Maintain Therapeutic Focus: Surface-to-depth, central-to-peripheral

Many therapists struggle with what to focus on, what to address, and when and how to do it. At times, we feel clients are giving us little to work with, and while this can be distressing for a beginning therapist, this problem has a much less nuanced solution than feeling there is too much to organize. When we feel the client has thrown too much at us, we feel "what do I respond to, and how?"

A comment on trusting yourself before we dig into the other topics

First of all, we must always use ourselves as an emotional barometer (this term is borrowed from Object Relations By Sheldon Cashdan, but a topic discussed thoroughly in psychodynamic literature). Our emotional reaction is considered not only objective data about therapy, but important data that needs to be used. It may sound easier to try to set it aside and refocus, and you might dismiss your reactions as a need for further self-analysis in the old psychoanalytic adage about problematic countertransference. However, contemporary literature, while acknowledging the possibility of problematic countertransference - some emotions might truly be our own stuff coming out during therapy, and not elicited by the client in anyway meaningful to their therapy - we look at interpersonal patterns and emotions that come out in therapy as co-created by the therapist and client.

Therapy note: I frequently ask my clients what their anxiety tells them about the other person involved in that situation. In other words, how can their anxiety actually be used as empathy.

If we are feeling something distracting, think of it as a co-pilot saying they need our attention for something relevant - they wouldn't distract you from safe flight to ask if you like cheese on your burger. So we pay attention. We can ask ourselves "what am I feeling, and why?" "Where do I feel this in my body?" "What does this remind me of?"

Therapy note: We might ask the client similar questions when they bring up strong emotions.

We may also ask ourselves what the client is doing that might bring up these feelings. What do our feelings - reaction to the client's behaviors - tell us about their behaviors? Surface to depth

The importance of depth in Western psychology traced back to its origin. Franz Mesmer, his surname being the origin of the term "mesmerizing," was an early influence to Freud's hypnosis, aimed at getting below the surface to the hidden psychological struggles in the unconscious. Freud's initial model of the mind, the topographic model, was primarily focused on depth or levels of consciousness, and his structural model, including Id, Ego, and Superego, maintained levels of consciousness - that certain emotions, experiences and parts of our personality existed outside of consciousness for various, and primarily self-protective, reasons.

The Id are impulses that might not be conscious for various reasons (the neurological origin of these experiences are separate from our cognitive and linguistic brain regions). One major reason is that these impulses might not be socially sanctioned and must be gatekept. But how does our psychology know what is socially sanctioned, and where does this gatekeeper come from? Certainly social sanctioning and cultural norms are not inbred in human psychology as society differs over time and across culture. It is internalized in a cognitive repository we call the superego primarily during early learning from caregivers. The superego crosses the bridge from conscious to unconscious - many of these rules are easily put into language. Cognitive therapists focus on "musts," "must nots," "have-tos," and "shoulds." But the origin and emotional experience of the internalization of these rules may not be fully or readily conscious.

What happens when an impulse opposes a rule set by the superego? The ego is a vast and diverse psychological organ that includes pre-conscious or unconscious mechanisms like defense mechanisms, which do the bidding of the superego and keep the peace both in terms of our internal psychological system but as well as our socially appropriate behavior. While they vary in maturity or effectiveness, they are all adaptive in some manner, or emerged out of adaptation. The ego also includes, and arguably more importantly, identity, sense of self, esteem, and other self-functions.

Contemporaries of Freud revisited this in multiple ways. The American counterparts in the 1950's, the interpersonalists influenced by Harry Stack Sullivan, used the terms "me," "bad me," and "not me." I recall reading that he or a colleague at presentations would ask the audience to spit into a glass of water they were so kindly provided at the start of the lecture. And then to drink the water. Of course, this was unappealing, but why? That spit was just in their mouth? This was meant to represent the "not me" that is projected outward, and then strongly resisted to be allowed back in.

Therapy note: the things we dislike most about others are often attributes we dislike about ourselves, push out of consciousness, and project onto others.

While tainted by Berne's temptation toward pop-psychology, Transactional Analysis also proposes a useful model of personality that includes a healthy Adult self, a self-parenting self, and an internal child. This should sound like Freud's Ego, Superego and Id respectively, and is arguably a different take on the same psychological phenomenon or structures. The work in transactional analysis is cathecting, or psychologically energizing, the healthy adult self, building the ability for that adult to sooth the hurt child, and disarming the critical parent. The work of a cognitive behavioral therapist would largely target the self-critical aggressions of the parent-self, which are taken out on the child when or so long as the health adult is taking a psychological back-seat.

Internal Family Systems looks are self-parts and how they create an internally stable homeostatic system, albeit an imperfect one with the sequelae of psychological and interpersonal symptoms until reorganized through therapy. This orientation posits we all have a healthy core self, and suggests other self-part identities including but not limited to a protector and an exile (and sometimes a firefighter that acts as a check-and-balance to the protector). The parent is quite busy keeping things managed and maintaining internal homeostasis. It is exhausted, but doesn't think it is safe to give up it's patterns. Its patterns are coping skills or defense mechanisms, frequently learned around adolescence, with a major goal of, on the surface, protecting the exile, but in actuality, keeping the exile exiled. Like the audience members who did not want to drink their own spit, the protector is afraid of letting the exile in and consequently having the internal psychological ecosystem contaminated. The exile is a dumpster of early-life painful emotions and memories, and the protector is the early ways we learned to cope with it, particularly denying that it is "me." The protector is the gatekeeper, and in therapy we must get its trust and permission to go further into the depth of the therapy to access the exile.

Hopefully you can see the bridge I am making. We are motivated to exile or project certain feelings, experiences and aspects of identity that we don't want to identify with or experience. These parts can bring with them a sense of weakness, badness, vulnerability, and ultimately sadness and depressed or anxious state. However, without acknowledging and taking care of these parts, feelings and experiences, they are never resolved or improved. Consequently, our coping that keeps them exiled also maintains our pathology. To get better means experiencing the pain, and we can obviously see why defense mechanisms are motivated to keep these things in the dark, out of consciousness, compartmentalized from our conscious self.

Consider the Allegory of the Cave

What does this imply for therapy? Therapists are the messenger and will be shot. Well, no,

not necessarily, but a haphazard therapist will blunder beyond the boundaries and find themselves a trespasser in off-limits territory. Some clients will make the off-limits explicit, so much so that therapy feels rigid and without avenues to wellness. Other clients cannot protect us or themselves from the off-limits or unsafe emotional experiences. This could occur for various reasons. Many people with trauma and/or severe personality disorders have very little to warn us or themselves that we are nearing and crossing this line, and consequently can quickly become emotionally dysregulated (one of the reasons why emotional dysregulation is a symptom in these diagnoses along with coping skills). [See article on Yerkes Dodson Performance Arousal curve]. Some people have very little awareness or insight into internal cues that they are nearing psychological danger - we might call this alexithymia. A third reason is compliance - the self-parenting or superego has rules that the client must predict or assume and follow the orders or desires of authority unquestioningly, and it is important to be a good patient.

Therapy Note: reflect on "what happened just there?" For the rigidly protective client, "when I/you said ____, I felt you pull away," or for the triggered client, "I see your emotions rising - let's pull back and refocus on what's happening now and how we got there." The latter is a major focus of Mindfulness-Based Therapy (MBT) on emotion regulation.

But if we go into therapy attending to our emotional barometer to help us gauge that interpersonal state and the client's internal state, and focus therapy from surface to depth, we can be much safer in terms of respecting this boundary even if it is not explicit or overt where the boundary is. We can always focus on "what is happening here, right now?" We can use skills like reflection, rephrasing or summarizing to stick with the surface rather than making assumptions or interpretations that might go below the surface. Until we befriend and disarm each layer of the onion, the next layer is arguably and often off limits. Sometimes a psychologically healthy and resilient client or a soothing and charismatic therapist can manage to forgo this to a degree, or a pathologically compliant client will permit it. But what is the purpose of this?

Kernberg felt it was prudent. He felt changing the clients pathology before concretizing their personality was key, and consequently we focus on interpretation rather than support. Conversely, his intellectual adversary, Kohut, felt empathizing with our role in the client's self-esteem was primary and we cannot safely or effectively create change without security between the client and us, and ultimately building this within the clients self-system or psychology. Kohut might be consistently asking himself "what is happening between us right now, what role and I currently playing in the client's self-esteem, and what effect would any action or response have on their esteem?"

While most models focus on the client's internal system, let's think of a graphic decisional model.

	Ego-Syntonic	Ego-Dystonic
Aware / Conscious	Ego / Me / Core / Adult Self: Easy to discuss, therapist should reflect and validate attributes early in therapy. Mirroring builds esteem and rapport. Not much therapeutic work to be done.	Superego / Bad Me / Protector / Parent: Acceptance of these things, non-judgmentally, in therapy allows for more self-acceptance and less social self-consciousness, as well as creating a sense of safety to open the doors to further depth in personality and therapy. Approach gently, but not so cautiously as to imply these attributes are not "okay."
Unaware / Unconscious	Creates a strong bond - feels "known" and "seen." Reflection of these attributes might feel like a revelation, getting to know self. Can become part of "me" and build ego-strength. These parts are unconscious because they conflict with early life external feedback and parent-self. They need to be reconciled.	Not me / Exile / Child Self: Wait until later in therapy or proceed with extreme caution if necessary. Before you know it, there will be enough therapeutic rapport and movement into the depth that this will be on the surface. Accept, sooth, and model these things for healthy internalizations (re-parenting). Challenge cognitions about this part or the experiences that shaped the exile's feelings.

Central to Peripheral

In addition to focus from surface to depth, we can also ask whether a topic, or perspective on the topic, is central to psychology and mental health or peripheral. This is informed by theory, philosophy and theoretical orientation, so professional opinions on the matter will vary somewhat. However, Jeremy Saffron verbalizes my opinion on this very well his in book Widening The Scope of Cognitive Therapy, focused on the integration of psychodynamic therapy and cognitive behavioral therapy. Saffron posits that, especially contemporary psychodynamic theory, referred to a relationalist, both lends itself to compatibility with cognitive therapy, and helps focus cognitive interventions on centrally-relevant distorted cognitions, thus improving effectiveness. The American psychodynamic therapists influenced by Harry Stack Sullivan make this quite clear in their literature including Lester

Cyclical Maladaptive Pattern (CMP). This version is an adaptation of the original.

Luborsky and Strupp and Binder, such as mapping out cyclical maladaptive patterns (CMP) that include beliefs (cognitions) about self and others, and how this shapes actions. This should sound similar to the cognitive information processing model in which an event leads to a thought or interpretation that shapes emotional reaction and behavioral reaction, this leads to a consequence which is itself a new event.

CBT Information Processing

You may be asking yourself what is the difference between these two models - are they essentially equal and interchangeable? The difference is that the psychodynamic theorists focus on intra- and interpersonal, and have a much richer background in depth, which focuses the therapist on central concerns to pathology; while cognitive therapy has developed much more refined technologies to challenge these cognitions if and when directive interventions are beneficial. I believe Saffron offers the example of a student going to a cognitive therapist early in their career. The student says "I am anxious because I think I will fail my test." The therapist gets excited to address what is clearly a distorted cognition, "what evidence do you have that you will do poorly?" However, if we think more centrally, we might wonder "what does it mean to you to 'fail'?" or "is that feeling, failure or fear of failing, familiar?", "does this bring up memories or feelings of past times or people that made you feel like a failure?", "what would it mean to you to fail your teacher?", or maybe you get the sense this client also fears failing therapy, failing to be a good client, and you address it in the here-and-now, "you know, that brings up a sense I've had, that maybe you carry some pressure or expectations for yourself here, in therapy. It is your space, but also maybe you feel you have to perform in some way for me?"

All of the example responses the therapist might give are also all on the surface. Things the client has shared or are immediately present in therapy in body-language and countertransference. If the therapist focused on evidence that the client would or would not fail in school, the client would likely comply and try to do a good job as a client. If they don't succeed and pass the test, now they also failed the therapist.