Michael Hoyt on Brief and Narrative Therapy

Michael Hoyt on Brief and Narrative Therapy

by Victor Yalom

Hoyt discusses brief and narrative therapy, working within managed care, and why some stories are better than others.
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The Interview

Victor Yalom: I'm really pleased you agreed to join me today for this conversation. I'm going to try to pick your brain in the short time we have, to really find out about you as a therapist and as an innovative thinker in this field.
Michael Hoyt: I appreciate the opportunity to meet with you. I wanted to start by asking you a question, if I could: What was your particular interest in inviting me to participate in this exciting series?
VY: My vision for this interview series for psychotherapist.net is to present therapists that are doing really innovative yet practical work, despite the pressures that we are all facing on various fronts. I'm most interested in those who are finding a way to be excited about what they're doing. I've had a sense from your work that you fit in that camp.
MH: Thank you. I'm delighted to be included. I'm very excited to participate.
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Narrative Constructivism: Is it All in the Mind?

VY: So, you've written a new book.
MH: Yes, it's called Some Stories Are Better Than Others. It was just published two weeks ago by Brunner-Mazel Publishers.
VY: How did you come up with that name? Obviously, it has a lot of meaning for you.
MH: It does have a lot of meaning. I've become, in the last several years, more and more interested in what is sometimes called narrative constructivism, how people put their story together. Rather than having the idea that we discover our reality, or that it's an objective thing that we find, we are oftentimes creating it. How we look at things affects what we'll see; and what we see affects what we'll do. I think that as people live their lives, they may generally be doing fine, but when they get stuck it's often because they're telling themselves a story or constructing a world view or a narrative that isn't satisfying to them—it isn't self-fulfilling in a good way, but instead it's frustrating. And people will come to therapy looking, in essence, for a new story, a new way of understanding, a new perception—which can lead to new behaviors and new outcomes. So some stories are better than others—because some stories give people more of what they want in life, where other stories will be more self-limiting. My recent influences include the work of Don Meichenbaum, Michael White, and Steve de Shazer, and other constructivist thinkers going back centuries.

... Continue Reading Interview >>
VY: Just this morning, I was reading a book by Zerka Moreno about her late husband Jacob Moreno. That's what he said about psychodrama—that it's used as a way for people to construct their life. Existentialists thought the same thing: we're here, we have to create our meaning, we create our lives with the resources we have. In that way, you're following yet another tradition.
MH: It's a long tradition. As I begin to say a few names of the people who've influenced me recently, I begin to think of all the people I haven't mentioned, including Irvin Yalom, George Kelly, and a whole host of people. I think it's important to realize, though, that this idea of narrative or story is not the entirety of people's experience.
Some people have misunderstood constructivism as meaning "it's just in your mind" or "that's your opinion." Yet, it's very important to recognize the realities that people are living in.
Some people have misunderstood constructivism as meaning "it's just in your mind" or "that's your opinion." Yet, it's very important to recognize the realities that people are living in. To use the title of one of Michael White's books,Narrative Means to Therapeutic Ends: the narrative is a means, it's a vehicle
VY: There is a quotation in your book; something to the effect that social constructivism does not mean that external reality is irrelevant.
MH: Yes. As obvious as that is to say, there's been a lot of misunderstanding, I think, and it's become a kind of tiresome argument. We're not saying that there's nothing outside. We're saying the knower has to know the reality, and that knowing involves construal, construction, mean-making, and so on. It gets filtered, mediated through our consciousness, and that we can affect consciousness The situation that people are in can be very significant.
Existence determines consciousness as well as consciousness determines existence.
Existence determines consciousness as well as consciousness determines existence. Salvador Minuchin has spoken a lot about this. Take the example of people in terrible situations of oppression and poverty—a radical constructivist might say it's all in the way they're looking at it—but that would be an absurd position to take, not really appreciating the horribleness of their situation. So obviously we have to take into account social and economic issues, not just internal, intrapsychic processes.
VY: What you are saying, and relating it to the current reality of the therapy world, and what's driving the idea of this website, is exactly this. Many therapists feel very oppressed, very disillusioned by the phrase, "realities of practicing therapy today"—managed care, a glut of therapists in many urban areas, lower fees. And the story that some therapists tell about themselves is that "we're in the wrong profession at the wrong time, and there's not much opportunity."
MH: I've seen and experienced some of that personally as well. There's a lot of demoralization. I think at the extreme psychotherapists are somewhat of an endangered species. On the one hand, there's the pressures of managed care: Get it done real quick, keep it on the surface and get it done quickly. Then there's the pressures of biological psychiatry: Use medication and you don't have to talk too much about it. It's a very hard time. It's an interesting coincidence that we're meeting here at the Evolution of Psychotherapy Conference. "Evolution" requires pressures in the environment, and some kind of genetic variability, and then some new things can emerge. You don't want to become extinct; you want new things to emerge.

I wrote a different book, in 1995, called Brief Therapy and Managed Care. At that time, I expressed the view that there are ways of working with managed care. And I still think there are ways of working with some managed care, but more and more I've heard too many horror stories that have impressed me with how much difficulty managed care—especially in the for-profit sector—has been thus far in the world of psychotherapy. Managed care has not yet produced the promise we were hoping for, of being more efficient and distributing services to more people.

It seems managed care has mostly been cost containment, which has meant cutting people off, rather than finding new ways to help people.
It seems managed care has mostly been cost containment, which has meant cutting people off, rather than finding new ways to help people.

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The Archaelogy of Hope

VY: How does your recent book shift your focus?
MH: Well, the reason I called my new book Some Stories Are Better than Others is because I think we're going to need to have a real shift in the field, in many directions, including looking more for clients' strengths and resources, not just focusing on their problems, pathologies, and pain. The "archeology of hope" (to borrow the subtitle of the 1997 bookNarrative Therapy in Practice, edited by Gerald Monk et al.) involves looking for competencies, strengths, overlooked possibilities, latent joy, and other little nuggets that we can pluck and bring forward. So when I say Some Stories Are Better Than Others, I think it's going to be incumbent upon therapists more and more to see the whole person, not just the problems. I think it's going to be much better if we're competency-oriented, more collaborative, somewhat more future-oriented.
VY: I think, going back to Freud, the model is "what's unconscious is usually bad." A seething pit of conflict and aggression. While those things certainly exist, my experience has been that some of the most powerful changing moments in therapy are when people discover positive things about themselves that they didn't know, that may have been repressed, or forgotten, or dismissed. Often therapists are looking for problems, they're looking for pain and conflict, rather than helping the client develop the capacity to sit with positive feelings which is no easy feat either. If a client comes in with something happy or joyful, the therapist may redirect them into the pain, rather than help them sit with it and explore and really experience something positive, at a deeper level--almost running from the joy. Yet, staying with the positive can lead to profound awareness shifts and life change.
MH: As one of my colleagues quipped,
most of the people in this field have been trained as "mental illness professionals,"
most of the people in this field have been trained as "mental illness professionals," not mental health professionals. We spend so much time pursuing illness and pain. Somebody will say, "I had a couple of good days, but then some bad things happened." "Well, tell me about the bad things." If somebody mentions pain, or sorrow, or looks sad or angry, we feel that's where the meat is. We're supposed to go for that. It would be interesting to me, not just to take a history of the present problem, but to take a history of the person recovering. "What in your past, what little clues or keys might help you deal with this better?"
VY: Or simply, "How have you overcome difficult circumstances in the past?"
MH: "How have you dealt with difficult circumstances? How have other people? Role models? Parents? People in your ethnic history? Are there examples you can draw upon? Ancestors you can call upon? Can you project yourself into a time in the future when things will be better? Imagine that time, and how are you going to get to that time? Thinking of times when things are better, a time that inspired you, can that give you some energy, some courage to go toward that?"
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Some Stories Are Better Than Others

VY: Can you think of your work with a client where you helped them get to a better story?
MH: I'm thinking of a woman, I'm thinking of how to respect her privacy and confidence, thinking of how to say this - OK, a woman I've known for some time who developed a terrible case of multiple sclerosis. Over a number of years she became very incapacitated, to the point where she's barely able to speak, incontinent, bed-bound. At one time she had been a fashion model—quite a lovely young woman.
VY: Pretty heartbreaking.
MH: Very heartbreaking, but that's not the whole story. There is a lot of sorrow there, and we cried together over that. But if we see her as only an "MS victim," then she's really stuck. Then she's been terribly delimited. I began visiting her in her home when she couldn't come to the office. She has cats all over her house. So we started talking about the cats—they're sitting in my lap—and I found out that even though she's very limited, she's doing animal rescue. She's a phone counselor and helps place animals. I also discovered that she has a whole world of artistic and aesthetic interests. So we were able, over time, without denying the medical reality, to at least enlarge the picture. That she's not just somebody with MS, but that she's an animal lover/activist, she's an art appreciator.

She sent me a Christmas card last year—her condition has even worsened—in which she said—if I could think of the exact words it would be better—I'm so choked up thinking about it that I'm blocking on it. It will come back to me.

VY: What's the feeling of being choked up?
MH: he feeling is that of being deeply moved. I love heroism, and heroine-ism. People triumphing over adversity. People who somehow, despite the odds, find a way to be happy. I met a kid recently down the street, a little boy who had some serious medical problems and he was in a wheelchair. In one way, you could look at him and see all the physical problems he had. And this little boy was laughing, and he had a balloon, playing. He was, at that moment, in a certain way healthier than I was. I was fussing and worrying about something, and he was experiencing the joy in life. I'm very interested in finding ways to bring out that joy for people.

And sometimes it's very hard. And it's getting harder for therapists. Most of us, I think, went into this crazy business—this wonderful, strange business—for very good reasons. We want to make the world a better place, we care about people. And oftentimes we get suspected: "You're doing this out of some neurotic need," "Aren't you co-dependent?" or "You're on a power trip" or something like that. The term "countertransference" has gotten to the point now where therapists are sometimes concerned about themselves too much. (See references for Hoyt, 2001a, 2001b, 2001c 2002.) I think it's very important for us to keep remembering the positive reasons we're in this field. Otherwise, I think it's a sure burnout.

VY: I think one way of doing that is to really be able to celebrate the triumphs with our clients. Were you able to emotionally share that joy with the woman you just so movingly described?
MH: Yes, and we both experienced it as a natural, genuine human encounter, not as a technique It's very important for us to anchor, reinforce, praise, acknowledge, celebrate—whatever terminology you like—our clients' successes and forward movements. In this case, our relationship has become very important to both of us. She had sent me a note and I wrote back thanking her for the session. I told her that there had been a couple of times that I had been very worried about something, and I thought of her example and it gave me courage.
She inspired me: if she could find a way to live her life meaningfully and have joy in it, given the challenges she has, then that inspires me to do the same in my life.
She inspired me: if she could find a way to live her life meaningfully and have joy in it, given the challenges she has, then that inspires me to do the same in my life. And for me not to tell her that would have felt inauthentic and incomplete.
VY: That's wonderful! I think one way to avoid burnout is to give yourself permission as a therapist to really be human. So much of the training in our profession runs counter to this and teaches us to hold back so much of ourselves.
MH: It's a fine line. Because I don't want her to feel that she has to take care of me, or "I can't tell him I'm having a problem because he'll be disappointed," so I think we have to be judicious.
VY: Yes, we don't want to self-disclose simply because it feels good. You always ask yourself "Is it for the benefit of the client?" In this case it seems like a no-brainer that sharing your joy about her triumphs is a good thing to do.
MH: Yes. I can see ways it would not be if it became her obligation; if she needed to prop me up somehow. But most of the time I think we're much too invisible; if we're a blank screen then we're not real. A colleague of mine, David Nylund, and I have developed an interesting exercise. It's in my new book. We interview therapists, but we interview them as if they were one of their patients. So, you would interview me as though I had been this patient. And you would ask, "What was it like working with Michael Hoyt? What was helpful and what wasn't helpful? What did he do that was really good for you? Did you ever let him know that you appreciated him?" There's a whole series of questions which are useful in evoking the internalized client that we all carry around. We've used this in a lot of workshops, and people often say it's a breath of fresh air, or "it's like getting a different take on myself." Particularly if we make it very real, if we start to ask a lot of specific questions. We all internalize our parents, our clients, our friends—all sorts of people. And I think they're a source of revitalization. You can be reinvigorated if you can find a way to access what inspires you. And this particular young lady really inspires me.

Hey, now I remember what the card said: "Memory is what God gave us that we might have roses in December."

VY: My - how very sweet.
MH: Yeah!
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Goals and The Discovery Process

VY: I want to go back to some of the other things in your work, in the brief /strategic/solution-focused types of therapy. One of the concerns I have involves the emphasis on goal-setting. How the hell can you set a goal with a client in the first session, when it is often the case that clients don't really know what they're there for? Their presenting problem is often so vastly different than what you're working on four sessions later.
MH: I think that most clients do know what they're there for, at least initially. And so I might say, "What's your goal at this time?" or "As we start today, what do you think would be helpful? What would you like this to be like? How will you know this has been useful?" And then, now and then in the course of the therapy—whether it's one-session therapy or 10 sessions or 100 sessions—I'll ask "How's this going for you? Where are you at now? How have we done in terms of the initial things we were talking about? What should be our focus now?"
VY: "How are we working together?"
MH: Yes. And "What's next? Do you feel this has been adequate and sufficient? Do you think there are other things?"
I think there's a danger that we can act as though we know more about the client, or what's best for the client, in ways that actually dis-empower the person.
I think there's a danger that we can act as though we know more about the client, or what's best for the client, in ways that actually dis-empower the person. Jay Haley wrote a great paper many years ago called "The Art of Psychoanalysis." You can keep saying to the patient, "You think that's the problem, but there's a deeper level." Oral interpretations trump. You can always go "deeper." You can say it was pre-Oedipal: "You'll have to have years to absorb me, because we can't even talk about it." And you can kind of undermine the patient's sense that they really have autonomy, and they really know what's best for them. I think sometimes people come in and it's not the goal I would pick; it seems to me too superficial. Or it's just skimming the surface. And I'll ask them, "Does that work for you?" And if they say it really does, I'll say it's fine. I might say—if I think they're taking a solution that's not really in their best interest — "I was thinking some other things that might be of some interest to you. Does that sound like something you might want to look at?" I might try to open some space. If the person says, "Nah, I don't think so" or "Maybe someday," I'll say, "I just want to let you know it would be available. I'm not necessarily saying it's good for you, or even true for you, but it might be something to consider." I don't want to give people the message, "You think you've dealt with this, but you really haven't," where you keep undermining their sense of self-control and autonomy.

Often times I think we've had the idea that we somehow have superior knowledge. And even if in some ways we know a lot, I think by following the client closely, rather than leading the client, in the long run, the person will become more empowered and more of a person.

You become a "person" by making "personal" decisions.
You become a "person" by making "personal" decisions.

VY: I agree with a lot of what you say. We can't know more about our clients, regarding the content of their lives, or in terms of what their actual goals should be. What we bring to the table is that we're process experts. We can see ways that they're holding themselves back, how they're defending themselves. And we have real skills to help deepen their awareness, to deepen their inward searching abilities. From another angle, one limitation of the question, "What are your goals?" is that it's a cognitively framed question, and you're going to get a cognitive response. A few sessions later the goals and the awareness can get larger if they've explored new territory and are starting to think and feel differently about themselves or their body.
MH: Yes. We're using certain metaphors: "superficial vs. deep," "cognitive vs. in your heart." And they can be useful metaphors, sometimes. So my deconstructive mind says, "What do we gain and what do we lose?" I'm familiar with the "deep" concept, and I sometimes think that way. I might, even in a brief therapy, say, "Does that solution fit all the way through? I know it sounds good in the 'top of your head,' but how does it set in your gut?" or "Does it fit all the way in your life?" or "Is there any part of you that doesn't feel right with that yet?" We have all sorts of language—we say "the tapes are playing," there's an "unconscious," and all these different metaphors. They all can be useful. I think it's critical, to try and stay as much as I can in the client's frame, in the client's phenomenology.
I am not an expert at everything by any means. But I am something of an expert at asking questions.
I am not an expert at everything by any means. But I am something of an expert at asking questions. We want to help create a discovery process, and we can ask questions that will open vistas, that will get people to look at things differently, without necessarily directing them. Not "You should do this and this and that."

For example, you might say to a depressed client: "What you call depression, what else might you call it? Some people would call that sadness. Or some people would call that oppression rather than depression. Is something putting you down or holding you back?"

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Managed Care... Or is it 'Mangled Care'?

VY: Let's switch to some practical issues. You've worked at Kaiser, a large HMO that gets a lot of bad rap from psychotherapists, as any HMO or managed care company does. How have you dealt with that? Obviously you care passionately about the field, and it's clear from this conversation that you do deep, meaningful work. And yet I've heard so often that at Kaiser you have to average 5-6 sessions or less per client. Also, you might see them for the first session, and then your schedule is so booked you can't schedule a follow-up session for three weeks. How do you work within such a system?
MH: I'm not here as a Kaiser spokesperson, but let me respond to several things you said. It's true I've worked at Kaiser for 20 years, and I'm certainly aware of people's comments, that it's "get them in and get them out." I think the pressures of managed care are affecting everyone, unless you have private pay patients and their income is such that they don't have to worry about the economics of it and can come as often as they want. There is a major distinction between the for-profit HMOs, who generate most of the complaints, and the not-for-profit HMOs, of which Kaiser is one. No system can be everything for everyone, but it's the for-profits that rake a large profit off the top rather than putting it back into services. Many years ago I coined the phrase "mangled, not managed care" to describe what some companies often wind up providing. According to all the polls—Time andNewsweek and U.S. News and World Report and various newspapers—Kaiser has actually gotten excellent ratings within the HMO world.

There's also a conflating or confusion between the idea of length of treatment and depth of treatment. There are some patients that I have seen once or twice or three times and it was "deep" or "heart" work or whatever one would call it. And other patients I've seen for long periods, it never really had much soul or passion in it. So I don't think that length of treatment is always the indicator of what is better.

What I have tried to do is a number of things. I'm fascinated with people, and I'm almost an anthropologist at times. I'm curious how people got to be who they are, what makes them tick, what their hopes are.

VY: How does that work in your brief therapy?
MH: For me, the hallmarks of brief therapy are the development of a collaborative alliance and an emphasis on clients' strengths and competencies in the service of an efficient attainment of co-created goals.
In brief therapy, people can get unstuck, or get back on track, get their process going, but I usually don't get to hear the whole story.
In brief therapy, people can get unstuck, or get back on track, get their process going, but I usually don't get to hear the whole story. I might get to hear one or two chapters or an interesting pivot or turn and then they carry on and do their work without me. I think it's one of the differences between more traditional longer-term versus briefer treatment. At the risk of oversimplifying it, with the former, the therapist goes well down the road with the patient, around lots of turns, with this shared idea that, "eventually we're going to terminate." Whereas the brief therapist, as soon as things really start moving, they're saying, "We're only going to meet a couple more times, let's talk about relapse prevention."
VY: So you can do some very useful things within the constraints of the system. And certainly it is better than no progress at all. But in terms of what feeds the soul of the therapist, and prevents us from getting burnout, that may be harder. We have a lot of difficulties in our professional life. We're dealing with lots of people with pain. We're not making as much money as a lot of other equally intelligent professionals. So we want the emotional gratification/satisfaction that the work brings.
MH: Freud said somewhere that the therapist should have the most satisfying personal life that he or she can have, so they won't look to their patients to make their life meaningful, to give them satisfaction. And I think some therapists have a strong need—I don't quite call it "addiction" or "co-dependency"—but there's some emotional reliance on the experience of getting close and being trusted. It's beautiful when it's happening. But sometimes I would ask, "What and whose needs are really getting served? Is it my need to be a long-term therapist for the gratifications—maybe not financial ones—
VY: —or maybe financial.
MH: Yes, maybe financial. I think there are some monetary incentives as well.
VY: Of course it cuts both ways. Clearly, as a private practitioner, there are financial incentives to keep patients long term. There's no way around that. And, conversely, in managed care, where someone has a pre-paid health plan, or a capitated contract, it's to the institution's economic incentive to keep the treatment shorter. So the economic incentives are there; we live in a free market economy; we know the impact of prices and money. And I think private practitioners need to be aware of the point you just raised, just as managed care needs to be aware of the converse dilemma. How do managed-care therapists and companies deal with this? Weren't you in the management end at one point? How do you deal with that? To know that you're doing that right thing, and not being coerced by economic pressures from up above?
MH: As well as being a full-time clinician, I was the director of adult services at a large Kaiser facility for many years. I stopped being the director a few years ago because I had some other interests I wanted to pursue. I think it's a complicated question. I address it at length in two chapters on likely future trends and attendant ethical dilemmas in my book, Some Stories Are Better than Others. There are lots of thorny issues, and 40 or 50 pages of discussion. I think we have to find ways to continue to function as professionals, with the intertwined implications of competency, autonomy, responsibility and ethicality.
VY: We certainly have to try to.
MH: As much as we can. And there is the fact that "he or she who pays the piper calls the tune," to some extent. Although it's true that that we are economic animals, that we're trying to make a living,
we have to safeguard what we think is best for clients, whether we're working in fee-for-service, managed care, or in whatever arena.
we have to safeguard what we think is best for clients, whether we're working in fee-for-service, managed care, or in whatever arena.

This long pre-dated the managed-care issues. Imagine if a patient came into a private practitioner's office with a long list of issues and problems that obviously required long-term intensive treatment. And imagine he or she says "But I don't really have any money—I can only pay you $300 total." Many well-intentioned practitioners would say something to the effect of, "Well, I can see you two or three or four times." They might do sliding scale, and maybe pro bono for awhile. But sooner or later they would also say, "If you can't pay, I'm not going to be able to give you professional services on an ongoing basis." So sometimes I've wound up in a situation discussing with patients—whether it's in an HMO or in a private setting—"How do you propose to pay for this? This is a professional service. For consideration of a certain amount of money you'll get a certain amount of service." It becomes a very complicated thing, because you don't want to just cut people off—but you also need to make a living

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Hoyt Under Pressure

VY: Let me put the pressure on you a little bit more.
MH: Good!
VY: I know that at HMOs like Kaiser, and others, in their benefits they give up to 20 sessions per year, and then if you read the fine print, it says, "As needed per medical necessity" Where do you draw the line? Five sessions versus 17 sessions? And what's "medical necessity"? It's not really a medical treatment to begin with.
MH: I have a big objection to the term "medical necessity." I much prefer to call it "clinical necessity." And they have defined clinical or medical necessity in terms of four dimensions, in general: One is a legitimate DSM-IV Axis I diagnosis. A second is "likely to show significant improvement," meaning "it's necessary because it will really help." A third is "necessary to avoid a worsening," meaning that if we don't do it, the patient is going to wind up worse. And the fourth, which has a lot of slimy politics around it, is that some companies are using the DSM-IV, Axis V, the Global Assessment Functioning, just setting a number: they have to be below a 55, or below a 50, or below a 60.
VY: Whatever that means!
MH: Whatever that means. It's semi-operationalized. But, how low do they have to go? How sick do you have to be? It's counterproductive and, in my mind, stupid, to say that you have to really fall apart, and then we can start therapy.
VY: There's an incentive for therapists to make the person look worse! An incentive to game the system.
MH: Right. What happened a long time ago is that we, as a field, made an alliance with the medical model. And insurance has been treated as an entitlement: "I'm entitled to my 20 sessions," or "I'm entitled to as much as I want." Whereas it has been written, in contracts, that only if it's a diagnosable "illness" and a "necessity" will treatment be covered.
VY: By doing that we signed a pact with the devil, if you want to call it that. But whoever bought into that is saying, "I'm going to agree that this is the illness model, the medical model." I agree with you: If we're going to go for that, we play by those terms.
MH: And then we're in the language of DSM pathology, the language of the medical model, and then we're into "Axis I," "presenting complaint," and "symptom resolution."
VY: And all that jazz.
MH: I do think it can be useful, to a point, at times. It depends what we're doing therapy for. When people are having panic attacks, and it's turned into panic disorder, it's a fairly circumscribed thing. Sometimes diagnosis is not a bad thing. Other times, people want to come to therapy for a kind of growth therapy, or personal enhancement. I've been in therapy for those reasons, more than once. It's a question about whether insurance should pay for it. "I wasn't there to treat DSM IV, I was there to grow Michael Hoyt." Insurance is for one thing, but this was a different process. HMOs and other managed-care companies are needing to specify what will and will not be covered, and for how long. (Hoyt, 2000, Some Stories Are Better than Others, Ch. 4, "Likely Future Trends and Attendant Ethical Concerns Regarding Managed Mental Health Care" and Ch. 5, "Dilemmas of Postmodern Practice Under Managed Care and Some Pragmatics for Increasing the Likelihood of Treatment Authorization" (with Steven Friedman); and Hoyt (2001d). Also see "The Squeaky Wheel: Don't Let Managed care Shortchange Your Clients." Family Therapy Networker, 25(1), 19-20.)
VY: But that's such a hazy line. When you talk about the woman with MS, you talk about despair and hope and inspiration. Where is the line between treating illness and symptoms, and growth?
MH: Yes, and one of the ways that treatment was justified to the insurance company was that there is some well-known research, with 50 or 60 replications, that good psychotherapy services reduce unnecessary medical utilization. That's one of the ways to sell it to the HMOs, showing them the bottom line. And so, if she could have some visits with the psychotherapist, there weren't going to be so many visits to the internist and the emergency room and the internist. We may have to be "bilingual," so to speak.
I could articulate "symptoms" and "enhancing coping" when I had to, but when I was with her, I wasn't doing medicine, I was doing humanity.
I could articulate "symptoms" and "enhancing coping" when I had to, but when I was with her, I wasn't doing medicine, I was doing humanity.
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Words of Wisdom

VY: Before we stop, any words of wisdom or advice or inspiration to the hordes of therapists, many of whom are feeling disillusioned with the field? What do you say to them?
MH: hope these are words of wisdom; they've been wise for me, and they may fit for somebody else. I think it's good to get more training and read books and go to workshops. I think that's helpful, but what we really need to do is remember why we came into the field, and honor it. We need to come from our heart. We need to come from our soul. We need to follow our passion, as Joseph Campbell used to say. Sometimes there is a lot of pressure and unpleasantness. That's true. But don't let the bastards get you down.
Don't let them define your reality completely.
Don't let them define your reality completely. Work hard and keep hope alive—right livelihood is worth it.

I think another word of wisdom is that it's important to be multi-theoretical, to have different lenses you can look through. The other word is "eclectic," but I don't like that word because it sounds like "chaotic" and "electric" in the same breath, like when you throw techniques at someone and you don't know why. But I think it's important to be "multi-theoretical."

We're in this wonderful, strange business: we go into small rooms with unhappy people and we try to talk them out of it, so to speak. We're here at the Evolution of Psychotherapy conference. The first speaker was brilliant and right on. And the second speaker was brilliant and right on, and completely contradicted the first. And the third said something really brilliant and right on and had a very different perspective—and each of them and their proponents have helped thousands of clients. Not everything is equal, but there are different ways to go, and nothing works all the time.

I think when you're stuck — and we all get stuck every day — we don't quite know what to do or the therapy isn't going anywhere—the first thing I'd do is consult my client. "How is this working for you? What am I missing? I don't think we're looking at this the right way. What are your thoughts and ideas?"

VY: Instead of peer consultation?
MH: Yes, I would start with the client, rather than assuming the resistance is in the client.
The first place resistance exists is in the therapist.
The first place resistance exists is in the therapist. We have a resistance—we are looking at things a certain way that doesn't let things go forward. I would start with the resistance being in me, than I would look at the resistance in the interpersonal field, that is, something not working between us right. And finally, and only finally, I might ask, "Is the resistance in my client?" Too often, when it's not going where we want it to go, we say ""Oh, they were Axis II," 'or "There's secondary gain," or "They didn't really want to change," or "They really like suffering," or "They're too attached to their negative affect because of their early experiences with abuse." We've come up with something to explain it, as though the other person is the problem rather than the difficulty is in our understanding them better.
VY: "If it doesn't work, it's their fault."
MH: Right.
VY: "And if it works, it's our doing."
MH: Yes. There's an old saying, "When you point a finger at someone, there are three of them pointing back at you." So I would take this and say, "What's going on with me? What am I missing?" That's one thing I would do.

I would also suggest talking to people who have a different theoretical orientation than oneself. If you're psychodynamic, go talk to a cognitive behaviorist. If you're a cognitive behaviorist, go talk to a Jungian. If you're a Jungian, go talk to someone who does biological psychiatry, and so forth. Because the way you're looking at it, your lens, your frame, your conception, may not allow you to see the client and to see solutions in a way that's going to be helpful for this person. We often want to go talk with someone we really trust, someone we went to school with, because we had the same professors and the same books are on our shelves. Sometimes it's like talking to a mirror. You almost know what they're going to say; they're going to confirm your pre-existing beliefs, because they have the same frame. It's OK to do that, because sometimes you get ideas. But if you're not getting the ideas that are going to move the therapy forward, it's time to talk to someone from a different orientation. How you look influences what you see, and what you see influences what you do. And if you're not seeing something helpful, get some new glasses. Some stories are better than others.

VY: Thanks, you've helped expand my perspective and greatly enriched my understanding of what your work is all about.
MH: I really appreciate your interest, trying to follow some passion and bring some energy and life into the field by interviewing different people about what turns them on. I would encourage people to look at this whole set of interviews, not just the people they may already be acquainted with. All the people who are going to be interviewed have something to say; if you can hear it. It's important to stay curious.
I used to think that if something didn't turn me on, it meant that it wasn't good.
I used to think that if something didn't turn me on, it meant that it wasn't good. I have now discovered that if it doesn't turn me on, and (especially) if it turns lots of other people on, maybe it's something I'm not hearing.
VY: Again, the three fingers are pointing backwards.
MH: Thank you for the opportunity.
VY: Thank you so much.

Copyright © 2002 Psychotherapy.net. All rights reserved. Published October 2002.
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Michael HoytMichael Hoyt, PhD, is one of America's most wide-ranging brief therapists. He is a senior staff psychologist at the Kaiser Permanente Medical Center in San Rafael, California, and is also a clinical faculty member at the University of California School of Medicine in San Francisco. Hoyt is the author of several books: Brief Therapy and Managed Care (1995), Some Stories Are Better than Others (2000), and Interviews with Brief Therapy Experts (2001). His latest book, The Present Is a Gift, a collection of recent interviews and essays (including several referred to in the interview), will be coming out in 2003. Dr. Hoyt can be contacted at Michael. [email protected] or at Kaiser/Psychiatry, 820 Las Gallinas Avenue, San Rafael, CA 94903.
Victor Yalom, PhD is the founder, CEO and resident cartoonist of Psychotherapy.net. He also maintains a part-time practice in individual, group and couples therapy in San Francisco and Mill Valley. He has conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and also leads ongoing consultation groups for therapists.

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Learning objectives: • Explore new perspectives on the role of managed care in psychotherapy.
• Increase understanding of the therapist-client relationship in brief therapy.
• Consider possibilities for infusing therapists, and the field of psychotherapy, with new energy and passion 
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