Don’t Ask, Don’t Tell

Posted on by Psychotherapy.net Team

Last Sunday night I dropped a pot of boiling water on my hand. My quick thinking teen aged son who was standing near by promptly grabbed me, led me to the sink and held my burned wrist under perfectly tepid running water. Shortly there after we took a quick trip to the ER where they wrapped me up and sent me back home.

I’m healing nicely. But the white bandage around my left hand has been good fodder all week in my office. There’s been an interesting hodgepodge of reactions from my clients, from not noticing at all to “Wow! What happened to you?”

It’s brought me back to the several pregnancies I’ve had while in private practice when my body was inflating in front of me, and in front of my clients. Some noticed early on, and others were shocked when – toward the end of the pregnancy – I said I would be out of the office for a bit. Some wanted to know why, others just wanted to know when I’d be back. It was indeed an interesting study in narcissistic transferences, object relations, relationships and character.

So here I am with white gauze wrapped around my literal wound debating about which figurative hat to wear in session. My own analyst, if wounded, (would I want her wounded? If so, why?) would most likely nod slightly and say something like “What do you think happened?” And then we might spend the session in some sort of fantasy exploration of my ideas, associations or feelings about what may have happened, about knowing or not knowing, and what that would or would not mean to me. Depending on my mood I would find this either interesting and helpful or downright annoying and useless. Probably some of both. But I would tell her that too.

That’s part of the freedom of being able to say everything and anything in therapy. It includes saying whatever you feel about the therapy and the therapist, which does often lead to better feeling states and more insight. So what’s better for my clients? To know? To guess? To talk and see what comes up? Or to satisfy the question if asked? Feed the desire, gratify the need? Or perhaps just to engage in the righteous social norm of polite dialogue? After all if I tell too soon, are we missing out on a memory of a mother being hauled off in an ambulance, or the time they cut their own finger? Maybe if I don’t answer too quickly I will find out that they feel concerned about me, that I mean a lot to them, or the opposite. Some folks just want to know that I am able to do my job or continue to take care of them or both. With some, the exchange has been sweetly and simplistically human, a currency of concern and connection that flows naturally through both the therapeutic and real relationship that exists between us.

Perhaps too, my injury offers an opportunity to explore empathy and to learn more about how aware we are of each other, of others, of ourselves. And for some, my injury means that I must know now, for sure, what it feels like to be hurt.

Mostly, my clients have been satisfied to know that my attention to them has not been affected by whatever has happened to my wrist, even though it does bring home, on some conscious or unconscious level the registration that I exist outside of the office and am susceptible to the perils of life just as they are. And that I too might benefit from an analysis of why I hurt myself, unconscious though it was.

Not mistreating the treatment seems to be the most important thing. That and taking very good care of the relationship. So, to satisfy or to analyze? It’s hard to know exactly all the time, but it seems to me that a little bit of both usually goes a long way toward healing and avoiding burns.

Who Else Wants To Know Why Americans Spell Counseling With A Single “L”?

Posted on by Psychotherapy.net Team

A while back, when I opened my afternoon snail mail I received a card from Dr. Thomas W. Clawson, CEO of the National Board for Certified Counselors (NBCC). Dr. Clawson asked in his correspondence if I knew why the words counseling and counselor are spelled with a single "L" in the U.S., while in England and Canada the words are correctly spelled with two "L's” (i.e., counselling or counsellor).

He then went on to answer his own question. The mystery, he noted, could be traced back to Frank Parsons, the so-called father of guidance and vocational counseling. It seems that the multi-talented Parsons was also trained as an attorney. To avoid confusion he would spell counseling or counselor with two "L's" when working in the legal profession (e.g., counsellor- at-law), but he used a single "L" spelling (i.e., counselor) to distinguish his work as a helper.

Clawson shared with me that his source for this information was none other than Dr. Joseph W. Hollis, a prominent figure in the counseling arena. Joe had been the Chairman of the Department of Psychology and Guidance Services at Ball State University in Muncie, Indiana. After thirty years of dedication to the university, he retired in 1984. But retirement for Dr. Hollis turned out to be the beginning of a new venture. He founded a publishing company, Accelerated Development (later purchased by Brunner Routledge, a division of Taylor & Francis), that he initially ran out of his garage. But the company blossomed and Joe brought a lot of the seminal titles to our field in the 80's and 90's. In addition, he was known for undertaking the first major study of counselor preparation programs. He also helped found and served as president of C-AHEAD, the Counselors Association for Humanistic Education and Development. I had the pleasure of coauthoring a book with Joe in 1994.

I emailed Dr. Clawson back to report that I had not only been privy to the story about Parsons, but my source was precisely the same as his: Joe Hollis.

At that point in time I became very curious and wanted to verify our hypothesis in a scholarly source. I searched near and far and was assisted by several talented college research librarians. I perused ancient tomes that had accumulated over nearly a century of dust (now I know why some books have dust jackets!) to no avail.

Since I came up empty handed, I thus contacted the one individual who I knew had publicly broached this subject, Dr. Samuel T. Gladding. Gladding is a noted counseling textbook author and a former president of the American Counseling Association (ACA) and the Association for Specialists in Group Work (ASGW). Indeed Dr. Gladding was espousing the identical explanation concerning Parsons. His source: None other than—you guessed it—Dr. Joseph W. Hollis.

For now, I'm sticking with the story because Joe never told me anything that wasn't the truth, the whole truth, and nothing but the truth! Sadly, Joe passed away at the age of 80 on November 23, 2002, so we can't ask him where he acquired his information.

But hey, if you uncover something in the literature that proves we are wrong, just give me a holler. I'm all ears.

Albert Ellis and the Traveling Road Show

Posted on by Psychotherapy.net Team

As a master's level graduate student at the University of Missouri, St. Louis, I was very fortunate to have Dr. Patricia Jakubowski as my advisor. Pat was not only a recognized behaviorist, but she was also a pioneer in the assertiveness training movement. Best of all, she had befriended a psychotherapist who was very close to Dr. Albert Ellis. That's right the Dr. Albert Ellis.

At the time, it was virtually impossible for a student such as myself who didn't own a master's degree sheepskin to attend an ongoing training session with Dr. Ellis, but Pat worked her magic (can you say used her connection?) and there I was at the Institute for Rational Emotive Therapy in New York City. Although Ellis came across as dynamic in his writings, he was ten times as colorful and entertaining in person. During the training Ellis cast many gems of wisdom related to his baby, RET, which stood for rational emotive therapy. In his mind it was the ultimate form of counseling and psychotherapy. Later, with a little coaxing from psychologist extraordinaire Raymond Corsini, Ellis renamed the modality rational emotive behavior therapy or REBT in 1993. Thus REBT is the name which lives on in the pages today's textbooks and counseling classes.

But the one thing that stands out in my mind after all these years was a remarkable story he shared that transcended the boundaries of his own theory. Ellis mentioned that during the early 1970s he was conducting a presentation at a major national conference. After his speech another presenter demonstrated a new form of therapy. Suffice it to say that this other treatment modality was everything RET wasn't. This novel approach stressed intense catharsis, abreaction, and focused heavily on one's childhood experiences. Convinced of the superiority of RET over any other form of helping Ellis was ready to dismiss the whole idea until he watched a demonstration of the new system in which an acutely disturbed client was cured of what ailed her in less than sixty minutes.

Even the great Dr. Albert Ellis was amazed and could not believe his eyes. Could this innovative form of therapy be that effective? But make no mistake about it—Ellis had an open mind and decided he would investigate the new paradigm. His investigation came to a surprising and screeching halt in less than 30 days. You see, not long after the first conference, Dr. Ellis was scheduled to present at still another national conference. At the second conference he spied the same psychotherapy expert, curing the same client, of exactly the same problem, in precisely the same period of time.

So the moral of the story is that if some new, improved form of psychotherapy makes a giant splash onto the helping scene that just seems too good to be true . . . just use a little creative visualization and think of Albert Ellis and the dreadful deception of the traveling road show.
 

Philip Kendall on Cognitive-Behavioral Therapy

Posted on by rezendevknowfully.com

Working with the Masters

Deb Kory: Hi Philip. You’re a researcher, scholar, clinician, and a professor at Temple University. You’ve done a great deal of seminal work on treating anxiety disorders in children and adolescents, as well as cognitive behavioral theory, assessment and treatment. In doing research for this I opened up your CV and noticed that it was 127 pages long. You’ve been rather prolific over the course of your career and have worked with some of the great masters in the field of cognitive behavioral therapy. This month we’re releasing two DVDs that contain interviews with Albert Ellis and Aaron Beck. Can you tell us how these guys influenced you and what it was like working with them?
Philip Kendall: Tim [Aaron] Beck had an influence because my first job was at the University of Minnesota and I was hired to do research on children and adolescents in treatment and outcome. I worked with Steve Hollon there, whose office was adjacent to mine and he had just finished working with Beck on the first outcome study for cognitive therapy for adult depression. So I was influenced, in part, by Beck through that process.
Years later I now live about 10 or 15 houses from where Tim Beck lives here in suburban Philadelphia. He’s 91 now and moving into a townhouse in the city, but up until a few months ago we were neighbors and I’ve seen him at movies and restaurants and such. But the intellectual influence was the manualization—or manual-based approach—to treatment and its systematic, organized evaluation, which I was doing with kids and he was doing with adults.
DK: And how about Albert Ellis and Rational Emotive Behavior Therapy (REBT)?
PK: A number of years ago I did a paper with Albert Ellis that was intended to correct a slight trajectory difference. Tim Beck had succeeded nicely in pursuing the research side of cognitive therapy, whereas Al Ellis had succeeded beautifully in the practice side of rational emotive therapy, but not quite as much on the research.
So we collaborated on a paper that was intended to outline what was known and what were the next needed studies in REBT to try to correct its trajectory, which didn’t include as much research. I would say the focus is similar. Al Ellis focused more on neurotic styles and Tim Beck focused more on the diagnosis of depression. But, interpersonally Al Ellis was much more the New Yorker and in your face and Tim is not. And so, you have some therapist personality differences.
DK: What was it like working with Ellis?
PK: I guess I would say this: I found him to be very true to his view. His theory would say things, many of which are very insightful and smart, like, “you can’t be liked by everybody,” and “you can’t worry about what someone else is going to say if you say what you think is true.” And I found in my interactions with him around several things that he didn’t pull punches.
DK: He “called a spade a spade,” as he was fond of saying.
PK: Yeah, and I found it a likeable quality. And to be candid, in the paper that I ended up writing, it included some comments that were less than supportive, so we had a little back-and-forth and he accepted my criticisms.
I would say he was a little bit more inclined to want to look at the literature from a view that supported what he thought. I would say he [Ellis was a little bit more inclined to want to look at the literature from a view that supported what he thought.] And I would come from a perspective that says, “let’s look at the literature and think about what we know based on what we found.” That’s a slightly different read on how you process information.
DK: What other major intellectual influences would you cite?
PK: Don Meichenbaum was probably just a few years past his PhD at the University of Waterloo and he was working with kids. He had written some materials and they were literally printed on an old dot matrix printer and when he and I were communicating it was snail mail. So I would get these correspondences in the mail and I would send him our papers. I didn’t realize at the time that he was a leading thinker on this theme and that I was involved early in a major shift in our discipline. Mike Mahoney, Al Kazdin and Ed Craighead were colleagues at Penn State at the time and some of their work was also important and influential.

“These Kids Think“

DK: How did you come to psychology and to CBT in particular?
PK: I would say my initial training in psychology was with learning. First with animal learning, where you study the acquisition of behavior patterns in fish, mice, monkeys, white rats, that kind of thing. One of the features that we were studying was called “avoidance learning,” where animals learn to make responses that they think are helpful but, in fact, aren’t. And they just can’t unlearn those unhelpful avoidance responses, which is a very behavioral learning theory view of anxiety.
Then in graduate school, while doing a lot of behavioral work, the animals were no longer the animals. The animals were people. And it became apparent not just to me but to others that these kids think. And how they think alters their behavior. So we started talking about cognitive behavioral therapy as a way to take learning theory and still pay attention to the cognitive processing of the participants.
DK: Did you have any psychoanalytic training?
PK: I never had graduate level psychoanalytic training, but I did have several courses that were psychoanalytic and I remember reading a book that was about children and adolescents that was psychoanalytic, but it kept blaming the parents, and showed no reflection of normal development. It seemed like everything a normal kid would do or say was seen as a symptom, and that’s very disrespectful of the fact that normal development includes times of sadness, times of anxiety, times of conflict. Psychoanalysts didn’t seem to be informed by what we know about human development.
Psychoanalysts didn’t seem to be informed by what we know about human development. So I kind of rejected it, thinking it’s a rich theory and a couple of things seem right about it, but so much of it seems not based on what we already know.I hate to say it, but I think that was in 1974. Oh my goodness.

DK: That was the year I was born.
PK: And I was getting my PhD, oh my God.
DK: Well…and 450 publications later here you are.
PK: Yeah, it seems to have gone by quickly because time does pass quickly as you age.
DK: I’ve noticed that.
PK: But it also seems to have been relatively cumulative. What we know now is informed by studies that were done in the last two decades. And that’s a good feeling.

CBT Then and Now

DK: That leads to my next question. How have you seen cognitive therapy change over that time? Looking at Aaron Beck’s cognitive therapy and what you today call cognitive behavioral therapy, are there any majors differences?
PK: My hunch is it’s very, very similar. For example, in cognitive therapy for depression, even though the word “behavioral” isn’t in the title, it’s in the implementation of the therapy. There’s homework, there’s practice, there’s even scheduling and rewards. Those things are out of the behavioral tradition. In cognitive behavioral therapy there’s certainly practice and reward and homework, but there’s also the cognitive part. It’s just the title that was popular at the time.As far as what’s changed, there’s the good and the bad.

One of the dilemmas is that CBT has become more accepted and more popular—that’s a good thing—but in the popularization, more people seem to misunderstand it than understand it.

One of the dilemmas is that CBT has become more accepted and more popular—that’s a good thing—but in the popularization, more people seem to misunderstand it than understand it. I think our profession is well informed, but people outside the field have some long-standing misconceptions. “CBT—Isn’t that the power of positive thinking?” No, it’s not. “Oh, isn’t that where you tell yourself not to be depressed?” There are these simplistic, if not buzz-word answers that are just wrong and a misperception.

In addition, you have a sort of knee-jerk reaction among some—“Oh yeah, I read about that. I tried it. It doesn’t work.” But when you actually ask them, they didn’t really experience it or try it. Those things are unfortunate.

What’s changed for the better, I think, is the cumulative part. Psychology and clinical psychology is not a breakthrough science. It doesn’t change overnight based on one study. It’s a cumulative process that takes decades, not days, for things to go from point A to B to C to D. And when I see the American Psychiatric Association say they require clinically supported treatments such as CBT taught to their residents, and I see empirically supported treatments reviewed at a government level or by a state like California, and the programs that qualify as empirically supported are largely CBT, it’s showing the positive progress of cumulative knowledge.

DK: You’re being generous in stating that most therapists really know what CBT is. That’s not been my experience. We didn’t get a lot of CBT training in my graduate program. I’ve found in professional circles that CBT is often conveyed as kind of wooden, lacking in spontaneity, not focusing at all on the quality of the relationship, etc. Can you speak to that conception or misconception?
PK: Sure. And I’m kind of smiling. If we were on Skype you’d see a big grin because we just finished two large and, I think, important papers on the role of the relationship in CBT for anxiety in youth. The first is based on 488 kids treated at six different universities by close to 40 different therapists. The supervisors rated the therapists. The therapists had to send us tapes, which we watched and rated. The methodology of the study is really good.The bottom line is that therapists who are “teachy”—as in “Hi, Johnny, you’re anxious about this. Here’s what you should do”—don’t do as well as therapists who are more like coaches.

Therapists who are “teachy”—as in “Hi, Johnny, you’re anxious about this. Here’s what you should do”—don’t do as well as therapists who are more like coaches.

A coach would be more likely to say, “Johnny, you’re anxious about that. Hmm. What are some things we could try? What are some things that might have worked for other kids? Which one of those do you want to try?” And then try it out and say, “Hmm, that one seems to work okay for you. What do you think?” The coach style had better outcomes than the teachy style. Clearly that reflects different therapeutic relationships, different ways of interacting.

When you do an exposure task in treating anxiety, you take an anxious kid and you put them in a situation that makes them anxious. For years people thought, “Oh, that damages the relationship.” But the second study we did, also looking at the relationship, found that conducting exposure tasks does not rupture the therapeutic alliance. The challenges that are brought to a kid in CBT do not damage the relationship. It holds up pretty well. The relationship’s important. There’s variability in the way therapists do treatment. But relationship alone is not sufficient. It may be necessary, but not sufficient.

DK: There’s a lot of emphasis these days on more experiential, emotion-focused therapies that draw upon the adaptive potential of emotions and work to elicit deeply emotional responses within the framework of an empathic therapy relationship. CBT seems to focus primarily on cognitions and behaviors, but there is a fair amount of empirical support for the efficacy of emotion-focused therapies. How does CBT work with emotions?
PK: Again I have a little bit of grin on my face. Although the words are different—“expressed emotions” and “emotion focused” might not be the way we describe it—we’re doing much the same thing. For example, a child says, “I’m afraid to talk to people I don’t know.” So on Thursday at two o’clock, if she has an appointment, we set it up so that there are three other kids who are going to be there and this child is going to have an opportunity to meet one of them and have a conversation.And we say to this child who’s coming for the two o’clock appointment: “We have it set up that you’re going to meet someone else. What do you think is going to happen? How are you going to feel? What happens if you get all nervous? What happens if you feel your heart racing? What are you going to do if you get confusing thoughts? What are you going to do if you have to go to the bathroom? What are you going to do if you can’t think of what to say? What are you going to do if they ask you a question?”

Then we’ll go into the room. We’ll have the child being treated meet a new kid and every minute or two during that experience we’re going to say, “How are you feeling now? What’s your set rating? How anxious are you?” And then we’ll keep those ratings. Then when it’s over we’ll go back to the therapy room and say, “How’d it go? We can talk about it here. That was great! You said you were uncertain about what you were going to say, but you were able to come up with questions and he had the same interests you did in comic books.”

If you were to not call it CBT, you would see that anxiety, which is an emotion, was the primary focus. We were in the experience totally. We were getting their set ratings on a minute or two minute interval and we were very much focused on how he was reacting and feeling. It’s just somebody’s lack of understanding that contributes to the misperception of differences.

DK: So you’re saying there’s not a real split here between CBT and EFT?
PK: Right. There’s a common undertaking with the use of different descriptive language.
DK: Exposure therapy throws you right there into the midst of whatever really intense emotions you have.
PK: Exactly, but with proper preparation.
DK: But there certainly are some real differences in how emotions are conceptualized and responded to. In EFT or psychodynamic or existential therapies, the therapist often will dig into the emotions to better understand the meaning underneath the emotions. Isn’t there a real risk in trying to change the emotional response before it is fully understood?
PK: There are different opinions, with many folks saying that there is a degree of understanding within CBT, but in other schools of thought, the understanding alone is not enough. I would fall in this group.
DK: What about the unconscious? We certainly have plenty of empirical evidence that there is much outside of our conscious awareness, and as you know, in psychodynamic therapies excavating and bringing to light our unconscious beliefs, desires, drives, etc. is seen as an essential part of healing and becoming an integrated person. How does CBT conceptualize or make use of the unconscious—if at all?
PK: When asked if I believe in the unconscious, I answer “Not that I am aware of.” Kidding aside, the “underlying cognitive beliefs” are exposed as part of CBT. But, again, simply getting this to be more aware is not the end point, only a part of the goal.

CBT with Kids

DK: You’ve done a tremendous amount of research over the course of your career. In fact, you are one of the most frequently cited individuals in all of the social and medical sciences. I noticed that pretty much all of your research has been with children and adolescents. What’s the name of the clinic you founded and is that where the majority of your research is done?
PK: It’s called the “Child and Adolescent Anxiety Disorders Clinic” and I started it in 1985. Every child or adolescent who comes into the clinic pays a fee, but it’s a reduced fee. In exchange for the reduced fee, they agree to participate in research and complete all of the measures. So literally every child who comes through our clinic is a participant in research. And that allows for them to get carefully monitored services, including very detailed analysis of what’s going on and what happens in the end and pre- and post- and follow-up measurement and things like that. But it also allows us to have real clinical data with real patients. We have a small group of graduate students who are doing their master’s or their dissertation with funding we receive from NIMH, who are able to do a lot of pretty sophisticated work. So I think that helps the research productivity a great deal to have external funding, a real clinic, and bright, motivated staff and colleagues and graduate students.
DK: What was it about working with children that appealed to you?
PK: There’s a professional answer and then there’s kind of a silly one. The professional answer is that if you’re going to have an impact on how someone experiences life and thinks about the world, if you wait until they’re 20 or 30 or 40 years into it and have established biases and perceptions, your task is quite daunting and challenging.If you get to them early you can prepare them for these life experiences and catch—if not correct—some of the potential misperceptions when it’s developmentally appropriate. A first sleepover at age 12 is a meaningful social event; a first sleepover at age 30 is a different thing, you know.

DK: Indeed.
PK: The silly answer—and I have to be careful how I use the word patience here—is that I lose patience with adults. They can be rigid, misguided, less motivated and not quite as willing to try things. And I find with kids, they’re more willing to try things when they’ve got an adult who’s giving them some confidence to give it a try. And then it’s their own experiences that convince them to go forward. With adults there’s a lot of interference and baggage.
DK: I don’t automatically think of kids as having a lot of meta-consciousness around their thoughts and ideas. I think of therapy with children as being play therapy, where the therapist is making meaning of symbols and introducing ideas and concepts through a reparative relationship based in play. Do you still play with kids in CBT therapy? How do you incorporate concepts like homework and exposure into the play? Do they get homework?
PK: I’m going to do the homework part of the question first. We definitely have homework. Kids are accustomed to workbooks at school. They have math problems or other homework. So they also have homework in the “Coping Cat” workbook we developed, which they use as they go through their anxiety treatment.Rather than making treatment complicated and difficult, I try to make it acceptable to kids. So we’ll talk about a cafeteria of things like relaxation or talking back to your anxiety or trying things out to see how they work. You kind of walk through the treatment as a cafeteria, where you don’t have to eat everything that’s offered.

At first the homework is easy: remember your therapist’s name; write down a time that you had fun; write down a TV show that you’ve watched and enjoyed. You know, simple things.

But gradually that homework becomes the very challenge they need to do to overcome their anxiety. So homework later on in treatment, let’s say after 14 weeks, might be to enter a new group at school. Join the drama club, join the chess club, try out for a play, start a club with remote control cars. The aim is to do something that’s an initiation that might have been something they were so afraid of even thinking about months before.

So the homework becomes the practice of the skills that we teach them. It’s a very important part of CBT, because one hour a week sitting with us in a safe environment isn’t the real world.

So the homework becomes the practice of the skills that we teach them. It’s a very important part of CBT, because one hour a week sitting with us in a safe environment isn’t the real world. But if they’re out there doing what they’ve learned with us multiple times a week in the real world, that’s got some punch.

The other half of it you mentioned was play. And I have to be careful how I say this because I often put my foot in my mouth, meaning I misspeak. We do play with kids. But play is not the goal or the vehicle that’s crucial. Play is just part of what you do with kids to communicate with them. It’s more the context of building a relationship onto which you’re then going to add the challenges.

So as an example, if we’re talking about a misperception, a social misperception or a probabilistic misperception—and I wouldn’t use these words with kids—but the kid will think, “Oh, I can’t do that because lightning will strike me.” We might say, “Oh, yeah, lightning. What would happen if you got struck by lightning? Let’s look it up on Google or let’s do some homework. What are some things that increase the chances? What are the things that decrease the chances? Holding a metal rod increases the chance. Golfers hold golf clubs. Let’s see how many people play golf, how often, that have how many clubs,” and then you’re playing. But in the game you come up with the conclusion that it’s one in 64 million people who might get a bolt of lightning on a golf course with a golf club. The probability isn’t that high.

DK: So you’re disconfirming the fear.
PK: Right. And again it goes by that coach notion. When a kid comes in and says, “I can’t call a friend on the phone. I don’t interact with peers at school. I don’t raise my hand. I’m scared of what’ll happen,” we think of it as, okay, in 16 weeks we want the kid raising his hand, calling a friend to ask about homework and having a sleepover.In other words, the things that are difficult are the things we’re going to do. And how would a coach get there? A coach wouldn’t say, “You have to do it today,” because you haven’t taught them how. Just like a piano teacher wouldn’t say, “Perform your recital” the first day of your lessons. You have lessons, you practice and then you have the recital at the end.

So in our 16 weeks we’ll have lots of practice at pretend-calling people, at pretend-raising your hand, actually raising your hand in front of a staged audience, having catastrophes happen and helping you deal with them. So that when the kid goes to school and part of their homework is to raise their hand and ask a question, they’re kind of into it and practiced and know what to do. And that’s part of that coach notion that we allow them to have practiced at the things that may or may not happen so that they know how to deal with them if and when they do happen and it’s no longer so frightening or new or novel, it’s, “I’ve done that before.”

DK: Well that sounds different from one of the conceptions or misconceptions that people have about CBT, which is that the therapist is the “expert”–as opposed to, say, a more non-directive Rogerian approach or even the semi-directive approach of motivational interviewing, which guides clients with open-ended questions and seeks to “meet clients where they are.”
PK: In our approach we look at it a little differently. We say, “You’re the expert on you, Johnny. I’m sort of the expert on what other kids have tried and learned from. But I can’t do it without you and maybe you can’t do it without me. So we have to really collaborate on this. And I can give you some ideas for you to try out, but you have to tell me what works and what doesn’t work.”
DK: These approaches certainly make a lot of intuitive sense, especially when there is some clear behavioral change that is desired. But how does CBT think about situations where the emotional response of the clients seems appropriate—e.g. a girl is understandably distressed about her parents’ divorce, and she really just needs someone to talk to and work through her own feelings. Does CBT have anything specific to say about a situation like this?
PK: In general, the goal of “treatment” is to remediate an identified problem. For emotional disorders, for example, there may be irrational thinking or illogical processing that is interfering and maladaptive. These problems need to be treated.In cases where someone has a “genuine and real” reaction to a real situation that is not excessive (though reasonably distressing), the rationality isn’t faulty nor is the thinking illogical. Rather, these are relatively normal processes that don’t meet criteria for disorder and don’t necessitate treatment.

If someone wants to have “personal growth” and learn about their thoughts, feelings, and behavior, that’s fine, but it’s not the same as effective treatment for an identifiable problem.

“I Must Be Doing Something Right”

DK: Of your many roles—teacher, researcher, writer, clinician—what’s your favorite?
PK: How do you pick a favorite child?
DK: Well, parents usually secretly have one….
PK: I don’t think I can pick a favorite. I can maybe rank them on different dimensions. I get a great deal of satisfaction from mentoring and seeing people go on and have their own careers flourish. I get a great deal of pleasure out of kids who were scared shitless (pardon my language) when they came in, going on to do things and 16 years later we’re in touch with them and they’re doing well. I like that stuff. That’s very satisfying. And then professionally I like doing good research and publishing it in good journals because I feel like that communicates to my colleagues, even though I recognize that the impact takes a long time.
DK: Okay, final question. I’m just starting out. I’m about to get licensed and I’m just wondering what advice you have for new therapists in the field.
PK: Every happily married person had been turned down prior when asking for a date. Every successful book author has had a proposal not go perfectly well. Every successful scientist has had a paper not accepted on first submission. And the best basketball player on the planet, Michael Jordon, shot 49.9 percent for his career. So having things not go well should be expected. And doing the best treatment you can might mean four or five out of ten get better. And if you do that, you’re doing better than most. Our profession is such that we remember the ones that don’t work and we blame the treatment we’re doing for its failures, rather than an objective view which states that this treatment response rate of 60 percent is 20 percent better than anything else, so I must be doing something right.
DK: That’s lovely. Thank you.

The Joy of Small Miracles in Psychotherapy

Posted on by Psychotherapy.net Team

I confess that sometimes in the course of my work sadness overwhelms me. I am not talking about compassion fatigue, burnout or a concoction of transferences and inductions. I’ve been listening to folks talk for almost two decades now, but sad narratives still affect me, as well they should.

Sometimes the healer in me dips under the radar and I feel only like I am standing at the station watching a train wreck happen, or so I think. Faith and that good old fashioned “patience for the process” that I learned back in social work school get eclipsed by the urgency and impulsiveness that often walks through my office door. Even though I know that we do not control outcomes (and as my career ages into its mid life, I am finding this truism to be a relief), I do sometimes wish for miraculous epiphanies and prescient strides forward.

Not too long ago, I got my miracle.

A couple I’ve been seeing was in therapy to discern whether or not they were going to stay together. He wanted to stay married and she was, she said, not sure. She did not feel loved. He did not feel supported. When she felt angry or hurt, she threatened divorce, or told him what she hated about him. When she did this, he became more frustrated, backed away further, and so went the dance.

We’d been unpacking things for a while—the dialogue between them, her history, his. But still she maintained that he was a louse. (He had never impressed me as such.) There’s more to their story, but over the course of the therapy, I began to feel utter sadness. I found myself wondering why I was such an advocate for their marriage. Was I thinking of their four kids? Was I feeling his sadness? Or hers? Was I feeling my own sadness? How do I know what’s best for them? Or their kids? Was I lapsing into judgment? And if so, why?

My sadness in this case was this too: This guy really did step up. And this woman kept knocking him down at every turn. She seemed to be deeply, wholly cathected to killing him, the marriage and love itself.

As a defense against my sadness, I began to diagnosis her in my head. “She is borderline,” I’d tell myself. Or, “She is a typical ACOA.” And then, “She suffered too much trauma to be able to sustain a mature relationship.” Silently I found myself begging her not to destroy her home. She did love this man, she claimed. And she fessed up to his good fathering. But for session after session she wept about how her husband was not her hero, and how out there somewhere her real love awaited.

And then one day, out of the blue, she came into session and said that she had prayed. And that she had made a decision. She said that she had been behaving terribly and it was going to stop. She said that her husband was a good man and deserved her respect and support. She said that she sees that he is not her father who disappointed her, that she is loved and loveable and that her relationship with her husband and her self fair much better when she acts reasonably and kindly, and handles her feelings better. She told me that she understands that when she feels vulnerable and afraid she threatens instead of saying a feeling or expressing a need. She understands that words can build or break, and that she wants to build. That she is now fully aware of this and can and will do it differently.

Her husband was right on board, appreciating her openness and her effort, restating his love for her and his willingness to keep working on himself and on their emotional connection.

Perhaps all those elements of EFT, IFS, CBT, DBT, Imago, Attachment and good old psychoanalysis that I’d been pulling from did their job. Or maybe it was my attentiveness or occasional loving looks, or as of late, my restraint from saying very much at all. In my mind, as I listened to her I would visualize writer Ann Lamott’s acronym for WAIT – Why Am I Talking? Perhaps in my silence she felt understood, and that her profound longing and sadness could breathe.

I admit that I really do like to see breakthroughs now and again. I suppose they help me hang in better when all those feelings come through my door, whipping up my own like a wind gust on dry leaves. With all my ideas about what really happened swirling about, I’m settling on the miracle. I’m giving myself the gift of joy, of seeing the train wreck derailed and not the train. I know that in this business some miracles are temporary—sometimes it seems like character, relationship and repetition difficulties are more resilient than their resolutions—so I’ll take the miracles when they come.

Grief and Gratitude: Working with Stroke Survivors

Posted on by rezendevknowfully.com

Together

May we sit with wisdom and compassion

at the ancient fires
of dashed hopes
and lost dreams.
May the pain which brings us together
become the cave we enter
in reverent descent
and surrender
to what
IS.
May we have the courage
to bear this rebirth
together.
—Carol Howard Wooton

 

An Interruption

In 2005, our circle of six met in a poorly lit room of a community hospital. This afternoon, Tom had the floor. A former surgeon, he had been looking forward to cutting back his practice to spend time with his grandkids.

Tom had lived his life in constant motion. He had been a football star in high school and college before going to medical school. Now, at 67, he was paralyzed on his left side: his left forearm contracted in spasm, his once-dominant left hand clenched into a permanent fist in front of his belly, his left leg rigid below his knee. His chiseled face still handsome, he sat straight in his wheelchair, strong muscles supporting his torso—a powerful presence. But his eyes always gazed down; he barely looked at anyone.

“I used to be able to ski, drive, do everything around the house,” he said. “I loved my work. This summer, I planned to take the grandkids to the ocean, show them how to dive into the surf. What can I show them now? Nothing.” The other group members listened quietly to his grim litany; all of us recognized his truth.

One day in 2004, Tom had come home from work and eaten dinner as usual. His wife was in the next room when he felt himself lose balance and topple over. He called out to her.

“I’ve had a stroke. Call 911,” he told her from the living room floor. She made the call, then came back into the living room and sat her petite frame on Tom’s head until the paramedics came, knowing he would try to get up.

“I had it all planned out,” Tom said to us. “And now I can’t do any of the things that I want to do. All that time I spent in medical school and working hard while my wife raised the kids—this was supposed to be my time with my grandchildren.” Each week he repeated these thoughts while gazing at the fingers of his left hand, pulling each one out as straight as possible, then resting it on the arm of his wheelchair or in his lap. On this day, the door banged open, interrupting him.

In barged a large woman in a motorized wheelchair, which she drove fast and well. Her left leg was swollen huge, the bare right foot discolored, her skirt hem hardly covering the Foley catheter bag strapped around her calf. In a croaking voice, she declared, “There’s only two kinds of people in the world: keepers and assholes. And you’re all keepers!”

Everybody, including Tom, guffawed. Amidst the belly laughter, she zoomed over to our small circle, which had opened to give her room. She told us she had been sitting outside in the warm air for 45 minutes, thinking she was early. When no one else arrived, she’d opened every unlocked office door until she found us, arriving with only 30 minutes left in the session.

“Hi there,” she said with a wide grin. “I’m Alexandra.”

None of us could have guessed that day how much Tom and Alexandra would change each other’s lives.

The Group

When I’d spoken to Alex on the phone for the group screening, I hadn’t been sure whether I should allow her in at all. I could tell immediately that she would be a handful. She spoke nonstop. Her history included two violent deaths in her family and probable childhood verbal and physical abuse. There was no way to determine what aspects of her personality resulted from the innumerable medications she was taking, and what was caused by her stroke and or by PTSD. The nurse case manager referred her to me because of her complex medical conditions and because the psychosocial situation at home was especially difficult. Along with the stroke, which had left her completely paralyzed on her left side, she suffered from diabetes and lymphedema. Her husband was away at work or commuting during their waking hours, leaving Alexandra isolated at home with only the companionship of a part-time caregiver.

Any group therapist would have been concerned about the severity of her situation, her apparent need for attention, the feasibility of containing her, and the unpredictable impact she could have on others. However I also realized that she needed the group and had many stories that needed witnessing, as well as much wit and spice to offer her groupmates. And this was my mission: to create a community of belonging for stroke survivors to grieve, heal, grow, and keep hope alive—the space I wished I’d been able to find in the first years of my own “recovery.”

The Beginning

“I had a stroke in 1985. I was 38, with no high-risk factors.” Having just been minted as a licensed MFT, I was living a typically stressful existence building a practice and taking whatever jobs I was offered. It happened at a work-related event, a friendly barbecue for a support group of women Vietnam veterans which I co-facilitated. All of a sudden, I grew dizzy and wasn't sure if I was sitting up straight; the world receded to a distant buzz. I slept on the hostess’s couch that night, unable to drive home. When I woke to find I couldn’t stand, or even crawl, she brought me to the ER, where my husband met me.

The neurologist diagnosed me with a cerebellar stroke or CVA, etiology unknown, and gave an excellent prognosis: I would be fine, and it would take a while to learn to move again, to walk, to have a brain that worked at “normal speed.” When I asked what “a while” was, he hedged. “Six months from now, you and your husband will know,” he said finally, “but other people probably won’t be able to tell.”

Six months later, that was not true. Two colleagues who had suffered a stroke and a traumatic brain injury, respectively, told me, “Don’t worry about your progress for at least a year or even two. Just keep at it, no matter what.”

“You Don't Get It”

Before my stroke, I’d consulted with a therapist named Helen on my own cases. She was a smart, warm, empathic woman several years older than me with a well-established practice. Within 24 hours of my hospital admission, I asked my husband to call her: I needed her help in formulating a plan for handling my caseload. After we made arrangements, she continued to call me during my rehabilitation. Our regular contact reminded me of my professional-self while being a patient.

Returning home a month later brought me face to face with my new limitations outside the safe hospital environment. I was frequently overcome by waves of strong emotion, mostly frustration and sorrow. I determined that weekly psychotherapy would assist my physical recovery. My therapy with Helen began on the phone; when I was able to leave the house, my husband or a friend would drive me.

My neurologist had advised to me to wait six months before driving. After about nine months and many practice drives with my husband, I drove myself for the first time to Helen’s office. “During the entire drive from San Francisco to the East Bay, I held onto the steering wheel so tightly that my knuckles turned white”—not out of fear, but because I wanted the pressure of my hands against the steering wheel to anchor my attention. Without that strong sensation reminding me to keep my eyes on the road, I might have become so riveted by anything moving alongside me—the beauty of leaves dancing in the wind or the blue BMW passing me—that I might forget about looking straight ahead.

I was drained by the time I reached Helen’s office. “You made it! How was it?” she asked.

When I mentioned that it was hard for me to concentrate, she replied, “Oh, that sometimes happens to me, too. I’m driving and thinking about what I’ll buy at the grocery store or the calls I need to make.”

With a pit in my stomach, I realized, “She doesn’t get it. It’s not like that now.” I didn’t have words yet to tell her how it was for me, or to explain to her what she was missing. So I said nothing.

It happened that I also knew a therapist who had suffered a traumatic brain injury in a car accident. I knew he would understand, so I began to meet with him. Together we explored and named the difficult parts of our experience: slow thinking, unreliable memory, trouble concentrating, having to relearn everything, wanting to be “normal” while also being impaired. He supported me with anecdotes from his own experience and comments indicating that he understood. This was enough to allow me to go back to Helen and have the words to talk with her about our rupture.

“No, no, no, you didn’t understand,” I told her when I returned. “Part of me wanted to pass as normal, as someone who’s simply distracted by making a mental shopping list. Not being able to rely on my capacity to direct my attention was frightening.” As we talked, I came to understand that her well-intended response grew from her wish to join with me to help me feel understood and less flawed. Later, we also spoke of her fear and grief in the face of all my sudden losses.

Be Curious

As I learned with Helen and would keep learning in my group work, it’s essential for a therapist to acknowledge discomfort in the face of the sudden profound loss of physical, communicative, and cognitive capacities, all highly valued abilities that may lead to loss of social, family and vocational roles—loss of identity. Making assumptions that he or she understands is a great defense against that discomfort, but it doesn’t help the client.

Therefore, it is especially important to practice curiosity. When clients say something’s hard for them, ask, “How,” or, “What’s that like?” or “What’s that mean to you? Exactly what part of it is hard?” “Asking questions like these gives the survivor an opportunity to attend to inner experience and attempt to articulate it.” Stroke survivors’ process of authoring their own new stories enlarges rather than diminishes their sense of self.

The process of articulating a narrative doesn’t happen during rehabilitation, which currently averages 16 days in the U.S. There, the focus must be on the rapid regaining of lost function so the discharged patient can perform as many ADLs (activities of daily living) as possible: the basics like sitting up, transferring from bed to wheelchair, standing up, walking, toileting, climbing up and down stairs, swallowing, feeding yourself, putting your pants or bra on.

Since there is little time and training for rehabilitation staff to focus on enhancing the patient’s new identity, we therapists have a big job. It is all too is common for patients to feel diminished and “less than” in medical settings: imagine having to focus most of your attention on exactly what you can’t yet do. How we respond as therapists, friends, and family makes a big difference in the healing process.

Sometimes it can be hard for a therapist to remain curious when a client seems to simply repeat the same story over and over, as Tom did. But consider this: it’s exhaustingly hard work for an already injured brain to develop new neural pathways. This spurt of neuroplasticity is nonetheless necessary for both physical and emotional recovery. No wonder survivors often repeat the same stories; pure neurological exhaustion can lead anyone to opt for the better-established neural route. If you keep hearing the same story, you might want to say, “I hear you. You are working so hard just to stand up again.” Follow-up questions will prompt clients to experiment with new thoughts and stories.

Finding a Community

Even though I had loving friends and a devoted husband and family, I felt isolated when I returned home. After the crisis, my life consisted of weekly physical therapy—learning to walk again, regaining strength—and resuming tasks like buying groceries, balancing my checkbook, making dinner. Meanwhile, my friends and family went back to their busy lives. I was left moving through my day incredibly slowly, and mostly alone.

“I began to wonder: “Where do I fit now?” What were my chances for a career, or any role in society?” Would I be able to resume a full professional life like my colleague who had a traumatic brain injury?

Three months later, with the help of my therapist Helen’s consultation, I resumed seeing one client a day in my home office. Despite lingering but outwardly subtle attentional difficulties, I discovered that I could still listen deeply and skillfully to one person at a time. After walking my client to the top of my long stairwell, I had to rest for several hours before a simple dinner with my husband and bed. Still, this was a personal triumph, and the beginning of reclaiming my professional confidence.

I also began to search for a community group where I might find guidance and a place I could belong. City College of San Francisco had a program for Acquired Brain Injury survivors, but the organizer told me I was too high-functioning. Yet I was not high-functioning enough to occupy my own life in the way that I had before.

Through friends, I found my way to the Stroke Club, which met monthly at a local YMCA. First I was a guest speaker, then I became the volunteer co-leader. The group provided the opportunity to test my ability to perform professional functions I had used before my stroke. I was pleased to find that my attentional difficulties didn’t interfere with my ability to lead the group. In fact, I proved to myself and to others that I could still conduct a group class for a few dozen adults, using my skills as a counselor and educator as well as my personal experience to serve others as we learned to cope with life after stroke.

The Stroke Club provided social connection, education and some support. It was perfect for some, but it didn’t satisfy the therapist in me. My professional experience as a therapist working in a psychiatric halfway house and with Vietnam vets had taught me how potent small group intervention is for marginalized and stigmatized populations. I wanted to start a small group for stroke survivors. But how?

After hearing a local neuropsychologist give a talk to mental health professionals about his group work with brain-injured adults, I called him and told him my idea to organize a group for folks who’d had strokes. He suggested we talk more over lunch. He was very encouraging.  After we discussed logistics and recruitment, he asked me, “Are you going to volunteer to do this?”

“Well, I’ve been volunteering for the last two years and seeing clients in my private practice,” I responded. “I’d like to ask people to pay me. I am a therapist, after all.” In response, he expounded on the rewards of volunteering. It was as though he was saying, “Oh, you’ve had a stroke? I’ll let you volunteer. Oh, yes, I think you’re competent, but you want to charge money?” I held my ground, and was proud of myself for doing so, despite my own still-shaky sense of self-efficacy.

To his credit, he listened, thought about it, and said he would try to work out payment. A few weeks later, there was an envelope waiting for me in the staff mailroom of his hospital, St. Mary’s, where my group had begun. He had written me a personal check.

When I asked him about it, he told me, “We can’t get the money from St. Mary’s yet and I often make donations. I know you and think this is a good idea, why not help you launch this? Seems more important than giving to United Way.”

This was a pivotal moment. Not only was it a kind and generous gesture, but even more than that, it was a sign of the neuropsychologist’s professional dedication and esteem. Neither of us knew for sure where I belonged in the medical model—star patient or competent professional. The donation moved us both across an invisible threshold.

A Different Kind of Challenge

The loss of competence and control over his daily life was understandably trying for Tom, the former surgeon. During his first years with the group, he said no to every suggestion that his loving family offered, most especially his wife. He refused physical therapy. He refused occupational therapy, though his wife had already arranged his eligibility and prescription. “No, no, no, no.” The only suggestion he took was coming to this group, which his wife had also recommended, worrying about how little he left the house. She had to learn to tolerate Tom’s “no.”

It was easier for me, as the therapist, than for Tom’s family to see that “saying no was the only control Tom could exert in his life.” Still, I advised them that if they could just let it be and stop pushing, maybe he would say yes, but on his own schedule.

Of course, I did break my own rule occasionally. Countless times over the course of the group, I had given Tom the name of an extremely talented and competent physical therapist who specialized in neuro-rehabilitaton. Each week, I would ask him, “Did you call her?” And, like a high school student, he always had an excuse. “I spilled coffee on it.” Or, “I’m going to call. I just haven’t gotten to it.”

Finally, I called the physical therapist and asked her if she would come to the group in order to provide a short lecture and demo to all the members. She knew that I had referred her to Tom. When she came, she made a special pitch to him. We watched her use all her strength and skill to pull his contracted left arm as straight as she possibly could against the resistance of all its spasticity. His look of surprise grew into a smile as she uncurled his fingers one by one and placed them on his lap. It helped, of course, that she was confident and attractive. Finally, he asked her in front of the group, “When can you come over?”

Over the next several months, Tom progressed from being wheeled into the room in his wheelchair, to walking while holding onto the chair with his caregiver nearby, to using a four-pronged cane while his caregiver wheeled the chair in behind him.

The group witnessed and applauded his progress week after week. Nevertheless, Tom’s grief trumped all: “Yeah, but the wheelchair’s still here.” “Yeah, but this isn’t really walking. Walking would mean that I would be out there on my own again.”

Tom’s despair did lead him to make a suicidal gesture. I classify it as a gesture, not an attempt, because he did it at home, with his wife in the other room and the physical therapist scheduled to come.

After this incident, Tom didn’t return to the group for a while. When he did, it was clear something had shifted. Before his stroke, he had always been healthy and well adjusted. He had lots of great coping skills that had enabled him to focus on achieving external goals; he hadn’t had a reason to reflect on his interior life. Now, even though it was physically and emotionally painful, Tom was learning how to face and cope with his own despair. He began to see a cognitive-behavioral therapist who helped him utilize his intellect to gain insight into his own thoughts and feelings. In this way, he learned about depression.

When Tom came back, he was initially subdued, and at the same time, sardonic—a new sign of energy appeared in his eyes and voice. His mantra became, “Well, I guess I’m not going to be taking the grandkids to the ski slopes,” as opposed to wishing he could. He hadn’t yet fully accepted his new life, but he was getting there.

The arrival of a new group member soon afterward gave Tom the push he needed. George was also in his late sixties, a medical professional, and paralyzed on his left side. Only several months post stroke, he was still wheelchair-bound. But George had explored his dark side prior to his stroke: he’d been in a 12-step program for years.

One day in group, George addressed Tom point-blank. “You were a surgeon,” he said. “You knew what to do if you wanted out.”

Tom had met his match. No more BS. George called him on his actions, and set him some new expectations. He wanted Tom to be a role model. “How long did it take you to stand up on your own?” George would ask him. “What do you think about stem cell transplants? Neuroplasticity?”

They met man to man, and began swapping golf and football stories and off-color jokes. With George’s support, Tom not only became the group’s in-house physician and renewed his medical license: he had found a new role for himself.

Look for Wholeness

Tom’s struggles exemplify the profound grief and loss that can engulf a stroke survivor’s perspective. As the facilitator and a fellow survivor, it was hard for me to hear Tom’s despairing litany week after week. While the group had made space for Tom to speak his dark truth, I also knew from personal and professional experience that it was possible to move beyond the focus on what had been lost.

It is crucial for survivors and their therapists to know that recovery doesn’t stop at six months or a year, or even at two years. Now, with new research into neuroplasticity, we know that people can continue to progress 10, 15, even 20 years after a stroke. Although, there is no way to know how much healing is possible for an individual survivor.

Oftentimes, people become focused on regaining their capacity to ski, like Tom, or to go back to work. But if the goal is too concrete and narrow, they might be severely disappointed. It took a couple of years to go from mastering the stairs to my apartment to being able to walk six miles; in order to appreciate my successes, I had to stop comparing myself to who I had been.

Grieving is necessary, along with the acceptance that there’s a new normal. That’s why I hate the word “recovery”: it implies a return to a prior state. But moving forward from a stroke is not as simple as trying to get your life back to the way it was before, because it will never be the same.

So instead of aiming for the impossible goal of returning to a previous state, clients must re-imagine themselves and their lives. The term I have chosen, for lack of a better one, is “revisioning.” And neither feeling—the sense of loss nor the sense of possibility—ever goes away completely for a stroke survivor. “I think that the best outcome for folks with strokes is that grief and gratitude live side by side.”

A Good Boy and a Bad Girl

As the group progressed, Tom and Alexandra formed an unexpected bond. They seemed like polar opposites: he was the quintessential altar boy, the high school football star, the successful surgeon. He did the best he could at whatever was in front of him. On the other hand, Alex was a troublemaker who questioned authority, and who gave everybody a hard time probably from her first words. Tom and Alex had actually gone to the same religious school, but Alex had been suspended for asking questions about birth control.

When, week after week, Tom was stuck in his “yeah, buts”—“I walked a little further with my physical therapist this week, but it’s still not throwing a football” —Alex would finally be the one to say, “I’ve had enough of that. You’re just feeling sorry for yourself. Come on, I’m happy for you! You’re out there walking. If I could walk, I would be really happy.”

Tom would break his self-absorbed downward gaze at his spastic left hand and look at Alex, in her motorized wheelchair, who hadn’t stood on her own two feet in who knows how long and wasn’t going to be walking two inches. That stopped him dead in his tracks.

Alexandra’s directness and her outrageous sense of humor unfailingly got her the attention of the group, along with her stream of hilarious stories about her past traumas and clever triumphs during her checkered career. Her level of her socioeconomic dislocation and physical disability was also the most profound in the group. Her husband ended up losing his job, so they lived on food stamps and MediCal.

When Tom had been absent from the group following his suicidal gesture, I used the opportunity of that emotional upheaval to ask, had they ever felt suicidal? We all talked about our own moments of despair and discouragement. Alex’s half-joking response was, “Suicidal? Heck no. I might have felt homicidal.” And the truth was, that’s how she dealt with things. Because of the extent of her disability, she was constantly undergoing humiliating and painful medical treatments. Instead of becoming passive and defeated, she chose to be a “difficult patient.”

Alex had a suprapubic catheter, which went through a hole in her abdomen directly into her bladder and had to be changed weekly. Sometimes, predictably, this routine procedure was very painful. Once, Alex related a story about a nurse who replaced the catheter especially roughly, jamming his elbow in her face in the process. She begged him, “It hurts! Stop! Please stop.” When he ignored her, she bit his elbow hard enough to draw blood. She laughed raucously as she told us this story. And while we appreciated the comic relief, we were horrified at what she had been put through, and awed by her behavior.

Though I had initially worried about Alex dominating or disrupting the group, I learned to let her have her way and to let her speak. She also learned to restrain herself when I glanced her way. The group’s attention began to transform her. Alex was always self-aware enough to know that she played the role of the bad girl, and that she used her own humor as a defense. Over time, she began to able to talk about what was really difficult for her, without the defenses.

For instance, in order for Alex to get out of bed and be put in her wheelchair, because she was large and because she was completely paralyzed  on one side, a machine called a Hoyer lift had to be used to move her around. After several years, Alex began to talk more about her own sense of humiliation and discomfort around this device. She once told us that, moving her from her chair to her bed, her husband had dropped her by mistake. She told this story without her normal humor and outrage. She let her sense of vulnerability be seen and felt. The empathy and resonance in the other group members as she shared was palpable.

She also began to name some of the things that were especially difficult for everybody to talk about: What it’s like to be incontinent. What it’s like to wake up in a bed filled with your body fluids, and have to wait for somebody to come change you. Her bringing up these difficult moments in turn freed up some of the more reticent men to comment on the reality of those experiences for them.

So, as it happened, Tom, the good boy in the group, was learning from the “bad girl” about how to resist passivity and defeat in the face of his condition. And at the same time, the bad girl had gained the attention, respect, and admiration of the surgeon, the archetypal good father. Thanks to these relationships and the support of the group, Alexandra gradually moved from being the negative leader who challenged authority—mine and everybody else’s—to becoming a positive leader and thinking about herself in a constructive way. I believe that the group’s curiosity and openness to her perspective of the world allowed Alex to fully own not only her story but her personality, her own way of being.

Warrior Heart

The extent of Alexandra's transformation became clear to me when she organized an award ceremony for the group. She came up with the idea of awarding a former group member with the Warrior’s Heart Award. The award had been inspired by a group conversation I initiated about what it means to have a strong heart and be courageous. In that discussion, most of the members, including Alexandra and Tom, had agreed on John.

John was in his early forties, with red hair and an elfin smile. He used to be a chef, and still loved food. He was partly paralyzed and had expressive aphasia, which means he understood almost everything, but his verbal capacity was limited. He spoke primarily with gestures and facial expressions: his hand on his heart, wide smiles, quizzical looks. He had joint custody of his eight-year-old son, for whom he prepared meals with his one functional hand. And even though he was partly physically disabled and his speech was limited, he was always out in the community, swimming, grocery shopping, helping with events at a local community center. When people saw him around, he was always happy.

When Alex brought up the idea of the ceremony, I agreed it would be wonderful. I decided to wait and see if she was serious about putting effort into helping to make this happen. Several months later, Alexandra approached me about it in the group. “What about the celebration, Carol? Are we going to do this? I really want to.”

And so, with the group’s help and Alexandra’s leadership, we put on the First Annual Keeping Hope Alive Warrior Spirit Award Ceremony. It was moving to see her in her new role: as a leader, an organizer, an eloquent writer. For the award ceremony, she composed a poem that captured for all of us the strides we continue to make together as a group:

“John, you stand tall
your head above others, your back straight.
You are universally liked, your friends, legion. You inspire
us with your dogged
persistence in the face of challenges that defeat others.
Your warrior spirit proves to the rest of us, you are our representative
as we stand upright against the vagaries
of our conditions, and proof we will recover,
and contribute to each other’s success.
Thank you for being who you are:
Our warrior spirit.”

[This article was written with the consent of the group members portrayed therein.]
 

Paul Wachtel on Therapeutic Communication

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The Third Wave in Psychotherapy

Ruth Wetherford: Along with being the distinguished Professor of Clinical Psychology at the Graduate Center at the City University of New York, you’ve won many honors and awards throughout your career, including, in 2010, the Hans Strupp Award for psychoanalytic writing, teaching, and research. You’ve also been called one of the leading voices for integrative thinking in the mental health sciences. What does that mean?
Paul Wachtel: I think what that refers to is that for many, many years now, it has felt to me that psychotherapists operate like battling ethnic groups. They stereotype each other. They’re overly attached to their own language and make fun of the language of the other. They gather in their tribe-like congregations and miss a lot of value in the other orientations. So my interest has been not only looking at what has been called the common factors–the processes of change that are common to many orientations–but looking also at the differences, and how we can put together what’s similar and what’s different and create a more comprehensive approach to theory and to therapy.
RW: What are some components of what you want to be your message, your legacy?
PW: What’s important is getting ourselves out of the ethnic battles and thinking instead about what’s really of value to people. I was originally trained psychoanalytically, and then became interested in behavior therapy and then cognitive-behavior therapy, and then also family systems and emotion-focused approaches. One of the things I learned from the behavioral and cognitive-behavioral end that has profoundly influenced every moment that I think I’m working psychoanalytically is the absolute importance and compatibility of the exposure paradigm. Much of what promotes change is the experience of repeatedly confronting and being exposed in a full, emotional way to the aspects of our lives that we have turned away from in fear or guilt or shame. Sometimes those can be external stimuli like a phobic object, but very often, they’re our own thoughts and feelings and experience of self. What I’ve learned from cognitive-behavior therapists, and I never forget it for a minute in my sessions, is that

it’s not enough just to name it, interpret it, label it. You have to experience it. And that’s a place where the cognitive-behavioral and the psychodynamic can converge in powerfully important ways.

it’s not enough just to name it, interpret it, label it. You have to experience it. And that’s a place where the cognitive-behavioral and the psychodynamic can converge in powerfully important ways.

RW: This reflects, I think, what Dan Wile works toward in his collaborative couple therapy when he says that it’s important for the therapist to continually monitor internal thoughts, feelings, and impulses toward clients or patients we find in some way offensive–to continually look toward why that’s offending us and to look for what may be legitimate or reasonable. How can we understand it from that person’s point of view? It seems like it’s inherently about the therapist’s capacity to see things from another person’s point of view.
PW: I think job number one for a psychotherapist is to be able to understand how the world feels and looks to the people we work with. That’s another interesting point of convergence, by the way, in the larger realm of psychotherapy, that the ethnic waters are making less apparent than they should. In cognitive therapy, in particular, practitioners actually fall prey to the very errors that psychoanalysts fell prey to, which was thinking that if you just say the right words and label things and get people to think right, you’ll do the job. They will often treat the client’s thoughts as irrational and erroneous, and that’s very much the opposite of what you were just talking about.But there has been a trend in CBT in recent years that’s often been described as a third wave, that includes dialectical behavior therapy (DBT)–Marsha Linehan and her colleagues–and acceptance and commitment therapy (ACT)–Steven Hayes and his colleagues. Central to both of those are two things that create potential convergence with psychodynamic and experiential therapies: an emphasis on acceptance of the person’s experience, and a respect for emotion that was largely excluded from CBT for a 20- or 25-year period.

When I first got interested in behavior therapy, I was interested in it not because it was behavioristic, but almost for the opposite reason—that it was actually very deeply experiential. Instead of just talking about what you were afraid of, you actually put yourself there. I listened to what clients were saying and what they were feeling as they were confronting it. That experiential element was very important. I learned a tremendous amount from the early behavior therapists, so I was stunned to see tapes of the very people I had learned so much from, when they started to fall under the sway of this rationalistic approach to cognitive therapy. Suddenly they were trying to talk people out of their feelings, trying to tell them, “If you think right, you don’t have to be sad. If you think right, you don’t have to be angry.”

What DBT and ACT do, instead of trying to talk people out of the feelings, is they go into the feelings. They validate them. They accept them. They bring them forth much the way a good experiential or psychoanalytic therapy does. And that’s combined with an interest in eventually promoting change. There’s a seeming paradox there, but I think Marsha Linehan’s term “dialectical” captures it well. It’s a term, by the way, that’s also used by Irwin Hoffman, a relational psychoanalyst. It is that tension between acceptance and change, between following the protocol and varying from the protocol. Hoffman calls it going according to the book and throwing away the book. That’s how we work most effectively.

“What Should I Say?”

RW: One of your most important messages from your earliest works through the new edition of Therapeutic Communication: Knowing What to Say When is about our faulty assumption that if we truly understand the person, we will automatically say what we intend to say that will be effective in this dialectic between acceptance and change. Say more about how you want therapists to acknowledge this assumption, and what to do about it.
PW: The importance of that was something I learned almost incidentally, though powerfully, taught unwittingly by my supervisors on the one hand and my students on the other.My supervisors taught it to me by its absence. In other words, I became aware that asking questions like, “What should I say?” opened me up to charges of being superficial and literal. The message I often got was exactly what you’re saying: “If you understand it, you’ll know what to say.” So for a while, I was just feeling, “Well, maybe I’m stupid. But I think I understand the dynamics pretty well, and I seem to be understanding them much the way my supervisor agrees they are.” Yet sometimes I wasn’t sure what to say.

As I began to think about that more and talk about it more in my teaching, my students made me aware that they were getting something from me that they weren’t getting from any of their other teachers. They would say, “When we talk to you, you actually talk about what we should say. We’re not hearing that anywhere else.” That’s what first got me interested in writing about those details.

Then that got me really thinking, as I’ve continued to do over many years, about the ways we talk to people, and all the ways it can be problematic, the ways it can be helpful, and how it both shapes and is shaped by the ways we think about people.

RW: One of the ways you have demonstrated your gift for feeling is in your discussion of the implied message of different word choices. In other words, you talk about the focal message and the meta-message. You’re so attuned to the connotations of words and how they carry the meaning of respect or acceptance, versus accusatory, pejorative meanings. And this is the thing that so many therapists you’re trying to address seem tone-deaf to. They can hear a recording of an interaction they’re having. Others can see that it’s coming across critically or accusingly, and they can’t hear it. How do you address that?
PW:

Hearing and understanding the tone of what we’re saying is one of the hardest things for people to do. It’s one of the most important,

Hearing and understanding the tone of what we’re saying is one of the hardest things for people to do. It’s one of the most important, and I think people with good interpersonal skills do it naturally. I think it can be trained. But I do think it is hard.

One of the examples that I’m always struck by is if you’ve ever been in an unpleasant interaction with a sales clerk at an airport or something like that, often if you say something about what’s going on, they will say, “Why are you getting so upset? I haven’t said anything wrong.” And if you look at the manifest content of what they’ve said, that’s true. But if you listen to the tone of voice or you hear the way the sentence is constructed, you know you’re meeting with a hostile response. But the person who is being hostile or dismissive toward you often doesn’t understand that. That’s one of our real challenges.

On Modeling

RW: I read recently in a neuropsychology article that so much of our brains, particularly the right hemisphere, are designed to assess how we’re doing with another person, constantly monitoring, second by second, where we stand vis-a-vis that person. Tone of voice is one of the primary ways of doing it, along with facial expression, eye contact, body language, and that sort of thing.But we have a culture that is so dismissive, many people don’t know that tone is important, even though they’re constantly reacting to it more or less unconsciously. I like to use the phrase TODD: Tone of Disapproval and Disdain. I’ll point out to people when TODD has entered the conversation. And when people go from thinking tone is not important to realizing it is, that’s a huge opening. Bringing that message to people seems so elementary, doesn’t it? How do you cope with that?

PW: I think one of the things that we do, whether as teachers or as therapists–and here, I depart from the traditional psychoanalytic view’s emphasis on autonomy–
RW: Oh, no. You’d better not do that.
PW: I’m going to do it. Brace yourself.
RW: Radical!
PW: The idea of modeling is a very, very important one. We offer ourselves as models. Not that we’re model human beings, not that we’re any better as people or any more effective as people. But when we’re attending to the tone, to the effect, to the relationship, and when we do it well, our patients pick that up from us.I’ve had patients say to me without our ever to having talked about it explicitly before, “You know, you always manage to say what I’ve just said in a way that feels like you hear it, you care about what I’m saying. It sounds better in your words than it sounded in my mind. But I’ve begun to learn to say that to myself now.” And it’s not that I’ve asked them to. That would be an authoritarian, mechanical way. But the modeling or identification that goes on is selective. The patient will take what works for him or her.

And it occurs mostly implicitly. The set of patients who have talked about this mention it after they had noticed that they’ve begun to do it. In other words, they don’t sit down and intend to do it, but they begin to notice it. Just the way they gradually notice the way I’ve been talking to them, they later gradually notice how they have begun to talk to themselves or to other people.

RW: With a more empathic voice.
PW: Yeah. I’m often a critic of excessive explanations in terms of infancy because they contribute to the pejorative sometimes–described as pre-Oedipal and archaic and primitive and all that sort of stuff.
RW: Those are pejorative words for sure.
PW: Very much so. But if we think about the early attachment relationship, one of the things that’s interesting is that a parent’s interaction with an infant is almost completely about tone. It almost doesn’t matter what he or she says, because the infant doesn’t understand the words anyhow. But the infant does understand the tone, the feeling. So we develop very crucial skills in hearing the tone of others, which is part of what also is very central in good couples therapy, where the couple can have bad feelings keep reverberating between them. When you change the tone, good feelings start to reverberate.
RW: You give an example in your book: when therapist delivers an interpretation or comment without the accompanying meta-messages of acceptance or empathy, it’s like an organ transplant. It arouses the immune rejection by the body as if it’s foreign or alien. But with empathy, it’s not rejected. I call empathy the spoonful of sugar that helps the medicine go down.What are your thoughts about how this can be taught to therapists?
PW: Some of the teaching is explicit. Clearly, we need to articulate and point out that theory does have value. But some of it occurs through identification. With my students, as they hear my way of speaking and thinking, those for whom it’s not alien and rejected begin to take it in and make it theirs. What comes out in some ways sounds like me, but, very importantly, it also sounds like them. It isn’t a copy of me. It’s the aspect of me that’s of value to them, and they know implicitly what’s the kernel and what’s the husk.
RW: You were saying a minute ago that you were going to diverge from psychoanalytic thought, and we joked about being radical. That surprised me because 20 years ago I read, in a review of current issues in psychoanalysis, a segment along the lines that the optimal criterion of positive mental health in psychoanalysis has changed from autonomy and self-sufficiency to the capacity to interact with another person in ways that are mutually enhancing, and that analysts’ focus is shifting from accuracy of interpretation to quality of relationship. So I thought that was more or less widespread. Are you feeling like it is not widespread?
PW: I think you’re very accurately describing the direction of change in psychoanalysis. I, myself, identify very much with the relational point of view in psychoanalysis, and I’ve written from a relational point of view. And that point of view does embrace the very ideas that you were just mentioning. But when I wrote my book on relational theory and began to closely examine the relational thinkers whose ideas I felt fit well with mine, I also noticed that there were ways in which some of the older ideas continue to operate sub rosa, in a way that’s almost psychoanalytically validating in the sense that the early development of the field continues to influence it. The ways people talk about things explicitly is not necessarily the same as what is operating implicitly.It seemed to me that, for example, relational analysts who are increasingly the emerging dominant perspective in psychoanalytic thought operate nominally and explicitly from a two-person point of view, a point a view that emphasizes mutuality, reciprocity, the way in which we are both in the room co-creating the subjective reality, and so on. Those are the conceptual terms, and they are certainly a really important part of relational practice.

But

there are also ways in which relationalists continue to operate by the older one-person set of assumptions. They throw out terms like “pre-Oedipal” and “archaic” and “primitive” at almost the same rate that classical Freudians did.

there are also ways in which relationalists continue to operate by the older one-person set of assumptions. They throw out terms like “pre-Oedipal” and “archaic” and “primitive” at almost the same rate that classical Freudians did.

The Old Guard

RW: It reminds me of meeting a couple in which the man was a psychologist. I knew that he espoused principles of nonsexism and egalitarianism, and yet his wife did everything for him, and his interactions with her conveyed, “I’m the superior one.”Are you saying these relationists who do not see how their language and behavior toward their clients contradict their values of reciprocity and mutuality are emotionally dishonest in favor of maintaining a superior position, or for some other unconscious emotional reason that has to do with the relationship to the clients?
PW: I think “emotionally dishonest” would be a harsher evaluation than I would make.
RW: You’re right. It’s like saying we’re dishonest if we see that the emperor has new clothes when he pretends he’s naked and we’re caught up in the denial.
PW: All of us as fallible human beings are struggling toward ideals that we don’t always reach. But I think there’s value in the struggle, and I think we can move ahead. For example, there are very real ways contemporary relational analysts do practice very differently from traditional analysts of several decades ago.But there’s still a way to go. And I’m sure, for example, in my own work, there’s still a way to go that I’m not recognizing. It’s inevitable. But I do think that the idea of something deep underneath that’s being hidden is a very seductive idea. To say that my relational colleagues might have some unconscious motivations for the particular positions they hold is not necessarily a criticism, because we all have unconscious motivations. It’s part of being human. You can’t not have them. That’s not the problem. The problem is when there are aspects of the way we’re thinking and feeling that don’t have a place to evolve and be looked at and experienced and integrated and modified.

If I have an experience that the patient is being emotionally dishonest–let’s say the patient is talking about his feelings about his wife, and I am hearing that there’s a lot more there than he’s willing to acknowledge–my role is not to point out to him his contradictions, his self-deceptions, his illusions. My role is to make room for the full range of his experiences so that he can examine them more fully. I would not be inclined, even in subtle ways–at least if I’m working as I hope to work–to point out his dishonesty. But I might say, “I’m hearing the ways in which you admire your wife’s achievements and feel that she’s misunderstanding you when she says that you’re being competitive with her. I hear that part of it. I’m wondering if there’s another part of the experience that you’re feeling isn’t acceptable, the almost unavoidable experience of also being envious or competitive with her.”

RW: With the word “unavoidable,” you normalize it.
PW: Exactly. And that normalizing is not a denial–it’s an invitation. It’s not a way of shutting out the so-called unacceptable. It’s a way of inviting it in.I think the other crucial word there is “also.” In workshops, I’ve sometimes jokingly said that your functioning as a therapist could improve 31.6% if you would just substitute one word for another. And I ask partipicants to guess what those words are. “Both, and” is one way, or “also” versus “really.” Often either saying or thinking, “What you’re really feeling is…” implies, “What you think you’re feeling is false.” I would suggest that if you think you’re feeling it, you almost inevitably, necessarily are feeling it. But you are likely also feeling some other things that are harder to acknowledge and harder to accept. So I switch from “really” to “also.”

Shaming

RW: In the examples you give in the new edition of Therapeutic Communication, there is particular sensitivity to comments that are inherently shaming. And you have a very attuned ear. It occurs to me that so much training, particularly psychoanalytic training, at least in my experience of it back in the ‘70s, was extremely shaming and challenging. I wonder how much of the tone-deafness to that note of shaming is part of the training experience and modeling–we want to talk to our patients the way we were talked to?
PW: The ways that we actually talk to people and the feeling tone in the room often follows more from the tone we absorbed in our own personal therapy and supervision. And that that’s one of the reasons that older ways of practicing and thinking persist even after the official position has changed.I also think, apropos what you were saying about what training used to be like and how it sometimes still can be, that for many years psychoanalysis was organized in a rather authoritarian way.
RW: That’s an understatement.
PW: Yeah. You had self-contained institutes with very little check on them. You had a hierarchical structure, you had training analysts, and you often had a kind of thought control: you would go into analysis, and until you got it right, which meant you got it the way you were supposed to think and feel, you wouldn’t even be approved to work with patients. That was a very problematic structure. It’s certainly been changing, but there’s still a long way to go.

The Gold Standard?

RW: Speaking of structural changes, and returning to your original metaphor of ethnic battles, what is the value for the tribal leaders of our profession to embrace the more integrated view of therapy you advocate for?
PW: That is a big problem. I think the only thing that, by and large, brings tribes together is an external enemy. The fact that our whole culture is being increasingly dominated by nonpsychological thinking altogether, by corporate bottom-line thinking, will hopefully be a spur to seeing what our common interests are.
RW: In the article you wrote recently, “Are We Prisoners of the Past?” you end by saying, “In the practice of psychotherapy, much harm had resulted from the efforts of therapists to help their patients achieve autonomy. Being able to stand alone is the false ideal of the culture of Ronald Reagan. Patients who benefit from psychotherapy are those who learn the lesson of mutuality, who move beyond both helpless dependency and the false ideal of independence. Mutuality and interdependence are the lessons we must learn on a social level, as well. Our fates lie in each other.”This seems germane to what you were saying about what the tribal leaders need. A common enemy can create a sense of mutuality against the threat. But also it seems like a recognition of the fact that security is higher if we are mutually interdependent. That’s certainly true internationally–if I have a bunch of factories in your city, I’m not likely to bomb it. So how can the tribal influences in current psychoanalysis, behavior therapy, and the others you’re trying to integrate, continue to not see this when it’s so reasonable, so obvious?

PW: I think all psychotherapists know that people don’t always see what’s reasonable.

A lot of our work is trying to figure out how to get people to see what’s plain as the noses on their faces, but not evident to them.

A lot of our work is trying to figure out how to get people to see what’s plain as the noses on their faces, but not evident to them. Often, whether it’s working individually with a patient or client, or trying to produce social change, it’s an uphill battle, and you have to be in it for the long haul. It’s one of the reasons that I also think the current corporate-promoted trend toward very short-term therapies, which translates into cheaper therapies, is often a mistake. Producing really meaningful change often takes a lot of effort, and it takes time.

RW: Along with these financial pressures, there’s also the increasing manualization of psychotherapy. What are some of your thoughts and reactions to that phenomenon?
PW: I have two different concerns about manualization. My strongest concern is that recently, when people have advocated criteria for demonstrating that psychotherapy is empirically supported, one criterion that’s often introduced is manualization. I think that that’s a very misleading and problematic criterion. It’s not that manualization can’t help in establishing what therapists are doing. But I’ve written in a number of places recently about some of the fallacies in requiring a manual as a criterion. One of the things it does is it creates a kind of caricature of science.Science is supposed to be about finding creating ways to empirically investigate phenomena, but the criterion of manualization defines away any investigation of nonmanualized treatments. In other words, if your treatment isn’t manualized, then by the empirically supported treatments criteria that have been propagated in recent years, it can’t even be investigated. Therefore, it’s dismissed by definition rather than through research. And that’s very problematic.
RW: Give me an example of some of those criteria that you object to.
PW: In the recently consensual (almost consensual, because I don’t consent and some other people don’t either) definition of what it means to be empirically supported, there are three things, each problematic, that are usually introduced. One is manualization. And the rationale for that is if we’re going to say that a treatment has been empirically supported, we have to know that was the treatment being administered. That much is reasonable, as far as it goes. But the problem is that manuals aren’t the only way to do that. You can, for example, have practitioners of a particular approach rate blindly a series of sessions, some of which are and some of which aren’t the kind of approach being investigated. And you can get high reliability, and that way you can investigate treatments that are not manualized and still establish whether that is the treatment being practiced. That’s one reason that manualization is a foolish criterion.A second criterion derives from a kind of false precision. The idea is that we look only at patients defined by a particular diagnostic entity. So if you have a general pool of patients and they get better, that gets dismissed because the claim is that’s a nonspecific finding. The irony of that is by and large the vast majority of advocates of this empirically supported treatments paragon are cognitive-behavioral. And for many, many years, cognitive-behavioral therapists were condemning psychoanalysis for being supposedly a medical model. And now, here you have CBT people embracing the psychiatric DSM–a committee-wrought set of categories that have little to do with empirical science–as if it were the Bible. And there’s certainly a medical influence: requiring a specific diagnosis and slicing people up that way is aping physical medicine, in which you need to distinguish diabetes from rheumatoid arthritis because you treat them differently. But most of what we work with as psychotherapists is not usefully or validly understood as a series of discrete diseases. So to introduce that as a criterion is very problematic.
RW: It’s the same reductionistic thinking everybody’s been yelling about for decades, but we can’t seem to get past it.
PW: Well, right now we can’t get past it because it’s politically useful for people who are advocating a particular point of view.
RW: You say that with a fraction of the anger that Thomas Szasz says the same thing.
PW: I don’t know how my fraction compares with his, but I can get pretty angry about what is happening these days.

Psychotherapy research is crucially important, but it’s got to be done honestly, and I think a lot of it these days, it’s not.

Psychotherapy research is crucially important, but it’s got to be done honestly, and I think a lot of it these days, it’s not.

RW: In the last review I read of evidence-based treatment, which I think was John Norcross’s review commissioned by APA, the vast majority of the studies started at the beginning of the first session and ended with the third session. I just started laughing and dismissed the whole thing. I mean, we all know better than that. The forces that keep this model going are the desire not to know the truth, but to justify the status quo.
PW: And a part of that is this third illusory criterion, which is most seductive because there’s a lot that does make sense in it, but it’s, again, used politically rather than scientifically: the emphasis on randomized control trials (RCTs). That gets called the gold standard. Whenever I hear that, I like to think of the story King Midas, because turning everything into gold doesn’t always turn out well.I think here it’s a gold standard only under certain circumstances. For example, in the studies of drugs and medications that most psychotherapy RCTs are modeled after, one of the crucial elements is that nobody takes seriously a drug study that isn’t double-blind. Otherwise, the placebo effects are completely undetermined. In psychotherapy, it’s never double-blind. You can’t have somebody say, “We’re going to give half of you psychoanalysis five days a week and we’re going to give half of you an exposure therapy three times once a week. But we won’t tell which we’re giving.” Obviously, that’s absurd. People know what they’re getting, and people know what they’re giving.

So there, already, the RCT is overblown and misses something. But, more than that, in order to maintain the RCT, two things happen. One, the studies have to be very short term, because otherwise, the more it goes on, the more you have uncontrolled variables, which excludes what you can do research on.

RW: As if there are no uncontrolled variables in three sessions.
PW: Even in three sessions, they are an enormous number.
RW: Three minutes!
PW: Absolutely. And that’s, in fact, the other part of what’s problematic. Every psychotherapy offers us an opportunity to learn something. But if we are doing false homogenization and trying as hard as possible to give “the same thing” to each person in the group, we have very little opportunity to creatively learn from what we’re doing. And the crucial thing is that that’s not an anti-research view, at all.
RW: What advice you would have for a person who is working a clinic, hospital, or institution of any kind in which they’re being forced to adhere to evidence-based therapy, like the VA, where prolonged exposure therapy is institutionalized? The therapists don’t like it, but they have to do it anyway. What would you advise them to do besides quit their jobs?
PW: Social change is hard and slow, especially now that so many decisions are being made on an economic basis that secondarily justifies the psychological operation. So it’s hard to know what to tell them exactly. But the one thing I would say is that in making your case, understand really well the limits of the research that seems to support this truncated, limited, homogenized approach to things, because that research is very, very seriously flawed.
RW: It is. But what about all the research about the importance of the relationship? How does that factor in?
PW: That’s exactly the kind of thing that we need to emphasize. And this brings me back to why I was saying that I was not anti-research. I do think that because psychotherapy does create, almost instantly, a unique miniculture that evolves over time, it’s really hard for either party to understand or know fully what’s going on or to remember the sequences. You are recording this interview because if you try to reconstruct it a couple of hours after, it would be only a vague approximation of what’s actually going on between us. The same is true in psychotherapy.So I’m very much in favor of research based on audio- and videotapes that give us a database. But those tapes can be examined in the naturalistic process of psychotherapy, rather than in a homogenized, manualized treatment for one kind of research paradigm. There are a whole range of process outcome studies that teach us things that the other kinds of studies can’t teach us.
RW: You mentioned social change is slow. That reminds me of the curve of innovation, with the new innovators, and then the early adopters, and then the middle adopters, and then there’s the tipping point and everybody gets on board. It’s unfortunate that the new innovators are the people who were doing what the people did who discovered the importance of relationship 30 years ago. It’s the pendulum swung one way. Now it’s coming back.
PW: I think one of the problems in psychotherapy these days is that up until now, the people with the more narrowly mechanical ways of thinking have been more politically astute. And I think those of us who stand for serious research that addresses the true complexities of the phenomenon have got to do a better job of getting our point across.
RW: Tell us about your organization that you cofounded back in the 1980s, to create a forum for people who are interested in exploring the integration of psychotherapy. What are some of your goals, satisfactions, and frustrations?
PW: The name, Society for the Exploration of Psychotherapy Integration, is a mouthful, so we usually just refer to it as SEPI. It’s an international organization. It has members in 37 countries, and we meet all over the world. This May, we met in Evanston (Illinois). In 2013, we’re meeting in Barcelona.Our members represent all of the major orientations. We all have our identities as psychoanalysts or cognitive-behavior therapists or systems therapists or experiential therapists, but we also are interested in learning from each other and integrating other people’s ideas.

I thought of SEPI when you were asking earlier, “What do we do about this tribalism, and how can we get people to listen to each other and learn from each other?” It is hard within organizations devoted to a single point of view, because in those organizations, often the other points of view are experienced as Other.

In SEPI, there is no Other. There is a sense of coming and listening to each other. It is a place where we try to heal that breech.

I would be delighted if anybody reading this interview who was interested checked out the SEPI website, sepiweb.org.

I would be delighted if anybody reading this interview who was interested checked out the SEPI website, sepiweb.org. They can learn more about it from there.

Integration of Neuroscience

RW: One of the big new movements, with all the new technological advances in biochemistry, is the recognition of the connection between micronutrients and our brain’s capacity to make neurotransmitters that affect mood, thought, and behavior. How do you see that being incorporated into not only the integrative cultural, community, and interpersonal levels you’re talking about, but also in the intrapsychic and the physiological levels?
PW: I think we clearly are embodied beings. We’re not just abstracted minds. Anything that affects our bodies affect our minds. So all of our experiences at every level, whether they be cultural or nutritional, are part of this set of mutually reciprocal interactive processes that shape and reshape our experience. For example, if we think about the relation between psychological processes and neuroscience, neuroscience is only as good as psychology and vice versa. Mutual bootstrapping is the only way that we learn about, and even know how to look at, the differences between parts of the brain and what it means when one part of the brain lights up in a fancy fMRI study. Those lights are only as good as the psychological criteria that are showing what the lights are about.But that’s not psychological reductionism, because at the same time, the differences we see in parts of the brain lighting up can then re-attune us to notice differences in the psychological experience that we missed before, which in turn gives us still more refined tools for doing the next round of neuroscience studies. They keep going back and forth. It’s not just, “Neuroscience is the real thing and psychology is the surface.” They need to inform each other.
RW: The more we learn, the more we realize there are new unknowns.
PW: Yeah, and the more we can create new knowns. We keep building on both, as long as we’re not afraid of the unknown and we have the courage to acknowledge the known, in the sense of not having a kind of false modesty, but having the courage to say, “I’ve learned something. I know something.” On the one hand,

we need to be extremely modest as therapists. We need to be very careful about assuming we know, assuming an authoritarian position, assuming we understand.

we need to be extremely modest as therapists. We need to be very careful about assuming we know, assuming an authoritarian position, assuming we understand. That’s crucially important. But we also need to be able to acknowledge that we know something. When we speak to the patient in certain ways with a voice of authority, that’s the authority that just comes with having immersed ourselves in many lives in depth, and having been changed by that experience. We’re not just some new random element in the person’s life–we enter with some expertise. And if we can hold both our ignorance and our knowledge in tension with each other, then I think we can be more effective, more genuine, and more able to move forward.

The Miraculous (or not) Efficacy of Solution-Focused Therapy

Posted on by Psychotherapy.net Team

For years solution-focused therapy approaches have been all the rage; the popularity of this distinctively brief therapy method is unarguable. Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. If you recall, that was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Nevertheless, as much as I’d like to ignore all evidence contrary to my own beliefs, I also find myself attracted to old-fashioned modernist reality—especially that scientific research sort of reality. Consequently, over the years I’ve often wondered: “What the heck does the scientific research say about the efficacy of solution-focused therapy anyway?”

Well, here’s a quick historical tour of scientific reality.

• In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”

• In 2000, Gingerich & Eisengart identified 15 studies and considered only five of these as relatively well-controlled. After analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”

• In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies–a fairly small effect size.

• In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted. But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is only modestly effective.
 

Psychotherapy: Terminal or Interminable

Posted on by Psychotherapy.net Team

“I was okay until I met you!” she said and slammed the door of my office as she left. I have never forgotten that moment. I was shocked, not just by the vehemence, her incandescent anger, but by my complete failure to anticipate her reaction. I thought I was a good judge of character and I had got this woman badly wrong. I had invited her husband to attend the previous session and, instead of supporting her jibes and scarcely veiled attacks on him, I had taken a neutral stance. In her eyes, I had let her down. The one certainty was that the therapy had ended. Abruptly, unilaterally, angrily, admittedly, but it had the virtue of being unambiguous. I never saw my client again. 

During my long career as a psychotherapist I rarely experienced such a definitive ending. Fortunately, one might think, but was it? Looking back, I wonder whether I missed a trick, that, basking in my role as the Good Therapist, I colluded with my clients’ fantasies that therapy might go on forever. I would always be there, willing to see them again if they wished, for a few more sessions or a resumption of therapy. There were many clients who returned to me after an apparent ending. Smugly, I thought of myself as good at this job. I was not taken in by the idea that CBT or any other set of techniques was what determined outcome. It was the therapeutic relationship that mattered most and, for many clients, that relationship was the gossamer thread that linked us together. It might be scarcely visible but it was always there in the background even after therapy had ended. Now I wonder if something else was going on and the reason I was prepared to let people return, encouraged it even, was a fantasy of my own. Was it that I thought I was truly important to my clients, indispensable even, and that each time I received a phone call or a letter asking for more help, I felt the warm glow of satisfaction at the confirmation of my self-worth? 

This is not a comfortable thought. It would be easy to dispel it. I could tell myself that therapy rarely works in a straightforward way at first, people need more than one bite at the cherry, and those who returned to me did so because they trusted me and valued what they had received. And they benefited. All that may be true. But perhaps it is not the whole truth. Sometimes, therapist and client are dazzled by the therapy. It becomes a unique, special relationship. They have fallen in love. I do not mean that romantically or sexually but that something of the same specialness delusion operates. Good sense goes by the board and the relationship seems timeless. Until at some point it has to end.

“I have something to tell you,” I say. I am apprehensive, hesitant.

Patricia gives me a hard look. “That’s what people say when they want to end a relationship.”

“Well, that’s partly what I mean.”

Suddenly, her eyes fill with tears.

“In a year’s time I am stopping being a psychotherapist. I thought I should give you a year’s notice.”

She looks down. Tears are falling freely now. “Do you think that makes it any easier?”

I had thought exactly that but I don’t say it. I had wound down most of my clients. And earlier, I had thought that I might just keep Patricia on, to keep my hand in so to speak. When I mentioned this possibility to my supervisor, she looked me straight in the eye and said: “Why would you do that, John?” And I knew immediately that it would be wrong. 

“I’m sorry,” I say, inadequately, deflatedly, although what I am apologising for is only clear to me much later. 
All therapies have to end. When a therapist loses sight of the ending, it is no longer therapy but something very different.

Cathy Cole on Motivational Interviewing

Posted on by rezendevknowfully.com

Talking About Change

Victor Yalom: I think a good place to start would be to define and describe exactly what Motivational Interviewing is.
Cathy Cole: Motivational Interviewing is a counseling approach that has a very specific goal, which is to allow the client to explore ambivalence around making a change in a particular target behavior. In Motivational Interviewing, the counselor is working to have clients talk about their own particular reasons for change and, more importantly, talk about how they might strengthen that motivation for change and what way making that change will work for them. It’s a way for the counselor to guide a conversation toward the client’s goals, making the choices that are going to work for a particular person.
VY: I know the founder of this, Bill Miller, started in the field of addictions, where, at least for many counselors, there is a very different model of change, which is that the counselor needs to somehow break through the client’s resistance or denial about their drinking problem. In that context, MI has a very different philosophy.
CC: We really wouldn’t view that as resistance. In Motivational Interviewing, we’re listening very closely to what the client says and, more importantly, how the client is saying it. We’re listening for two kinds of language with clients: either sustain talk or change talk. What we might have considered resistance or what had been called denial in the past would actually just be consider sustain talk—reasons not to do something different, like reasons why stopping drinking would not be important, or reasons why, even if it’s considered important, the client doesn’t think they’re capable, or reasons why the client says, “I’m not ready to do this.”
VY: So in traditional alcohol counseling, for example, reasons why they don’t want to change are seen as resistance or denial.
CC: That was considered denial in the past. And it was viewed as the client not having paid enough attention yet to what the professional said they need to take a look at.
VY: So the professional is really the expert.
CC: That’s right. And in Motivational Interviewing, the client is considered the expert.
VY: Miller gives a lot of credit to Carl Rogers’s person-centered therapy in that regard.
CC: He does, and the basic conversational methods that are used in Motivational Interviewing came out of some of the client-centered work, particularly the use of reflective listening. When Bill Miller began to discuss this, he talked about the client being the expert. The clients are the ones who know themselves better than anyone else. The clients have strengths and capabilities, and clients have the ability to decide if making a change is important to them and why, and what would work best for them in terms of going about that change.

This is quite different from the traditional model of, “Here’s your problem. Here’s what you need to do. And if you don’t do it, that’s your problem, too.”

Of course, the counselor has an important role with this, because sometimes clients want to make change but they don’t really know how. So if, after fully exploring clients’ ideas about making change and what would work for them, the client still feels lost, we’re able to come in and provide some ideas for them to consider—things that we know have been helpful to other people or specific ways of approaching, say, stopping drinking. But ultimately, the clients are the ones who decide what they’re going to do. So this was quite different from the traditional model of, “Here’s your problem. Here’s what you need to do. And if you don’t do it, that’s your problem, too.”

VY: That’s the underlying philosophy of it, and then there are a lot of specific techniques. It’s very strategic, from my understanding. You mentioned one idea of sustain talk, and that is the clients telling you why they want to sustain or continue what they’ve currently been doing.
CC: Right. They’re telling you why they’re not going to do something different.
VY: When you’re hearing sustain talk, your goal is not to try to argue them out of it. You’re not trying to show them that they have some irrational thinking or beliefs. What’s your goal in listening to sustain talk?
CC: To me, there are two goals in listening to sustain talk. The first goal is for me to listen so that I really understand the client’s perspective and of why they are where they are with this particular behavior, and what might be interfering with them considering making a change. So I want to first really work on understanding that. And the way that I’m going to convey that I’m understanding that is by the use of reflection. The next thing that I want to do is to use various kinds of open questions to help the client completely explore the sustain talk, again, toward the goal of the client being able to make an informed choice about whether or not they’re going to change.
VY: And the other type of talk, to call it that, is change talk. That’s a really interesting idea, I think, especially for therapists. What is change talk?
CC: Change talk is when the client begins to shift and say that perhaps making change is important, or perhaps they are able to do it, or perhaps they are ready to do it. They begin to shift away from the reasons not to and they move into the direction of the reasons to make change, or the capability of making change, or that readiness to make change. And that change talk can be very subtle; it can be something that we have to really listen for. It may not be the dramatic, “Yes, I have changed my mind. Now I am definitely going to start losing weight or stop drinking or making a change in my drinking.” It could be as subtle as, “Maybe I should start thinking about that.” And the moment that that occurs, we want to then change what we’re doing in relation to that change talk.
VY: I know that Motivational Interviewing is used in a wide variety of settings, from addictions to healthcare, medicine, the criminal justice system. But just to keep things simple for now, let’s use the example of addictions, where it started. Can you give me an example of someone is struggling with drinking and give an example of sustain talk and change talk, and how you might listen for the change talk, and what you might do with it?
CC: The sustain talk might be something like, “My drinking is no worse than any of the other people I hang around with. In fact, sometimes I don’t think I drink as much as they do.” So that’s saying this is no big deal.A shift of that might be, “Well, when I think about it, I realize that some of the people I drink with actually do say ‘I’ve had enough’ and they quit. And I don’t always do that. Even if I feel like I’ve had enough, I just keep on drinking.” Many people might not hear that as change talk, but I hear that as change talk because the person is beginning to take a look at this and the drinking in a different way. I would really want to attend to that very carefully, and then help the client expand on that.

VY: How do you help them expand on it when you first hear that subtle shift?
CC: Continuing this example, my first response would be to do a reflection. I might say, “You’re beginning to pay attention to how your drinking pattern is not the same and realizing that there could be some pretty important differences.” I’m reinforcing the beginning of the client looking at this in a different way. By doing the reflection, that then provides the opportunity for the client to expand on what he’s beginning to think about.
VY: But you’re not jumping on it.
CC: No, I’m not jumping on it like, “Okay, so you really want to do something different,” because I’m just hearing the beginning of it. Again, MI is very client-centric, so I am helping the client move forward just a little bit, and I’m letting him now expand on this little bit of daylight that has started to show up here in terms of him thinking, “Maybe this is something I could look at in somewhat of a different way.” I want to help him move that along. But if I get too far ahead by saying, “Okay, so you realize that you have a problem,” the client will probably immediately push back to sustain talk because I will have gotten ahead of the client or really created some discord in the relationship at that point. So it’s very strategic in terms of how far ahead I’ll actually move.
VY: I know it’s a really important concept in Motivational Interviewing, for the therapist or counselor not to be the one arguing for change.
CC: Absolutely. The clients are always the ones that argue for change. We set the stage for them to be able to do that, should they want to, but they always present the argument for change.
VY: What is the rationale behind that?
CC: The rationale is if we have decided on our own that making a change is important, we’re far more likely to do it. And it’s also human nature that if someone else tells us that we have to make a change, even if we know we need to do that, we argue against it. We push back.
VY: So with this hypothetical client, say you reflect back the early change talk. How might it progress from there?
CC: Then the client says, “Yeah. I realize that if we go out drinking on the weekends, my other friends know that maybe they can drink a little bit more on a Saturday night, but when it comes to Sunday that they need to cut back and maybe not drink at all, or just have one drink. And they go to work on Mondays. I often don’t really slow it down. I continue to drink just as much on Sunday, sometimes maybe even a little more. And I sometimes don’t end up going to work. So I’m a little bit different than they are with my drinking.”To that, I might actually say a reflection back: “Your drinking takes on a life of its own. It actually gets ahead of you.”

VY: Okay, you summarize what they’re saying. You say you don’t want to get too far ahead of the client, but sometimes you might amplify their reflection?
CC: I’ll amplify that a little bit more. I took a little bit more of a step out this time, a little bit more of a risk, because the client actually started giving me more information. He started to have a different perspective. So I edged it out a little bit and really did a metaphor: “Your drinking has a life of its own, and sometimes it moves ahead of you.” I started to help the client really compare and contrast his drinking with other people’s drinking and just expanded, really, on what the client has said.
VY: It’s really a conversation between the two of you. The therapist does a lot of reflection and trusts that ultimately it’s the client’s decision whether they’re going to stop drinking, start exercising, manage their diabetes better, or whatever the behavior is. Does this tend to go on for a long period of time throughout a course of counseling? Is it very focused on a specific behavior?
CC: Motivational Interviewing the way that we’re using it is focused on a particular target behavior. It’s something that the client is talking about with a sense of, “I need to figure out how to deal with this.” Motivational Interviewing is actually considered a somewhat brief way of working with people in that the person is deciding whether they’re going to do something and then what they’re going to do.Let’s say the drinking from our earlier example is the target behavior. The client decides over the course of a couple interviews that this is a bigger deal in life than he had looked at before, so he’s saying, “Now I’m going to do something about this.” Now we’re getting a clear message of, “Yes, I want to move ahead.” So we begin to take a look at how capable the client feels of doing something about this and what it is he wants to do.

Let’s say I’m an outpatient therapist and doing a specific alcohol treatment is not necessarily my strong suit, but I have this client who comes in and that’s what the client wants to explore. It could be that in the course of that conversation, the client decides, “I’m going to do something about this. I’m going to go to a specific center or perhaps even an inpatient program that deals with alcohol problems.” Or let’s say that it’s a brief intervention to help the client get to the place of saying, “Yes. Now I’m going to do something about it,” and then he moves into planning how he’s going to do something about it. That might mean that the person moves away from me and that I’m not working with him any longer.

But let’s say that I am comfortable working with an alcohol problem. So now we have resolved that initial ambivalence. We’ve moved toward, “Yes, this is what we’re going to work on together.” At this point, we’re going to be working with whatever the client needs to take a look at: for instance, is he planning to try to moderate, or is he planning to try to stop altogether? If he’s going to stop altogether, what do we need to address with that? What might be barriers for him in continuing to maintain abstinence once he’s established it? So we’re not into the nuts and bolts of how he’s going to do it. I’m still not telling him what to do, but I’ve shifted away from that first part of Motivational Interviewing, which is just to resolve that ambivalence about doing it in the first place.

But let’s say that client is continuing along in therapy and with this change plan, and couple of months down the line, the client now says, “I don’t know. Maybe I don’t really need to continue to do this any longer.” So now we’re just going to explore that again. I’m always listening for where the client might become uncertain about continuing to work on this particular behavior. Then we’re going to come back and use Motivational Interviewing to work with that ambivalence.

Stages of Change: Importance, Ambivalence, Confidence

VY: Coinciding with this interview, we’ve just completed a series of Motivational Interviewing videos with you. The first one lays out the general principles, and then the next three address different stages in the change process. It’s an interesting way of thinking about the process of change in general. The first one deals with the idea of increasing importance. Can you just state briefly what is meant by that?
CC: When we talk about increasing importance, we are basically talking about the client’s buy-in around making change. The client has to decide, “Why is this an important issue for me in the first place? Why is it important for me to take a look at the role of drinking in my life? In what ways might it be creating problems for me? In what ways would taking a look at this and making some changes enhance, perhaps, parts of my life or what difference does it make for me to actually control my diabetes when I’m going to have it forever anyway? Why would I stop smoking? Why would that be important?” That’s the first thing when we’re talking about making a change. First, we have to believe that making the change is important, because if we don’t believe that it’s important to make a change, then we’re really not going to do anything.
VY: So first the client has to at least consider that it is important for them to change. And even when they consider it’s important, the idea that they might change is often counterbalanced by inertia or sustain talk—they still might be ambivalent about actually going ahead with it.
CC: Exactly. If we think about it, probably one of the most common questions that the majority of people deal with is, “Is it important that I eat in a certain way so that I maintain the health that I currently have? Is it important that I have a regular exercise routine?” And a lot of times, clients don’t actually realize that it is important for them to make a change.Let’s take an example of a client who has had a yearly physical with routine screenings, lab tests, things like that. The doctor points out that some of her lab values are off. Let’s say liver enzymes are off or cholesterol is high. The client has really not even considered that she needs to make any kind of a change, and now the doctor is saying, “These are indicators to me that you should take a look at these things in your life—that you should take a look at your diet, you should take a look at your drinking, you should take a look at the use of exercise to have an impact on these particular health issues that I have a concern about.”

VY: So this is all new information to the client. For the first time, she thinks, “Gee, maybe it’s important that I make some lifestyle changes.”
CC: Exactly. And other times clients have sought counseling about something that they think might be important, but they’re not sure yet. So they’ve come to sort that out for themselves. Or perhaps someone is saying, “I’ve really always identified myself as a person who speaks my mind. I want to express myself honestly, but I’m beginning to get some feedback at work from my boss that that is really not going to help me advance in my career. So I’m thinking maybe I should take a look at that, but I’m not so sure.” So he’s trying to figure out if changing something about the basic way that he has been interacting is important for him to work on.Or perhaps a young mother has been following the ways that female relatives have been telling her she needs to be dealing with her newborn baby, but she’s read some literature that maybe that’s not quite the right thing. So she wants to talk to the baby’s pediatrician about whether or not she should do something different, because she’s getting conflicting information.

VY: We’re moving into territory where the client is aware that there’s some potential need to change, reason to change, but they’re ambivalent. There might also be a reason not to change.
CC: Right. It’s so much easier to do things the way that we’ve been doing them all along. In the case of the young mother, it could be that going against the grain of what she’s being told by these other significant people in her life is something that, while she might think it’s important, maybe she doesn’t think she can pull it off. Maybe she thinks she’s not really capable of standing up to them and saying, “I’m going to bring my child up in a different way,” so it’s easier for her to say, “No, I don’t think it’s that important.”
VY: Throughout the course of counseling, assume you resolve this ambivalence in one way or other and the client decides, “Yes, I do want to cut back on my drinking,” or, “I want to quit my drinking,” or, “I want to lose some weight.” Then you move into the territory of whether they have the confidence to make that change.
CC: Exactly—whether they feel that this is something that they’re capable of actually doing. And if we look at, say, people who have decided that they want to stop smoking, many, many people can say, “I know it’s important not to smoke, but I have tried and failed so many times to stop smoking that I’m just not sure that I can actually do it. So maybe I should just keep on smoking because I really don’t want to fail again.” Now we’re now helping them take a look at the issue of confidence and capability.
VY: What is MI bringing to the table there? How do you help increase someone’s confidence or likelihood of making that change?
CC: One of the things that I would do is explore with these people any past attempts that they’ve had. If they’ve had any success at all, even if it’s just been for a day, I’d like to find out what helped them, or what happened that they were able to be successful even for a short period of time. I’d also want to explore with the person other areas in their lives where they have actually tackled some sort of challenge or made a change successfully, and help them talk about what helped them be successful at that time. Perhaps it was outside support from another person, or it was buddying up with a person to be able to pull off an exercise routine.I also help them determine what natural traits and characteristics they possess that help them tackle things in life that could be difficult, and how could they use those particular traits to help them in this particular area.

Another thing that helps with confidence is actually giving people sufficient information about how they might go about making this change, and helping them explore whether or not they think that would work for them.

Most of us are not going to step out into making a change unless we think we can pull it off, so to actually have an idea of how to go about it can be very helpful.

Offering Advice and Information

VY: As I said, Motivational Interviewing is widely used in healthcare and medicine, although our audience for this interview is mainly counselors and therapists. I think it’s just important to note that, say, in a medical setting, a healthcare provider might have very specific information about managing diabetes or quitting smoking. But also in counseling, if we have particular expertise in addictions, again, we might not tell them what to do, but we might say, “Based on our experience, this is going to be more likely to be successful than this.”
CC: If a person is saying, “I want to do this, I just don’t know how, and therefore I’m not confident,” we might say, “If it’s okay, I can give you some information on what has been helpful to other people, and from there we can see what you think about that in terms of it being useful for you.” I might present two to three ideas, then stop and go back to the client and explore again. “What do you think about that?” And see how they would work with that.So in addictions, I might say, “Some people find it helpful to do things like 12-step recovery and others find it helpful to go to specific treatment kinds of programs, while still others use things like web-based programs to help them deal with establishing abstinence and getting support. Other people have turned toward their faith, if that’s been something that’s important. So I’m just wondering, out of some ideas that I’ve presented, what ideas that brings up for you or what other questions that you might have.”

I’m always coming back to the client and checking in again, because ultimately the client is the one who’s going to decide.

VY: That again, is quite different from an approach where you say, “You really need to go into an inpatient program.”
CC: It’s very different from a prescriptive approach. I want to make sure, though, that folks listening to this don’t misunderstand: the counselor can actually provide specific recommendations, but it’s done in a way that ultimately our clients still know that they are the one making the choice. We’re reinforcing our clients’ autonomy.Let’s say that I have done an assessment with someone in relationship to drinking patterns and what kind of impact drinking has had in this person’s life. And let’s say that the client is now trying to decide whether or not he wants to do some harm reduction, or whether he wants to be completely abstinent. The client might ask me what I think, and it’s perfectly okay for me to give my point of view, but I would say it perhaps in this way: “Ultimately, you’re the one that’s going to make your choice. But from my review of your history and from what I hear about you trying to do moderation in your past attempts, it looks for me like going for abstinence is the right thing for you to do, certainly at this time. That’s my professional recommendation based on what I learned from your history. But again, I want to know what you think about that. Ultimately, you have to make the decision.”

What’s New About MI?

VY: It sounds very consistent with how a lot of therapists work in general. We generally don’t tell the client what to do. We think that we’re listening to them and being supportive. For the therapist who wants to integrate this into their general work with clients, what’s most new about this? When you are training counselors, what do you find really stands out for them about this approach?
CC: Particularly with seasoned counselors, what stands out as new for them is listening for when the client becomes uncertain again about addressing their target behavior—when they begin to shift and begin to have some doubt, perhaps, that they are capable of doing this or that it. It remains important to listen for that and realize that when we begin to hear that, we now need to shift and start to explore that uncertainty again and not act as if we’re continuing to move forward, because then we’re not really in sync with the client any longer.
VY: By that, you mean the client has been exploring the possibility of change but then hit a roadblock and start to get stuck back into ambivalence.
CC: Yes. They go backwards. They shift directions and move back into sustain talk. Let’s stay with the drinking example: say your client has decided that he wants to establish abstinence and he’s done that, and he’s been abstinent for three months and continued to work on possible barriers in supporting that.Then he comes in one session and says, “I’m doing really well with this, but I’m beginning to think that I just needed a break. I just needed to stop for a little while. I could probably go back to drinking again.” So he’s shifted directions. He’s said, “I’m thinking about this in a different way” which means that we have to now shift and begin to explore what’s happened and see where they want to go with this. Perhaps he has decided that the break is what he’s had and now he would like to try harm reduction or moderation. So now we’re attending to this in a new way.

VY: And the therapist needs to watch out for that tendency to want to kind of jump on the client, saying, “But you already decided this.”
CC: That’s exactly right.The temptation is to come in and try to convince the client, “You’ve made this decision. You shouldn’t turn back. You should keep going with this decision.” But then we will have moved into a position with the client where we’re not partnering with him any longer. We’ve decided that we’re the expert and we’re going to tell him what to do.

The other thing I think is new, in terms of really attending to it, is this difference between sustain talk and change talk. Motivational Interviewing really emphasizes that in a way that other counseling approaches doesn’t, and we’re really explicit about this. I find that this is new territory for counselors, to think about client language in this way.

In the years that I have been doing training, I have found that it’s challenging for people to pick up on change talk and to reinforce it. Counselors have to really start to tune the ear to pick up on change talk, to notice when that occurs and then shift direction and actually start to reinforce that change talk. Counselors often know the good client-centered skills, as you have mentioned. But listening for that change talk and beginning to reinforce that is often novel.

I think there’s something about us as therapists, and I think it’s our desire to know, and to know more detail. We get really seduced by the detail. We want to keep hearing more about the why-nots that are on the side of sustain talk. Our curiosity about knowing everything on that side of the world gets us in trouble sometimes, because when that change talk occurs, we really need to abandon everything that has occurred up until that time that has to do with sustain talk, and move ahead. It doesn’t mean that we don’t come back later and explore some of the barriers that the person might have talked about. But we do that once we’ve moved ahead and we’re saying yes to change. Now we may look at what gets in the way. But actually hearing the change talk and, when we hear it, immediately moving with it, can be a challenge.

VY: One way I’m hearing what you’re saying is, as therapists, we often like to look at people’s struggles and how they get stuck. It reminds me of an interview we did with Martin Seligman on positive psychology and psychotherapy, where he said that most traditional psychology is focused excessively on pathology and not giving equal focus on positive factors, on our strengths. So I’m thinking of it in that light, that therapists may get stuck on wanting to explore people’s challenges and problems and not give equal weight to hearing about people’s motivations for change and exploring that equally.
CC: I think you’re absolutely right. And in some ways, I think our initial training may have set us in that direction. To look at the positive side of this for us, we are really good at sitting with the struggles that a client has, at being able to understand it. And sometimes I think that strong capability that we have in that area might get in the way of us hearing those subtle changes of, “I don’t want to struggle this way any longer.” So we have to be very tuned into that.
VY: And sometimes therapists think, “Well, if you’re moving into just supporting them to change, that could be superficial.” I’ve seen you work, and I’ve seen videos of Bill Miller as well. And what strikes me is it sounds simple, but to do it well it’s really very nuanced. It’s very subtle and very strategic.
CC: Yes, very strategic. And there’s nothing more exciting to me than to have a client begin to embrace the changes possible and begin to believe in the capability that they can have in making that change and just watching that deepen. That, to me, is an extremely exciting thing to see happen. And I’ve equally seen the same thing when a client is with a counselor and they have started to say, “I’m really tired of talking about why I wouldn’t change. Now I would like to talk about why I would change and what I’d like to do about it.” When the counselor doesn’t listen to it, the light goes out of the client and the interview. It’s like the client gives up. So it’s a very special way of working with people, to reinforce client autonomy and to realize the extremely valuable role that the therapist has in guiding this process. If clients already knew what to do to make change, they wouldn’t be sitting in our offices in the first place.It’s very rewarding to work in this way and to watch clients become excited about themselves and what they can do. They often will say, “Thank you so much for telling me what to do,” when we’ve not said anything about what to do. They’ve come up with those ideas themselves, but they kind of think that we have. It’s a very fascinating thing for me to watch, and I often will say, “No, you’re the one that came up with that. I didn’t tell you what to do at all. You came up with that idea.” But they appreciate the process.

VY: Again, the counselor or the therapist has expertise in the process of change but they’re not the experts on clients’ lives and what clients should do to live their lives.
CC: That’s exactly right. Our role is to help our clients figure that out and to put words to that, so that they can really solidify that and deepen it.

MI with PTSD

VY: You work in the VA, where of course they’re very concerned about treatment being effective and using empirically validated approaches. I know there’s been a lot of research on Motivational Interviewing. Are you familiar with the research?
CC: I’m familiar with the research on Motivational Interviewing. There’s lots of evidence that clients make more changes in whatever the target behavior is when Motivational Interviewing approach is used rather than some other standard approach. Motivational Interviewing has a specific niche, and that niche is resolving ambivalence to change. I can give a brief example of how I use that in my work.I work with folks who often have had long histories of problems related to trauma, particularly sexual trauma in my line of work. They have posttraumatic stress disorder and have developed a number of behaviors, primarily avoidant behaviors, to help themselves feel safe in the world. And at some point in time they’ve come to my office, either self-selected or by a referral from someone else in the hospital, because they’ve screened positive on a PTSD score or they’ve said something to their doctor, and the doctor has encouraged them to see me. So now they’re in my office and we’ve done some history. We’re now at the place of the client deciding, “Am I going to do something about it?” The target behavior is this avoidance behavior, perhaps, that’s come from the PTSD, and clients now have to consider, “How important is it for me to actually do something about this? What’s that going to mean for me and my life? Am I willing to go through what might be a painful process to address this? Am I willing to face these fears in order to make some changes in my behavior?”

I’m using Motivational Interviewing at that point toward clients letting me know yes or no. “Am I going to work with this or am I not going to work with this?” That’s the engaging, the focusing, and the evoking part of Motivational Interviewing processes that we use.

Let’s say a client comes to a clear yes: “I really need to get on top of this because my 25-year-old son is saying to me, ‘I won’t leave home until you are less fearful,’ and it’s not okay for me to hold my son up in his life.” So the importance is not based so much on what the client wants for herself; it’s based on what the client wants for that son. It’s a clear value issue around the son. The client is now saying, “Okay, I’m willing to do this because it would benefit my son. And perhaps I’ll get some benefits, too, but it’s really so I don’t hold my son up in life.”

Now I have a clear yes, and we’re going to move into talking about the possible ways that this client can actually go about doing this work. And that’s where I can then present the evidence-based therapies that are available, either through me or through our institution, so that the client can then decide which of those evidence-based therapies she will use. So I have done the first task of Motivational Interviewing, which is resolving ambivalence, and now the person moves into some other specific form of therapy.

VY: Which you might provide or someone else might provide.
CC: Exactly. I can then review what we currently offer. I’m still using Motivational Interviewing because I’m letting her know the possibilities, and then she can decide from those possibilities which one do she thinks she would like to try, what might work best for her.
VY: It’s a nice example because it shows how you can integrate MI into a traditional course of therapy and also shows how you can use it with a problem. It’s not as circumscribed as a drinking problem or a specific healthcare issue. It’s a psychological problem that results from PTSD and fear. But it’s circumscribed enough that you can use MI to decide whether or not a client wants to tackle it or not.
CC: Right. So then the client has made a clear, informed decision. I continue to talk about Motivational Interviewing as informed consent. The client is thoroughly exploring the issue and making the decision, and that’s informed consent.

Teaching MI Skills

VY: Another thing that’s impressed me about it from what I’ve heard primarily from you, Cathy, is the training in Motivational Interviewing is very detailed. A lot of training in our field is more theoretical or overview focused, but from what I understand, to be certified in MI or as a trainer, people really look at your work and you get very specific feedback.
CC: Right. I always speak to the certification issue. There’s no particular certification process for people learning Motivational Interviewing, but many people go through training with folks like myself who provide training in MI. And it’s not just coming and sitting through a lecture; it very much involves practicing all the parts of Motivational Interviewing. Then, working with a person who can provide feedback and coaching by actually listening to interviews is what increases trainees’ competency in using Motivational Interviewing.
VY: When you’re listening to someone’s interview, what are you listening for?
CC: Actually, there’s a particular scoring guide that many of us use who provide coaching and feedback. I’m listening for whether or not the person is using what we call MI-adherent behaviors, using open-ended questions, using a higher reflection-to-question ratio, avoiding telling the client what to do, working fully to understand what’s happening with the client’s point of view.We’re listening for whether or not the therapist is keeping the focus on the direction in the interview; focusing on the target behavior, helping the client fully explore and understand the current issue, allowing the client to explore their own ideas about change, and helping the client deepen the meaning of making change.

There are many counselors who are very good at guiding the direction of an interview. They can keep a client on target. But they don’t necessarily do very well at exploring the client’s understanding, exploring the client’s own ideas for change, really validating. They might hear a client’s idea and immediately say, “Yeah, that’s a good idea, but let me tell you a better one.” That statement is completely non-adherent.

We’re listening for all of those things in an interview and providing very direct feedback on what the counselor’s doing. We know that the only way to really develop skill in Motivational Interviewing is to get feedback.

VY: I think we’ve really covered a lot of material here, at least to introduce people to some of the core concepts of MI. If folks are interested in learning more, where would you direct them?
CC: There’s the Motivational Interviewing website, and trainings are listed there. I certainly provide training myself. The trainings that I provide throughout the year are all listed on my website. There are a number of trainers who provide workshops throughout the United States. It’s also possible to engage a trainer to come to an area and provide a two- to three-day training for a group of people that someone organizes locally. So there are a variety of ways to go about getting training.
VY: You’ve been training therapists and counselors in MI for a long time. How have you evolved personally in your understanding and skills?
CC: Yes, I’ve been practicing Motivational Interviewing since 1992 or so, and I’ve been training since 1995. It’s changed me as a therapist very much in terms of my ability to listen, to not judge the client, to really be accepting of the client and the struggle that the client is bringing to the table. Again, that’s basic Rogerian counseling, and it sounds simple. You can spell out the principles in a couple sentences. But it’s very subtle and it’s not easy to do.
VY: Are there gradations in that ability to accept clients where they’re at? Do you see yourself doing that more, better, deeper now than you did 10 or 15 years ago?
CC: Yeah, I do. I think that when I became aware of Motivational Interviewing and I began to learn the very specific ways to have a conversation with a client using MI methods, I became even more aware of the strengths that clients bring to the table, and I became even more appreciative of clients knowing what is right for them, when it’s right for them, and accepting choices that clients make, whether or not I thought they were the right choices for the client or not.

I feel calmer as a therapist working in this way. I’m not disengaged from the process or detached from it at all, but I’m fully appreciative that responsibility for change lies with the client and that I have a very important role to help that client fully explore this possibility, but that ultimately, I’m there to respect the decision the client makes. It’s a very refreshing and calming way to work. I think the feedback from clients really reinforces that for me. It’s not a struggle.