Preface

This article intends to suggest some reflections on the goals of psychotherapeutic work. In a recent research carried out by the Faculty of Clinical Psychology on the representation of the psychotherapy demand, an interesting dichotomy between two ways of interpreting therapy emerged: the first one strongly oriented to the classification of the client in descriptive categories, and to his inclusion in the "normality" envisaged in the theoretical reference model; the second one more oriented to the creation of a relation where the therapy goals can be shared with the client (Paniccia, Dolcetti, Giovagnoli & Carli, 2005).
The two representations recall the debate on the cultural models of our profession . In the second case, more oriented to the client's development, the medical model of deficit correction, present in the first case, seems not to be reflected. "Working at client's development" does not mean knowing in advance the direction of the development process. The goal does not consist in achieving the final target as it is in the theoretical model, but in increasing the ability to direct this process starting from the client's development targets. The use of the term "client" refers explicitly to the beneficiary of the psychotherapeutic work, a person with goals and skills, therefore having a specific, new and variable demand. Development implies the direct participation and commission of the client, in contrast with the representation of psychologic work as a technical performance of professional knowledge which the client is dependent on. A difficult, puzzling goal for anyone looking for immutable laws and firmness in the psychologic procedure, for anyone who finds it hard to give up a representation of the profession as linked to power.
The purpose of this article is to trace the meaning of this goal within the strategy of action used in a clinical case.

The article is divided in to two parts. In the first one, the case of E. will be presented and some theories on the problem which motivates the psychotherapy demand will be put forward; in the second one some elements of the strategy used will be analyzed.

Intervention demand.

E. is a 26-year-old woman born in a provincial town of Campania 1; at the age of 19 she moved to Rome to study Law at university. Her father, manager in the public sector, and her housewife mother are from Calabria 2. She has got a 24-year-old sister, a graduate in Economics, who lives with her parents.
E. contacted me in January 2005 and told me she was a friend of one of my clients who had concluded a psychotherapeutic cycle 6 months before. "It feels like I already know you", she said during our first meeting. She asked for therapy because she could not finish preparing her final dissertation. After finishing all the university exams with good grades she could not "go ahead".
We found some difficulties in agreeing on the schedule for the first appointment and she anticipated to me that, because of her being extremely busy, we would have to "negotiate" on the following ones.
During our first meeting E. stated she could not understand the reason why she was "stuck", she admitted she was happy to be at the end of her course of studies, to become independent from her parents and to be able to "pay them back for all the sacrifices they had made for her". E. stated it was her parents' wish for her to study Law and, in the past, for her to attend the Liceo Scientifico 3. She would have liked to attend an Art School but her parents "had lied" to her saying that in her hometown there was not this kind of secondary school. She had always been seen as a rebel, as a hot-headed girl unlike her younger sister whom E. saw as "in line" with her parents' way of thinking.
With the passing of time she had learnt to "obey" because, she asserted, to keep on opposing her parents' wishes would mean being excluded from the family. After the degree in Law she would take up her hobbies: drawing, dancing, singing, acting and social work..
Her parents were very worried about her being late with her studies and would phone her every night to check whether she needed anything and to make sure she was studying.
E. could not stand her parents' concern with her life because she thought that their only interest was to use their children's success as evidence of their being good parents. She thought that, since she was a child, her mother had turned the relationship with the cousins into a competition between sisters, in which, to her mother's disappointment, E. had always refused to take part.
E.'s demand was to find the "energy" to keep on studying and "take the burden of the degree off her shoulders". The problem, she said, was that she "would lose control" and would not be able to achieve "self-discipline". If she forced herself to stay home, she would spend her time idling. If she decided to go out she would come back very late at night, she would drink too much and would not be able to get up the following morning.
She had not spoken with her university professor for months and she even feared he did not remember he had assigned her a dissertation. She felt guilty, she was really not able to contact him again even though, she stated, he had always proved to be helpful and respectful of her timing.

Initial interpreting theories.

E. suggested I should oblige her 4 to graduate. Also I, like her parents, should worry and force her, so that she could keep on resisting, rebelling and disappointing instead of starting to plan her professional development. Having a third person forcing me releases me from the effort of thinking.
My hypothesis is now that E.'s problem was "taking the burden of the degree" off her shoulders, denying her implication in her course of studies and her involvement in the planning of her life. Dancing, singing, drawing did not seem interests she intended to take up seriously but a way to provoke and make others worry, and therefore to control them.
In the relation established with me, E. would invite me to repeat the same relational pattern experienced in her family. She would forget about the appointments, she would get here too early, more often late. Every time, humiliated by her incapability to "discipline" her behavior, she would say sorry and justify this lack of attention with stories of nights spent drinking and smoking. During the sittings, she would happen to suffer from a sudden and terrible headache that would prevent her from thinking and would "force" her to ask for the curtains to be drawn, lights to be dimmed, the appointment to be interrupted, for which, she would stress, she would pay me the whole fee.
I could either be worried about her and become interested in alcohol, smoking, headaches, or get angry, remind her of the rules, impose discipline. In this case, reminding her of the setting's rules risked being seen as the prescriptive dimension which exempted us from sharing the sense of what we were doing, which placed us under obligation and cancelled thought.
The obligation, as said before, guarantees control over the relation, a control that had been evident since her first phone call. She tried to handle our relation through an anticipation of the many things which made her busy: singing, dancing, drawing. Since the beginning I, as well as the other people she talks of, had been tested: according to my response I could be compared either to her insensitive parents or to her helpful professor.
Anyway, even before getting to know me, E. guessed I was an enemy, unless proved otherwise 5. E. lived her friendship with my ex-client according to her need for control: "it is like she already knows me".
Any relation E. established fell within this vision: the one with me, with her parents, with her professor, but also with her friends, with her flat mates.

The problem which motivates E.'s therapy demand can be seen as the failure of the models of relations which have organized her social life so far. University studies seen as "compulsory education" are about to finish. Other relational patterns are needed so as to use these studies as a useful resource for her professional development.

Which strategy of action intervention could be organized to allow E. to create relational models able to handle the new demands of reality? What is the best way to facilitate the understanding of relational dynamics at the base of E.'s problem? The setting up stage of the therapeutic relation can be used to ground this strategy.

I will now try to trace some components of this strategy.

Agreeing on the work to do.

At the end of the 3 meetings dedicated to the exploration of the therapy demand I suggested E. should understand which relation patterns she had built in the contexts she was telling me about, starting from the one we were sharing.
In this proposal some coordinates of action can be traced. Let's see which ones.
Suggesting the sharing of a goal means pointing out a new relational pattern which does not imply obligations but involvements, not tasks but products. The agreement on the goal is not a work phase but a dimension which goes through the whole psychological intervention; from a certain point of view we could say it coincides with the psychological work.
This goal aims to know the relational patterns which E. contributes to create, not the achievement of the degree. Graduating is not only a goal; it is a goal within a conformist theory which releases me from thinking about the meaning I am giving to the event. Without the involvement and a wish for the future, there are no goals. The point is not to decide whether to be a lawyer or a dancer but to understand which activity is supported by a project grounded in reality and in the limits 6 reality implies.
Therefore I was not interested in classifying E.'s problem within the diagnostic categories of a theoretical method. The goal was not the achievement of a final stage of a predefined growth model, but the joint exploration of the planning hypotheses we could formulate and what relation existed between the Law degree and this hypothesis . That is to say: What interest could E. have in giving up control and obligation?

From the symptom to the relational contexts

Together with E. I started to explore who she is, which social contexts she has been living in and which kind of relational modalities are involved, and what her interests and prospects are. I then shifted my attention from the symptom, her "block", to the person as a social actor. Especially during the first months of therapy E. was surprised and annoyed by this attention shift, her response revealed her expectations of being confirmed as a social victim. On the other hand, E.'s family history easily supported her way of perceiving herself as a harmed individual. Treating her as a person with resources and interests , and not only wounds, has often been perceived by E. as if I refused to "align" with her. In this case, aligning with her would have meant helping her in accomplishing her work related to the dissertation, thus confirming her lack of achievement expectations. This hypothesis is what E. demands and at the same time is afraid to see confirmed.
By exploring the social contexts in which she has been living we understand that E. has got interests and prospects she is afraid to acknowledge . Her feeling of graduating, with the degree seen as linked to its symbolic-affective dimension, seems to jeopardize that unspoken agreement that allowed E. to attend, belong and take part to the social contexts she talked about. Both the family and the university context, with the first one being predominant, were perceived as non-productive. Belonging and achieving appear to be as two conflicting motivations.
Therefore the degree seemed to lead to a break, to the loss of a given relational arrangement, where madly conflicting opinions of a single person reassure the others through predictability and control over variable and unknown events. If I don't graduate I will perpetuate my parental bonds. If I fail, I'll make them fail, and keeping conflicts at a high level is the only way I can guarantee the relation.
Feeling the other as known enemy enables some economy of thought, draining at the same time potential productive energies. I set and recognize myself only within this way of perceiving the relational context, where I dig my own social niche that I will be very unlikely to leave unless I start to be curious about what's outside and then, unless I start to acknowledge I have interests I cannot pursue as long as I remain in my niche. The Law on the one hand and dancing, drawing and singing on the other hand lead to a split between reality and desire. I can desire, produce and develop creativity only if I do the reality and its restraints in. Working is always split from creativity which can only exist free of restraints, perceived as obligations.

The use of the relation "here and now".

The social context that best enabled us to develop a new way of thinking has been the psychotherapeutic setting. Starting from the shared emotional experiences within the therapeutic relationship, we were able to produce thoughts about emotions and try out a different way of representing social relations. Although E. didn't conform to the proposal of collusion, she got continuously involved in my work plan thus allowing me to assess her interests and resources capable of modifying the relational pattern.

An example.

During the first months of treatment E. got back in touch with her professor. By working on the literature related to the subject of her dissertation E. found out she was interested in Law much more than she thought. The reason is that she stopped using her study (not-study) of Law as a pretext to control her relation with her parents. Finally she saw the subject as strangeness to her and therefore to be known, she started to notice it and be interested in it.
At the same time, E. asked me more and more often to catch up on the sessions she forgot to attend, other times she asked me to bring them forward because of an emergency. These two attitudes are of course related to each other. By the time E. started to free the university context from her fantasies she wanted me to enable her to play them once more.
In March she called me in tears and requested to bring our appointment forward because her work for the final dissertation was now "spoiled". Her professor had apparently asked her to return him some books so that he could give them to another graduating colleague who was interested in the same subject. E. felt guilty because she had not read the books yet and did not know how to tell him. She interpreted his request as he was no longer taking her work into consideration and was calling her to order.
We met the fixed day and E. complained about my lack of "empathy", and angrily told me that in order to trust me she had to be sure that I felt the way she was feeling. Since I didn't meet her needs I showed that I was not supportive towards her, just like her professor who was now preferring another student to her. There were no doubts on the meaning of both my behavior and her professor's. The relation with me was not being used as a means for understanding but as a signal that automatically triggered the friend-enemy pattern hindering the arising of any knowledge.

After this event we could experience E.'s conflicting proposal within a relation, the therapeutic relation, the one promoting the development of a new way of thinking because it doesn't reproduce the same conflicting arrangements.

Trusting someone is not the goal, it enables one to keep control but does not lead to any development. The same happened with her professor: his being "respectful of her timing" did not help her produce her work. We were able to spot E.'s request of a limitless relation: no agreement, no deadline, nobody with whom to share her resources, all this relates to her fear of involving herself in productive relations . She feared and therefore rebelled against any possibility of achieving her goals. She could be in relation with someone else only if he/she would think and feel like her. Controlling the other results in the denial of productivity.
Thanks to the limits set by the therapeutic setting it is possible to get to know these emotional representations of the relation. These would otherwise remain unspoken, hidden behind the rhetoric of empathy 7, and E.'s pretext to be a victim of the other's insensibility.
E. finally started to understand that empathy was a violent request, doing otherness in, as well as that the other, insensitive to her needs, was functional to eluding her problem: not being able to get in touch with what she did not know yet and take care of her own development.
In the case presented here this meant talking to her professor, stating that she was interested in the books she had borrowed and wanted to keep them for a little longer, setting a deadline with the professor for returning the books, getting in touch with her colleague to share her agreements with her.

Some developments.

In the following months E. would continue working on her dissertation, partly with interest, partly still worrying and forcing herself, until the day of the final discussion.
Despite what she had initially planned, she decided to invite her relatives to the dissertation. She hesitantly planned to find a legal office for her apprenticeship following the end of the university studies. She was feeling the degree as a useful means to achieve professional plans and not as a debt to pay back.
A representation of social relations open to a possibility of self-achievement starts to be seen.
In spite of that, or perhaps because of that, on the day of the final dissertation, E. told me, both she and her parents had tried to somehow go back to the old "rules of the game": inexplicably, for some reasons she was hardly able to remember, proving therefore they were intentionally made up excuses, a quarrel started, heated enough to make her parents leave without taking part in her celebration party. This time E. found it less hard to understand the relational dynamics that allow a reading of the event. What seems to be quite clear is her active role, her need to keep on having an "enemy" able to "force her not to develop". As E. would say some sessions later: "I see the absence of control over my parents as a loss".
That was the start for E., in her own words, of a very difficult period in which she was feeling lost and lonely. It is exactly this loneliness, intended as a deprivation of the arranged dynamics which have "kept her together", which allows a change. We understand that "feeling bad" can have different meanings, in the same way that "feeling good" is not a work target. At present, E. is looking for a legal office where she can start her professional apprenticeship, now seen as an investment she intends to risk.

Conclusions

The strategy of intervention, in line with our target to allow the client's development, is built in the contingency of the situation. The "right" hypothesis is the one the client uses to think. The strategy is organized according to the hypothesis's usability. In this view, the problems arisen in the relation with the client are often, rather than interpreting mistakes, valuable occasions of knowledge and development. In the example mentioned, not responding to E.'s request to meet up meant testing the hypothesis according to which E. was asking not to be treated as a victim. It is because E. chose to come to the appointment and talk about our relation with me, instead of cancelling me as a representation of another enemy, that I was able to test the hypothesis.
To be able to use the therapeutic relation as an occasion for thinking we need to agree with the client on that possibility, though. Agreeing can mean suggesting explicitly the goal mentioned as well as organizing the relation according to that goal. In any case, the therapeutic relation is the means I use both to understand the problem and the client's resources and to choose a treatment. In this case the establishment of the relationship is not the requirement but the target of the therapy. In this view, the way the relation is intended is far from the concept of "therapeutic alliance". I am not interested in establishing a relation of trust which enables the therapy; therapy coincides with the establishment of a relation founded on agreed set ups which allow risks and investments. Having a goal instead of creating a difficulty for the client seems to make some of our profession's representations fail. The interest in our client's goals drives us away from that powerful position which seems to guarantee our professional life and which shares much with some ways of interpreting the social relations the clients find problematic.
The clinical report represents a useful means to monitor the strategy for action. It is in the very moment I write, when I strive to communicate to another person the principles which have driven the therapy, that I understand them. The report, as the clinical action, is strictly linked to the ability to deal with the strangeness t of the other, in this case the reader.

References

Carli, R. (1987). Psicologia clinica: Introduzione alla teoria e alla tecnica [Clinical Psychology: Theory and tecnical introduction]. Torino: UTET.

Carli., R., & Paniccia, R.M. (2002). L'analisi emozionale del testo: Uno strumento psicologico per leggere testi e discorsi [ The Emotional analysis of the text: un instrument for reading texts and speaking ]. Milano: FrancoAngeli.

Carli., R., & Paniccia, R.M. (2003). Analisi della domanda: Teoria e tecnica dell'intervento in psicologia clinica [Demand's Analysis: theory and technical of psychological clinical intervention]. Bologna: Il Mulino.

Carli, R., & Paniccia, R.M. (2005). Casi clinici: Il resoconto in psicologia clinica [Clinical cases: the report in clinical psychology]. Bologna: Il Mulino.

Corsini, R.J., & Wedding, D. (Eds.). (1995). Current psychotherapies. F.E. Pescock Publisher (trad.it Psicoterapia: Teorie, tecniche, casi. Milano, Angelo Guerini e Associati, 1996).

Paniccia, R.M., Dolcetti, F., Giovagnoli, F., & Carli, R. (2005, September). La domanda di psicoterapia [The demand of psychoterapy]. Paper presented at the national conference SPR/Italia, Research in psychotherapy and quality care, San Benedetto del Tronto (AP).

Notes

* Specialist in Clinical Psychologist - Lecturer in Psychology Faculty, "La Sapienza" University of Rome, Italy. Top

1. A region of Italy. Top

2. A region of Italy. Top

3. Italian School. Top

4. With the term obligation we refer to a neoemotion. Together with expect, control, distrust, provoke, complain, worry, it represents one of the ways to organize relations within the relational contexts we belong. The concept of neoemotion has been suggested by R. Carli e R.M. Paniccia, 2002, 2003, 2005, as elaboration of the context's emotional symbolization. As organization of social relations, emotion is not seen as a primary and individual response to external spurs. Top

5. "Friend-enemy" is a primitive categorization of social relation. Identifying the enemy, his exclusion, is paramount for survival. The symbolization of the other falls completely within this categorization; therefore his non-involvement is denied. We use this person to control the relation, not to analyze it; the goal is the other person's possession, not an exchange. The "possession-exchange" relation organizes the models of life together within the social contexts in which we live. Around the possession's polarity we find the modalities of neoemotional relation. For an analysis of the relation between the genesis of the relation's emotional symbolization and the "friend-enemy" model, see R. Carli 1987. Top

6. The absence of limits is coherent with the representation of the other as never ending "tank" of resources we can possess. Again it is possession, not exchange, which organizes the relational fantasy. Within this fantasy the limit is seen as a bond which hampers any hypothesis of achievement. Top

7. According to some models, empathy is considered as a quality of the therapist, the basic requirement to properly start a sitting. It is interesting to notice how the case presented here suggests not applying any theoretical concept as a rule. To further analyse the concept of empathy within the "individual-centered therapy" we recommend the thorough bibliographic review that N.J.Raskin and C.Rogers proposed in the book Psicoterapia. Teorie, tecniche, casi by R.J.Corsini and D. Wedding, 1995. Top