Posts Tagged ‘outcome’

I’ve been blogging away for about six months now, and have decided that it’s high time I named a principle after myself as my enduring contribution to psychotherapy. I’m not entirely sure how I arrived at what I arrived at (which, as you’ll see, is a rather neat case in point) but it was fun getting there.

I was thinking about the seemingly diametrically opposed focuses of process and outcome in psychotherapy. I think of therapies like CBT as being essentially outcome focused, the logic being ‘so you suffer from panic attacks? Right then, we’ll find a way of stopping those damn panic attacks!’. A process focused therapist might well scoff at this attitude. I think of therapies like humanistic person-centred as being essentially process focused, the logic here being ‘so you suffer from panic attacks? *therapist looks warmly at client whilst embodying the core conditions*’.

The two approaches are, of course, focusing on two completely different things. The CB Therapist (btw, please can everyone stop saying CBT Therapist? What you’re saying is Cognitive Behavioural Therapy Therapist; my brain automatically expands the acronym and it causes me physical pain! Thank you) wants to solve the problem (outcome), the HPC therapist wants to explore the problem (process).

In HPC, the idea is that the panic attacks are something the person needs to experience in some way. Roughly speaking, the person, driven by their actualising principle to develop and grow, encounters some deep-rooted obstacle to that growth, resulting in panic attacks. By supporting exploration of the problem, the HPC therapist is supporting the person’s growth with the belief that the actualising principle will eventually win out, with the person spontaneously discovering their panic attacks to be meaningful expressions of their humanity. This may or may not result in release from panic attacks, but will certainly lead to an expanded consciousness.

By contrast, in CBT, the idea is that panic attacks are an undesired consequence of the person’s thinking and behaviour. This person wants and needs to change their thought and behaviour patterns in order to gain release from the suffering of panic attacks. The goal is to stop the panic attacks, and this is achieved by identifying the problematic thought and behaviour patterns and changing them to non-problematic thought and behaviour patterns. Successful CBT ends the panic attacks, unsuccessful CBT doesn’t end the panic attacks; expanded consciousness is beside the point.

If you’re HPC or CBT trained and are currently frothing at the mouth at how badly I’ve misrepresented your field, please do correct me; I reserve the right to disagree with your interpretation of your own area of practice for entertainment purposes.

Gestaltists will most readily ally themselves with the process focus but to be honest I think gestalt actually moves between the two, with the majority of the time spent with a process focus. The fact that I engage in creative experimentation in my practice places at least some of what I do in the CB camp. Experiments, by their nature, are a behaviourist approach to therapy. And sometimes, they have an outcome focus.

If I was working with panic attacks, for example, an experiment might be to re-create a low-level panic attack situation in the therapy room (like reading a passage from a book to an imagined audience). The point of this in gestalt is to gain direct access to the feelings involved in a safe environment instead of being two steps removed from the issue by talking about what happened last week (and of course, I wouldn’t do this with someone if I felt they weren’t going to be able to re-stabilise afterwards). This can be process focused; the experiment brings powerful feelings into awareness and we see where those feelings take us. Or this can be outcome focused; the experiment serves as a training ground for building tolerance for the panic-attack situation (it becomes exposure therapy really).

‘Yes yes, but what about this principle you’ve invented?’, thanks for the reminder…

Heisenberg’s uncertainty principle postulates that:

“The more precisely the POSITION is determined, the less precisely the MOMENTUM is known”

Roughly speaking, determining the position of a particle in space is difficult because all things are in motion relative to each other. So the momentum of a particle is a function of its spatial relationship to other particles (note here the similarity to gestalt’s field theory where behaviour is a function of a person’s environmental/situational relationships).

Consider the earth orbiting the sun. We know the speed with which the Earth orbits the sun because we take the sun to be a fixed point. But of course, the sun is also hurtling through space; it is only a fixed point relative to the planets that orbit it. The moon orbits the earth at the same time as the earth orbits the sun, so how fast is the moon travelling and in which direction? It’s ok, my mind just melted too.

My argument is that the same uncertainty applies to process and outcome in psychotherapy, hence The Staff-Tow Uncertainty Principle:

“The more precisely the OUTCOME is determined, the less precisely the PROCESS is known”

As a guy I once knew used to say, ‘you can have yan or t’other but ye anae avin’ baeth’.

This doesn’t mean that one factor is better than the other, only that you can’t have a full and vibrant awareness of both at the same time. And that’s because the sheer scope of possible outcomes for any given process is huge. In order to arrive with any kind of probability at a pre-determined outcome, the process has to be geared towards that outcome, meaning that the possibility of all other outcomes is closed off as much as possible.

On the other hand, focusing on process, on what is happening right now, opens up progressively more outcomes that themselves become part of the process until there is only process and no outcomes at all. Again, this is relative; in order to define something as an outcome, we have to create a fixed state, and the illusion of an outcome as a final state of affairs.

Strictly speaking, stopping panic attacks only counts as an outcome if we arrive at a point where the person never has a panic attack again. Hence, the outcome is relative to the process of a person’s entire lifetime. And there is one very good reason why, as unpleasant as a panic attack is, the removal of panic attacks is an undesirable outcome; survival. I would quite like to have a panic attack in a life threatening situation if that panic attack mobilised me into running away and surviving.

We can become more precise about our outcome: no more panic attacks in such and such a situation. In which case, we become less precise about the process of being human of which those panic attacks are an expression. We can also become more precise about the process: panicking is a fear reaction to certain environmental factors that were real once but are now largely internalised and projected onto similar situations in the present and actually have as many pros to the individual as cons. In which case, we become less precise about the outcome we’re aiming at.

In gestalt theory, this would be an example of need configuring the field. A desired outcome is our need, so we arrange our perception of our current situation around that need; hence, we are most aware of aspects of our situation that will bring us closer to our desired outcome, and lose awareness of other aspects of our situation. This is a good thing, by the way, because if we were fully aware, moment to moment, of every aspect of our immediate situation, we would quickly lose ourselves in an overhwelmed state in which we would be unable to selectively block out environmental stimuli.

Just like position and momentum, outcome and process are two ends of the same continuum. I think of this as having an outcome/process dial. A CB therapist most likely has that dial way in the outcome direction, whilst the HPC therapist will be way in the process direction. My personal preference as a gestalt therapist is to change my dial’s position depending on the therapeutic situation. Generally speaking, I enjoy being more on the process side than the outcome side. But just try having a traumatic flashback in my therapy room and see how quickly I turn that dial to outcome!

Outcome and process are two ways of focusing the same experiential lens; awareness. Awareness is often likened metaphorically to light (which is apt bearing in mind that light can be considered a particle or a wave depending on the situation). If we use the outcome/process dial to change the focus of the light of awareness, then maximum outcome is going to be highly focused like a laser beam and maximum process something more diffuse like twilight.

Try out this metaphor for yourself. Imagine a dial that goes from (maximum process) 0 to 100 (maximum outcome) with an exact halfway point at 50. What is your dial turned to right now? Where do you habitually keep your dial? What range of settings feels possible/impossible for you? Where’s your comfort zone?

For me, the ideal isn’t to find the right setting on the dial. The ideal is to be able to change the setting from situation to situation by choice; and that is organismic self-regulation.


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