The Clinical Benefits of Required Continuing Education By Roberta Satow, PhD on 12/12/19 - 2:32 PM

Like most professionals, I am required to earn continuing education credits in order to maintain my license as a psychoanalyst. I usually experience this requirement as a pain in the neck. I have to find lectures or conferences that invariably interfere with my weekends. But each time I go to a lecture or conference kicking and screaming (metaphorically), I always leave feeling that this is a really good requirement and that I've learned something valuable that is useful to my psychoanalytic work. Most recently, I have been watching videos or reading lectures on because I can earn CCE credits at my leisure--without having to give up an entire weekend.

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A few weeks ago, I read an interview with Allan Schore about the neuroscientific underpinnings of psychotherapy. He pointed out the traditional way the different functions of the left and right hemispheres of the brain have been explained: the left hemisphere is engaged in objective thought, reading, thinking and language; while the right hemisphere is the center of subjectivity--e.g. empathy, intuition and emotional processing. Shore says that the core self-system is in the right hemisphere and hence the change that goes on in therapy is in the right hemisphere. Change and/or repair occur in treatment at the most cathartic moments--e.g. when we become aware of our body-based emotions more than our thoughts, when we have an "aha" moment,when a shared metaphor is imbued with emotion or when patient and therapist share an insight through humor. All of those, Shore says, are right hemisphere functions.

That was all very interesting, but the part of his discussion that really stuck with me was about the relationship between affect dysregulation and psychopathology. Schore said that affect dysregulation is the result of insecure attachment, and the two major ways that people try to regulate themselves when they suffer from it is by over-regulating (i.e. avoidance strategy) or under-regulating (anxiety strategy) their effect.

Soon after I read the Schore interview, I was in a phone session with a patient, Jonathan, who had his secretary call me and cancel four sessions in a row. I felt angry that he did not communicate with me himself because we had discussed having his secretary communicate with me at other times. I also felt frustrated that he had cancelled so many sessions when, in the sessions before that, he had been feeling unusually connected to me. I wondered if that had frightened him and perhaps caused him to create distance. I was thinking about his fear of intimacy.

When I asked Jonathan what he thought it meant that he had cancelled so many sessions and had his secretary communicate it to me, he said he was frightened of having to give an important talk at a conference and did not want to speak to me because he felt so fragile. I immediately realized that this was not about intimacy, but about attachment. Attachment issues are more primitive than intimacy issues.

             I said, "It sounds like you felt that talking to me would make you feel upset."

             He agreed. "I didn't want to talk to anyone. I am feeling calm about the talk at this moment and didn't want to take a chance."

             "So, it sounds like when you are frightened, you don't expect that connecting with me will make you feel better."

             "No, it's funny. I know that in reality I feel better after I talk to you," Jonathan said, "but I always expect it to make me feel worse. I've been in a state of terror about the talk and I just want to be alone."

             "What do you make of that?" I asked.

             "I never felt that I could go to my parents when I was worried or afraid," Jonathan said tearfully.

           "You feel like you're drowning," I said, "and no one can help you, you just keep flailing to try to get a breath."

           "Yes, exactly," he cried.

Because I had just read the Schore interview, I immediately understood he was describing a disorganised-disoriented state of insecure attachment. The issue wasn't that he was withdrawing because of being afraid of intimacy with me. Rather, Jonathan could not generate an active coping strategy to confront subjectively perceived overwhelming, dysregulating events, and thus he quickly accessed the passive survival strategy of disengagement and dissociation.

Jonathan was incapable of maintaining intimacy because of his insecure attachment. He could not think about talking to me when he was struggling with what he perceived as an overwhelming event. This happens with women he gets involved with as well. He cannot maintain the connection to them when work or life events overwhelm him. The affect dysregulation that results from insecure attachment leaves no room for providing comfort or give-and-take or commitment. Since an intimate relationship is mutual, affect dysregulation limits or precludes intimacy.

Clearly, being introduced to Schore's ideas sensitized me to what was happening with Jonathan--I was able to empathize with the terror he felt as a result of his affect dysregulation. Using the metaphor of drowning was reparative and strengthened our alliance because it helped Jonathan feel that I understood his body-based raw emotion.

I have decided to stop complaining about mandatory CE credits. 

File under: Musings and Reflections, Therapy Training