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Clinical Pragmatism and Therapeutic Action

The ultimate compliment is to be found and used...

-D. W. Winnicott

Researchers speak of “the dynamics of neuroplasticity” and the “mechanisms of therapeutic action” in their writings on change and growth, but we rediscover the voice of our patients in the clinical situation, joining language and life, speaking of “experiencing,” “feeling,” “willing,” and “acting” as they negotiate problems in living. In embracing the values of clinical pragmatism, as we have seen, we focus on our patients as subjects, exploring the phenomenal realms of lived experience, working to understand the nature of their suffering, worries, hopes, and prospects—what, now, is the matter and what carries the potential to help. We think of psychotherapy as an open practice, emphasizing the crucial role of the relationship, collaboration, dialogue, narrative, and experiential learning, and we assume that beneficial outcomes follow from flexible use of different formulations, approaches and methods as we carry out “experiments in adapting to need.”

In this chapter I present two cases and show how the principles of pragmatic thought deepen our appreciation of essential concerns in the clinical situation, emphasizing the importance of idiographic approaches and the practical outcomes of ideas and methods over the course of the therapeutic process. The pluralist orientation of clinical pragmatism, encompassing scientific and humanistic domains of understanding, makes the multiplicity of approaches a defining feature of therapeutic practice. The cases illustrate the challenges we face as we negotiate tensions between particular approaches and alternative points of view in our conceptions of therapeutic action, change, and growth.

Case 1: Jonathan

Jonathan, age 28, developed diffuse anxiety, panic attacks, and dissociative states 18 months after he was critically injured in an explosion during military service in Iraq. He had suffered a severe concussion, internal injuries, and multiple fractures of the spinal cord and both legs, and was left with hearing loss and chronic pain after back and leg surgeries. In addition to the injuries that he had suffered in the explosion, he had witnessed the deaths of civilians and soldiers over the course of his service. He had completed an intensive course of rehabilitation in a military medical center after his recovery from lifethreatening injuries and developed the above symptoms after returning to his childhood home, where he lived with his aunt. He was frightened by the sudden onset and intensity of his symptoms, unable to make sense of his experience.

Beyond the physical injuries and traumatic events that he related in the accounts of his experience in Iraq, other sources of vulnerability emerged in his developmental history. His mother, divorced shortly after his birth, had died suddenly when he was 6, following a dissecting aortal aneurism, and he and his older brother were placed in foster care. Nearly two years later they were adopted by their aunt, his mother’s younger sister. They lived in one of the most blighted neighborhoods of Chicago, an African-American community increasingly fragmented by warring gangs, violence, and crime, but his aunt took them to the botanic garden near their home every Sunday after church where they spent the afternoon playing in the park.

Jonathan developed a deep love for his aunt, who taught kindergarten in the public school system. She appears to have been taxed beyond the bounds of what she could manage, however, and he recalled fears that she, too, would suddenly die. She helped him with his homework, as he struggled in school, and he developed an interest in math and computers, hoping to begin an apprenticeship program in information technology following graduation from high school. He changed his plans at the start of his senior year, he explained, after his brother was killed by a stray bullet in a gang shooting. He joined the army, in search of a new life. He served in the infantry, attending an advanced training school before he was deployed to Iraq, and had found a sense of belonging, meaning, and purpose in the military'.

The vulnerability and dependency that he had experienced over the course of care in the rehabilitation program appeared to have intensified needs for closeness and connection after his return, but he found himself avoiding contact with family members, fearful that they' would press him to talk about the course of events in Iraq. He had come to feel a growing sense of hopelessness, helplessness, and dread—“like something bad is always about to happen”—and described a range of problems in functioning that met diagnostic criteria for post-traumatic stress disorder. He also showed signs of post-concussion syndrome, including lapses in attention, concentration, and memory', difficulties putting thoughts into words, sensitivity to light and noise, and fatigue.

He had begun a course of antidepressant medication, following consultations with a psychiatrist and neurologist in a military medical center, and reported some improvement in symptoms. He was exploring options for services through the Vocational Rehabilitation and Employment program of the federal government, hopeful that he would be able to arrange on-the-job training in the field of information technology' and find an accommodating work environment. The psychiatrist encouraged him to consider a course of

Clinical Pragmatism and Therapeutic Action 169 psychotherapy, believing it would help him process his experience of trauma and negotiate the challenges of his transition from military service to independent living.

I began to meet with Jonathan weekly in the community clinic where I carried out my practice. I realized that his current range of functioning, compromised by the traumatic brain injury’ and extended periods of panic, fragmentation, and dissociation, and the history of early loss, disruptions in caretaking, patterns of attachment, and trauma potentially’ limited his ability' to form an alliance and make use of the therapeutic process. I followed his lead as he related the course of his experience, working to understand why, now, he found himself overcome by dread, unable to eat or sleep, fearful to leave the surrounds of his home. As he described his symptoms I related them to our understanding of post-traumatic stress disorder and post-concussion syndrome, reviewing the dynamics of hyperarousal, numbing, and avoidance, working to create a heuristic that would help him make sense of his experience.

The nature of his symptoms would have led many clinicians to initiate a standard course of cognitive-behavioral therapy at the outset, following evidence-based guidelines for treatment of post-traumatic stress disorder, but such a nomothetic approach in itself would have been reductive in light of the wider range of concerns that Jonathan related over the course of the consultation and the global compromise in functioning that likely would have limited his ability’ to make use of technical procedures or skills training. I feared that any standardized course of treatment would have intensified his experience of limitation and loss. Above all, I thought it was crucial to establish the therapeutic relationship and begin to co-create a holding environment that would allow us to explore options for treatment of specific symptoms and emerging concerns in light of his current capacities and range of functioning.

As we have seen, psychodynamic perspectives emphasize the sustaining functions of the therapeutic relationship and the constancy' of care in the holding environment. We realize the crucial role of empathic attunement, synchrony, and repair following breaks in the continuity' of interactive experience, focusing on the non-verbal, right-brain dominated aspects of the therapeutic relationship that we register through what we sense, feel, and do rather than through what we say.

I attended closely to Jonathan’s experience of our interaction and the surrounds of the clinic as he related the course of his symptoms and concerns, working to provide the constancy of care that Winnicott describes in his conceptions of holding. He was particularly reactive to bright light, sudden noise, and the scents of cleaning products that we would relate to implicit memories of his experience in Iraq. I attempted to reduce stimuli that carried the potential to intensify fear or activate dissociative states in the therapeutic setting. We pulled the blinds to filter the morning sun and used white noise to limit the impingements of unexpected sound. He experienced chronic pain in his legs and back, and we rearranged cushions to help him feel as comfortable as possible. He sometimes stood to ease the pain, walking back and forth.

His experience of my presence, acceptance, attunement, and concern appeared to foster the development of the therapeutic alliance and the holding environment, facilitating our efforts to explore the dynamics of problems in functioning, formulate goals, and think about the course of help and care. In accord with findings in the field of interpersonal neurobiology, I realized that our ways of being together and interactive forms of communication, mediated largely by the functions of the right hemisphere, carried the potential to help him strengthen capacities to regulate emotion and restore cohesion in sense of self following periods of fragmentation and dissociative states. (Recall Allan Schore’s formulations of right-brain interactive experience and therapeutic action reviewed in Chapters 2, 3, and 5, and Carl Rogers’ formulations of “psychological contact” and Leslie Greenberg’s accounts of “therapeutic presence,” described in Chapter 8).

Although Jonathan struggled with a range of problems in functioning, he found himself disabled by his experience of panic—“frozen,” he explained, unable to carry out the activities of everyday life. The beginning phase of our work, accordingly, focused on ways of managing his experience of fear. His sudden episodes of panic were associated with a range of symptoms, including sensations of choking, shortness of breath, chest pain, palpitations, sweating, numbness, nausea, vertigo, and feelings of unreality; at points he feared he would die. I drew on standardized protocols for treatment of panic disorder as we proceeded, selectively integrating educational, cognitive, and behavioral approaches developed over the course of clinical research (see Barlow, Allen & Basden, 2007). We reviewed the dynamics of his physiological reactions, thinking of the panic attacks as a “misfiring” of the sympathetic nervous system, precipitating the full-blown fight or flight response. I shared my understanding of the ways in which fear compromises executive functions, limiting our capacities to process experience and cope.

I drew on a range of concepts and methods developed in the third wave models of cognitive-behavioral therapy in an effort to help him begin to shift the way he related to his experience of fear, focusing on the development of capacities to actively engage, observe, and accept the flow of the sensations, feelings, and thoughts rather than trying to avoid, challenge, or escape them. In accord with fundamental concepts of therapeutic action, our goal was to change the context in which he experienced fear and panic, coming to recognize sensations, feelings, and thoughts as transitory phenomena rather than as fixed realities that represented the totality of his experience. I outlined basic breathing exercises that carried the potential to help him manage his symptoms, engaging “bottom-up” mechanisms of re-regulation.

As discussed in Chapter 3, the middle prefrontal region of the brain is instrumental in emotional regulation, integrating information across core structures, while the dorsolateral area, associated with the “rational mind,” is specialized for conscious, verbal processing of experience. Accordingly, as David Wallin explains, “simply thinking aloud about difficult emotions with our patients—particularly traumatized patients—may be useful... but insufficient”

(2007, p. 81). What is crucial is activating the middle prefrontal cortex by helping patients process their experience of sensation and emotion in real time. The focus on bodily experience and on breathing can strengthen capacities for emotional regulation and management of the dynamics of inner life.

As Wallin observes: “This interoceptive attention is a form of mindfulness that helps ground patients in the present moment, potentially modulating the distress associated with the traumatic past and feared future” (2007, p. 81). As patients find the words to formulate their experience of sensation and emotion they activate cortical capacities in processing subcortical realms of experience. Deepened awareness of somatic experience and incremental efforts to tolerate overwhelming emotion prepares patients to more fully process and integrate previously dissociated feelings, thoughts, images, and memories.

Although Jonathan’s continued experience of anxiety', fragmentation, and dissociation limited his capacities to make use of cognitive and behavioral methods in the first phase of therapy, he came to view his recurring experiences of fear and panic as occasions to strengthen the development of coping skills—a shift in perspective he introduced that appeared to deepen his sense of agency, challenge, and mastery'.

His experience of dread and panic fluctuated with sudden drops into pockets of dissociation and numbing in the middle phase of therapy as we began to explore the course of traumatic events in Iraq. He had found himself unable to relate memories of what he had witnessed at the start of our work, fearful that he could not manage his emotions, but he increasingly felt the need “to find the words” to describe events he had not shared with others, including the injuries and deaths of fellow soldiers as convoys were hit by' improvised explosive devices. I spoke of the ways in which the sensations, emotions, and thoughts associated with trauma are split off from awareness, encapsulated as frozen fragments—“splinter psyches,” as Jung called them, carried as implicit memory.

As discussed in Chapters 2 and 3, researchers propose that ongoing engagement of sensation, emotion, and cognition over the course of the therapeutic process fosters the reorganization of under-integrated and underregulated neural networks believed to perpetuate dissociation and dysfunction. As we return to various aspects of traumatic experience, presumably, we activate neural firing associated with earlier events, creating new synaptic connections, reorganizing neural networks. If we think of dissociation as the fundamental problem of trauma, as Jung proposed, the aim of therapy is association—integrating the split-off elements of traumatic experience into our ongoing sense of self and life story' so that we come to realize “that was then, and this is now” (Van der Kolk, 2014, p. 183).

Object relations formulations guided our exploration of the ways in which working models of self and relational life had influenced his perceptions of traumatic experience, current relationships, and patterns of interaction in the therapeutic relationship, including transference reactions. As a child Jonathan had come to experience his needs as a burden, following the death of his mother, his placement in foster care, and the adoption by his aunt, fearful that she, like his mother, would die suddenly. Our exploration of interactive experience in the therapeutic situation revealed that he feared the accounts of his experience in Iraq would also overwhelm me. Enactments and the dynamics of transference and counter-transference reactions served as crucial sources of experiencing and understanding as we processed less conscious elements of his trauma and strengthened his capacities to formulate and share his experience of vulnerability and need with me and family members, realizing that he did not have to protect others from himself.

We drew on the methods of classical cognitive therapy in efforts to challenge vicious circles of thought, feeling, and action (“My life is over,” “I’m broken,” “Nobody really wants to spend time with me”) and take more full account of actual circumstances and realistic prospects. He had come to experience the world as a dangerous place, restricting patterns of activity, avoiding opportunities to engage extended family in spite of his longings for closeness and connection. Following the basic principles of behavioral activation, we identified tasks that provided occasions for him to challenge his avoidance of experience, enlarge ranges of activity, and engage relational life in light of essential concerns and goals, creating sources of positive reinforcement. I accompanied him on a return to the botanical gardens where he had spent Sunday afternoons with his aunt and brother, and he began taking weekly walks in the park, finding comfort and restoration in the experience of nature (see Sacks, 2019, for an account of “hortophilia” and the therapeutic functions of nature).

As he continued to relate accounts of events in the middle phase of therapy, recounting the particular details of his experience, expanding earlier reports of what had happened, his fear receded and he found himself increasingly able to manage his symptoms of anxiety and dissociative states, making more full use of cognitive techniques and breathing practices. From the perspective of the behavioral paradigm we can think of our repeated exploration of sensations, feelings, thoughts, and images associated with events as a form of in-vivo exposure. He was able to experience and integrate aspects of inner life that he had avoided out of fear. (Recall Wachtel’s formulations of exposure outlined in Chapter 6). From a psychoanalytic perspective, we can characterize this phase of our work as the process of “remembering, repeating, and working through” that Freud describes in his classic formulations of therapeutic action and change, facilitating the reorganization and integration of neural networks (see Chapter 4).

Traumatic experience threatens basic assumptions about the resilience and worthiness of the self and challenges fundamental conceptions of meaning and justice. In the face of adversity, the assumptive world that has given us a sense of coherence and continuity may be taxed beyond the range of its adaptive function, leading to disorganization and the onset of post-traumatic stress disorder. Inevitably, the effort to restore a sense of order and meaning assumes the form of narrative: stories are ways of organizing experience, interpreting events, and restoring the sense of self, identity, and the assumptive world.

Jonathan began to review the course of his life as we entered the fourth year of therapy, coming to understand earlier events in a new light. The dynamics of narration are thought to engage the core structures of the brain, as discussed in Chapter 3, synthesizing our experience of sensation, emotion, imagery', thought, and memory' as we elaborate accounts of events, fostering integration of neural networks throughout the cortical and subcortical regions. I had studied classics in college, and I found myself beginning to make connections between the stories he related and accounts of war and loss in ancient Greek theater. The tragedies may have functioned as a ritual reintegration for combat veterans, as Bessel Van der Kolk notes, providing occasions for catharsis and healing. Peter Sellers was directing a production of Handel’s Hercules at the Lyric Opera in Chicago at the time, and he organized a discussion of the work with a group of veterans from the community'. Jonathan attended the program, deeply' moved as fellow veterans shared their stories, bearing witness to the experience of war, trauma, and loss.

Psychodynamic understanding continued to guide our exploration of the ways in which earlier patterns of care, relational life, social surrounds, trauma, and loss had shaped the course of his life, influencing ways of being, relating, and coping. We explored the meaning of traumatic events in Iraq in light of his earlier experience of loss, connecting the sudden onset of symptoms after the return to his childhood home to the tragic deaths of his mother and brother. He was increasingly able to make sense of his symptoms in view of the losses, exploring the meaning and implications of events, working to clarify essential concerns as he elaborated his personal narrative and life story. Humanistic perspectives guided our exploration of existential concerns.

Jonathan decided to end the course of his therapy, carried out over seven years, after he accepted a position with the human service organization that had sponsored his on-the-job training program. He had deepened his sense of connection and closeness with extended family and was beginning to form friendships. He continued to live with his aunt, exploring shared interests in urban gardening, moving into what he came to call his “second life.” Over the years he has returned for brief courses of therapy at symptomatic junctures, continuing to negotiate emerging concerns, challenges, and possibilities.

Case 2: Marta

“You are my' toy,” Marta announced at the start of our consultation. “You move when I want you to move, and you speak when I want you to speak... If you don’t do what I want,” she challenged, “what good are you?”

“Useless,” I found myself saying. “We will have to find out if I can be use fill.”

Marta, approaching her 30th birthday, had been referred to me by a social worker in a community' mental health center where she had received psychiatric care for more than a decade. She was thought to be autistic as a child and diagnosed as schizophrenic in adolescence; more recently, social workers had documented a range of problems in functioning encompassed in reformulations of borderline personality disorder, emphasizing her inability to regulate emotion, control behavior, and negotiate relational life.

I learned that she had been born in a state psychiatric hospital and placed in foster care after her mother, believed to be schizophrenic, was unable to care for her. She had had a succession of foster care arrangements through childhood and had been placed in residential treatment as an adolescent. She was hospitalized at the age of 16, after a suicide attempt, and had been followed by a series of psychiatrists in the mental health center for pharmacotherapy and supportive care. She had found antipsychotic and antidepressant medication helpful, over the years, and was completing a psychiatric rehabilitation program affiliated with a university medical center, preparing to begin work as a data entry clerk. She had been unsuccessful in her earlier attempts to carry' out psychotherapy' in light of her disruptive behavior, and unable to form an alliance with a series of clinicians, but her case manager explained that she was reconsidering the possibility of therapy as she anticipated the transition to full-time employment and independent living.

I would follow Marta in intensive psychotherapy for more than a decade. In this account I show how the developmental psychology' of Donald Winnicott served as an orienting perspective for therapeutic action that allowed us to integrate a range of approaches and methods over the course of our work. His conceptions of trauma, developmental arrest, and the maturational process shaped my' understanding of essential concerns as we carried out pragmatic “experiments in adapting to need.”

Winnicott believes that we are born with an inherent drive to actualize the “true self,” the inviolate core of our being, and he describes the “maturational process” that governs the course of development. When caretakers fail to provide a good enough holding environment at the start of life, however, our sense of “going on being” is disrupted and we are thrown into chaos. In light of my' understanding of Marta’s history’ and the etiology' of borderline personality disorder, I assumed that genetic factors and traumatic conditions over the course of care in infancy and early' childhood had compromised the dynamics of neural integration and the establishment of a core sense of self, leading to developmental arrest, predisposing her to a range of problems in functioning. Neuropsychological testing had shown deficits in executive function, attention, and memory' consistent with a large body of research documenting altered patterns of brain maturation in borderline disorders (see Cozolino, 2017, for reviews of empirical findings).

Like many patients diagnosed with borderline personality disorder, she struggled to preserve cohesion in sense of self and identity, unable to regulate her experience of sensation, feeling, and behavior. Her capacity to tolerate distress was limited and she was slow to restore equilibrium following periods of disorganization and dysregulation. Over the years she had cut herself frequently, threatened suicide, and used alcohol and marijuana to regulate her

Clinical Pragmatism and Therapeutic Action 175 feelings. She had developed ways of managing self-destructive behaviors over the course of her rehabilitation program, drawing on the methods of dialectical behavior therapy, but she found herself overwhelmed by emotion much of the time, caught in vicious circles of feeling, thought, and action. She continued to experience transient psychotic symptoms and extended periods of dissociation, relying on what Winnicott describes as “omnipotent defenses” in efforts to manage “unimaginable terrors”—fears of “going to pieces” (Winnicott, 1960/ 1965, p. 47).

Although radical lapses and failings in care may undermine the integrative functions of the maturational process, Winnicott believes that we continue to search for conditions that carry the potential to reinstate the course of development, engaging the dynamics of “going on being” instrumental in the emergence of the self as subject—what he calls the experience of “I-ness:” “1 am, 1 exist, I gather experiences and enrich myself... and have interaction with the not-me, the actual world of shared reality” (1962/1965, p. 61).

In accord with his faith in our capacities for development, Winnicott assumes that the patient structures the therapeutic situation to recreate conditions that were compromised in earlier caretaking and reinstate the process of “going on being,” fostering the integration of the self. He compares the fundamental provisions of holding in infancy to ways of being in the therapeutic situation, emphasizing the crucial functions of the clinician’s presence, acceptance, attunement, and responsiveness, joining the patient as they co-create moments of meeting that open new possibilities; the “ultimate compliment,” Winnicott writes, “is to be found and used” (1968/1987, p. 103; see Borden, 2009, for expanded accounts of Winnicott’s developmental psychology).

I began seeing Marta twice a week in the community' clinic where I carried out my practice. I followed her lead as we began our work, finding myself challenged, like earlier therapists, in our efforts to form an alliance and establish the holding environment. She sat in silence, watching me, seemingly transfixed, unable to find the words to say' what had moved her to begin yet another attempt at therapy, irritated by my expressions of concern, interest, and support.

Language is a core constituent of neural and psychological development, instrumental in the formation of memory' and identity', but Marta was unable to provide a coherent account of her life. She had little memory' of her childhood or adolescence, she told me, and no interest in exploring the course of her earlier experience: “It was what it was.” She experienced fluctuating states of dread, anger, deadness, emptiness, helplessness, and hopelessness as we began our work, finding me “useless,” “a deadbeat,” like her earlier therapists. At other times, however, I found that she was able to focus on the concerns of everyday' life and register her experience of my care and efforts to help as she shared her worries, engaged in the therapeutic process, seemingly' feeling a sense of hope and possibility.

I functioned as a case manager much of the time, providing information, advice, and guidance as she moved from a single room occupancy housing arrangement to a studio apartment, settled into a new neighborhood, and began to carry out the activities of her new job. We talked about the concrete particulars of shopping, cooking, housekeeping, and domestic life. I helped her negotiate bus routes as she found her way around the city from her new home. Winnicott’s accounts of case management, emphasizing the ways in which concrete forms of help potentially foster change and growth, deepened my appreciation of the critical functions of instrumental activities, often seen as extrinsic to the therapeutic process (see Kantor, 1990; Winnicott, 1963/ 1965). There were good days and bad days, good moments and bad moments, as we continued our work.

The mental operations of splitting generated distinct qualities of experience in the first phase of the therapy, and there was no middle ground between good and bad. Most of the time Marta felt a pervasive sense of agitation, anger, and destructiveness that she was unable to relate to the dynamics of inner life or outer circumstances; we could not identify the precipitating conditions. She saw herself and me as bad—“evil”—in these states and showed no capacity to summon alternative views of either of us as good. When she identified with the experience of herself as good, however, she found me caring, supportive, and helpful, and had no memory of having felt otherwise. She was unable to connect these radically different experiences of herself, others, and the world. We came to speak of the fluctuations as her “inner weather,” shaping ongoing experiences of herself, others, and world.

Marta had not developed the capacity to process or formulate internal states of herself as a subject, reflect on her behavior, or consider different ways of seeing, understanding, and acting as she related the course of her days. It was as if she were devoid of subjectivity, not having established a core sense of self, unable to experience herself as an agent. She seldom used personal pronouns or active verbs in her speech. For example, rather than saying, “I’m having a hard day and I feel bad,” she would say “it bad today... hate it... everything bad.” There was no distinction, seemingly, between perception and interpretation of events in such non-reflective states; it was the realm of things as they were—good or bad—and it seemed crucial that only one emotional plane exist at a time. In the absence of a reflective self, she lived in a surround shaped by actions rather than thoughts, words, or reflection (see Ogden, 1986; Wallin, 2007, p. 239).

From the perspective of Winnicott’s developmental psychology, I came to understand that Marta experienced me as a “subjective object” over the first phase of our work, unable to engage me as a distinct, independent person beyond the bounds of her inner life, relating to me largely through the dynamics of projection and omnipotence, speaking and acting as if she were in possession and control of me and the world. “You’re not human,” she continued to tell me. “You’re my toy... You speak when I want you to speak... you move when I want you to move... humans have feelings... I don’t have feelings.”

What matters most at this point in the therapeutic process, Winnicott emphasizes, is not what we say but what we do. The concrete help that I

Clinical Pragmatism and Therapeutic Action 177 provided in my role as case manager continued to strengthen the therapeutic alliance and the constancy of care in the holding environment. Crucially, I did not challenge her renderings of me as an object, “a toy,” an elaboration of inner world. I felt I must accept her as she was, without imposing any need to change herself. Following Winnicott’s formulations of therapeutic action, I remained steadfast and joined her, co-creating ways of being together that carried the potential to reinstate the maturational process. Our task was to fashion a facilitating environment and co-create conditions that would allow her to go about the business of being herself, providing “environmental adaptations” that she had presumably lacked in the course of her development (see Winnicott, 1960/1965).

In doing so, however, it was critical that I preserve the deeper structure of the therapeutic frame that made our ways of working possible, attending to boundaries and the concrete details of care. I set limits as she repeatedly tested me in her expressions of anger and threats of suicide, telling her what I would and would not do in a given situation. I understood her behavior as enactments— forms of communication reflecting the depth of her despair and the hope that I could help her, allowing me to act decisively without threat of abandonment or punishment. As Winnicott emphasizes, “You accept hate and meet it with strength rather than revenge” (1963/1965, p. 229; see also 1947/1965). My willingness to struggle with Marta was essential. At this point in development, as David Wallin observes, the subjective realm is largely a world of physical action: if we can speak of a therapeutic dialogue, it is a dialogue of action (2007, pp. 239-240). Lacking the capacities for mentalization or reflection, Marta could tell the story of her experience only through enactments, not having fully established the capacity for symbolization and use of words.

As we moved into the fifth year of our work Marta was increasingly able to process her experience of splitting and contradictory states of mind, coming to realize the ways in which her fluctuating perceptions of others as good or bad perpetuated vicious circles of feeling, thought, and action. There were times, for example, when she experienced me as caring and helpful, grateful for my support and understanding, and there were times when she saw me as cold, uncaring, incompetent—“useless.”

The repeated experience of strain, rupture, and repair over the course of our interaction provided crucial occasions for experiential learning as we explored the dynamics of underlying emotions, thoughts, and behavior. I drew on basic methods of dialectical behavior therapy as we continued to explore the realms of sensation and emotion, focusing on the development of skills that would strengthen her capacities to attend to experience, tolerate distress, and regulate emotion. More and more she came to embody, name, and share—rather than enact—what she was feeling, deepening her sense of agency, mastery, and self-esteem. In time, she would come to regard feelings as ways of knowing herself more deeply, more fully accepting herself as “human.”

Marta discovered transitional phenomena and the experience of play in the holding environment of the therapeutic surround as we entered the eighth year of our work. One day she walked over to the book case and picked up a pot. “Look at this!’’ she exclaimed. “I made it! It’s mine.” She took the pot home, brought it back on her next visit, placed it on the book case, returned to it at the end of the session, and took it home again. She would repeat the ritual over the next year.

We had entered the realm of transitional phenomena that Winnicott describes in his developmental psychology' (1971, 1988). In this “third region,” bridging inner experience and outer realities, ongoing experiences of merger and separation establish the sense that what is needed can be created or found, fostering the emergence of capacities for “object use.” The experience deepens the subject’s sense of aliveness, as Michael Eigen observes, “opening the way for a new kind of freedom because one is coming to experience the other as real” (1981/1993, p. 112).

Marta continued to move out of the encapsulated world of omnipotent fantasy as we carried out our work, consolidating a core sense of self, increasingly able to relate to me as the “objective object” of Winnicott’s developmental narrative. She came to experience me as real, distinct and separate from herself, as an individual with an independent center of feeling, thinking, initiative, and action, able to relate to me in our experience of similarity' and difference. Her illusions of magical creation and control receded as she consolidated capacities to make use of my' provisions—“reality' presenting,” in Winnicott’s phrase—and engage in a back and forth with actual experience in the outer world. She was developing capacities for “I-ness” and object use— “other than me experience,” as Winnicott thinks of it, deepening her sense of aliveness and strengthening her ability' to engage in dialogue, negotiate the dynamics of relational life, and live in the world of others.

Discussion

The accounts of Jonathan and Marta, representative of many' patients followed in community mental health clinics, deepen our appreciation of essential concerns in our conceptions of therapeutic action, help, and care. In this section I consider the course of our work in light of the orienting perspectives, values, and themes of clinical pragmatism introduced in Chapterl.

Individuality, Subjectivity, and the Human Particularity of the Therapeutic Process

In following the basic principles and values of clinical pragmatism, as I have emphasized, we focus on the subjectivity' of the individual and the unique circumstances of the clinical situation that defy classification, taking account of the complexities and contingencies that shape the course of the therapeutic process. We challenge a technical rationalism and reductive approaches to help and care based on rigid adherence to particular theories, empirical findings, methods, or procedures, rejecting views of practitioners as instrumental

Clinical Pragmatism and Therapeutic Action 179 problem-solvers, realizing the limits of nomothetic models of treatment. As I show in the accounts of Jonathan and Marta, we co-create “experiments in adapting to need” in light of emerging concerns, goals, capacities, and skills, exploring the ways we make use of different elements over the course of the therapeutic process, embracing idiographic formulations of help and care as we discover what proves usefill.

Relationship, Collaboration, and Interactive Experience

We recognize the crucial role of the therapeutic alliance, collaboration, and the functions of interactive experience in change and growth, realizing the critical importance of the bond between the clinician and the patient and their shared understanding of the goals and core activities of help and care. We carry out open-ended dialogue and emphasize the co-creation of narrative and meaning as we proceed, accepting the limits of our understanding, remaining open to the occasions of experiential learning that deepen insight and inform different ways of working.

As we have seen, the dynamics of interactive experience carry the potential to foster change in a variety of ways. In the domain of interpersonal neurobiology, we assume that the core conditions of the therapeutic relationship activate biological mechanisms that enhance neuroplasticity. The experience of synchrony and attunement and the constancy of care in the holding environment, mediated by right-brain modes of communication, strengthen internal functions instrumental in regulation of emotion and subjective states. New and different ways of relating are believed to reorganize networks of association across neural structures, including motives, emotions, and cognitions linked with representations of self and others, defensive processes, and behavior. Ongoing interaction facilitates efforts to process enactments and transference and countertransference states, deepen capacities for reflection, and develop more functional patterns of behavior through the dynamics of internalization, modeling, and experiential learning. The working alliance serves as a catalyst, helping the patient more fully engage the core activities of the therapeutic process and make use of enriching relationships, activities, and places in everyday life.

We revise understanding and action in light of evolving outcomes. Jonathan was able to reflect on his experience of the therapeutic process from the start of our work, sharing what he found helpfi.il or limiting at particular points, and his ongoing accounts shaped the course of therapy as he explored concerns and expanded the range of his capacities and skills. Marta, in contrast, was limited in her ability to engage in dialogue or reflect on her experience of the therapeutic process as we began our work. If we could speak of a therapeutic dialogue, as I explain, it was a dialogue of action; she spoke through enactments of behavior. In time, as she consolidated a core sense of self, she developed the capacity to make use of words in the give and take of relational life, reflecting on her experience of the therapy, describing approaches and methods she found particularly helpful as she negotiated ongoing vulnerabilities and the challenges of everyday life.

Pluralist Orientation, Encompassing Scientific and Humanistic Domains of Understanding

In accord with the pluralist orientation of clinical pragmatism, we recognize the value of scientific and humanistic realms of understanding, considering a range of orienting perspectives, theories, empirical research, therapeutic languages, and models of intervention as we formulate our understanding of the case and consider potential courses of help and care.

In the domain of science, I drew on conceptual syntheses and empirical findings in the fields of interpersonal neurobiology, developmental psychopathology, and trauma as I carried out my work with Jonathan and Marta, taking account of biological factors as I formulated my understanding of vulnerability, problems in functioning, and therapeutic action. I reviewed research documenting the range of neurodevelopmental vulnerabilities associated with borderline personality disorder and post-traumatic stress disorder, realizing the potential benefits of pharmacological approaches, psychotherapy, and the experiential opportunities of everyday life believed to foster neural integration and strengthen capacities to regulate emotion, thought, and behavior.

I reviewed evidence-based protocols for treatment of post-traumatic stress disorder, panic disorder, and post-concussion syndrome in my work with Jonathan, selectively integrating concepts and methods from nomothetic models of intervention over the course of our work. I followed research on the etiology and treatment of borderline personality' disorder over the course of my work with Marta, integrating methods from third-wave cognitive-behavioral models. Although scientific reasoning guided my ways of working in both cases, I avoided reductive or rigid applications of treatment guidelines or protocols, willing to forsake technical rigor in my efforts to help, trying to figure out what elements seemed sensible, valid, and useful.

In the realm of humanistic understanding, as discussed in earlier chapters, we focus on the individuality' of the person and subjective experience; notions of personal agency, intention and will; exercise of freedom and choice; the cocreation of narrative and meaning, and inherent capacities for change, growth, and realization of potential. We think of the humanities as a foundation of practice, recognizing the ways in which the liberal arts enrich our faculties of reflection, imagination, emotion, and empathy. Stories help us appreciate the workings of fate, circumstance, and fortune that shape the course of our lives, as Jonathan found when he joined the group of veterans to discuss Handel’s Hercules and the experience of war.

As we have seen, the foundational schools of psychotherapy differ in the philosophical perspectives, root metaphors, values, and methods that shape conceptions of therapeutic action, enlarging ways of attending, understanding, and acting. We must inevitably negotiate fundamental tensions between more pure conceptions of the therapeutic endeavor and more pragmatic renderings of help and care as we proceed with our practice.

From the perspective of clinical pragmatism, as 1 have shown in my accounts of both cases, we consider the perspectives of our purist thinkers selectively in light of changing needs, capacities, and circumstances, combining ideas and methods from divergent approaches that would be considered incompatible in more pure renderings of the therapeutic endeavor within the foundational schools of thought. I drew on ideas and methods from psychodynamic, behavioral, cognitive, and humanistic approaches over the course of my work with Jonathan and Marta, thinking of the therapeutic process as open-ended and provisional, guided by experiential learning and practical outcomes rather than by fixed commitments to particular theoretical perspectives, empirical findings, or technical strategies per se.

Therapeutic Action, Experiential Learning, and Practical Outcomes

We change over the course of psychotherapy, making use of different elements as we negotiate problems in living, deepen understanding, and strengthen capacities and skills. In working from a pragmatic perspective, as noted, we vary ways of working in light of emerging concerns, evolving circumstances, and the ongoing outcomes of experiential learning rather than applying a standardized model of intervention based on a diagnosis made at the start of treatment. In following the principles of clinical pragmatism, we emphasize process and context in our formulations of therapeutic action, change, and growth.

As I show in my accounts of Jonathan and Marta, different approaches proved more or less helpful at different points in the therapeutic process. At the start of our work Jonathan found himself compromised by a range of symptoms, limiting his ability to engage experiential opportunities that carried the potential to bring about change and growth. As we established the therapeutic alliance and the constancy of care in the holding environment, however, he was increasingly able to make use of cognitive and behavioral methods as he managed his experience of anxiety and panic; in time, he was able to engage a wider range of relationships, activities, and places that he had avoided out of fear. As he continued to restore a cohesive sense of self, he shifted the focus of our work from management of symptoms to his experience of trauma and loss, finding the words to form accounts of what had happened in Iraq, revising and expanding the narratives of his life story as he explored existential concerns. Psychodynamic, cognitive, and humanistic approaches served as orienting perspectives in the later phases of our work.

Winnicott’s formulations of trauma, developmental arrest, and the matura-tional process offered a coherent way of understanding the course of Marta’s experience as we began our consultations, providing a flexible, pragmatic framework for different ways of working over the course of the therapeutic process. I followed her lead, joining the instrumental activities of case management, the skills-based approaches of dialectical behavior therapy, and the relational perspectives that Winnicott had described in his case studies. Her capacity to make use of various approaches shaped the course of our work, in accord with his developmental perspective, guided by changing needs, experiential learning, and concrete outcomes.

Concluding Comments

If we are to avoid the dogmatic embrace of a purist paradigm, a willy-nilly eclecticism, or reductive versions of evidence-based practice, I have argued, we must formulate basic principles and values that guide our ways of working in the concrete particularity of the clinical situation.

As we have seen, the orienting perspectives of clinical pragmatism center on essential concerns widely believed to shape the course and outcomes of psychotherapy: our focus on the patient as an individual, subjective domains of experience, and notions of personal agency, freedom, and choice; the core conditions of the therapeutic relationship, collaboration, and the dynamics of interactive experience; open-ended dialogue and the co-creation of meaning and narratives that deepen understanding of self, life experience, and anticipated future; pluralist approaches to understanding, guided by scientific reasoning and humanistic values, that offer plausible ways of formulating what is the matter and what carries the potential to help; varied opportunities for experiential learning, fostering a sense of mastery and the development of capacities and skills, and ongoing assessment of progress and outcomes over the course of the therapeutic process.

The fundamental ethical value of clinical pragmatism lies in the practical outcomes of help and care, as Brendel (2006), Goldberg (2002), and Strenger (1997) emphasize in their accounts. We consider a range of paradigms and perspectives as we work to understand the patient, problems in living, and what carries the potential to help, taking account of differences in personality and temperament, the nature of subjective experience, capacities and skills, experiential learning and the irreducible features of the therapeutic process that defy classification.

Although advances in clinical neuroscience and psychopharmacology at the end of the 20th century had moved some scholars to predict that biomedical models of explanation and treatment would supplant the practice of psychotherapy, as noted in earlier discussions, ongoing research on neuroplasticity reaffirms the crucial role of established psychological and social practices in our efforts to bring about change, growth, and healing. The brain is far more plastic than modern neuroscientists had once assumed, and we increasingly appreciate the critical role of relational life and experiential learning in change and growth. Diverse forms of activity and learning carry the potential to change the brain and mind across the course of life.

We have explored the ways in which recent developments in interpersonal neurobiology deepen our appreciation of subjectivity, relationship, narrative, life experience, and different forms of therapeutic action in accord with the principles of clinical pragmatism. If we consider the neural substrates of the

“talking cure,” I observed in the Introduction, a fundamental task of psychotherapy is to generate experiential opportunities that strengthen the integration and regulation of neural structures and functions thought to underlie our sense of self, well-being, and adaptive functioning. In accord with continued research in the fields of neurogenetics, molecular biology', and brain imaging, the experiential changes we see over the course of psychotherapy would appear to be closely linked with changes in the structure and function of the brain.

Drawing on conceptual syntheses and empirical findings in interpersonal neurobiology, psychotherapy research, and clinical observation, we explored overlapping domains of experience that would appear to be fundamental in enhancing neuroplasticity, validating concepts of therapeutic action across the schools of thought. We focused on: 1) the core conditions of the therapeutic relationship, the dynamics of interactive experience, and the constancy of care in the holding environment; 2) the experience of emotion, challenge, and optimal stress; 3) the recurring engagement of sensation, emotion, imagery, cognition, and behavior in the interactive experience of the “working through” process, believed to facilitate the reorganization and growth of under-developed or under-regulated neural networks in accord with the dynamics of longterm potentiation; 4) the co-creation of narratives, synthesizing our experience of sensation, emotion, imagery', thought, and memory', strengthening coherence and unity in sense of.self and identity'; and 5) engagement of relationships, activities, practices, and places in everyday life.

Our reviews of the paradigms of psychotherapy' deepen our appreciation of core processes believed to operate across all forms of treatment, as well as specific methods of intervention developed within particular schools of thought; as discussed, some researchers propose that different approaches engage different neuroanatomical structures instrumental in our experience of sensation, emotion, imagery', thought, and action. Converging lines of study' in the science of mind emphasize the need to consider multiple theories, therapeutic languages, and technical procedures as we carry’ out “experiments in adapting to need,” creating diverse forms of experiential learning in flexible, integrative ways of working.

While recent developments in the fields of neuroscience reaffirm the fundamental importance of theoretical pluralism and comparative approaches in therapeutic practice, as discussed, clinical training programs in psychiatry', psychology, counseling, and social work continue to marginalize theory', often limiting content to cognitive-behavioral perspectives. Many' educators embrace reductive models of evidence-based treatment, emphasizing empirical research, technical procedures, and mastery' of skills rather than comparative study' of clinical theories that provide foundations for critical thinking, experiments in adapting to need, and individual approaches to practice.

The principles and values of clinical pragmatism challenge educators to expand the scope of clinical training. As we have seen, the foundational schools of thought set forth compelling accounts of the human situation, focusing our attention on overlapping realms of experience from different points of view, offering a variety of metaphors, languages, narratives, models, and methods that influence what we observe, say, and do in the clinical situation. Without a grounding in the foundational theories of the field, I have argued, we run the risk of reductive, mechanized approaches to treatment by protocol, unable to negotiate the complexities of the clinical situation, failing to understand the elements we are trying to integrate. As discussed, we may underestimate the potential benefits of different ways of working over the course of the therapeutic process, just as we may fail to appreciate the power of more focused, circumscribed approaches.

In accord with Dewey’s emphasis on the critical role of collaboration in learning, understanding, and growth, I have emphasized the importance of ongoing dialogue across the fields of neuroscience, psychology', and the humanities. As we explore different ways of attending, understanding, and acting, we discover shared concerns and purposes, deepening our appreciation of the varieties of therapeutic experience. As James reminds us, the world is full of “partial purposes” and “partial stories”—“one” in some respects, “many” in others (1911, p. 134). As we carry out our work, he shows us, we can never make the big claim from a fixed point of reference. The fundamental question is not “Is it true?” but rather, how would our lives be better if we were to believe it?

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