The Lose-Lose Comment: A Therapist By Michael Karson on 11/2/18 - 12:54 PM

In my years of practicing therapy, I frequently would not know what to say. Once, a woman made a classic doorknob disclosure as the session was ending: “When I was 14,” she said, “my uncle sexually abused me.” A male patient made fun of me for not following a story organized around economic theory. A woman wanted me to praise her for resisting temptation the week before. At these moments, I would typically frame my predicament as egalitarian (be spontaneous and gratifying) versus authoritarian (be withholding and rule-bound), and I would choose the egalitarian path. Other therapists, I’ve noticed, have other ways of framing therapy dilemmas.

I wish I’d known at the time how to make a lose-lose comment. For example, with the first patient, I might have said, “If I just say goodbye right now, I seem to be communicating that what you said is not that big a deal. But if I ask you about it, I seem to be communicating that it’s such a big deal that our relationship can’t take it in stride. I don’t think this dilemma is new to you in dealing with the abuse. Since both alternatives have disadvantages, I guess I’d like to keep our agreements intact, while assuring you that we will talk it over next time.”

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Two of the many ways of understanding therapeutic success make sense of the lose-lose comment’s effectiveness. First, Gregory Bateson, the anthropologist, observed therapy in a VA hospital and concluded that therapists teach patients how to metacommunicate. He meant that many people do not take advantage of their capacity for reflection before taking action, largely because they never learned to talk things over in a reflective space, much less in their own heads. He said that almost all therapies of every orientation excel at this because virtually all therapies talk things over. The dilemmas I mentioned above pressured me to act, and the lose-lose comment demonstrates that even intense pressure can be reflected upon.

Transference resolution seems outdated as a therapy construct, but it can be understood in contemporary terms. Jonathan Shedler has said that therapy teaches the patient, “That was then; this is now.” I have long maintained that successful therapy depends on the fact that the patient will mess up the therapy in the same way that they mess up other relationships, and the therapist’s job is to help resolve these relational conflicts. In this context, many therapy dilemmas arise when the patient promotes a characteristic mode of relating and the therapist is trying to promote a therapeutic mode. The lose-lose comment is intrinsically therapeutic, even when the alternatives specified by the comment are not, so it restores or maintains the therapeutic relationship.

To the economist, I might have said, “If I fight back, our relationship becomes a stag fight, but if I don’t, I will lose your respect. I get the sense that you might not be too familiar with other ways of relating.” If the last sentence seems like a putdown, I could have said, instead, “I’m not sure how we got to this point.” To the woman wanting praise, I might have said, “If I praise you, then it might cast you as a little girl, the very image that precedes your yielding to temptation; if I don’t, you might feel lonely, which we have also identified as a precursor to temptation.”

The structure of the lose-lose comment can become monotonous, but it lends itself to other forms. I could follow up the lose-lose comment with something like “Are those my only choices? I wish I could think of a way to show you how important I think that is while also showing you that I think we can take this in stride.” Or, with the economist, just holding my hands up in a timeout signal might have gotten us back on track.

File under: The Art of Psychotherapy, A Day in the Life of a Therapist