Truth and Fiction in Psychotherapy

Truth and Fiction in Psychotherapy

by Keith Fadelici
Therapists can best serve their clients by listening for their realities rather than pursuing elusive truths.
Filed Under: Addiction, Trauma/PTSD

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Arrhythmic Interventions

Sometimes with clients, I feel that I have gone on too long, offered several mixed if not confusing metaphors, used far too many words.

It is a familiar, critical, internal voice that identifies my arrhythmic intervention as a product of inept clinical desperation
As confusion settles like snowflakes in the client’s eyes, drifting left to right, forming frosty banks of disinterest beneath the eaves of their lids, a sense of failure comes over me. It is a familiar, critical, internal voice that identifies my arrhythmic intervention as a product of inept clinical desperation, further proof of my sporadically undisciplined, ego-driven approach. Attempting to re-engage the client I often and fumblingly ask, “Does that make sense to you?”

This is intended to communicate that my preceding monologue was a humble offering for the client’s consideration, neither a pronouncement of truth nor an authoritative directive. I explicitly invite disagreement by disclosing therapeutic doubt as to the relevance of my intervention, graciously allowing space for the client to reject, accept, or reconstrue my thoughts to fit their own preferences. A leveling of the clinical playing field, I suppose. An empowerment of the client, particularly highlighting their interpretive role, calling them into a more active engagement in the dialogue.

But it is merely a closed, if not defensive question: it invites either a yes or no answer. What I justify as empowering of the client is actually highly restrictive. It fundamentally does not, regardless of my sound intentions, invite the client to reflect on their own thoughts and feelings. The query instead directs an assessment of my words and my performance as a therapist!

It is uncomfortably reminiscent of the stock illustration of common narcissism: “Enough about me! Let’s talk about you. What do you think of me?”

Perhaps when I respond negatively to my own clinical intervention, it’s because I recognize it as an unintended self-disclosure. Perhaps I am frustrated by the client’s perceived lack of progress, or they provoke in me uncomfortable personal associations. Or maybe there was an annoying itch on my left ankle. In asking the client to make sense of my words, I may be attempting to coerce them into helping me bury what I have inadvertently exposed about myself. Smoke and mirrors to distract from my embarrassment! A fiction masquerading as curiosity to distract us both from the truth about my outburst.

The Fallacy of Making Sense

Another problematic aspect of my question—“Does that make sense to you?”—is the importance it places on things making sense. But must every sentence in a therapeutic exchange be complete? No. Do the associations we make need to conform to a logical rubric? No. Must our emotions be reasonable and defensible? Of course not.

When I ask a client whether things “make sense,” I may be communicating that they should
When I ask a client whether things “make sense,” I may be communicating that they should. In so doing I might exile from therapy parts of the person that are either currently or permanently outside of the logical realm. Such parts may contain important information about the problems faced, and they often are part of the solutions. Simple acceptance of unarticulated emotion, whether loss, pain, anger, or sadness, has so often marked the turning point in a client’s healing process. That such emotions may be illogical, in conflict with relevant facts, or appear baseless when judged cognitively, often serve as the underlying motivation for denial and repression.

Therapy needs to be a space where we witness and accept the patient’s narrative, in whatever form they choose to offer it
When I over-value making sense within psychotherapy, I am suggesting that we are searching for a Truth. Not merely a true expression of the client’s experience but rather a Truth that will stand up to objective investigation. Something that stands the test of logic and reasoning, as some subjective experience does. For example, if I report that my wife hates me, and my wife explicitly confirms this impression, my felt experience is supported by objective evidence. In the case where my wife denies such hatred, psychotherapy teaches us that my experience of being hated by my wife is of equal or greater significance when it is disproven by factual inquiry as when it is supported. In the instance where my impression appears unsupported by the facts, further clinical work may reveal that I am suffering from paranoia, or it may reveal that my wife’s love is expressed in a manner easily understood by me as disinterest or hatred.

Therapy needs to be a space where we witness and accept the patient’s narrative, in whatever form they choose to offer it. For there are truths about sexual assaults that I have only come to understand when a client expressed themselves with a vague gesture, or another victim described watching their own rape from the ceiling of the room, or another interspersed details of the assault with seemingly unrelated and irrelevant trivia about their daily routines.

In Fiction Lies Truth

A central theme in the writings of Tim O’Brien, an acclaimed novelist and Vietnam veteran, is that a war story that is not fictionalized is not a true war story. Why? Because war is such a massively distorting human experience that telling of it in a rigidly accurate, factual manner is wholly distorting the truth about war. A war story without fiction is, by necessity, a lie:

In any war story, but especially a true one, it’s difficult to separate what happened from what seemed to happen. What seems to happen becomes its own happening and has to be told that way. The angles of vision are skewed. When a booby trap explodes, you close your eyes and duck and float outside yourself. When a guy dies…you look away and then look back for a moment and then look away again. The pictures get jumbled; you tend to miss a lot. And then afterward, when you go to tell about it, there is always that surreal seemingness, which makes the story seem untrue, but which in fact represents the hard and exact truth as it seemed.¹


A war story without fiction is, by necessity, a lie
When clients tell of traumatic events, exposing not just what happened but speaking of “its own happening,” I have experienced the raw power of their account and self-protectively withdrawn by responding with curiosity about what actually happened.

In his recent memoir, Dad’s Maybe Book, O’Brien instructs his two sons that maintaining humility about our own understanding and experience is an essential safeguard against arrogance and our own vulnerability to notions that there are truths we hold as self-evident. He argues that all such truths are subject to change and to cultural relativism. Better to say “maybe” than to believe you have a hold on Truth; better to say “it seems” rather than “it is.” In these times of “epidemic terror” and intolerance of ambiguity and uncertainty, O’Brien pleads: “I’m asking only that you remain human in your terror, that you preserve the gifts of decency and modesty, and that you do not permit arrogance to overwhelm the possibility that you may be wrong as often as you are right.”

Better to say “maybe” than to believe you have a hold on Truth
One of the examples of a war story O’Brien tells in The Things They Carried is of a six-man patrol assigned to establish a listening-post in the mountains. They sat, camouflaged in almost complete silence and stillness for a week listening for enemy movements. After some time, they hear music, chit-chat, and what sounds like a cocktail party, with popping champagne and clinking glasses. The soldier telling O’Brien this story clarifies that the voices he and his comrades heard were not those of people but were voices arising from the mountain itself. “Follow me? The rock – it’s talking. And the fog, too, and the grass and the goddamn mongooses. Everything talks. The trees talk politics, the monkeys talk religion. The whole country. Vietnam. The place talks. It talks. Understand? Nam—it truly talks.”

Driven to their wits’ end, the patrol calls in air strikes and the mountain is bombarded throughout the night. When they return to base camp and a senior officer questions the basis for the airstrike, none of the men respond. “They just look at him for a while, sort of funny like, sort of amazed, and the whole war is right there in that stare. It says everything you can’t ever say. It says, man, you got wax in your ears. It says, poor bastard, you’ll never know – wrong frequency – you don’t even want to hear this. Then they salute the fucker and walk away, because certain stories you don’t ever tell.”

On the Wrong Frequency

How often am I as a therapist on the wrong frequency? Am I tuning in to analysis? Diagnosis? Cognition? Emotion? Is the client communicating in the equivalent of a dog-whistle? Is the lie telling me a truth? Is the truth masking what is not true but essential? It is not difficult to imagine clients who have saluted me and walked away thinking that I was a well-intentioned poor bastard who hadn’t heard them at all.

It is not difficult to imagine clients who have saluted me and walked away thinking that I was a well-intentioned poor bastard who hadn’t heard them at all
Earlier in my clinical career, a middle-aged man, Curtis, sought me out for my expertise in trauma. He complained that earlier therapists had been unable to impact his symptoms, including persistent intrusive memories of early childhood sexual trauma perpetrated by a family member. I had recently been trained in EMDR (Eye Movement Desensitization & Reprocessing) and was eager to utilize the approach with a case of complex trauma. After gathering a general history, forming an understanding of his current relationships, internal/external resources and supports, I was confident of a reasonable degree of rapport. We cautiously waded into an exploration of Curtis’s childhood relationships to both of his parents and how those dynamics, combined with family finances, regularly left him in the care of his perpetrator for most of each weekday through the years of his childhood.

Details of the sexual assaults were not remarkable to me. They were consistent with common incestuous, pedophilic behaviors. What struck me, however, were Curtis’s accounts. From session to session they seemed to become increasingly detailed, and the details sounded increasingly melodramatic. What I heard initially to be cold-blooded genital manipulation evolved into stories of emotional attachment, culminating in a seven-year-old’s feeling emotionally abandoned by his molester and proceeding to threaten her with exposing her deeds if she didn’t comply with his wishes. After several months, Curtis began disclosing memories of horrific, ritualistic abuse involving multiple members of their rural community.

there were signs that the clinical exposure to the increasingly disturbing memories were making things worse
EMDR was having no significant impact on Curtis’s current levels of distress. In fact, there were signs that the clinical exposure to the increasingly disturbing memories were making things worse. His alcohol consumption was on the rise and seemed linked to increasing conflicts with his wife, who served as his principal support. To mitigate these negative secondary effects of the therapy I began to lessen the use of EMDR and increased identification of his drinking as a principal obstacle to healing from his past wounds.

Within a month of making this shift, Curtis withdrew from treatment with little comment or clarification. At the time I saw this as an indication that he wasn’t ready to confront his addiction, which was disabling him from processing the past traumas effectively.

In hindsight, and with my evolving perspective on truth and fiction, Curtis seems to have been in the same predicament as the soldiers in O’Brien’s account asked by their commanding officer to justify their ordering up an airborne attack based on their experience of talking rocks, grass, and fog. The soldiers opted to walk away from the commanding officer without a word. Curtis tried to communicate to me how his misshapen inner landscape was behaving. To his credit, he didn’t bother to salute when taking his leave.

I thought if we got the alcohol out of the picture we had a shot at finding out what really happened all those years ago
Now, I imagine he knew I didn’t want to hear what he was telling me. This resistance led me to make a distorting effort to escape the truth via facts. I thought if we got the alcohol out of the picture we had a shot at finding out what really happened all those years ago.

Having since worked for close to ten years with victims of sexual abuse, I understood that the narrative often evolves over time. Difficult facts and experiences might be avoided in early sessions and disclosed later in the process. Conflicts in current relationships might reflect dynamics of the abuse. Adult memories of childhood events are most often fairly accurate as to the essence of an experience. Use of alcohol and drugs or other dangerous behaviors are adaptive means of survival, often difficult to abandon for less harmful comforts.

I was fleeing from a combination of the client’s disturbing narrative and the failure of my interventions to make a dent in his very distressing symptoms
Now, ten years later, I have come to understand how crucial it is to believe the victim’s recounting, regardless of its form, and why it was difficult for me to fully accept Curtis’s narrative when I first began this work. The details of his account sounded like the climactic scene of a horror movie. I didn’t want to believe that such things actually occur in the basement of a neighbor’s house and that a half-dozen or more people could be complicit in such acts. My gut told me: Rosemary’s Baby was not only a fiction, it was, and is, impossible! Another part of me knew that the kind of nightmarish abuse Curtis described has happened before and, therefore, it remains uncomfortably possible that his memory may be partially or wholly accurate.

I fled to the problem of alcohol consumption.

I was fleeing from a combination of the client’s disturbing narrative and the failure of my interventions to make a dent in his very distressing symptoms. My flight was an abandonment of this client to his painful story, a story that he had bravely shown and invited me to enter.

Beyond Self-Protective Fictions

When Billow, an important voice in Relational Group Therapy, asks, “Where is fact, where is fable?” he is not only asking this about the client’s statements. His focus is on the therapist.
 

My self-disclosures give some idea of how I think and feel, how I think I think and feel, and how I would like others to believe I think and feel. Perhaps we need to put a Surgeon General’s Warning on all clinical contributions, certainly not just those intending self-disclosure: The analyst’s communications contain aspects of infantile as well as dissociated inner experience. Gross commissions and omissions are to be expected, involving conscious and unconscious censorship, relating to the analyst’s emotional, cognitive, and psycho-linguistic limitations, shame and guilt, fear of embarrassment, humiliation and ostracism, fear of the unknown, and fear of loss of livelihood…²


As a therapist, I have lots of reasons to generate fictions. We are trained to assume these human responses are regularly present throughout clinical work and to task ourselves with recognizing and utilizing them both in service of the client and of expanding the therapist’s own self-awareness. Richard Billow’s clinical warning label is not an identification of life-threatening effects of exposure to psychotherapy and its practitioners, it is a reminder that the truths being uncovered and the healing achieved in clinical interactions are inseparable from distortions by both the client and the therapist.

More recently, I was working with a client, Maureen, who was also an adult survivor of childhood incest. She courageously disclosed a series of traumatic childhood events over several sessions. We planned to proceed to processing these traumas utilizing EMDR. When the next session began, however, it was clear that the self-confidence evident in prior sessions was now absent. Maureen shared with me that the events we’d previously discussed had overwhelmed her during the week, and when I inquired as to the specific nature of the overwhelm, she explained that while she intellectually knew that these traumatic events were separated by significant periods of time, they’d been presenting as interconnected. Pieces of one event seemed spliced into the images of another. This not only condensed images but also magnified their emotional and psychological power. Maureen described feeling “shook,” out-of-control, and increasingly uncertain as to her experience and her memories.

With Maureen I was able to hear this distortion of her memories and her current experience of past events as essential points of focus for processing. In fact, I made the choice to explicitly communicate to Maureen that I heard this unification of her historically separate events, accompanied by numerous somatic expressions, to hold greater “truths” for our clinical work than the accuracy of her historical and chronological memory. She could see that all these terrible things, while having happened separately, had happened to her one and only body and brain. This communication had an immediate effect of relieving her emotional and physical tension. It also led directly to a discussion of how she could utilize the historical memory to reduce the sense of overwhelm that might resurface prior to our successful processing of the trauma. Unlike in my work with Curtis, I tuned into and remained on Maureen’s frequency, accepting her version of the truth as the Truth.

 

***


What O’Brien says about war stories is closely related to what Billow says about therapy. An exclusive focus on facts tends to obstruct recognition and development of appreciation for the truth of the human experience, whether that experience is a past traumatic event or a current meeting with the complexities of a clinical conversation. For the most important truths are always in the moment of the telling—not in the subject of the story. Therefore, the value of the telling is not located in its being verifiable. All effective communication, in fact, relies heavily on the honest, truthful aspects of our fictions.

¹O’Brien, T. (1990). The Things They Carried. Mariner Books; Houghton Mifflin Harcourt.

² Tzachi, S. (Ed.) (2021). Richard M. Billow’s Selected Papers on Psychoanalysis and Group Process. Routledge.

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Bios
Keith Fadelici Keith Fadelici, LCSW, has been providing psychotherapy for over 22 years in both private practice and agency settings. He co-authored a chapter in Strength and Diversity in Social Work with Groups based on his group work with adolescents with sexual behavior problems. Keith was the Assistant Director of Victim's Assistance Services in Westchester County, NY for approximately 13 years and then served with Safe Horizon as the Director of Clinical and Forensic Services in Brooklyn's Child Advocacy Center — one of highest volume CACs in the country. With his years of experience specializing in trauma treatment, Keith has also been published at Psychology Today and at The Good Men Project.