How Psychotherapy Works (continued…)

Pathogenic Beliefs: the Root of Psychopathology

Pathogenic beliefs can develop as the result of a “shock” trauma (war, rape, natural disaster, etc.) or they can develop as the result of a “strain” trauma such as when parents are chronically critical or neglectful. However, pathogenic beliefs do not necessarily require abusive behavior to develop. For instance, a child whose father is chronically depressed or whose mother is constantly preoccupied with work, may develop the unconscious pathogenic belief that they are not worthy or deserving of attention or joy.

Pathogenic beliefs were onceadaptive adjustments made by the patient in the service of protecting him/herself or loved ones. For example, the abused little boy who learns to keep himself quiet and small out of fear, was well served at the time, by his guiding belief that people (mommy and daddy) are unpredictable and dangerous. However, as an adult these beliefs do not serve him so well. Whereas his guiding beliefs formerly protected him by keeping him small and quiet, now they prevent him from pursuing romantic relationships; they prevent him from being promoted at work even though he may be genuinely attractive, interesting, talented and deserving. What’s more, this man is not even aware that he has the pathogenic belief that he must keep himself small and quiet in order to avoid being abused or humiliated. All he may know is that things never seem to work out for him. He may then develop other more conscious “explanatory” pathogenic beliefs to account for his unhappiness such as “I’m just a failure, God hates me, it is pointless to try, life is meaningless, etc.”But he does not really understand why he becomes paralyzed with anxiety, and speechless in the presence of an intelligent, attractive woman. Nor does he understand why he is continually passed over at work, while others receive promotions and salary increases. His firmly held pathogenic beliefs lead him to passively accept whoever or whatever comes along. Instead of actively pursuing a relationship with someone who would make him happy he continually dates women who are not good for him. Not surprisingly he feels unhappy, depressed, and bitter.

In psychotherapy patients work with the therapist to disconfirm their pathogenic beliefs.One way in which patients disconfirm pathogenic beliefs is by using insights gained from therapist interpretations during sessions. Another way patient’s work to disconfirm their pathogenic beliefs is by “testing” the validity of these beliefs in their relationship with the therapist. There are two forms of testing: transference testing and turning-passive-into-active testing. Both are described below.

Transference Testing

Transference testing comes from Freud’s observation that his patients tended to transfer the role of a parent or some other authority figure to the therapist. The idea of transference can sometimes feel a bit confusing, far-fetched, and even magical, as if the patient somehow believes the therapist is actually her father. However, all transference really implies is that we interact with others and expect others to interact with us in familiar ways. For instance, if we come from a home and culture where it is common to greet others by shaking hands, then we will expect to shake the therapist’s hand. If we come from a home and culture where it is common greet others with a bow, then we may expect to bow and to be bowed to. In many ways, transference is about expectations for how we will be treated, and how others will respond to us. Further, we tend to not to pay much attention to these expectations, unless someone violates them by failing to respond in an expected way.

Transference testing with the therapist plays out in a variety of ways during therapy. For instance, consider a woman who was raised by a narcissistic and controlling father who frequently became wounded or angry whenever she attempted to assert herself by disagreeing or simply offering her opinion. As a child, this woman learned through repeated interactions, that to have an opinion and a voice of her own meant hurting her father or enraging him. Because she loved and needed her father, she adapted herself as a child, rarely speaking up or disagreeing. In therapy, this woman may engage in transference testing with the therapist by constantly deferring to the therapist, stating that she doesn’t know what to do, that she cannot make a decision, and asking the therapist to tell her what she should do and maybe even what she should talk about in therapy. In this case, it would be important for the therapist to recognize this woman’s history and to refuse to tell her what she should do or what she should talk about in therapy. By refusing to make the decision for this woman and in fact encouraging and valuing her ideas, the therapist conveys the message that she is capable of making her own decisions and that her doing so will not wound or enrage the therapist the way it did with her father. Through this interaction, the therapist has taken a small step toward disconfirming the patient’s pathogenic belief that she must not speak up or assert herself lest she hurt or anger others. This and similar interactions will need to be repeated many times over, in different ways during the course of therapy in order to alter the very powerful learning that this woman has previously undergone. Her repeated experiences with her therapist of asserting herself and not being punished, but instead encouraged, will likely embolden her to begin asserting herself in other areas of her life such as with partners, family, work etc.

I want to reiterate that the above patient does not actually believe the therapist is her father, nor is she consciously trying to treat her therapist like her father. She has simply become accustomed to deferring to others due to an early, overlearned belief that she will either wound others or draw their anger if she asserts herself. She may enter therapy very aware that she has a tendency to defer to others, or she may not.

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