The Institute for Advanced Psychotherapy at Loyola University Chicago offers a yearlong certificate program for licensed professionals, aimed at enhancing clinical skills through an integrative training method. The program incorporates advances in trauma and neuropsychological research within a framework rooted in attachment theory. Participants engage in onsite residencies that last three full days each, featuring hands-on training by nationally acclaimed faculty. In between residencies, distance learning continues through monthly 90-minute case consultation meetings and bimonthly live webinars. The program is approved for CEU Credit by the APA and NASW, and awards a total of 72 credit hours. To learn more, please visit https://www.luc-iap.com/
Transcript
Hey there podcast listeners, Jonathan here. Today’s episode of the Social Work Podcast explores the idea of therapeutic complexity and why therapists should embrace it. But before we hear from our guest, Dr. Patricia Gianotti, author of the book, Embracing Therapeutic Complexity, and Director of the Institute for Advanced Psychotherapy at Loyola University Chicago, I wanted you to think about the people on your caseload. Do you have any clients whose lives or treatment concerns were simple or uncomplicated? I can’t think of any clients I’ve worked with whose lives and treatment concerns were simple. They’ve all been complex.
So how do we deal with this complexity? I’m thinking of an anecdote attributed to Milton Erickson that I’ve probably shared on the Podcast before. When asked how he was so successful helping clients no one else could help, he said, “people come into my office with problems they can’t solve and leave with problems they can solve.” One interpretation of that anecdote is that the therapist’s job is to simplify a complex and overwhelming set of problems. I don’t think that’s wrong. But, I think that there’s a difference between a therapist embracing the complexity of a client’s situation and helping them get clarity, and a therapist “prematurely locking into one possible explanation, hypothesis, strategy, intervention, or treatment approach (Kahneman, 2011; Mudd, 2015; Nisbett, 2015 cited in Selekman, 2017).”
I know that in my practice sometimes in my eagerness to find solutions, I’ve latched onto a single explanation or treatment approach too quickly. Why? Social worker and author Matthew Selekeman would say that I’ve fallen victim to a “confirmation bias”. I look for confirmation that a simple explanation or solution is correct. I stop being curious about alternative explanations, different strategies, or the advice and guidance of my colleagues. As French Existential philosopher Emile Chartier said, “Nothing is more dangerous than an idea when it is the only one you have.” But why do we often seek out simple solutions and avoid the complexities?
- Dealing with complex cases requires significant mental effort and cognitive resources. Simplifying the problem can reduce this cognitive load, making it easier to process information and make decisions, especially when managing a high caseload or working in a high-stress environment.
- In many therapeutic settings, time is a limited resource. Simplifying problems can lead to quicker interventions, allowing therapists to see more clients and provide timely support. This efficiency is crucial in settings where there is a high demand for services and limited availability of therapists.
- Therapists may feel more confident and comfortable working within familiar frameworks and approaches. Complex cases can be daunting and may challenge their expertise and skills. By simplifying the problem, therapists can rely on their existing knowledge and techniques, providing a sense of security and control.
The final possibility - and the premise of today’s episode - is that therapists are trained to focus on acute symptom relief, rather than embrace therapeutic complexity. To unpack why and how therapists can embrace therapeutic complexity, I spoke with Dr. Patricia Gianotti. Not only did she write a book with that exact title, but she’s also the Academic Director of The Institute for Advanced Psychotherapy at Loyola University Chicago, a year-long certificate program that offers licensed professionals in-person learning, webinars, case consultation and a method of case conceptualization that incorporates multiple theoretical disciplines. At the end of the interview I’ll tell you a little bit more about this amazing program.
In today’s episode, Patricia and I speak about the neurobiology of shame, why depth work is important, and how to think about human complexity in a therapeutic context. She emphasizes the impact of attachment failures on a person's sense of self and the role of shame in therapy. She explains the concept of loyalty contracts and how they shape individuals' beliefs and behaviors. She underscores the power of psychodynamic techniques in uncovering and addressing these dynamics. Throughout the conversation, she highlights the hope and resilience that can be found in therapy.
A couple of notes about today’s interview. You’ll hear Dr. Gianotti talk about micro/macro in a way that is different than the way social workers typically use those terms. We address this difference in the interview, but just to give you a heads up, she talks about macro as case formulation - the ways that a therapist conceptualizes what’s going and how they structure the clinical work. Micro is the specific techniques a therapist uses.
We also talk about repair work, but don’t define it. In the context of attachment theory, "rupture and repair" refers to the process by which disruptions in a relationship (ruptures) are resolved and the relationship is restored (repair). This concept is particularly significant in understanding and fostering healthy attachment relationships.
- Rupture in this context usually means a breakdown or disruption in the connection between the attachment figures (often between a child and caregiver, but it can apply to any close relational dyad, like between partners or friends). Ruptures can be caused by misunderstandings, conflicts, unmet needs, or misattunements, where one party feels that the other has not understood or responded appropriately to their emotional state or needs.
- Repair involves actions and interactions that restore the damaged relationship and rebuild trust and understanding. In attachment relationships, effective repair processes are crucial for developing resilience and secure attachment. This involves recognizing and addressing the rupture, communicating openly about the disruption, and both parties working together to restore emotional connection and understanding.
The ability to repair relational ruptures is considered a fundamental part of healthy relationships. It teaches individuals that relationships can endure difficulties and disagreements, and that they are capable of restoring warmth and trust after conflicts. This process is also critical in therapeutic settings, where the therapist and client might experience ruptures in their therapeutic relationship, and the process of repair can become a powerful part of the client's healing and growth.
And now, without further ado, on to Episode 138 of the Social Work Podcast: Embracing Therapeutic Complexity: Interview with Patricia Gianotti, Psy.D.
Jonathan Singer: Patricia, thank you so much for being here on the Social Work podcast.
Patricia Gianotti: Well, thank you. It's my pleasure to be here.
Jonathan Singer: In your book, you talk about the importance for therapists in understanding complexity. Why is it important for therapists, for clinical social workers, psychologists to understand the value of complexity? How does that complexity come into the therapeutic practice?
[09:53]
Patricia Gianotti: So that's a great question, Jonathan. And part of how I organize things in my most recent book is there are unifying principles within clinical practice that cut across theoretical disciplines and orientations and how do we identify what those unifying principles are? Because they're unifying, because they show up with clients in our office sooner or later. All of these considerations need to be factored in. And one of the things that I would say is a unifying theoretical principle is attachment theory that connects psychodynamic, cognitive, behavioral, any of the relational approaches, trauma, treatment. We need to look at attachment theory and understand how attachment theory or failures of attachment impact present functioning in day-to-day life in the form of unrequited longings and yearnings, wanting to make up for an attachment failure as well as ingrained, fear and mistrust that get so deeply internalized that it is part of what a patient brings into the office. A second piece is that neuroscience has shown us that the quality of the relationship between the caregiver and the child impacts the development of the limbic system and thereby the capacity to effect affect regulation and whether that gets internalized and restructured. But what we know is that even with attachment failures, therapeutic interventions can help restructure, co, regulate and heal damaged relationships of early attachment failures. So, if that's the case, a third principle is we need to have a knowledge of transference and countertransference dynamics because whatever is unfinished from the past will show up in the present moment. You don't have to do a thorough history to get that it will show up in the treatment hour. And so because of that, we understand transference and countertransference as an enactment of a client, showing us what they can't quite put into words or symbolic form. And so those kinds of enactments are just as important communicators as what they tell us on a verbal level, what is part of their narrative. Another unifying principle is we need to understand the concept of figure and ground. We need the macro and the micro, and we are continually moving back and forth between the two. So the macro is how do I understand the conceptualization of how the parts fit into a whole or don't fit into a hole or split off from each other? And then once I have a working formulation, I am better informed around the timing of an intervention, the pace of the therapy, and how I'm going to move in at a micro moment. Because it's the micro interventions that are the treatment techniques and the treatment modalities that we've been trained in in graduate programs. What has been, I think, gotten a little short shift is looking at the macro picture to help steady us at any given moment in time because the macro picture changes over the course of therapy. Why is that? Because we're working on relational repair and then therefore the macro picture how the parts fit or don't fit continue to change and evolve over the course of therapy.
Jonathan Singer: And so just to jump in because for the social workers listening when we generically talk about macro we're actually talking about national level policies. We're talking about things that are going on that don't have a specific interaction day to day interpersonal. But you're talking about macro as in case conceptualization, how do I understand all these pieces as a framework so that when I am doing something in the session I have an understanding of why I'm doing what I'm doing, what this person said, what that might mean. And then the micro are these individual techniques or interventions?
[14:42]
Patricia Gianotti: Yes. And thank you for clarifying that. And that came up in the yearlong certificate program because there is a language difference between social work training and psychology training in that. And this is where I think social work was way ahead of the game in terms of psychology because you've always been looking at systemic structures and policy and systems in place. And I think that was a blind spot in psychological training for many, many decades. And now I think what we're seeing is we're taking more of that larger macro picture in when we're looking at issues of injustice and inequity because that's part of the social and cultural picture. So yeah, thanks for clarifying that.
Jonathan Singer: What are the other principles that are important to understand in the therapy room?
[15:29]
Patricia Gianotti: So some of the other principles are that when you're talking about attachment injuries that part of what happens is the internalization of shame. And what do I mean by that? So, if there's an attachment failure what the child does in order to make sense out of that and create safety is that the child will do whatever he or she can to preserve the relational connection. Which translates as well, there must not be anything wrong with mommy and daddy. There must be something wrong with me. And otherwise, they'd treat me better. And so, what can I do to please Mommy and daddy or become invisible? So, it's not so scary. But what ends up happening as a result of that in terms of a belief system about one's sense of self is then there must be something wrong with me. And then how we can understand the defense postures as children grow up is that belief system gets deeply, deeply internalized. But because shame is such a painful feeling the defense postures come into play to overcompensate. Then I have to prove myself. Then I have to work harder. Then I have to keep part of myself in hiding and so then what happens is shame never gets examined. There's an attempt to avoid or hide from it, which perpetuates a cycle of shame, begetting more shame, beginning more shame. And until shame gets unearthed and healed and understood, where the therapeutic dialogue can say, you know, it really wasn't your fault, you made the only choice that you could to preserve connection. That's reflexive, that's a neural reflex, that's hardwiring. This is not your fault. Framing it in that way is so liberating and by the way, non-shaming. And so, acknowledging that grounds us to think about the fact that we are going to make mistakes as therapists and activate shame or shame sensitivity or the fear of being criticized or judged within the treatment hour. That's part of the transference and the counter transference because we're all carrying our own pieces of internalized shame because nobody had a perfect childhood. So, what is critically important, and this comes out of the research, child research from Ed Tronic and Claudia Gold, which is it's not so much a problem of rupture, it's the concept of rupture and repair. And when Ed Tronic did the original still faced experiments and really developed all of the styles of types of secure or insecure attachments, they originally thought that the least amount of ruptures created the healthiest individuals. After decades of research, what they found is that's not the case, that 70% of the time, people who have secure attachment bonds, 70% of the time experience ruptures in the queuing response between the infant and the caregiver, between the child and the parent. So, it's really how we repair the rupture that creates a feeling of hope, a feeling of personal agency. You don't have fear, you don't have shame. It gets neutralized and normalized because the attachment bond gets resecured.
Jonathan Singer: As I'm hearing you say all of this, it's very hopeful that there are neurobiological explanations for shame, that there is a way in which these relational ruptures, right, sort of the criticism or the not being there or whatever it is that ruptured the relationship, that it's not as a parent or as a therapist. It's not that I didn't do something, it's what do I do after that? Right? And I'm a jazz musician and so one of my favorite quotes is, in jazz, it's not the note you play that matters, it's the note and the note that follows that makes it music.
[20:05]
Patricia Gianotti: Not only is it hopeful, just if you think about it as a therapist, doesn't it take a lot of pressure off? I mean, it's like, oh, if I make a mistake and I can catch it, and I catch it by being very careful to watch what the next note is going to be if I watch the next note. I mean, that's how we track process dynamics. So, it's not that I have to do a technique properly, it's that there is an exchange and a back and forth and a queuing and attending to the serve in return, where you're waiting for the next note to see. How did that go over? And right brain to right brain, body language, other intuitive cues. If it didn't go over well, a client will look away from you, their posture will collapse. But you can process that as well because that then becomes part of the repair and out of that rupture and repair and further repair and further repair. We are changing the hardwiring of the brain. We're not just doing talking therapy, we are also working on a neurological level. Which is why the depth, therapies in my opinion, have so much power in the long run. Not just to fix a symptom that will show up six months or a year later, but we're talking about long term repair of an injury and we're talking about changing the hardwiring of the brain, so the person becomes less reactive. Which leads me to my final principle, which is the concept of resilience. And that no matter how much trauma or deprivation most humans have experienced, they will hide out. That part of the authentic self, that part of the resilient core. And they're lying in wait for someone to recognize it, for someone to make it safe enough so that part that's been in hiding has a chance to come forward. And you see the emerging authenticity coming forward. And what's more hopeful than that? It doesn't get any better than that.
Jonathan Singer: I'm so glad that you're talking about relationship ruptures and of course you talk about it in the book but you also talk about it in relationship to something called loyalty contracts. Could you talk about the connection between the two?
[22:53]
Patricia Gianotti: Sure. So in the book how I phrase attachment injury and attachment rupture is you need to think about what a child is doing early on, what's the message that's transmitted between the parent to the child and how the child internalizes that. And there really is set of rules that a parent is conveying to a child that is saying well, this is what you need to do in order to fit in and be a part of the family and receive love from us. And so we talk about loyalty contracts as those rules that become internalized as a system of beliefs and feelings and reactions and expectations that are initially communicated within the parent child bond but that they become so internalized that they operate as the spoken and unspoken rules that a person carries forward in present day relationship. And those rules are there because they carry assumptions around well, this is what I need to continue to do to feel safe and to develop a sense of personal value and what I need to do. So you will give me approval and you will see me. But with unfair loyalty contracts there's so much of the real self that had to go underground and be compromised that it's a narrow, narrow way of operating in the world. So if we think about the difference between healthy loyalty contracts, healthy parent child expectations, if a family has messages that are fair, loving, consistent and applied equally to all members of the family, then a child is going to grow up with a sense of confidence, a trust in others, a general sense of optimism and a capacity for mutuality in relationship. On the other hand, unfair loyalty contracts consist of expectations that were unfair, harsh, abusive or depriving or inconsistent. And the result of these contracts is that the child will form some varying degree of an insecure attachment. Okay? And how they will move through the world is through a compromised and narrowed and reflexive reactive pattern in relationship unfair loyalty contracts. What's I think a cardinal feature about them is even though they guide so much of human behavior on a day to day basis from beliefs that we've internalized to how we treat other people, they are the most unexamined aspect of human dynamics, which I find fascinating. Now, why is that so? It's because these unfair rules and expectations started to get laid in from day one of infancy. And what we know about neurobiology is for those first two, three years of life, it's pre verbal, it's right brain encoded, it's in the implicit memory system, and it's largely unconscious and hence the lack of examination. But the opportunity for us as therapists is beginning to translate and ask questions about, well, is that fair to you? Or where did these ideas and beliefs come from? And did you ever wonder if it could be any different than that? So the questions are trying to open up a window of curiosity about those rules that remained unquestioned. And that is such an opportunity for a dialogic interchange between the client and therapist.
Jonathan Singer: So as you're talking about these loyalty contracts, my training as a family therapist comes in and I'm imagining scenarios where you have a family therapy session and you can see these unwritten rules getting played out. How does this work when it is a diatic situation with you as the therapist and an adult? Right? How do you uncover this as an individual therapy setting?
[27:53]
Patricia Gianotti: Yes. And that's a really good question also because it may take a little more time than when you're seeing the dynamic exchange right in front of you. But part of the principle of transference and countertransference is that dynamic will play out with you in the relationship eventually, particularly if we're talking about doing longer term depth therapy work. But even if that's not the case, and even in shorter term models, how we recognize that is through repeated patterns. And it may not come out directly in the transference with you, but you'll hear it in the derivative, by the way they talk about relationships at work or they talk about their partner and what are their assumptions and their expectations? How do they handle disappointment? What do they do with disappointment? Do they retaliate against? Do they internalize that and blame themselves? Then that gets translated into their belief systems about how they should behave. And so you hear that in the derivative and in the patterns that are repeating themselves. And I think one of the most obvious and clear cut ways is what happens when a person is triggered by a disappointment. What do they say to themselves? What do they do in response to that? To what degree do they overcompensate? And that shows you a picture of the early loyalty contract. Are they harsh with themselves when they make a mistake? Can they ever apologize for a mistake? Do they retaliate against a mistake? You're seeing the parent child DIAD in action right there in front of you.
Jonathan Singer: So I love how you just made that connection between a family systems perspective and what sort of a psychodynamic training can bring, right? Because you translated, you were like, okay, so you're not seeing it in person, but if you know what to look for, you can actually see it playing out. And I'm wondering what are some other things that psychodynamic techniques or concepts or ideas can provide to folks who are not psychodynamically trained?
[30:24]
Patricia Gianotti: So I guess I'd start by saying the way we teach psychodynamic depth approaches is first and foremost to take a stance of slowing the process down. And the more you slow it down, the more you can catch. You can see, you can listen for, but the more you can check some of the assumptions that you might be making. I think one of the dangers of being overly trained to technique is you may rush the process to push toward the technique as opposed to following the client's lead and trusting that the unfolding dynamic process will take you where you need to go. And so part of what I see in looking at process recordings of client interactions in our training program is you can really more easily catch where a therapist is making an assumption without getting more detailed information, which at times can lead you down the right track because you're doing a macro formulation in that assumption. But at other times, you're following your own lead into a hypothesis that may not be completely accurate or may not capture all of the parts. And that's what I mean by following the client's lead. So you're getting more and more information and you're not leading the client too much or moving to a technique too quickly. So that would be one way I would answer that question.
Jonathan Singer: So can you clarify what you mean by process dynamics?
[32:26]
Patricia Gianotti: Yes. So I think when most clinicians begin in this long learning curve of psychotherapy, we might overly pay attention to content of what the client is saying and maybe go down a rabbit hole with content some of the time. But what I mean by process dynamics is you're attending to the content, but you are also paying attention to what's going on in the room. What's the body language? I hear the content, but it seems inconsistent with the tone of voice or there's an avoidance of something else or you're getting the feeling that something is being hidden. There's a nervousness that's not being spoken to. A client may be flooding the room with a lot of talk. And so if you just try to track the talk talk, what are you not attending to on a process level that has to do with the anxiety. And so then what you would do in terms of shifting gears so that you can comment or reflect on that is you would stop the action for a little bit and maybe do a reflection. I'm noticing that there's a real speed in what you're saying and I'm having a hard time following you. Can we slow it down a little bit? Because I know you have so much that you need to say and want to say, but I'm wondering if you're a little anxious that you're not going to be able to get it all out today.
So that would be an example of shifting to a process dynamic comment. Because what that does is it attends to the underlying anxiety on a process level and it actually is a form of co regulation. And oftentimes when you do that, the client will settle down a little bit more and realize that we have all the time that we need to get to. What you need to say to me that's so important?Jonathan Singer: One of the classic solution focus techniques, which is the miracle question, right? So you're talking with your client about problem, let's say tonight while you're asleep, a miracle occurs and the problem that you came in to talk to me about, that we've been talking about right now has been solved. What's the first thing that would let you know that it's been solved? But the gift of psychodynamic as you're talking about it is the reminder to not ignore the process. So if the client is saying, well, the roof wouldn't be leaking, and then I would be sleeping in a big fancy bed, not just to focus on those concrete things, but to listen to how the person's saying it. What's going on with their tone that might suggest that maybe there is some anxiety or maybe there is so much kind of anticipatory hope that it's almost too much. And to sort of slow it down and to think about what is the process here so that you could then also ask about that as well as what they're envisioning their life might be like when this problem is gone. Am I hearing that right?
[35:46]
Patricia Gianotti: I think so, yeah. I think that's a good summary of it. And I mean, as I was listening to you, the question that would have come to my mind as a therapist is out of curiosity, is to say, so who fixed the roof? Who fixed the roof? Because what that gets to is in our four quadrant model, quadrant three, the relational quadrant, the wish that someone else would the magic cure or the miracle cure is that it would be fixed. But I wonder who fixed the roof? And that would tell you, I mean, that would lead you somewhere, too.
Jonathan Singer: Yeah, that's a great question. And it's interesting because I think that that question who would fix the roof? Is or who fixed the roof?
Patricia Gianotti: Because it's already finished. So I'm joining you in your miracle cure. But just out of curiosity, who fixed the roof? Because that goes back to parent child dynamics most of the time.
Jonathan Singer: It's so interesting because I don't think that is inconsistent with solution focus, but it is a different way of framing it, right. Because part of that question is like, okay, so how are we going to move from where you are now to what you want? Right. And if that means that you know, who fixed the roof at a certain point in solution focused, if that relates to a parent child dynamic, solution focus doesn't provide any insight into how to address that. And so that would be a really important piece of this is where psychodynamic really has tools and frameworks and understandings that can be really powerful even for somebody who is sort of solution focused, trained, or doing a solution focused session.
[41:17]
Patricia Gianotti: But what I like about that technique in solution focused, and here's where the integration comes in of all of the different techniques and theories within a larger umbrella of dynamic therapy. What I like about that, how I would explain that dynamically, is that what you did is you gave the person an opportunity to imagine and then experience neurophysiologically, what it would feel like to have that relief. And that opens a doorway, it opens a neuropathway, which is really valuable. So there's value in that as well. We need to be dialoguing about all of these techniques. That's part of the whole underlying point here, is that that's what's going to enrich and continue to grow our field together.
Jonathan Singer: Yeah, we need to do a modern day version of Gloria, but just sort of do it.
Patricia Gianotti: Exactly. Exactly.
Jonathan Singer: Well, Patricia, obviously we could go on and on about this, but I know that our listeners, they have clients to see, they have work to get back to, papers to write. So thank you so much for taking the time and talking with us today.
Patricia Gianotti: Well, thank you for having me, and this was so much fun, Jonathan, I really enjoyed it. And thank you to the listeners also.
Thanks for sticking around. I know you’re waiting for the Klezmer music. As promised a little more information about The Institute for Advanced Psychotherapy at Loyola University Chicago. The IAP offers a yearlong certificate program for licensed professionals. What makes this course different from other continuing education programs is that the framework incorporates multiple theoretical disciplines and offers a method of case conceptualization that includes various listening and intervention techniques from other treatment approaches. If you sign up for the IAP certificate program you get an immersive learning experience that combines 3-day on-site residencies featuring hands-on training by nationally acclaimed faculty, online small-group consultation and live webinars to enable you to continue working full time in their practice while going through the program. Professionals who have been through the program say that it offers a transformative experience, bridging the gap between theoretical knowledge and practical application, enabling professionals to enhance their skills and deepen their therapeutic practice. They benefit from a supportive community that fosters personal and professional growth, making it ideal for those returning to the field or seeking to refine their identity as clinicians. With a manageable time commitment and a focus on real-world applications, this program equips therapists to effectively address the root causes of client behaviors, enriching their ability to heal and support. The program is approved for CEU Credit by the APA and NASW, and awards a total of 72 credit hours. To learn more, please visit https://www.luc-iap.com/. Ok. Here’s the klezmer music.
[41:17]
References and Resources
- Embracing Therapeutic Complexity: A Guidebook to Integrating the Essentials of Psychodynamic Principles Across Therapeutic Disciplines
- Uncovering the Resilient Core: A Workbook on the Treatment of Narcissistic Defenses, Shame, and Emerging Authenticity
- Listening with Purpose: Entry Point into Shame and Narcissistic Vulnerability
APA (7th ed) citation for this podcast:
Singer, J. B. (Producer). (2024, June 6). #138 - Embracing therapeutic complexity: Interview with Patricia Gianotti, PhD [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2024/06/gianotti.html
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