Despite my mostly psychodynamic approach to psychotherapy, I sometimes include cognitive interventions as well. I think of this as choosing from a variety of tools to suit the moment. Generally speaking, cognitive techniques (and psychiatric medications) aim for symptom relief, while psychodynamic work aims for structural personality change, with symptom improvement as a byproduct. There’s a time and place for each, their relative value varying from patient to patient. The following is a cognitive framework I’ve introduced to a number of patients over the years. Let me know if it’s useful to you.
Essentially it’s a simple one to ten scale that highlights polarized thinking — “splitting” in dynamic lingo — and encourages modifying it through conscious effort.
Many patients who evidence polarized, black-and-white thinking — who devalue the bad and idealize the good — quickly catch on when I propose that their abject hopelessness and seething rage represent a “one” on a one to ten scale, whereas their over-the-top exuberance rates a “ten.” (Some take it further and claim their despair sinks to “negative 100” and positivity zooms up to “50” on that scale, but usually they’ll agree to keep it manageable.) The key intervention is then to point out that life is mostly lived between three and seven. Realistically speaking, bad experiences in life usually rate a “three” or “four,” good experiences a “six” or “seven.” Anything more extreme is rare. Feelings of “one” and “ten” are almost always exaggerations, polarized distortions that whipsaw the patient’s feelings and interpersonal relationships.
The concreteness of speaking in numbers comes easily to most of us. Once introduced to this scale, some patients spontaneously and enthusiastically rate their own feelings: a troubling encounter “felt like a ‘one’ but I know it was really a ‘three’.” More often they relate an experience in unrealistically glowing terms, and I gently challenge their idealization by asking if it was truly a “ten” or more accurately a solid “seven” (and likewise with a “one” that upon reflection could be re-rated a “three.”) Some patients formerly prone to one-or-ten thinking soon begin sessions by telling me their day feels like a satisfying “six” or a disappointing “four”. Either way, I support this more nuanced assessment and discuss how they may nudge themselves up the scale.
Many patients, particularly those who take a degree of pleasure in the ups and downs of their emotional roller coaster, would never abide a monotonous life stuck at “five.” Where’s the fun in that? Fortunately, the point of the scale is not to aim for stagnation, nor to suggest that the midpoint is ideal. The realities of life assure that some days will be better than others. No cognitive trick will stop successes from feeling good and letdowns from feeling bad. The question is how much. Attaching numbers to feelings offers a little distance and perspective. It’s a gentle reminder that such emotional exaggeration may be a form of self-torture — and that an apparent “ten” is risky (and literally “too good to be true”), often crashing precipitously into a “one.” Most of the time it’s far more comfortable, safe, and sustainable to “live between three and seven.”
Of course, it wouldn’t be psychodynamic therapy if we stopped there. The numerical scale offers a useful language to describe unrealistic emotional extremes, and perhaps to help the patient mitigate them through conscious effort. However, it can’t account for the splitting itself, nor change the patient’s propensity in any structural way. For that, we turn to unconscious dynamics, and to a trustworthy, consistent therapeutic relationship that permits emotional nuance to gain a foothold. Rather than being seen as mutually exclusive — itself an unhealthy polarization — cognitive and psychodynamic approaches can complement one another.
Graphic courtesy of Danilo Rizzuti at FreeDigitalPhotos.net