as Suffering
• The supervisor will also be open to the
supervisee’s capacity to pick up on
dissociations emanating from the
supervisor, and not to respond defensively
when the supervisee raises them.
• All of this models “a way of being” (an
alternative view of therapeutic function) to
the supervisee she can then enact with her
patients.
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25. Supervision as Suffering
• The two-ness of the supervisee is a reality the
supervisor can never deny – this will cause the
supervisor to exhibit when he would otherwise
prefer to inhibit, and vice versa.
• This teaches the supervisee that the supervisor is
able to suffer for the sake of her learning, just as
the supervisee must suffer for her patients.
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26. References
• Aron, L. (1991). The patient’s experience of the
analyst’s subjectivity. Psychoanalytic Dialogues, 1, 29-
51.
• Bollas, C. (1989). Forces of Destiny: Psychoanalysis
and human idiom. London: Free Association Books.
• Chodorow, N. (1989). Feminism and psychoanalytic
theory. New Haven, CT: Yale University Press.
• Frankel, S. A. (2006). The clinical use of therapeutic
disjunctions. Psychoanalytic Psychology, 23, 56-71..
• Frosh, S. (2009). What does the other want? In C.
Flaskas & D. Pococh (Eds.), Systems and
psychoanalysis: Contemporary integrations in family
therapy (pp. 185-202). London: Karnac Books.
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27. References
• Ghent, E. (1990). Masochism, submission, surrender.
Contemporary Psychoanalysis, 26, 108-136
• Gilhooley, D. (2005). Aspects of disintegration and
integration in patient speech. Modern Psychoanalysis,
30, 20-42.
• Gill, M.M. (1982). Analysis of transference I: Theory
and technique. New York: International Universities
Press.
• Hoffman, I. Z. (1983). The patient as interpreter of the
analyst’s experience. Contemporary Psychoanalysis,
19, 389-422.
• Levenson, E. (1972). The fallacy of understanding.
New York: Basic Books.
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28. References
• McLaughlin, J.T. (1981). Transference, psychic reality,
and countertransference.
• Pizer, S. (1992). The negotiation of paradox in the
analytic process. Psychoanalytic Dialogues, 2, 215-
240.
• Pizer, S. (2003). When the crunch is a (k)not: A crimp
in relational dialogue. Psychoanalytic Dialogues, 13,
171-192.
• Renik, O. (1996). The perils of neutrality.
Psychoanalytic Quarterly, 65, 495-517.
• Renik, O. (1999). Getting real in analysis. Journal of
Analytical Psychology, 44, 167-187.
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29. References
• Stern, D. B. (2010). Partners in thought. Working with
unformulated experience, dissociation, and enactment.
New York: Routledge.
• Stolorow, R.D., Brandchaft, B., & Atwood, G.E. (1987).
Psychoanalytic treatment: An intersubjective approach.
Hillsdale, NJ: The Analytic Press.
• Wolstein, B. (1983). The pluralism of perspectives on
countertransference. Contemporary Psychoanalysis, 19,
506-521.
• Wolstein, B. (1988). Introduction. In B. Wolstein (Ed.),
Essential papers on countertransference (pp. 1-15). New
York: New York University Press.
• Wolstein, B. (1994). The evolving newness of
interpersonal psychoanalysis: From the vantage point of
immediate experience. Contemporary Psychoanalysis,
30, 473-499. 29