Addiction: What Glory in the High Recidivism Rate?

Posted on by Psychotherapy.net Team

When I began my career as a psychotherapist, I was sure I would focus on addiction recovery. After graduate school, I ran into an amazing professor and took a year of courses with her on dual diagnosis. Thirty-six years sober, she was my guide to a world I hoped I would never enter personally, but would focus on professionally.

I proceeded to work at a number of drug and alcohol rehab clinics, from tony Malibu in-patient programs to down-and-dirty outpatient clinics for people fresh from prison or the streets. I was a “newbie,” one of the few working in these organizations that did not have prior addiction as one of my credentials. I talked my way into the jobs by stating that I could offer an alternative to the way people had been living. I had learned how to talk the talk, from AA to NA to no A’s at all. But I learned that as hard as I worked and as connected as I felt to clients, I was never going to lower that +70% recidivism rate reported by the National Center on Addiction and Substance Abuse. Success stories were rare. Those who emerged from a facility often found their way back in. I treated a 20-year old woman in her 10th rehab program. When asked the first thing she would do when she had completed this stint, she stated she would escape from her home and go straight to her dealer for ‘H.’

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In private practice I continued working in addiction recovery. There was the shopping addict whose addiction not only emptied her pocketbook, but also derailed her marriage. I like to think out of the box, so we made a deal: she could shop till she dropped on Saturday, Saturday night she could try on her bounty, but on Sunday she had to return all of her purchases. This was monitored by mandatory photos sent of the purchases and returns. It became such a tiring process for this client that she eventually gave it up. When she needed something for a special event, she had to call me for permission. When she “graduated” from therapy, it was with a growing bank-account, sadly a divorce, but an understanding of her addiction and the knowledge that she could never go back to that behavior again. You might be saying, oh a shopping addiction is not as life-threatening as drugs or alcohol, but in another way it is. The depression precipitated by being broke and now divorced was mentally debilitating. Take gambling addiction. All you need to do is read former Good Morning America anchor Spencer Christian’s book, You Bet Your Life, about the thirty years of shame he hid and the near ruin he continuously faced, to know that addiction in almost any form is a health threat.

I also began to understand that giving up one addiction often leads to another. Why do you think that during AA breaks, so many people are outside smoking? The hole that created the addiction in the first place needs to be filled. So why not with something healthy? I began to find those “hole-fillers” for my clients. Exercise became the most successful. Hangovers and the day-after partying like a rock star are not feel good moments. Getting your health back, your body back, a clear mind—that became the goal.

One client was a law school student. After two years of Taco Tuesdays, Thirsty Thursdays, Freaky Fridays, Saturated Saturdays—and oh well, Sunday too, she was a full-blown black-out drunk; failing out of law school, sabotaging friendships, avoiding her family. When she came to work with me, eschewing AA, she had to come three times a week. She also had to pick a physical activity; her go-to instead of drinking. It was a long year. It became a long second-year of maintenance and on the anniversary of the completion of year two, her official graduation from therapy, I had baked a cake and had sparkling cider ready. She walked in, and to my shock, was followed by her parents, 2 sisters and her soon-to-be fiancé. There were hugs. There were tears. She was carrying a large wrapped photo.

I looked and said, “What a great picture of you and your Mom.”

“Susan,” she grabbed me. “That is me when I started seeing you and me now. I am sober and 60 lbs. lighter and a rockin’ marathoner.”

Did I move the needle on the overall recidivism rate? Probably not, but small successes are what makes this profession worth practicing.  

When the Grass Becomes Greener

Posted on by Psychotherapy.net Team

I feel fortunate to live in a climate where four seasons prevail. The first having passed for the year (ski season), we are on the precipice of entering the second: lawnmower season. Spring has sprung! And, with the recent rains we’ve had, our grass is taking off to new and varied heights! It’s about time to unearth the mower from way back in the back of our garage, get dressed in some comfortable work clothes, put on some old tennis shoes, and officially commence lawnmower season, week after week, one hour at a time.

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The usual routine involves noticing that the grass is starting to eclipse the stone borders around our blackberry and raspberry vines, and lamenting the development of dandelions and hard woody weeds that tend to shoot up above the rest. The latter of these are actually the persistent leftovers of a sour cherry tree that we used to have in our backyard, perennial manifestations of seeds haphazardly planted by the birds who used to steal the ripened berries straight off its branches.

After a long day of therapy, processing trauma with clients who have lived through the darker side of our shared humanity, I welcome the physical exercise that weeding and lawn mowing provides. With old volleyball kneepads pulled over my knees in homage to my favorite sport, I work at ground level, eye-to-eye with the garden nemeses that impede our barefoot backyard adventures. (If you’ve never stepped on a sprouted sour cherry tree root barefoot, it’s like traversing your living room and stepping on an errant Lego® block, randomly left behind, circle-side up! Ouch!)

While weeding, I enter the quiet space of a self-induced Eriksonian trance and process my day, thinking of clients’ stories, past and present, and their journeys to face the unimaginable to try to evolve beyond what they’ve experienced. I think of the importance of taking the time and putting forth the determination and commitment it takes to dig with my hand trowel to the bottom of those sometimes sprawling roots to carefully and tenderly lift them out of the ground so as not to leave a piece of them behind that can regrow and repopulate in their place. I meditate. If only the “errant” thought, belief, or behavior (their own or someone else’s) that caused or continues to cause them harm could be uprooted, whole and in its entirety, and cast away onto a compost pile to be transformed and recycled, seeped of its energy and sustenance and used to nurture a new thought, behavior, or self-affirming belief in its place. Perhaps the grass truly could be greener on the other side.

I continue my gardening from behind the lawnmower, upright and removed from the closeness of the weedy encounter, gear up to “rabbit” mode, and pull the cord until it sputters to a start. Although it sometimes takes a few tries to get our old mower going, once it is, we’re off and running steadily for about an hour together. I typically break a sweat as I push our mower back and forth, systematically turning around trees and our kids’ swing set, breaking down the task by completing small sections of the yard one at a time. Despite the heat of the day, I take comfort in the steady pace I can keep, guided by the mower’s propulsion system, and the constant hum of the engine in motion. I can more easily see the progress we make using the larger and more powerful tools of the trade. The tall and uneven blades of grass are trimmed for a fresher and more orderly appearance.

As I push the mower, it’s easy to set the direction. The machine, unthinking and unfeeling, willingly moves forward and turns under my guidance. Its ease of use allows me to enter the same unthinking and unfeeling space by the grace of our interaction, a welcome break after a hard day at work, providing therapy, then weeding. We only need to pause once or twice so I can empty the grass catcher and refill the gas tank, operations that are simple to complete and require no real brain power on my part. The wonderful part about mowing is how progress is steady and visible, and how it’s easy to estimate how far we’ve come and how much is left to go before it’s done.

As a therapist, I find it important to be able to do things in my personal life where the beginning and end are easily marked and where progress along the way is obvious and quantifiable. Systemic training has taught me to look for the smallest incremental measures of success, counting each little step as a victory, and celebrating each in turn. To have physical reminders of this progress and the success it implies is rare in the therapy room.

We need to concentrate and rely on our clients’ reports, drawing out the stories of their successes with our encouragement, questions, and genuine interest, because gardens invaded by weeds do not tend themselves. Neither do gardens of the mind invaded by psychological trauma. Left to fester, the deleterious effects that characterize what Judith Herman referred to as “the central dialectic of trauma”—simultaneously wishing to deny the existence of the events that underpin the trauma, and needing to uproot them from their nestled hiding places and expose them to the harsh light of day—require an experienced hand to contain and prune them until they can be thoroughly weeded. Gentle guidance, using the powerful tools of the trade and the established therapeutic relationship, can help our clients activate their own self-propelled encouragement engines, even if only for an hour a week, during a season that may be more—or less—long in their lives. I fervently guard the hope that with practice and over time, they will learn to operate at a higher gear, developing their own containment, pruning, and weeding skills, will recognize their own successes, and will notice the greener grass growing in their own backyards.

Reference

Herman, J. (2015). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror. New York, NY: Perseus. (Original published in 1992)

Grasping at Optimism: When Helping a Suicidal Client Means Letting Life Happen

Posted on by Psychotherapy.net Team

A Woman Named Charlie

I tend to think of the initial few sessions with clients as a delicate endeavor, not so different from cooking a soufflé. If I ask them to dive too fully into a painful topic, or challenge their defenses too soon, the person may fold in on themselves, and the therapeutic process, like a rising cake whose oven door is opened too soon, haplessly deflates. But when we proceed gently and slowly during this early phase, a client who is in real trouble may allow her reality to surface, even revealing a serious crisis that might otherwise have been missed.

“My most delicate soufflé was a woman named Charlie”. I was just five years post-practicum when Charlie, ten years my senior, sat across from me for her first appointment. She held a strong, upright posture and bravely deliberate eye contact that didn't square with her disheveled appearance. It was as if her combination of long, scraggly hair, wrinkled clothes, slouched posture and no make-up were deliberate tools used to give the middle finger while at the same time beckoning for help. Her voice was menacing with this tone that was a combination of critical professor and sincere consumer. As we got to know each other, she rattled off effortless soundbites about her position as a president of research development with one of the world's largest technology corporations. She then detailed an exhausting list of stressors, including frequent eighteen-hour workdays, nightmares, loneliness, bereavement from a recently ended relationship and admitting that she knew, given the way she lived and what she did, that there might be no end to the pressures.

The more we talked, the more I marveled at how my conversation-style intake questions were answered with explicit brags about her academic and career accomplishments. This chance to let a new client explain why she’d come to therapy started to feel like a verbal tennis match, with each volley of words leaving me a little more bowled over by her intelligence and concerned that I had nothing to offer her.

And yet, I could hear in her voice a tinge of high-pitched panic just beneath the surface. It surfaced in response to her commenting about my arms being crossed. My gut told me this was a test to see if she could put me in the spotlight so that she might feel safe and no longer the focus. I responded by asking her what her incentive was for investing her precious little surplus time and energy in therapy. What was in her life or what did she want to have in her life that would make this worthwhile? “She stared at me for just a second, but looked right into my eyes and said, “I want to not want to die.”” She then said, “I ‘m not sure you can handle this, and, in a way, I apologize for being here.” My gut told me not to bluff and so I told her what was true; “I can handle hearing about your hell here on earth. I can handle learning what that is like for you. There is an unknown beyond this, because we are just starting, and the work and the process remains to be seen. I can handle someone feeling like giving up. But to handle you actually giving up is something I will do my best work to spare us both from.” Now I had the most important piece of information that was so well hidden under layers of success. This super-powered woman was in desperate pain, and for this, I vowed she would get my best efforts. Even if she did scare the crap out of me.

Playing Emotional Poker

One of the perks of being a therapist is that honesty and transparency are prime capital. I like how free clients and I are to ask each other deep questions, and I think there is something inherently optimistic about a conversation focused on learning how to heal and grow. In that first session, Charlie seemed to tune into that optimism herself. She said she was surprised that she didn’t feel like leaving, adding with a grimace, “at least not yet.” Soon she was telling me about her father's death when she was twelve, and how her mother reacted by shutting down, quitting her job, and beginning a new existence of voluntary confinement to her house.

Charlie sat forward and exhaled slowly before saying, "My mother made me promise not to go out after school so instead I kept to myself and read. It was my freshman year of high school when I checked off three months of not talking to anyone outside of school besides her."

It was nearing the end of the first session and besides forming the frame of therapy with the set weekly time and day, I continued to stay almost solely in the information gathering mode. By doing this, I stayed with Charlie as I let her know what she could expect from me and that she could refuse to provide any information she did not want to at any time by just telling me no. I assured her that the fact that she didn’t want to discuss something was enough of a reason to stop. During a pause in our dialogue, I wanted to tell her she was brave, that it wasn't too late for her to live life with happiness, but the immediate therapeutic silence won out.

Two reasons prompted me to keep my encouragement unspoken. Even though my optimism was sincere, I had no idea of how to create a plan of action for her, nothing specific on a clear behavioral goal level to point to as a potential defining path. Also, “I ran the risk of her perceiving my optimism as evidence of my failing to appreciate the magnitude of her pain”. The timing was off as what was relevant in that moment was that she endured hardship and was hurting and wanted these two points acknowledged without any competition. I was the port in the storm, and I was acknowledging her pain. Regarding adding anything more, this was one of those times when more would he the enemy of good.

Once we were there with the sadness of her early life out in the open, something shifted in Charlie, and she began testing me by admitting to a problem and then pelting me with a personal question. First, her voice inched up a register and she said, " I've never had sex. Not until three months ago when I met…his name is Daniel and he is not available. I knew he was married but I hooked up with him anyway. You would never do anything like that, would you?"

The way she stared at me in that moment I knew she wanted to see if I would judge her and was also letting me know that she was not afraid to shift focus and put me on the spot.
"You know, I can't really delve into my personal life, Charlie, but I’m curious. What makes you so sure about what I’d do? What makes you so sure that when or if faced with a mirage in the desert at a time when I’ve reached a breaking point, I might not try to drink the water?”

The staring continued but was now accompanied by silence.

“Look, I get it,” I said. “Sometimes the world makes professional therapists out to be mascots of all that's socially ideal, when in reality, I may be just as isolated as you. And capable of making similar choices."

"Sure, you are," she said, settling her gaze on my diploma on the wall.

“Was Dan…” I stopped myself for a second. I wanted to ask about Dan, but not have her feel defensive or think I was trivializing, “can you tell me about him?”

“I can’t. He’s a father, husband, son, best friend, author, researcher, gym rat, middle class. Cute, more than handsome. He needed braces and never got them. I can’t talk about him any more than that. Oh, except he’s my co-worker on certain projects we work together.” She was being vulnerable with me. “She was sharing something that hit on such a universal theme: unrequited love” of sorts. I saw an opportunity to bridge the gap between her and the general public by my relating. Since I was the mascot for the public at large, if I related, it would be a start to her being less removed, separated.

“Charlie, there are many things I would do differently if given a second chance. It sounds like we may have that in common," I told her. “And you have this is common with so many women and men”, I wanted to say, but didn’t for the sake of being too much the salesperson for society at large. She sat quietly. Then leaning forward, she said,

"Well, I hope you're nicer to yourself."

With that her eyes grew soft and she gazed at me with friendship. I chose not to hit any more balls back to her at that point. Instead I smiled, and told her, “Thanks.”

Being Both Therapist and Client

For her second appointment, Charlie sat again with hands folded and posture strong, and then began the session by telling me that my arms were again crossed, and I seemed like I didn't want to really talk with her. This test, I thought, may have been an attempt to obtain reassurance that she hadn't overshared at our last meeting. Perhaps she also needed me to know what it felt like to be evaluated, in case I was doing a similar thing to her. My reply, I decided, would be measured kindness, but I needed her respect too. Instead of saying "my guess is you're scared, but I promise, I'm safe,” I went with what felt like cliché boundary setting 101.

"You seem concerned about making sure I'm really interested in talking with you. I'll confess, I tend to be on the cold side temperature wise, you may see my arms crossed at times."

I decided then that giving her the overview of early therapy would be better than either continuing to spar or immediately picking up with what she said last session. I did this because I was concerned the deep, candid disclosure she made last time might be a sort of self-sabotage whereby she made herself too uncomfortable to return, while at the same time getting some small relief by having shared. She might even see my bringing any part of this disclosure up as challenging or even shaming. In other words, way too soon for the soufflé!

I kept going. "Now, it's time for us to get to recent history. Probably like your field, which I know next to nothing about, we need to create a baseline and the first step is getting all the remaining important information out on the table."

She looked frozen and I grew concerned that at any moment her critical parent persona would return to challenge me. So, I quickly continued. "Recent-history is an oxymoron. It's a phrase to encapsulate my question of what life is like for you. In the back of my mind at this point, is the question of why decide to meet with somebody now?"

She didn’t move and didn’t answer me for what might have been a full minute. Finally, she said, "Do you like to get lost in all these little lives around you or just dismiss them by the time you leave?"

"Ouch, wow." I said.

I resisted my own people pleasing tendency—the residue from my own family of origin-—and just sat there, with my eyes as expressionless as possible. “I wanted, in that moment, to address her need to matter”. I did my best active listening pose and moved slightly forward, leaning in to communicate non-verbally without looking overly deliberate, like a perched egret.

She stepped up.

"I had to take a shower to come see you and it was the first shower I took in days. After my co-worker ended things, I started drinking at night. Every night. He would call all through the night and the next day saying he was worried about me, but that I had to stop calling him and that he could no longer respond. I don’t remember any of my calls to him, but he once sent me a call log. He disconnected our private phone line, but we still talked at work. To get through it I made myself more available for the bigger overseas meetings and wound up spearheading our entire overseas communications. Others have the in-person meetings, but everything starts and stops with me. That’s how everything at work changed. I now only work from home, with little exception. My world is my phone and computer. I have no time to eat or bathe. I hardly go to the bathroom. But I always walk Yoda."

“Her dog, Yoda was her love supply and a reminder that kindness existed in the world”.

I took a deep breath and but before I could exhale, she continued, "So now you have the following: alcoholism with blackouts for over six months, so Alcohol Dependency on Axis I, abandonment by father, then death and bereavement, oh, emotional incest is missing in the DSM, clinging relationship with obsessive features with anger outbursts, I'm saving that outburst detail for next session, so, that gives us a rule out of BPD, attachment disorder, co-dependency and intermittent explosive disorder on Axis II. There. I laid it all out for you. And I'm sorry."

While some of her diagnostic summary was surprisingly on point, I did not want to discuss that. She next told me she was valedictorian of her doctoral class at one of the top ivy league schools and studied psychology for her electives. In a way it seemed like she wanted to impress me. In another, it was possible she was fearful of her own problems.

"What are you sorry for?"

She paused for a moment. Therapeutic silence sometimes feels so long.

"I guess I'm sorry I'm here."

My interpretation was that either Charlie concluded that based on my young age I would find working with her overwhelming, or she liked me and felt guilty for bringing in “darkness.” Maybe a combination of the two. She was used to being smarter than everyone else, being the one with the information as opposed to the one seeking it. I told her that for therapy, she was doing exactly what she was supposed to be doing—albeit in a much more organized manner! She allowed us this humor and laughed out loud. I told her about the multi axis of 1-IV and how it is the format for putting everything together to map out a problem and solution. She didn’t chime in about being familiar with this. I continued by saying that I'd like to develop this together with her in session.

My goal was to take away any perceived armor she may have assigned me and by unmaking the work, she would feel safer. I described the importance of ruling things out and stabilization. Those two terms would be the focus before anything else. I didn’t want to go right back into what she said about wanting to die because I wanted her to tell me electively. We spoke about the hierarchy of her more negative circumstances and when I asked her which was the riskiest in her mind, I was prepared for her to face alcoholism in tandem with her upfront style.

"Oh, probably that I am very suicidal at times."

Suicide Enters the Room

I tried not to appear shaken and went into question mode to assess suicide risk. With each new question I tried to communicate care without sounding patronizing.

“Can you tell me what that’s like?”

Long pause.

“Do you ever think about how?”

Long pause. It would not have surprised me if she knew about passive and active ideation, but I didn’t want to get into an intellectual conversation, so I did not use those terms or ask.

“No, just that I want quiet and then I drink and take Yoda and go to sleep.”

“Does anyone in your life now know or even have hunches about your pain? ”

“My best friend, my one friend who I’ve known since undergrad is a psychologist in Beverly Hills. She’s like family and I consider her, her husband and sons my cousins.” She then started laughing.

I wanted to bring things back to my questions about safety but knew that would be too schoolteacherish.

“Something about her work in Beverly Hills always makes me laugh. We don’t talk as often anymore. Southern California gets crazy.”

I let the rest of the session go towards her friend’s work and the “imperfections” of the people of Beverly Hills. She seemed to enjoy this.

The next session, Charlie was ready to focus. She painted a picture for me of her day-to-day life: wake up between six and seven a.m., brush teeth, splash water on face, walk Yoda or let him out in the backyard, feed Yoda, sign in online, make coffee, take out a frozen something to microwave. The next few hours would be a blur of vomiting, coffee, mild level of shakiness, combined with conference calls, emails and other various computer-based tasks. Then after Yoda's second trip outside and a few hours post-lunch, she would begin drinking vodka. Sometimes in Diet Coke, sometimes straight. She would do this slowly while still working all through the night. Voice communication typically ended completely by 2am. At this point, her drinking continued and eventually she would "wind up in bed" after a shower, energy permitting. Occasionally, she had visits by phone with her cousin in California.

“I kept thinking, "start where the client is at."” Because I was not hearing about deliberate self-harm on a planned or immediate level, self-care became my target pitch with Yoda at the center. If I pointed out that I was concerned about black outs, the level of her drinking, the level of her depression, she would have shut down, possibly discontinued and perceived me as a critical parent. I would wait for just one or two more sessions.

"You want to be around for Yoda. She's dependent upon you, right? I'm not out to preach sobriety. My goal is to help you get what you want and for you to be happy—or at least feel less pain. But, I need your help on this.” She gave me a look that indicated an inner reply of “bull” and so I added that her drinking is risky and dangerous and that seeing what she wants in her life, such as caring for Yoda, is a step towards sobriety because it would be a by-product of it.

She responded by shifting away from the here and now and going into her teenage years with her mother, when she would read her schoolwork to her mother, working to get an eventual smile. This would be followed by cooking dinner, cleaning up, watching TV with her mother and helping her into bed. Often, her mother would wake her during the night in tears and she would do her best to comfort her.

“I would pretend that my mother had pneumonia and my father was stuck working late.”

“So that made it a more comfortable situation. Very resourceful and creative. You worked with what you had.”

“I got good at creating alternate circumstances. I did this when I made my speech to our graduating class. I pictured myself as a scientist wishing them well. I had no family in the audience.”

I did zero redirecting and just let her lead. Eventually she paused, looking sad.

"Is it me, or does it seem that I have more to deal with than most people?"

I nodded, "You have been through a lot and pain is the by-product. And you're still here."

"So, what does that mean?" she asked, her eyes boring into me.

"It means you can give" —ugh! beginner's mistake—better to have asked her what it meant for her, but too late to shift. “You can give love to Yoda, to your cousin. To the world you live in and are part of.”

"Oh God, you're one of those people," she laughed.

Our time was suddenly up and despite the bomb she’d dropped, she left my office a little bit happy.

I hoped at this point that the therapeutic alliance, combined with Yoda, seemed enough for the time being to compete with any desire to die. My experience at that point of working with suicidal patients was limited to practicum work in a residential facility, where supervision of the patients was constant. On the one hand, my assessment was that her ideation was passive, and she was not at risk of intentional self-harm. On the other, she could possibly hurt herself unintentionally while under the influence of alcohol, or her tolerance for her pain could escalate along with a decrease in impulse control, making it tempting for her to torment herself. My next worry was along the lines of “who was I to determine such a thing?” I was afraid to trust myself, but at the same time, if I continued with that thought process, I would not be able to do my work at all. I needed to permit myself to trust my instinct. “I white-knuckled it until she returned for her next session”, convincing myself in the intervening days that she’d just need to avoid alcohol clumsiness or an impulse emotional reaction to something, such as a conference call where Daniel was a participant. Thankfully, none of that happened.

I did not disclose my concerns because I did not want to seem controlling, but in hindsight, this would have solidified my role as a professional and communicated care. A novice mistake, I wanted her to see me as an ally or possibly even a friend on some level, though I was not aware of this at the time. This personal state of mind may have interfered with expressing my concerns directly at that time.

Atypical of my work style, I placed stability and structure as the focus of the initial sessions and her life, while not touching the alcoholism-in-the-room. I was afraid that if I tried to finesse recovery beyond minimal references to it, she would terminate therapy. It seemed to work. Charlie made every meeting with me and was actively engaged in her therapy. I’d asked her to try expanding and deepening her support network and she tried. We talked about developing a curiosity of others and using this a fuel for practicing casual conversation. She reported more conversations with her cousin in California and she stopped and chatted enough to get on a first name basis with a couple of her neighbors whom she met while walking Yoda. My plan was for her to achieve a set routine of basic self-care, physical hygiene, and an emotional hygiene of having a “no fly zone,” where she dedicated a set space and time to be work-free, even if just a half hour in her living room. From this, we’d then work on social hygiene—a routine interval of basic conversation with neighbors or others. Once these forms of care were in place and working with me was more familiar, then the odds of a conversation about alcohol being productive were greater.

“But then one day this optimistic effort all came to a screeching halt”. Her drinking escalated once again after Daniel began refusing to answer even her work calls. She had been redirected to a new administrator every time she tried to speak with him. Sessions were never the same. Her depression was escalating and riding right along with it was active suicidal ideation. She attended therapy without fully emotionally attending. She had this blank stare and even left early a few times, telling me she needed to go. I increased her sessions to twice a week, and to my surprise, she complied, no longer leaving early. Her disheveled look returned and gone was the new ponytail and barrette she began wearing just a few sessions ago. I felt like I was watching a flower shrivel up in anticipation of the inevitable. I wished she had better care than what I was providing, to then have better results—less pain. I knew referring her out would be seen as abandonment. I also knew she had made progress.

Though she kept showing up, she was becoming more and more zombie-like in sessions. One day she had a mark on her cheek, but shrugged her shoulders when I asked about it. It matched dark circles under her eyes. Next I asked about her drinking and got the same shoulder shrug in response. And then I asked about wanting to live. Void of emotion, she shook her head no.

"But what becomes of Yoda?"

"I'm thinking about taking her with me."

That's when I knew I needed help.

I asked her to help me understand what that meant. She said that was a “nice try,” but that she had already said too much about it. She then said that she “must leave” but would be back for her next appointment.

The Ground That Was Gained

After Charlie left that session, I broke her confidentiality by speaking with the psychiatrist from her company’s HR network. I had a release from her original paperwork and did not mention this to her at her next appointment. She sat down, looking slightly more rested. I told her she needed intensive treatment and that residential detox and weekly group therapy were my minimum requirements for us to continue working together. She refused and tried to talk me into keeping things as they were. I terminated our work, making it clear she could contact me any time after completing the two requirements. She denied any ideation during this last session.

I felt a combination of self-serving relief from a challenge being taken away from me, second guessing what else could benefit her right then as some sort of discharge plan, and some faith that she had an inner resilience.

To me, this was not a complete failure because, in my experience, people never lose the ground they gained while in therapy. They may disregard it, but the experience of having learned cannot be deleted—it happened, learning happened. I knew this logically, but this was sad for me. The magnitude of her suffering, the factual collective meanness in her experiences of the world, felt sad to witness. I wanted to alter it, or rather, have her alter it, and for me to be able to provide what was needed to empower her to do this. No matter the logical argument that some progress was made, pain won that day. I felt sad, scared for what she might do—but I did believe she would survive. I questioned my motives—did I want to end the risky work for my own benefit? Though she could make it less risky with compliance. In a way, I did feel some relief, but not enough to acknowledge at the time.

Epilogue

Five years later, the mystery of what happened to Charlie would be solved quite by happenstance, when I ran into her on one particular sunrise. We literally crossed paths as I was headed to my car after a run. Charlie seemed happy and calm. She was walking her dog, a new puppy she introduced as Chewy, and told me she was married to an artist. We briefly joked about the unofficial pre-sunrise running/walking community. With the laughter in place, I smiled and said it was good to see her, and resumed my morning activities. I wasn’t able to grasp the meaning of that encounter at that time beyond an intellectual level. The significance was that this was someone who once wanted to die and now was walking her puppy, happily married and healthy in appearance.

I’ve thought often about the weeks it took for Charlie, someone so successful and yet struggling so much, to express her suicidal feelings to me. Since suicidality has an aspect of masking, it is only natural for a client to keep it hidden at first. We therapists get it—why would someone who feels so little power be eager to turn over the one thing they have control over? And to a stranger, no less? It makes sense that they’d feel it might be too early to know what this relative stranger would do with the information.

But then, what can we really do once a patient does make the declaration? Yes, we can thoroughly access the ideation. Is it active or passive? Longstanding or reactionary to something recent? If active, how likely is the plan to be attempted and, if passive, how likely to progress to active? But really, we are just people, with our own subjective views, painful memories and blind spots.

We have the capability as therapists to gain entry into our patient's lives, learn the particulars of how they see themselves, who they want to be, what they want in life, what they see as impasses, how they feel. We are given access to the personalities and relevance of spouses, partners, exes, family, friends, co-workers and neighbors. We offer validation to people who feel misunderstood. Sometimes we help them to connect the dots, making what feels confusingly fragmented into related parts that share a pertinent life-theme. We do this by offering clinical explanations for what they describe as struggles, helping them see the relationship between what they are experiencing and their own internal motivators. At once we are both the motivational cheerleaders and the "Keepers of the Gloom" (borrowing from Robert Plant). But at no time are we mystical fortune tellers and at no time can we clap with one hand. “When it comes to suicidality, we aren’t the only link to staying alive”. We’re one in a chain of a system of care that’s there not just for them, but for us too.

In retrospect, I told myself that breaking Charlie’s confidentiality those years before was supposed to feel like being clinically responsible. Despite my direction, at that time, I felt like I was some kind of a turncoat traitor, even as I was dialing. After some exchanges and being transferred, put on hold and transferred again, I was trading information with the director of human resources for the entire company. He was a clinical psychologist who had an Ivy league quality. From my Philly background, I placed his accent as having a familiar quality, from what I always saw as the “other” Philadelphia, and I later learned that he was adjunct faculty at Penn. I gave him a full overview of Charlie, her progress, her impasse and the status quo. I felt a phone version of “active listening” and from his prompting, I felt comfortable continuing. He continued to ask questions that encouraged more information from me. Finally, I had said it all. The specifics of what he said escape me now, other than one surprising thing. He said that he thought I would benefit from looking at why I accepted this case in the first place. His direction felt like it should feel uncompassionate, but it did not, rather it felt sincere and matter of fact. Surprised, sad, somehow oddly feeling vindicated, I thanked him for his time, and without asking the actions he would take-or not take, we ended the call. 

Dual Aspect Monism: Centering Psychotherapy on Mind

Posted on by Psychotherapy.net Team

“My brain needs to be fixed.” My prospective client looked down, then up, to search my eyes.

The statement is deceptive in its simplicity. I feel an involuntary retreat from almost all the multiple layers of meaning I can fathom for the utterance. I don’t think my client’s neuro-chemical functioning is the cause of his pain. I think I can help him more effectively if we explore his mind.

Back in the day, there was body, and there was mind. Medical practitioners treated bodies. Therapists and analysts treated minds. Every binary hides a hierarchy: the people who treated bodies were highly respected. Those who treated minds were considered, well, a little off.

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Then people started realizing how much mental and physical functioning affected each other. They can’t be completely separate. The obvious solution (that preserved the hierarchy) was that mind must be an epiphenomenon of brain. Somehow, matter (brain) behaves in a way that creates a non-material phenomenon (mind). The battle cry became “mental illness is disease of the brain.” If you believe that mental illness is a disease of the brain, the way to fix it is to alter the brain. Chemically, surgically, magnetically, whatever. Talk therapy in this scenario is a poor substitute for direct neuro-chemical intervention, and one glorious day we will remember psychotherapy as a treatment analogous to applying leeches.

Except…logic dictates that the effect cannot impact the cause. The effect cannot precede the cause. So, if mind is caused by body, then mind cannot, logically, affect the body; a change in mind cannot precede a change in the body. And yet we know that it does. So maybe mind exists separately from the body after all? But if they’re separate, we’re still left with the problem of how two completely separate things can interact with and affect each other, as we know mind and body do.

As an ontological position (a statement concerning the nature of reality) offered by some philosophers of mind, Dual Aspect Monism offers a simple solution. The position is that there is a single reality that has two equal and irreducible aspects: mind and matter. Prior to the development of Dual Aspect Monism, there were basically three competing views concerning what is real. The dominant view today is Material Monism. From this perspective, reality is believed to be that which has physical properties. If you can’t measure it, it isn’t real. From this perspective, mind is the product of physical (neuro-chemical) activity. Idealistic Monism is the view that what is real is mind, and that matter is an illusion generated by mind. The third ontology is Dualism, which posits that mind and matter are both real, but they are completely separate realities. If they are completely separate realities, it’s hard to imagine why changes in one covaries with changes in the other.

According to Dual Aspect Monists, there is a single reality that is both physical and mental. Neither of these aspects is derived from or reducible to the other. These aspects are like two sides of a coin: you can’t make the head side of the coin square without altering the structure of the tail of the coin. But this does not mean that the change in the head caused the change in the tail. It is the change in the coin that changes both the head and the tail. When we use this analogy to understand humans, we see that some changes are more easily accomplished if we focus on body (I would not suggest that we focus primarily on mind to treat cancer), others may be more malleable by focusing on mind (I would not want to give a client a drug to help them develop a more fulfilling sense of self).

The implications are profound for psychotherapy: if mind is real and irreducible, we can legitimately aim our interventions directly at mind. We can use our minds to help clients change their minds. That means that our minds are the mutative factor in therapy. More precisely, the connection between our mind and the client’s is the mutative factor in therapy.

This means that some of the most profound changes our clients experience are changes in qualia (purely subjective experiences), and hence difficult to put into words, let alone observe from some outside objective position. It means that we know when our clients are improving because our minds are working together, and when their minds change, ours does too, a little bit. It means that what I do/say next is completely dependent on what my client and I are experiencing in the connection, not on some pre-determined protocol. That, in turn, means that my mind must remain attuned to the connection between our minds, not busy trying to problem solve, predict, or control the direction of the process.

We are psychotherapists. Many of us entered this field because the human mind is fascinating to us. Some of us have felt that the understanding of what we do has been slowly eroded as mind has become more and more devalued as an epiphenomenon of body. We always knew the two were connected (Freud was, after all, a neurologist). But many of us also know that what we do is not best captured by purely physical descriptions, or best understood using methods designed to understand the physical world. For us, dual aspect monism offers a way of understanding the world that explains what we do.

“Can you tell me what it feels like for your brain to be the way it is?” I try to join my client’s quale. By seeking to do so my mind reaches out, searching for, inviting a connection that can lead to change.  

It’s Time for Supervisors to Help Clinicians Marry Data with Intuition

Posted on by Psychotherapy.net Team

“It’s easy to lie with statistics, but it’s hard to tell the truth without them.”
—Andrejs Dunkels

Nearly every therapist I ask says that they regularly monitor the progress of their clients. Besides, why wouldn’t therapists check in and ask for verbal feedback?

Yet, given our clinical expertise, how is it that the assessment of our client’s progress is often inaccurate? In addition, why is it that therapists’ view of the process of clinical engagement is less predictive of outcome than that of their clients?

I believe this is because of our over-reliance on clinical intuition. We are trained to listen and take heed of our gut sense. Don’t get me wrong; intuition is critical, as scores of studies on this topic will attest (see Gary Klein’s body of work). Yet, relying solely upon clinical intuition is like asking a physician to treat a patient without the use of a stethoscope, a thermometer and the results from a bloodwork.

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From Assessment Thinking to Conversational Thinking

It’s time that practitioners learn to use outcome measures and engagement tools as part of regular clinical practice. And not merely as assessment tools, but as conversational ones. And to make this happen, clinical supervisors need to be on-board, trying it for themselves (especially if they are also practitioners), learning as much as they can about how to integrate measures as part of treatment and then teaching them to supervisees.

I once had a supervisee who wanted help getting “unstuck” with a client. We talked at length about the presenting concern, clinical background and what she had previously tried. The supervisee and client had just completed their 4th session when the therapist described that “things aren’t moving.” In other words, there was no discernable clinical progress.

Therapist View of Progress in the First Four Sessions.

I asked if she used any form of measures in her work. I learned that this therapist had been using outcome and alliance measures in her practice, but had not reviewed the graphic description of those measures. She was using the measures only because the management team insisted that she do so. I suggested that she bring the graphs to our next supervision meeting.

Here’s what the graph looked like:

Therapist View of Progress Alongside Client’s View of Session-by-Session Progress and Engagement

Even though there was a dip in the alliance at the 2nd session— a rupture from which the clinician was able to bounce back—contrary to her perception, this client’s experience suggested that outcomes were gradually improving. Not only was the therapist’s appraisal off the mark, but the plans we had devised with which to repair the perceived rupture were not right for the context. It was like wearing winter clothes in anticipation of being in the frigid Alaskan north, but instead finding ourselves baking on a beach in Bali.

We went back to the drawing board. We spent time working through the supervisee’s uncertainty and anxiety about her perceived lack of progress, while keeping in mind that the client was clearly perceiving and experiencing benefit from the engagement. As it turned out, the therapist was torn between addressing the psychiatrist’s referral concern of OCD, versus the client’s implicit desire to improve his relationship with his father. Thankfully, the therapist maintained fidelity to the client’s rather than the psychiatrist’s concerns.

In supervision, we re-focused our attention around attending not only to this particular client rather than the referral source, but how to do so with future clients so we could also address the perceived need of their referring sources. More importantly, the therapist needed to unpack and clarify some inferences about what she was doing and thinking that might have contributed to this gradual improvement, despite thinking that none was being made, so that she could continue doing so.

In this instance, thankfully, the client was improving. However, the opposite can just as easily happen, i.e., when we think that improvement is being made, but the client reports that “things aren’t moving.” When intuition and real-time data are either out of synch with each other or not taken together into consideration, clinicians (supervisees in this case) are prone to self-assessment bias. While we are re-playing mantras in our heads that say, “The clients will get worse before they get better,” we quickly realize that our client has dropped out of treatment.

Quick tip: In clinical supervision, make sure that supervisees bring in graphs of the client’s outcome and engagement. This is one critical way to privilege the client’s view of progress and engagement across time, while incorporating it into supervision. In turn, we can also monitor the impact of the “backstage” conversation of supervision on client outcomes.

But Why?

Here are two primary purposes for weaving ongoing measures into therapy and using them in clinical supervision:

1. At the Client Level

a. Guide the treatment process: “Are we on-track, or are we off-track?”

b. Use the feedback to feed-forward: Real-time feedback allows you to tweak the service delivery to fit each client, each step of the way.

2. At the Therapist-Level

a. Effectiveness: If used systematically, session-by-session with every client, the
therapist can figure out the nagging question at the back of all our minds: “How
effective am I?”

b. Individualized Development: Once you figure out where you are with the help of a
supervisor who is attuned to this type of process, you can start the journey of figuring out
“where you need to go” in your individualized professional development. (More on this in an upcoming blog post).


There may be many reasons not to use routine outcome measures in therapy, and only a few good reasons to do so. Personally, I am not a fan of numbers. The irony is not lost on me being Chinese and failing math (and Mandarin) in my early years. Besides, it is not as if therapists around the world need another thing to pile onto their existing and ever-growing paperwork! Yet, the benefits far outweigh the costs of not integrating some form of measures—tracking what is of value to the client.* A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduce deterioration in client well-being by a third, but doing so cuts drop-out rates by half, and as much as doubles the overall effectiveness of therapy.

The use of intuition without high-value data** is like trying to drive in a foreign country without a GPS or an old-school map. It’s possible to still get to your pinpointed destination—especially if your sense of North is better than mine—but the journey is likely to be mired in and derailed by unwanted detours. On the other hand, the use of data in the absence of intuition is like blindly following your GPS into a ditch, when the new road, which is just to your left, has simply not yet been updated into the system.

The knowledge gained from the marriage of data and clinical intuition contributes to a type of dialogue that is richer and aids clinical decision-making. Sometimes, client-reported data confirms what we intuit. Other times, the data contradicts our gut sense. The point of monitoring progress and weaving it into clinical supervision is not to defer all judgement to cold and unintelligent data. The point is to wrestle with this tension in order to see and think more clearly.

To learn more about becoming a better supervisor, check out the in-depth online course, Reigniting Clinical Supervision.

Notes:

*It is highly possible to be measuring something systematically that is not relevant to your client. For instance, capturing data without integrating the measures to inform the treatment process. Second, dogmatically using a symptom-specific measure that may not make sense for all your clients. This is why it makes more sense to be capturing information about a person’s global wellbeing.

** Data is only valuable when you are not valuing whatever you measure but measuring what is of value. 

The Performing Art of Therapy: Acting Insights and Techniques for Clinicians

Posted on by Psychotherapy.net Team

“Where does the actor acquire the understanding that for the doctor takes years of study?"
-Theater Director, Peter Brook

Act I: Therapists as Performers

Therapist, you are a performing artist, whether you realize it or not!

The moment a client enters your office, you are on stage, face-to-face with an audience, a scene partner, and a variety of characters you do not yet know how to play (after all, our clients both become and cast us in all of these roles faster than we can say, “How can I help you?”). And every move you make—or don’t make—influences the treatment, the play, the story you tell together.

“Like actors, as therapists our appearance, aura, voice, and relational responsiveness often leave stronger impressions on clients than the words we say or the techniques we use”. This is not to say that our clinical training is of no use; of course it is. But effective technique is less about what we do—less about reading a script by rote—and more about how we do it, how we use ourselves, how we perform our interventions.

When you watch actors performing in movies or plays, do you think about their techniques?—whether they used Strasberg, Adler, or Meisner? Probably not. You are more likely moved by the performers themselves—their ineffable presence, their use of self. Likewise, our clients are more affected by us than by our schools of thought—whether we studied psychoanalysis, CBT, or family systems.

No matter what kind of therapist you are, if you approach your work like an actor—or better yet, like a performing artist in your own right—I promise you will become more awake, alive, and engaged with your clients, while also having a greater capacity to care for yourself. I offer this promise as a psychotherapist who has used my experience as a trained, professional actor every day.

The skeptical reader may think that the words “perform” and “act” don’t belong in the therapy office. When I tell people that I use my training and experience as an actor more than any other resource as a therapist, they often take me to mean either that I’m “fake” with my clients, or that I deploy literal dramatic exercises in session. I’m not (or at least I try not to be) fake with my clients, and I rarely, if ever, use theatrical interventions in session, unless I believe they might be useful for a specific client in a specific moment. However, when I simply think about my clients the way actors think about their characters and scene partners, I enhance my capacity to dive into the deep end of their stories, beyond the words they speak—their “scripts”—even when I do nothing more than listen to them compassionately.

I may not end up doing anything radically different in session from what any other clinician might do instinctively. But by thinking of myself as a performing artist, as opposed to just a clinician, I find creative ways to join my clients in their emotional subjectivity, relate to them like a character who can help them grow, and allow myself to expand personally in the process.

Again, to be clear: “Acting” does not mean being fake, it means finding truth within a given set of circumstances. So, in that sense, “as therapists we are all actors: we use our selves (our primary instrument) to help bring other people’s authentic selves to life”.

Below is a pair of vignettes, each including a significant learning moment for me as an actor, and a corresponding revelation as a therapist. These dramatic/therapeutic narratives, illustrate how my use of self helped me to pursue the three main objectives that apply to the creative process of both artforms:

  1. To create a treatment frame in which our scene partners feel safe, oriented to the nature and purpose of our work, and free to participate in it.
  2. To join our clients in their emotional subjectivity, like actors embody their characters.
  3. To relate to our scene partners as a character who can help them to heal and to grow.

Act II: Using My Self as an Actor

I was 20 when I was cast as the gun-obsessed Quigley in Hyperactive, an edgy play about teen angst by Olga Humphrey. Quigley was described as a “masculine, hard-edged” adolescent, whose favorite magazine was Soldier of Fortune. I was an effeminate, soft-natured man, whose favorite magazine was Entertainment Weekly—in other words, nothing like Quigley. But I was also an actor, and as an actor’s my job is to find diverse characters within myself, even if they seem very different from me on the surface.

Other than having a teenager’s build, the only quality I seemed to share with Quigley was the determination to prove my worth. In my case, proving myself not only meant getting hired, which I did, but also finding some genuine version of this unlikely role within me. My greatest challenge was to make an empathic connection with Quigley’s bullish personality, his gratuitous language, and (most difficult of all) his obsessive, violent fantasies. All these qualities—or symptoms, if you will—made me extremely uncomfortable and seemed to alienate me from him, rather than to invite me into his emotional world.

My first task was to create a framework for my rehearsal process, within which I would have room to discover and explore who this person was, through trial and error—ideally without judging him. Rather than begin with preconceived acting choices for Quigley—much like therapists are often tempted to impose treatment interventions onto new clients—I needed to find a way to let him speak to me on his own terms. And since my head could not make sense of this boy, I had to find a way to access him viscerally—using my body, voice, and imagination.

As I began reading his crude and aggressive lines aloud at our first rehearsal, I imagined I was one of the bullies from my own high school past. I widened my legs, puffed out my chest, and spoke with an affected tough-guy bellow, straining to produce the intimidating, nasty persona adopted by so many males from my youth.

The result was what the kids call a “fail!” “My performance was cartoonish and over the top”; I’d created a caricature, not a human being. “Um, that’s a bit much,” my director said, with a penetrating squint of disdain in her eyes. Humiliation flooded my body and shut down my spirit. My effortful impersonation seemed to expose my limitations as both an actor and a man. I wouldn’t need to try so hard if I was actually talented or masculine enough, I thought to myself, further shamed by my inner critic.

But in the same moment, a window opened for me into Quigley’s inner, subjective life. I had unwittingly, but effectively, joined him in his debilitating self-consciousness, vulnerability, fear, loneliness—and self-hatred. His core intention wasn’t to intimidate and destroy other people, I realized. Those behaviors were secondary to his primary objective: to protect himself, validate himself, survive.

With those visceral motivations living in my body and mind, I could commit to Quigley’s macho expressions while maintaining an underlying sense of vulnerable truth. And as I played with this duality—grounded in my own fear of failure, and my instinct to overcompensate for it—I increasingly understood how he/I was motivated by a desperate need to be validated by other people. I could now bring a genuine version of him (and me) into the rehearsal studio with my scene partners, supported by the technical breathing and vocal exercises, as well as mind/body practices I had developed in drama school. (Again: the creative use of oneself is not a replacement for technique, but rather it informs the performer of what specific moves we need to make at any given moment in our scene work.)

By the time the production was on its feet, I was able to embody Quigley without extraneous effort: from his brusque introduction to his cathartic end, in which his mother and best friend hold him in their arms and thwart him from carrying out a violent attack on his classmates. Actors often try to force emotion and tears in high-stakes moments like this—not unlike therapists when we impose heavy-handed clinical interventions onto challenging clients we want to “fix.” As my actor friends say, we often try to “play the end of the scene” too hastily, rather than allow ourselves to be present in every step of the journey.

But I didn’t have to strain myself to find Quigley’s deep-rooted pain for this scene. All I had to do was surrender my feelings to my scene partners, with whom I’d cultivated a great deal of safety and trust throughout our creative collaboration. As we performed the climax of the play, Quigley’s taut energy thawed from my jaw, neck, and shoulders—where it had been deployed as a shield—and it dispersed throughout my body, accessing a range of other emotions. In fact, at one point I awakened to the insight that all along Quigley had been defending against, and overcompensating for, the absence of his father. It’s an abstract clinical exercise to analyze a data point like this about a person’s life, either in a script or a psychological evaluation. “But when we make efforts to join that person in all their subjective bodily, emotional, and intrapsychic complexity, we expand our capacities for empathy”, mutual recognition and creative transformative action, both on and offstage, in and out of therapy. Best of all, we learn to relate to that other person (character or client), no longer through the trailing edge of their transference, as the recipient of their resentment, frustration and fear, but through the leading edge of their transference—as the embodiment of their generative desire, longing, and hope.

Act III: Using My Self as a Therapist

Harry burst into my office each week like he was in a race against time; he wanted answers, and he wanted them fast. A straight, white, corporate millennial, he was used to instant gratification, and he expected no less from his therapy. He emphasized that he already understood himself “extremely well,” and that all he needed from me were “professional tips” to reduce stress in his highly successful life.

I was flattered; I’d been cast in the role of commercial guru, the kind who might dominate the American market with bestselling, confidence-inspiring catchphrases. Except I felt too slow, discursive, and insecure to play this part for Harry, more the man behind the curtain than the great and powerful Wizard of Oz. Each week, I expected him to look at me incredulously—much as I’d feared audiences would respond to me portraying a butch, gun-wielding teen—and see that my training and degrees were all a sham. I anticipated the day he’d tear back the curtain and expose me as the talentless hack I felt myself to be in his presence.

On the plus side, Harry showed up for our weekly “rehearsals” consistently, which spoke to the frame I had provided, which apparently made him feel safe enough to “play” with me. But each scene between us had a palpable yet indiscernible tension. First, he’d summarize his week, speedily and with the energetic poise of a cocky movie star—shoulders back, chest protruding forward, eyes sparkly with intense self-assurance. Then he’d present a dilemma—“I need to make more time for relaxation and balance,” for example. At this point, he’d look to me as if to indicate it was my turn to perform, and to prove I was a worthy scene partner.

I would then try to seize the spotlight, so to speak, masking my self-conscious insecurity with a commanding delivery of a line like, “I recommend yoga, three times a week. Put it in your calendar.” I was desperately trying to personify the omnipotent coach I imagined he wanted me to be. And though my “acting choice” arguably answered Harry by his own method, it felt as though I was trying way too hard to impress him—much as I had overcompensated in my bullish portrayal of Quigley, as I stumbled through my first few rehearsals of Hyperactive.

Eventually, I’d look back on these moments and realize how all these unnerving sensations could help tune me in to Harry’s complex internal world, and to join him there. But in the meantime, I felt blocked, like a superficial actor who failed to connect with his character on a deep personal level.

Over time, it became abundantly clear that Harry couldn’t be bothered with my attempted interventions. He’d wince disapprovingly at my suggestions and say things like, “Yoga never works for me. I just end up obsessing about the more productive things I could be doing with my time.” At the end of our sessions, “he’d stride out of my office with a proud posture, leaving me behind to reel in a slouch of inadequacy”. I couldn’t seem to reach him, no matter how hard I tried. I felt like the FBI agent Tom Hanks played in the movie Catch Me If You Can, endlessly chasing Leonardo DiCaprio’s slick and wily character, a master of escape.

This frustrating dynamic manifested in a number of ways between us, including our weekly schedule. Harry would frequently ask to alter our meeting times due to his ever-changing obligations, and I’d accommodate him more than I wanted. I did this because I was afraid to disappoint him. Not only did I sense he’d fire me if I didn’t manage to keep up with his demands, but more significantly, I had an inexplicable sense of dread that he’d erase me from his mind entirely if I let him down. Unwittingly, I was tuning in to Harry’s inner life. I could feel his deep ambivalence about trusting and depending on people vibrating within my own body. And as it turned out, my fears were not unfounded.

One day, after two years of working together, Harry raised the emotional stakes of our scene work. I was running behind (by about a minute), between notes and phone calls, and he had no intention of waiting; it was his time, and he’d enter my office if he wanted to. I was completely shaken off-center as he blasted through my door. Within the flicker of a second, my face flushed with a combination of shock and shame, but also disapproval and a smidge of anger.

As we made eye contact, Harry stopped in his tracks—and his reaction to me was startlingly evocative. While his body asserted its typical conviction, his eyes betrayed a doubt, fear, and deference that I’d never consciously sensed from him before. Since I was too caught off-guard to address this novel improvisation between us in the moment, Harry made a beeline for the couch and shared his latest dilemma as if nothing had happened.

The latest dilemma, it turned out, was that his long-term girlfriend, of whom he’d always spoken glowingly, had proposed to him. “It came out of nowhere!” he exclaimed wide-eyed. “I was totally thrown off my game. Shaken.” Hmm, like what just happened to me now? I thought to myself. “We’ve talked about getting engaged for a while,” he continued, “but I just thought when it happened, it’d be…different.”

“You mean you thought you would be the one who proposed?” I asked.

“Well, yeah,” he replied. “I mean, not because of gender roles and tradition and all that. It’s just…I would’ve made sure it was perfect.”

“What would you have done differently?” I asked.

His eyes squinted as he struggled for an answer. “I guess I just wish she…” he paused for a while, “seemed surer of herself?” As we talked, he realized that this proposal had surfaced an implicit contract in their relationship: that he was in charge of their major decisions as a couple. His girlfriend had gone out on a limb and broken that contract—and now Harry was struggling to understand why he didn’t feel safe following her lead.

Uncharacteristically, his body sank back into the couch as he stared blankly in silence for a while. Finally, he spoke again: “Maybe she’s not the right partner for me.” There it was, the confirmation of my underlying fear; if his long-term girlfriend was expendable, so was I.

“It’s normal to feel a range of emotions at a pivotal time like this,” I said in an effort to validate him. “I appreciate your confusion and doubt, and since your girlfriend seems willing to give you some time to reflect, I suggest we continue talking before you make any big decisions.” He seemed momentarily held by this, but as I watched him take a minute to shield himself with his typical smug poise before leaving the office, I understood deep inside that this sense of security was tenuous, for both of us.

“Harry colonized my mind for the rest of that day, much like a challenging character might consume me as an actor”. At home, I looked in the mirror and tried to emulate his self-possessed posture. As my shoulders dropped back and down, my chest expanded, and my eyes and mouth affected Harry’s cool-guy charm, I began to recall the unpleasant sensations I’d get when trying to play the part of his expert guru. The external posturing I would affect at those times didn’t feel grounded in confidence, but instead seemed to serve as a shield to my internal self-doubt and fear of rejection.

Suddenly, I understood that the same was true for him. The look on his face when he’d barged into my office earlier that day, and the months and months of tension between us, began to make more sense. And as I joined his mind/body experience of self, I realized that what he really wanted was not for me to catch up to him or project the same overcompensating confidence that he did, but to get ahead of him. He longed for me to become someone who could set boundaries with him, disagree with him, and ultimately, care for him—without getting caught up in the same debilitating self-criticism that plagued him. But how could I successfully embody these qualities in the therapy room, and become the character with whom Harry longed to relate?

I thought about the end of Catch Me If You Can, when Tom Hanks learns to approach Leonardo DiCaprio no longer as an elusive fugitive, but as a boy abandoned by his father. I thought also of Harry’s father, who’d died suddenly of a heart attack when Harry was a child. Gazing in the mirror and focusing on the sensations within, I rediscovered what I had first learned with Quigley: biographical details about clients and characters alike resonate within us much more richly when we embody them, rather than simply study or analyze them. I then shifted roles and explored ways that I could present myself to Harry that might make him feel safely held.

I drew inspiration from men, in my life and onscreen, who were both palpably strong and nurturing, including Tom Hanks, Robin Williams, and Barack Obama. I considered their physical groundedness, the clarity of their thoughts, as evidenced by the easy poise of their heads, but also, most significantly, their emotional openness, illustrated by the lack of tension and flow of energy in their chest region.

As I played with where I felt these qualities in my own body, I didn’t try to impersonate the men superficially, but to connect with the experiences in my life—like caring for my younger brothers when I was growing up and being a camp counsellor—that brought out the warmth and confidence Harry needed from me now.

“When Harry next raced into my office, I was prepared to get ahead of him, and relate to him with focus, calm, and an embodied sense of security”. As we revisited the previous session, I validated his anxieties about depending on his girlfriend (or any intimate “scene partner” in his life) and invited him to talk about the pressure he puts on himself to “be ahead” of other people, including me.

Throughout this session, there was more ease, vulnerability, and play between us than ever before. But it wasn’t what I said, so much as how I’d learned to be in the room with him, that made the difference. I was even able to recommend self-care activities like yoga, which he’d rejected in the past, in a way that he now responded to with complete openness—in theater terms, same script, better performance.

As Harry exited that day, he turned around in the doorway, took a moment, and then said through the shimmer of a tear, “Thank you.” I simply smiled in return, maintaining the combination of groundedness, strength, warmth, and vulnerability that we’d discovered together in our session.

Finale

While I waited for my next client, alone in my office, I reflected on the connection Harry and I had found, and I recalled an interview with Meryl Streep, in which she explained that in her view, her success as a performer was only as good as it was “the last time.” Thinking of our sessions ahead, I knew we could expect more tension, insecurity, fear, and doubt to manifest between us. But at the same time, I knew my acting training could help me perform on this different kind of stage, where we’d continue to explore various versions of ourselves together.

I initially felt I needed to be someone else in order to access both Quigley and Harry. Like so many actors and therapists, I am driven by the desire to please my collaborators, to be the “expert,” and to “get it right” on the first line reading. But at the same time, in order to connect with our clients, characters, and scene partners as performing artists, we must practice our craft with humility, patience, and the belief that we are enough. We must trust that if we show up to each “rehearsal” with the willingness to be fully present—along with our vulnerabilities, naivete, and deep self-reflection—we will give our creative partners what they need to be present with us as well. Especially if we engage each other in a process of imaginative, empathic play.

Through our respective play sessions, Quigley and Harry both showed me that their apparent toughness, butchness, and self-containment were part of me as well—keys existing somewhere within my instrument, even if I don’t embody them every day. But an even greater revelation for me in both cases, was that the idiosyncratic “soft” qualities that makeup my everyday self—and that I originally believed were obstacles to bringing both young men into the spotlight—turned out to be exactly what they needed to find hidden keys within their own instruments. By playing these untapped versions of ourselves—even, and perhaps especially, when we felt inadequate—each of us found a way to breathe, to integrate, and to become more fully alive.

Note: This article has been adapted from Mark O’Connell’s new book, The Performing Art of Therapy: Acting Insights and Techniques for Clinicians, and his article “Character Work: What Therapists Can Learn from Actors,” in the Psychotherapy Networker, March/April 2019 issue. 

Premature Endings: When Clients Leave Therapists

Posted on by Psychotherapy.net Team

Premature Endings in Therapy

In this blog post, I consider the impact of premature endings of therapy on psychotherapists in general, and on myself in particular. I am focusing here on situations where a client leaves and breaks off therapy without giving the psychotherapist any preparation for the ending.

In my clinical experience, few scenarios have been as challenging as premature client termination, especially when I have not been prepared for that ending, and/or it was not foreseeable at the time. Certainly, many clients do not return after the first or a few visits, but others break off the relationship after considerable work has been done.

This may be years-long, ongoing treatment which involves complicated work around critical and aggressive transferences, and client concerns around trust. In such a case, a client may use attacking defenses to provoke reactions from the therapist, reactions that will serve to prove that the therapist cannot be trusted.

If we think of Freud’s 1912 Remembering, Repeating and Working Through, we have to work with our clients knowing that the therapeutic relationship may be part of a broken repetition of a previous relationship, rather than a more complete and healing experience that culminates in successfully working through the client’s issues.

When there is a premature ending, the therapist is often left with the sense that the client has used the work and the premature ending to remain fixed within their problems, rather than be able to work towards a better solution.

Because the premature ending of treatment is always an ongoing occupational risk, it is helpful for the psychotherapist to have come to terms with the way in which his or her own early environmental and attachment failures and problems exist as real and deeply felt experiences that may not have been healed but had to be painfully and quietly endured. There may be cases where we have become deeply invested in long-term therapy, where we may have worked, alert as possible, to projections and different transferences.

When the work breaks off suddenly, it can wound us deeply and leave us with grief and loss, along with a profound sense of failure, disappointment and rejection. Sometimes this occurs with a client who may have been overly critical and anxious about trusting the therapist throughout the work. This can be particularly so in treatment which has gone on for several years and in which the clinician worked hard on the client’s behalf.

The Pain of Premature Client Termination

Such a difficult client-initiated termination happened to me last year and I found the suddenness of the ending extremely hard to deal with. I felt myself overtaken by painful grief. I went over and over the final sessions questioning myself as to what I might have done differently.

What strikes me about these kinds of situations is the way in which, after the ending, the client remains in one’s mind, the way the transference remains alive. For example, on coming into my consulting room after a break, I tidied the place up a bit, and could vividly recall the way my client would often criticize my room.

In the end, and upon reflection, I don’t think there was anything I could have done. In one way, it could be said that my client broke off with me the way her father had broken off with her. This was a client who had particularly strong and unresolved attachment issues in her very early years, had gone through the breakup of her parents’ marriage at age four, and had then lived with her mother and brother. Her mother then remarried a very abusive man and the client witnessed as well as personally experienced violent abuse.

During our work, her capacity to trust me was the paramount cause of her recurring anxiety. Progress might have been made, but the question of trust would always hang over us, and in the end, the breaking off of the work, I think, had very much to do with the question of her not being able to trust me.

It is a difficult burden for us to carry when we are left suddenly in situations like these, when we are very invested in the work. In fact, we may not realize how much we are invested until the work has suddenly broken off and we are left dealing with the ending alone and/or in our supervision.

I am aware of my enduring sense of attachment to my client, and that for a long time I still thought of the 6 p.m. Monday time slot as “her” session. When I gave it to somebody new, I had the sense that they only had it on loan from her. The pain of the difficult ending remained in my mind, thoughts, and psyche. I wondered if it remained in hers, or if by ending with me, she found the freedom to be creative in another area of her life.

Therapist Growth Through Client Transference

I say this because I was recently teaching a seminar on Freud’s 1905 case of Dora. One of the key events of that case was that Dora broke off her treatment. It may be that the energy Freud was left with in the abrupt termination was part of what fueled him to write the case up. This in turn makes me think of the acrimonious split between Freud and Jung, and the creative energy that was released in each of them following the breakup of their work together.

One interesting thing about the ending of Dora’s case is what she did after leaving Freud. Because she returned to see Freud, we know that she confronted Herr K about his advances towards her and received an apology from him. For Dora, breaking off the work with Freud can be read as part of her way of escaping the abusive paternal transference. For Dora, the right to break off the treatment was crucial.

Could something similar have been provoked in my client? Could it be that in ending with me she was starting something that would lead to healthy creative expression? I like to think so. This abrupt ending may have felt premature from my side of the couch, but it might have been right for her. Nonetheless, I am still left working on the painful sense of loss, and perhaps abandonment, that her premature separation evoked in me.

Questions for Thought and Discussion

How did the author’s reflections on his case resonate with you?

How have you dealt with clients who have terminated without explanation or warning?

How would you like to use the information in this essay in your own clinical work?

Think Act Be: A Whole Person Approach to Healing

Posted on by Psychotherapy.net Team

When John came to me for treatment, he’d lost his job a year earlier; at 58 years old he was not optimistic about finding a new one. Since then, he’d stopped exercising, his diet had deteriorated and he’d had a recent health scare. His relationships were also suffering, as he often argued with his wife, felt alienated from his adult children and rarely got together with his friends. He felt broken, and sometimes wondered if life was worth living.

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John’s situation is not at all uncommon. As one part of our life suffers, others often go down with it. What might start as a physical illness soon affects our minds, just as a psychological stressor like losing one’s job can lead to physical exhaustion and poor health. The cascade can continue and affect us at our core, leaving us feeling lost and dispirited.

I’m well acquainted with this downward spiral not only from my clinical work but from my own extended physical illness that resulted in social isolation and a major depressive episode. Eventually I felt like a burden to everyone and wondered if my family would be better off without me.

Just as our struggles often spread into many areas of our lives, our healing requires a multi-faceted response. My own approach as a therapist integrates cognitive behavioral therapy (CBT) with mindfulness, which I call “Think Act Be.” It’s a simple reminder of three interconnected paths to healing—Mind, Body, and Spirit (see figure).

When I’m working with clients I often ask myself which of these paths might be most helpful to them at this point in their treatment.

  • Are their thoughts serving them well?
     
  • Are their actions consistently rewarding them with enjoyment and a feeling of accomplishment?
     
  • Do they find meaning and connection to nourish their spirits?

Other clinicians before me have recognized the power of combining these three schools of thought (e.g., Mindfulness-Based Cognitive Therapy). Indeed, integrative approaches in general are commonly used by clinicians, whether or not they follow a CBT approach. Therapists of all stripes see the value in treating the whole person.

Bringing the Principles to Life

The principles of mindfulness-based CBT are very straightforward and easy to explain:

Foster healthy thinking.
Do life-giving activities.
Practice present awareness.


The challenge lies in bringing these principles to life, otherwise they’re no more effective than easy truisms like “be in the moment.” How do we retrain our minds? Which activities are the right ones for me? What are ways to practice mindful awareness?

In my experience, three ingredients are necessary to develop new and more effective habits that promote healing:

  1. A clear and focused plan
  2. Daily practice
  3. A wide range of practices
Without these three factors, we’re likely to slip back toward unhelpful thoughts and behaviors. Thus, each CBT session generally ends with planning for things to work on between sessions. This emphasis on consistent practice of new skills and techniques is part of what makes CBT effective.

In general, it’s best if the plan is written, which makes it much easier to remember and provides greater accountability. Some therapists write the plan on an index card so it’s easy for the client to carry it with them. That idea inspired me to develop The CBT Deck, a deck of cards printed with daily CBT and mindfulness-based practices. It includes many of the same techniques that John and I worked on during his treatment; example exercises from the deck are included in bold in the following discussion of his treatment and recovery.

John’s Recovery

In my work with John, we focused first on adding valued activities back into his life because this seemed like an area of “low hanging fruit,” and behavioral activation tends to pay off quickly. His activities included going on weekend adventures with his wife and doing fun things that also provided physical movement.

We also worked toward taking care of tasks around the house that he’d been putting off and on building positive interactions with others since his relationships had suffered. Given his health challenges, we worked on ways to improve his sleep and eat more healthfully.

Soon we began addressing his thoughts, starting with recognizing thoughts as thoughts. He identified an overly negative self-critical voice that told him he was “unwanted” and “useless,” which we worked to correct in various situations (see sample card).

Mindfulness became the third pillar of John’s treatment and recovery. Through different meditation practices he learned to quiet his mind and recognize its chatter, and could prevent himself from getting caught up in negative trains of thought. He also found relief from putting up less resistance to reality, instead opening to the unpredictability of life.

We worked together to bring these practices into his daily life and his interactions with others. Gratitude was also an important part of John’s recovery, as he started to notice how much was right in his life.

It was only a few weeks before John was feeling markedly better. That said, the improvements were somewhat delayed; he didn’t feel immediately better after the first weekend outing with his wife, and his mindset didn’t change miraculously after one week of working on his thoughts. Just as giving up life activities took a while to affect John’s well-being, so the effects of resuming them were somewhat delayed. This delay is part of why consistent practice is important; if a person stops the practice after a day or two, they probably won’t have gotten a sufficient “dose” to see real improvement—and may conclude prematurely that “it didn’t work for me.”

John and I met weekly for more than a year as the improvements continued. Eventually we tapered down to meeting about once a month, which John finds helpful to maintain the practices that keep him well.

Healing for All

After many rounds of inconclusive medical tests, I began to accept that a mind-body-spirit approach to healing was just as relevant for me as for those I was treating:

Think: I’ve found it extremely helpful to make simple adjustments to my mindset—for example, seeing myself as “still healing” rather than “still sick.”

Act: I threw myself into life-giving activities like gardening, where I can see the fruits (and vegetables) of my labor.

Be: I’ve given myself space to connect with deeper parts of myself that I’d forgotten about, including a renewed connection to sacred scriptures.

It might sound funny, but I plan to use The CBT Deck myself as a regular reminder of the kinds of practices that enrich our lives.

As you assist others in healing—or work toward your own—what framework do you find most helpful? In what way does your approach tend to the mind, body, and spirit?
 

Qualia and Quiddities in Psychotherapy

Posted on by Psychotherapy.net Team

In this world of S.T.E.M. (science, technology, engineering, and math) education and careers, I’m an outcast. I’ve invented a new word for my position: “ascientism.” I am an ascientismist. It means that I do not believe that science can answer all of the important questions in life. Let me be clear: I am not anti-science. I am not a climate change denier; I am not an anti-vaxxer and I am not a flat-earther. In fact, I’m an academic who does research (albeit qualitative). I think most real scientists are also ascientismists. I think that an exclusive focus on STEM education may impair a generation of psychotherapists.

On a basic level, many of us who prize science (I really do) do not believe that the scientific method can answer all of the questions that are relevant to existence, and cannot in-and-of-itself provide for the quality of life of the planet and its inhabitants. The scientific method, like everything, is highly biased, and can only point toward a limited type of answer to the limited questions that can be processed through the method. This bias strangulates those of us who wish to help people who are suffering in multiple complex ways.

The answers you can get from the scientific method are answers to questions about amount: a quantity. The rise of scientism has thus contributed to the quantification of life. Culturally, we judge everything based on its number. How important are you? Well, how much money do you have? How much do you weigh? How many social media contacts do you have? The numerical bias inherent in scientism skews our values. This leaves clients unsure of their own relevance as humans and leave us therapists highly limited in terms of how we can understand and help our clients.

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The skewing of values is exacerbated by the fact that the scientific method elevates “objectivity.” What objectivity suggests is that one can shut off things like feelings, desires and motivations in order to apprehend the world as it really is. This is neither possible, nor is it desirable. It has contributed to a culture that is affect-phobic. People think that they should somehow be able to free themselves of all difficult feelings. Don’t be sad, don’t be angry, don’t feel guilt. When we turn off our own feelings, we lose a great deal of important information about ourselves and the world. We also lose the ability to connect to the motivations and desires of others. This decimates relationships. How many of your clients have diagnosed themselves as socially phobic? Most of my late millennials and gen Z’s do. Scientism may contribute to this particular problem in living.

Scientism is not an alternative to fundamentalist beliefs, as so many of the social media memes suggest. It is one. And as a fundamentalist belief, it is not an appropriate belief system on which we should completely base psychotherapy. Do we need some science to help us understand problems in living and how to help people resolve them? Yes! And we need the humanities in equal measure. The branches of knowledge subsumed under the term humanities include art, literature, music, history, philosophy, religion and language. They are called the humanities because they all in their own ways explore what it means to be human and some of the variations in the human experience. One of the advantages they have over the scientific method is that they explore humanity in the particular (an ideographic view), versus humanity in the abstract (a nomothetic view). We don’t work with aggregated “humanity.” We work with actual, concrete people whose complexity and uniqueness cannot be captured by any nomothetic technique or description.

We help people whose lives have been so quantified that they have no idea who they are or why they exist. Then we ask, “what is the frequency, intensity, and duration of these specific symptoms of codified mental illnesses?” We put more numbers on them. A humanist-enhanced therapy explores qualia and quiddities over and above symptom counts. Qualia (singular, quale) are “what it’s like.” It is a subjective experience that is difficult to succinctly describe. What is it like to fall in love? There are times these experiences undermine one’s well-being and become habitual: all experiences generate the same qualia. This then becomes the focus of change in therapy. As difficult as these experiences are to put into words, the process of attempting to understand, and to a small degree share, someone’s qualia is at the heart of ascientismist therapies.

The word quiddity means “essence.” Quiddities are those things that make an individual unique among humans: their particularities. “Who are you? How are you special?” Therapy becomes an opportunity to help people celebrate those quiddities that enhance the client’s quality of life and alter those that contribute to problems in living. This is an old kind of therapy. Perhaps what is old can become new again.

Yes, use science! Read outcome studies and meta-analyses. They are helpful. Also read religion, philosophy and literature. Attend to your clients’ language. Ask about what music and other art forms they enjoy. You might even “prescribe” specific artistic expressions to open up your clients’ experiences and trigger specific qualia. By all means, inquire about your clients’ religious/spiritual beliefs. Much of therapy often becomes helping them develop or refine their beliefs in meaning-systems. The meaning system does not need to be any organized meaning system, such as a religion or specific philosophy, but it can be.

Life is more than numbers. More than how many symptoms you have, more than the number of likes you get on a social media post, and for us therapists, more than a client’s score on a diagnostic or even treatment rating scale. But the STEM wave has some serious shortcomings. The humanities are necessary areas of knowledge for psychotherapists who wish to help people free themselves from the quantification of their lives. The humanities help us understand and celebrate or contribute to change in our clients’ qualia and quiddities.  

How to Master the Art of Developing Your Therapeutic Voice

Posted on by Psychotherapy.net Team

Becoming an Artist

Surrounded by a sea of attendees at Psychotherapy Networker’s annual conference, I waited to ask my hero the question that had been burning inside. One man, with an uncanny resemblance to Sigmund Freud, entranced us yet again with a story of the work we’d all been celebrating and emulating in our own offices for so many years. Our master clinician and storyteller, group therapy guru, and most importantly, the single most generous and open discloser of his clinical process, Irvin Yalom was reflecting on his lifetime contributions.

It was now our turn to ask him questions. “Dr. Yalom, you’ve shown us how to embrace the process, and as the poet Rilke advised, to: ‘be patient toward all that is unsolved in your heart and try to love the questions themselves.’” Was I even talking into the microphone? The notes on my phone bounced out of focus, but I pressed on.

“Like jazz musicians, you’ve reminded us to enjoy the dissonances and savor the surprises we find within them. Can you talk about that, the role and importance of being an artist in our field?” I was grateful when he acknowledged that yes, he had thought of calling his book Letters to a Young Therapist after Rilke’s famous missives. “Even though I idolized so many, no, no, I never thought of myself as an artist. Even though I had wanted to be one, it wasn’t me!” It was like I had framed the wrong man. With him ready to quickly move on, I was stunned, stung, crestfallen. If Yalom couldn’t recognize being an artist, how could any of us?

Luckily for me — and us — Sue Johnson, the puckish British couples therapist and our evening’s interviewer, held him up a minute to take stock of his knee-jerk demurral. Wasn’t his work — its graceful storytelling and open embrace of the therapeutic process a testament to the power of our art to heal and enlarge? Was this any less artistic than the poet, musician, or actor’s craft?

Yalom’s initial objection ripened into delight on stage, and after the conference, in a private email, he thanked me, stating simply, “I’ll remember your comment for a very, very long time.” That’s what this essay is about: the artistry of our work and how we develop a therapeutic voice to help us get there. This is vital not only for ourselves and our supervisees, but even more so for our clients, who cultivate their own voice in the interplay with ours. Happily, there is ample scientific and empirical support for this artistic venture and cultivation of the voice, and I will use it to contextualize and illuminate our journey along the way.

Finding Our Voice

All artists — whether writers, musicians, or actors — must develop a voice, that hard-to-define yet distinctive style which runs like an invisible thread through their work, opening a space of creative possibility between their art and audience. As a supervisor of beginning therapists, I view this as essential, and liken it to the process we see on television each week on the show “The Voice.”

Just as Kelly Clarkson, Blake Shelton, and Adam Levine compassionately and thoughtfully mold, mentor, and inspire young talent, so too must we as supervisors help our beginning clinicians. Each has their own music and style they come in playing, and supervisors help them draw out their raw talent, experiment with new genres, and ultimately learn about how to make music that is, as Duke Ellington said, “beyond category.” This is therapy that transcends theoretical orientations, becoming a unique blend of the clinician’s theoretical and empirical knowledge, their personality, and emerging therapeutic repertoire.

There is a yin and yang here that, when in proper balance and harmony, lead to a fully developed artistic voice. This voice not only serves the therapist but promotes the opening and expansion of the patient’s own voice, becoming the driving force of creative therapeutic work. This also forms the basis for a lifetime of creating art. Yes, all of us therapists (veterans too!) do this daily, in the poetic and musical lines we shape in what others easily pass over as ordinary prose. Freud had it right from the beginning when he suggested, “When we can share that is poetry in the prose of life.”

Wouldn’t it be inspiring if all of us — beginning and veteran clinicians alike, supervisors and supervisees — could embrace the artistry of our everyday work? Wouldn’t it be illuminating if we had a working model of how to cultivate and deepen this?

Building a Voice

The model that I’ve arrived at is both simple yet expansive. A therapeutic voice is the combination and interplay of therapeutic presence and therapeutic authority, the complementary and seemingly contradictory elements that like yin and yang, enable us to create a three-dimensional picture of our patients and ourselves. Think of it like how our two eyes, each with their independent perspectives, magically create depth perception.

An ambitious supervisee recently confessed to me, “I have to anticipate everything before our session, and know exactly where I am taking my clients. I feel like a white-water rafting guide who’s one turn away from taking the whole crew down with me!”

This supervisee, like so many others, is proficient at being directive, setting goals, and moving quickly towards intervention. Unfortunately, they don’t offer enough room for the patient to openly explore and steep in their feelings or draw on the relational process to entertain new possibilities, which is why they so often feel up a creek without a paddle.

Therapeutic Presence

What they need more of is the yin of therapeutic voice, therapeutic presence — the capacity to be receptive, mindfully attentive, emotionally available, nonjudgmental and resonant with the client’s unfolding experience (1). Freud originated this concept in his earliest recommendation for practicing therapists in 1912, underscoring the vital importance of “evenly hovering attention.” Like a koan, the therapist should “simply listen and not bother about whether he is keeping anything in mind.”

Considered the foundation for tuning in to the patient’s unconscious, it provided a potent tool for opening one’s mind and heart to new possibilities for understanding and engaging the patient’s psyche. Like the Zen Buddhist notion of “beginner’s mind,” or mindfulness itself, therapeutic presence comes from the framework of “not knowing” in the service of creativity. To paraphrase the Nobel prize-winning poet Wislawa Szymborska, the point — like the poet’s main task — is to say I don’t know and keep on going. It’s to wonder aloud!

Therapeutically present therapists are understanding, open-minded, and comfortable with a range of different feelings and perspectives.These therapists have internalized Robert Frost’s prescient quip, “No surprise for the writer. No surprise for the reader!” Patients feel a sense of safety, trust, and warmth in their company. The space seems to open with them. This disarming quality makes it easy for patients to explore new subplots and turns in their stories. They find themselves surprised at how much they are saying and learning in just the telling itself.

Therapists who practice this kind of presence don’t have to know immediately and aren’t bothered by the ambiguity or complexity of what they are hearing; they “dwell in possibility,” as Emily Dickinson said, a “fairer house than prose.” They allow patients to be in the driver’s seat so that they can show them the territory first, and in so doing, instruct their therapist how to best be of service. This openness allows patients to take more risks in therapy, to deepen the exploration of their thoughts and feelings, and to get to genuinely enjoy the deeper waters of the psyche, even providing modeling for them to be more open to the various and contradictory sides of themselves! In short, to paraphrase Whitman, they are reminded that, “We are large. We contain multitudes!”

Owning A Voice

Plopping down in my office chair, and letting out a formidable sigh, another supervisee recently lamented: “Sometimes I feel like I’m taking it all in but then can’t get a word in edgewise, and I’m not even sure if what I’m thinking even makes sense. Am I really helping them at all, or are my own mixed-up feelings just getting in the way of making any headway?”

I know many fantastic supervisees who excel at being empathic, reflective, and thoughtful with their patients, but lack the confidence to make discriminating interpretations that take into account their valuable instincts and intuition regarding new creative possibilities.

These supervisees, understandably, worry that if they use too much of their authority, they will overwhelm or possibly hurt their clients.

They need more of the yang of the voice of therapeutic authority — which I define as the command of theory and technique and a discriminating awareness of how to put these into practice. It is the confidence to properly select, apply, time, and adjust one’s interventions in a multicultural and relationally sensitive manner (by relying on the yin of therapeutic presence, of course!).

The clinician with therapeutic authority is happy to show patients how to blaze a new trail and empower them to sort through the various aspects of their experience to find bigger patterns and new possibilities. Like an artist mentoring a new student, they can see the bigger and smaller picture and can help with the difficult passages encountered in putting new skills and pieces together. Most importantly, the therapist with a balanced dose of therapeutic authority knows how to do this with proper timing, tact and empathy. They are not going to break patients down like a military drill sergeant, but instead are going to be thoughtfully discriminating and penetrate deeper into problems and their implied solutions.

Supervisory Support

It is vital for supervisors to support beginning clinicians in developing their clinical intuition and instincts, the confident application of their theoretical and empirical knowledge, and a sense for having the “authority” to make therapeutic moves. Just as a singer needs to take risks with trying out new ways to expand their interpretation of a song, so too does the beginning clinician, and as supervisors, we are right behind them to encourage it!

Supervisors also need to model how to both be comfortable with and to chase the kind of not-knowing that makes creative therapeutic work possible. Like Yoda to Luke Skywalker, we help emerging clinicians to learn how to use “The Force,” showing them that, paradoxically, it is only by surrendering and letting go that we truly open the space for something new to emerge.

Just like our young poet needed Rilke to learn how to become an artist (and Rilke in turn was mentored by the great sculptor Auguste Rodin), so too do our beginning clinicians need us to illustrate how they can be balanced and integrated in their own unique therapeutic voice by uniting these two crucial faculties. And it turns out that all of us, no matter what level we are at, need to remember that we are always cultivating and expressing this artistry!

Empirically Supported Artistry

Art never needs more than its own justification, but as a scientist practitioner, you might need to be reminded of the scientific support for viewing therapy as an artistic enterprise. Look no further than Neuroscientist Antonio Damasio’s recent book, The Strange Order of Things, which eloquently showcases the way in which our “right-brained” feeling comes first, inspiring and motivating our greatest cultural innovations and products, and that joined together with the logic and language of our left-brains, becomes something truly extraordinary. Daniel Pink in In a Whole New Mind illustrates the 21st century’s cultural sea change from a left-brained leaning computer age, to a right-brained leaning conceptual age that integrates right and left to make the best of both worlds.

In my model, therapeutic presence is the right-brain dominant aspect of our therapeutic artistry, and therapeutic authority is the left-brain pilot, so to speak. Therapeutic presence is at once dreamlike and free-associative, holistic and big-picture, image and metaphor centered, and largely implicit and nonverbal. It undergirds the profound empathic connection between us and our patients, especially to those sides of our clients that have experienced trauma and yet still long for—even in secret — a more redemptive narrative.

Therapeutic authority flows from the language and logic-based sides of our brain with its highly developed executive functioning. More largely conscious and deliberate, this side enables us to zero in and edit the many clinical possibilities before us so that we can work with true specificity and discernment, tailoring our treatment for the unique person sitting across from us, and getting to the heart of the matter.

A 19th century poem by Frances Cornford sums up this lovely process best. Entitled “The Guitarist Tunes Up”, we learn that this musician leans into their instrument with ‘attentive courtesy’:

Not as a lordly conqueror who could

Command both wire and wood,

But as a man with a loved woman might,

Inquiring with delight

What slight essential things she had to say

Before they started, he and she, to play.

For a visual of this interplay, we can look to none other than that famous Renaissance man — Da Vinci and his iconic drawing of his Vitruvian Man. It is only by integrating the square of our logic with the circle of our feeling do we become something truly divine — artists in our own right.

Learning & Teaching from Art

If we are to find and develop a therapeutic voice, we must first look at how therapy itself connects to the arts and how, as supervisors and supervisees, we can attend to these important dimensions. We’ll look specifically to poetry and music as starting points.

Poetry Lessons

A poem, such as a sonnet, compresses a question or problem, its exploration, and a final statement of some revelation or new understanding into 14 lines. In Shakespeare’s famous sonnet, “Shall I compare thee to a summer’s day?” the speaker wrestles back and forth with how his love is and is not like summer. Initially, it seems very fitting to compare her to the beauty and splendor of the season, but upon further inspection, new ideas emerge. Among other things, she is much more constant, evenly tempered, reliable, and more lovely than the summer months.

Much like Shakespeare’s speaker, we wrestle with our initial diagnostic impressions of our patients: Shall I compare thee to a borderline personality, a depressive, or an adjustment disorder? It is not immediately clear, and so many of our first sessions entail testing out various hypotheses to determine who the patient is and is not.

As Shakespeare’s poem continues, surprises and new discoveries emerge and toward the final turn of the poem, the poet concludes that his love will be eternal as a result of the poetic act itself: “So long as men can breathe or eyes can see/so long lives this, and this gives life to thee.” This is the aim of a transformative therapeutic process. Much like a sonnet, by the end of the therapeutic experience, a patient will be able to make a few “turns” and come to a way of internalizing the therapeutic process so that it too will become eternal.

Music Lessons

Beethoven’s fifth symphony provides an immediately recognizable compressed musical idea. In only four notes, a focal theme is established that is explored, varied, and reharmonized much in the same way that occurs in therapy. The capacity of the therapist to articulate that melody — the dominant trend or relational pattern that pulls the various strands of a patient’s story together —goes very far in clarifying what has been troubling patients while it points them in the direction of how they can move forward. Much of the time, patients are playing the notes of their issues but are not aware of the melody and cannot synthesize it into a focal theme. They bring us their own invisible scores and hope we will give them feedback to recognize their own music.

About seven and a half minutes into the third movement of Rachmaninov’s Symphony in E minor, we hear the main theme played by the French horn, in the manner that a patient initially expresses when it is recognized by the counselor: “You hear me! This is the song I didn’t know I was singing.” Shortly after, the theme gets played by the violin with a melancholy poignancy: “I have been waiting a long time suffering with this alone.” This is the sense of sadness and mourning that the patient feels for having had to sequester this aspect of self in the service of protection and adaptation.

As the theme gets worked upon and elaborated, new instruments, such as the oboe and flute, come in to take on the line, with hope gathering. Calmer and with greater poise, a certain pride and expressiveness opens now that this very significant idea can be incorporated into the larger musical narrative of the patient’s story.

Let’s see how this artistry translates to a representative case and get a preview of putting all the pieces together.

A Case of You

I’ve named this “A Case of You” as a nod to Joni Mitchell’s heartbreakingly beautiful song because this patient seemed at first blush like she was too much to handle. Pretty quickly into our first session, I realized that, like for so many of our cases, the following lyrics truly applied:

“You’re in my blood, you’re my holy wine, you’re so bitter and so sweet, oh I could drink a case of you, and I’d still be on my feet!”

A student came to her intake appointment complaining that her friends did not understand her, that she couldn’t fathom why they were so turned off by the razor blade that she kept on her desk as a reminder that she could cut herself, and that she had been told to come to counseling many times, but it had never been helpful in the past. She asked, why should she bother now?

Previous counselors told her that she needed a higher level of care than they could provide, and those appointments left the student feeling misunderstood and blamed for troubles she could not fathom. She also felt a sense of hopelessness at not being able to make true contact, just as she had not with family and friends. Aiming right for the jugular, she also scoffed at me: “Counselors are incompetent and don’t really understand me. You probably won’t either!”

In addition to feeling interpersonally rejected on several fronts, as a first-generation college student, she experienced the pressure of well-meaning parents who hoped to see the family’s metaphorical stock rise with her success. At the same time, her family expected her to be at the ready when they called her to take care of her younger siblings. She was a painter who loved the darkest colors of her palette, with her works centering on Hopperesque misfits wandering in the night.

Initially, her cutting was a regular strategy to express and modulate her emotions, combined with a preoccupation with death, and the ways in which friends and other therapists had been repelled by her behavior made me wonder whether this student had borderline personality disorder. Like in Shakespeare’s poem, though, I was not sure whether this comparison truly fit.

Here we see the internal wrestling of therapeutic authority and presence. The first stab at therapeutic authority can have us all too quickly categorize or even pathologize what we are seeing before we get the full story. At the same time, this discriminating faculty provides crucial information that we really need to follow. Like a samurai warrior, psychologically speaking we need to forge the sword and learn how to use it appropriately. Toggling back and forth between this function and therapeutic presence — the open and receptive Buddha nature — allows us to see the big picture clearly while also focusing keenly on the supporting details that we need to assess and intervene incisively.

As I got to know more about the patient’s relational backdrop and leaned into my therapeutic presence, things looked a bit different. I learned about her parents’ difficulty tolerating fear, anger, and sadness, and their own struggles with managing chronically high levels of stress. I also learned about my client’s repeated experiences of the family being unable to acknowledge or stay with her emotional experience.

Just as the subject of the Shakespearian poem was no longer so much like the summer, it seemed more and more that she was no longer like a patient with a borderline organization and instead more like one with a neurotic organization or a possible adjustment disorder. She appeared to be in a conflict that could not be acknowledged squarely as she was in the midst of an important developmental transition, both issues coloring each other and placing her in an ever-tightening Gordian knot.

By trusting my therapeutic authority, a focal theme emerged. When this patient expressed negative emotions, people could not tolerate them and emotionally and physically abandoned her. This pattern was consistent with her emerging friendships — others were not interested in hanging out with her despite her charm and intelligence — and extended to her early family experience, in which her parents subjected her to the silent treatment for days whenever her emotions ran too hot. Taken together, the patient internalized a message that her emotions were problematic and disruptive and that they must be put aside and suppressed. In other words, they became “not-me” and funneled into the dissociative symptom of cutting.

Until I was able to home in on a focal theme, I, like the therapists before me, was part of the problem, imagining in my countertransference that it was the patient who had the major issue. Internally, I underestimated how much my feelings were part of an enactment, containing only a small piece of the story. Initially, I was bracing myself for difficult work, assuming that the student had a great deal of pathology and would make little movement. In a way, I was reenacting the dynamic of the student’s relational backdrop, finding her issues disruptive to my sense of authority just like her parents and her prior therapists had — “it is not me, it is her.” By maintaining a therapeutically present stance, I was able to observe this crucial dynamic and incorporate it into a new understanding and relationship with the client.

Therapeutic authority led me to a focal theme that helped me see that it was totally understandable for her to shy away from sharing her intense feelings and need to hide and express them in her not-so-secret ritual of cutting. She was protecting both myself and herself from “not-me” and letting the world know, with what seemed to be twisted pride, that cutting was her right and a very valuable part of her emotional life. Looking back on that detail now, it was very prescient in the way it encapsulated her attempt to express and independently resolve her bind.

Reading and Tracking Changes

Guided by a mindful application of therapeutic presence and a discriminating use of therapeutic authority, the student went through the kind of musical sequence referenced above. Initially, having a therapist who was able to respect and receive the fullness of her experience without mistreating or abandoning her by becoming critical or explosive or falling apart was a tremendous step toward a new relational experience. The recognition that her focal theme was understandable and heard enabled her to begin to speak of it without the kind of shame and dissociation that often accompanies a “not-me” experience. It also enabled her to begin to trust and hope again.

She became inwardly and outwardly relaxed so that she could begin to examine the many facets of her current and past experience and thus begin the riffing that is essential to the jazz improvisation that is therapy. In short, she began to find and develop her own voice as a patient!

The patient could view her behaviors as more comprehensible and expressive of the hidden conflicts she had been harboring and that had been left unformulated and disconnected. This expanding sense of self-compassion became an important antidote to her cutting behavior and provided an alternative avenue for exploring and containing her emotional experience. Interpersonally, she became less defensive and fearful of others abandoning her, having had a transformative set of experiences in which she felt the consistent presence of a reliable other. She began to show her pain not only in her words but in the artwork, she did as a painter.

When a poetic turn or musical theme has been established, shifts can immediately be seen in the patient and felt in the relationship. These can occur simply in the change of posture (often, a straightening of the back and sitting up in one’s chair), a richer tone of voice, a feeling of newfound connection and space in the therapeutic relationship, or in the spontaneity and flow of narrative or images that emerge in the therapeutic interplay

In the first session, trust was developed as the student began to see me as a figure who could understand and appreciate the depth of her pain and recognize the myriad ways in which she had been misjudged and pigeonholed by her family, friends and, most notably, other therapists. We also developed a focal theme centering on how this rejection led her to suppress and negate her important and precious feelings. Taken together, I believe that these turns led to decreased scores in hostility and emotional distress, each indicative of the fact that she was feeling more trusting, less defensive, and relieved at being able to begin to experience her emotions more directly.

These scores continued to remain significantly lower than baseline for the next few sessions, whereupon we worked on developing ways of shifting patterns in her relationships with friends and family. At around session five, the student’s depression scores started to decrease as she began to feel greater self-efficacy and agency in being able to affect change in her life inside and outside of the therapy space. Simultaneously, her levels of anxiety followed suit as they made a statistically significant drop from baseline in our final session of the semester. Our work together concretized the notion of making a more poetic and musical line in our therapeutic work, and the importance of drawing on artistic metaphors to inform treatment and expand both the therapist’s and the patient’s voice in that process.

A New Slant on Working Dynamically

We are very accustomed as clinicians to thinking vertically, troubling ourselves over quick diagnoses and assessments, especially given the limited time we often have. At some points, this may take away from focusing horizontally on the musical line and the movement of the intervention. In music, in order to play or sing a melody successfully, one needs to be as attentive to the horizontal motion of the notes carrying a melodic line forward as to the vertical axis of hitting the note itself.

In clinical practice, one can analogize the horizontal forward motion to the momentum of an intervention, the movement toward a new relational experience. The vertical playing of the note is the clinical equivalent of ensuring you understand the patient’s experience correctly and getting a proper diagnostic read. This horizontal motion is informed by therapeutic presence just as, conversely, the vertical movement is guided by therapeutic authority. Both are essential, and they need to be worked in concert to turn notes into music.

This musical way of approaching relational work helps us to be more efficient, fluid, and creative, focusing simultaneously on how to skillfully assess and intervene in our fast-paced culture. Moreover, it enables us to carry the themes of the patient’s past into new orchestrations and harmonizations in the present, providing a model for continued transformative possibilities in the future. Through this process, patients internalize working creatively with their own themes and then take us into new melodic and harmonic territory, stimulating further treatment progress and development. Taken together, this fosters a positive feedback loop in the creative matrix between patient and therapist, and from this synergy, transformative changes quickly follow. This is precisely what a well-tuned therapeutic voice does for the clinician and their client.

References

Cornfeld, F. D. (1965). Collected poems. Cresset Press.

Questions for Thought and Discussion

Who inspired you to find your voice?

What are some of the unique attributes of your therapeutic voice?

Which of your clients helped you to find your therapeutic voice?

In what ways do you compare psychotherapy to an art?