Free Psychotherapy Training

Posted on by Psychotherapy.net Team

As a psychotherapy training nerd, I’m always looking for good training opportunities.  What’s the most training one can find on a limited time and budget?  I recently talked about this with Carol Odsess, PhD.  Dr. Odsess is a psychotherapy trainer in Albany, California who specializes in EMDR and Energy Psychology. 

What trainings have the best cost/benefit ratio?  A good place to start are the many excellent articles and interviews with master therapists available at psychotherapy.net, which are free to read.  (You only have to pay if you want the CEs.)  In addition, Dr. Odsess offered a few recommendations to stretch your training dollars. 

  • Instead of going to a conference, consider buying the audio recording of the conference instead.  You save the costs of airfare and hotel, and keep your weekend!  Additionally, you get to experience every training at the conference, which is more than you would get if you went in person.  Dr. Odsess recommends listening to audios of conferences while commuting (which has the side benefit of reducing road-rage.)  I’ve been working my way through 200 hours of the 2009 Evolution of Psychotherapy Conference during my commute for the past year.  She also pointed out that having the trainings on audio makes it easier to refer to them when writing or teaching.
  • A free way to enhance your training is to videotape your own therapy sessions and review them later.  There’s nothing like getting an un-edited view of your work to improve effectiveness.  Likewise, many consultation groups are free to join, or you can start your own.
  • Dr. David Nuys produces two excellent podcasts on psychology:  Shrink Rap Radio and Wise Counsel.  All past talks on both podcasts are available for download.
  • Check with your local library to see if they can order psychotherapy books or videos through their national link system. 
  • Join a listserv related to your specialties.  Many listservs have fascinating ongoing discussions about psychotherapy theory and technique.
  • Check out the great psychology blog mindhacks.
  • A few other websites offer free trainings via the internet or teleseminars, including traumasoma, wisebrain, and dharmaseat.
                Another issue to consider is the effectiveness of trainings.  For the most powerful and effective training, Dr. Odsess recommends live supervision, where the trainer observes (and sometimes intervenes in) a live therapy session.  Live supervision activates experiential learning, which she considers much more powerful than didactic or passive learning.  I myself prefer live supervision, as I wrote about here.  Live supervision is usually not cheap, however, so those on a budget might prefer the resources above.
 
 

Collaborative Couple Therapy With High Conflict Couples

Posted on by Psychotherapy.net Team

What’s hard, when dealing with high conflict couples, is getting their attention. If they do register your presence, it is to recruit you to their cause, confiding in you conspiratorily, “Look what I have to put up with.” And if they do acknowledge what you say, it is to turn your comments into ammunition against their partners, assuring you, “I do what you’re saying, but he never does.” High-conflict couples attack each other at such high velocity that you don’t have time to think. And you may not get much chance to talk, either, if, as sometimes happens, they keep interrupting you. Here are various methods I have heard therapists use to deal with these couples:

1. Take control from the beginning by doing individual therapy with each in turn in the presence of the other or taking them through a structured sequence.

2. Separate the partners. See each individually for a session and then bring them together. Taking it a step further, some therapists tell certain high-conflict couples that they each need a course of individual therapy before even considering couple therapy.

3. Ask them how they met and what originally attracted them to each other. In so doing, you distract them from their fight and introduce something positive.

4. Establish and enforce ground rules such as “no name-calling.” In a videotape of her work with a high-conflict couple, Susan Heitler gave the couple two rules: 1) stop talking when I say to and 2) don’t interrupt when I’m talking to your partner.

5. Tell the partners “hold it” or “stop” or wave you hands between them. Forcefully take command, as does Terrence Real. Or wave off the interrupting partner (Robert-Jay Green does this, but then later adds the wonderful touch of apologizing to the partner he waved off).

6. Confront the partners with the counterproductive nature of their behavior, saying, for example, “Listen to yourself!” or “Blaming doesn’t help” or “Talk about yourself rather than about her” or “Do you want to be right or do you want to be married” or “You’re acting like a couple of three-year olds in a sandbox fighting over a pail and shovel.”

7. Hook them up to a heart-rate monitor and when either partner’s heart rate exceeds one hundred, get them to take a time out. John Gottman came up with this.

8. Interrupt a fight to play back the video of it. John Gottman and Stan Tatkin do this.

9. Pick up a book and tell them you’ll stop reading when they stop fighting and get down to business.

10. Tell them that things are going too fast for you to think. Rather than blame them for doing something wrong, you take responsibility for the need to slow things down.

11. Move in quickly when things suddenly erupt and say “What just happened?” Susan Johnson does this.

You have to be forceful when dealing with high-conflict couples who interrupt each other and interrupt you and thus make therapy difficult. My way is forcefully to enter on the side of both partners and develop what they are trying say rather than to confront them with the counterproductive nature of their behavior and urge them to restrain themselves.

Why do I want to develop what the partners are trying to say? Because anger is typically a fallback measure, in EFT terms a secondary emotion. It’s what you’re often left feeling when you can’t express what you need to say—you lose your voice—or when you can express it, but you can’t get your partner to listen. In a couple fight—and this is the definition of such a fight—there are two people who feel too unheard to listen.

So I try to get the partners to listen to each other. I try to show them how it would sound if they were to express what they needed to say and take in what the other is trying to say. I move over and speak for them, in a method similar to doubling in psychodrama. I try to turn their fight into an intimate conversation.

And I do something else. I try to shift the partners to the meta-level—what I call the platform—and get them talking collaboratively about their fight. I want to get them commiserating with each other about it.

So these are the things I try to do with high conflict couples (and, actually, with any couple):

  • Help them express what they need to say,
  • Help them take in what the other is trying to say
  • Create this platform.

There is a natural sequence of things I do in my effort to accomplish these purposes.

The first is to catch the fight in its early stages before it builds up steam. If I see the emotional temperature rising or if one of the partners lets loose a zinger, I jump in. If George says something angry to Rose, I move next to him and, doubling for him, that is, speaking as if I were he talking to Rose, I say, “As you can tell, I’m angry and that’s because I felt hurt by what you just said.” I turn his angry comment into a confiding one. If I can’t think of how to do this, I repeat some version of what he said but in a nonangry tone. Alternatively, I might help Rose deal with what George has said by asking her, “How much does what George just said seem an accusation and how much an understandable concern?”

If I’m unable to catch the fight before it starts and it really gets going, I try to translate the fight into a conversation—that’s number 2. I go back and forth between the partners, doubling for each in turn, trying to detoxify each person’s comments. This can go on for some time. Sometimes the fight goes too fast for me to keep up with. When that happens, I wait until I regain my bearings and then go back over what they just said, but detoxifying it (“first you said…, then you said…., then you said….”). I bring out the conversation hidden in their fight.

Third, if I am unable to translate the fight into a conversation, I make a statement for each showing how each partner’s position makes sense. “Jim, it’s understandable that you don’t like Brenda’s bringing up something you did 20 years ago. It makes you feel she’ll never let you live anything down. And Brenda, it’s understandable that you’re bringing it up because it’s the clearest example of what you feel Jim continues to do in more subtle ways today.”

If I fail to get the partners to appreciate how each of their positions make sense, I try to get the partners up on a platform—a meta-level—talking collaboratively about how they are being adversarial. That’s number four: talk about the fight:

  • I ask, “Are you getting something from this fight, a chance to say a few things or hear a few things? Or is this fight discouraging, what happens at home, and what you came to therapy to stop?”
  • Or I ask, “In what ways is this fight useful and in what ways is it not so useful?”
  • Or I ask, “You came in today feeling relatively good about each other, but little by little the good will disappeared and now you’re quite upset with each other. Do either of you have any idea of what brought about this shift?”
  • Or I ask, “What should we do about this fighting? Should I step in more quickly to stop it?”
  • Or I ask, “Am I doing my job in keeping things safe? Or am I allowing too much fighting.”

While I am doing all these other things, I look out for and focus on conciliatory moments. That’s number five. I say, “Hey, I want to go back to what happened just a minute ago. You made that sweet comment (or you had that sweet exchange). What allowed that to happen? What were you thinking and feeling just before you said it that led to it?” And to the other partner I say, “How did you feel hearing it?” I’m looking for moments when these fighting partners aren’t fighting—much like a narrative therapist or solution-focused therapist looking for an exception. At other times I try to create a conciliatory moment. When one of the partners says he or she feels lonely or disappointed, I harken back to earlier in the session, or earlier in the therapy, when the other partner expressed such a feeling. I jump at the chance to show that they share a particular reaction.

Turning now to the situation in which one (or both) partners makes long provocative statements, either repeating (belaboring) a complaint or stacking complaints one upon the other,  I try to find a collaborative way to interrupt them. That’s number six: “interrupt tirades in a collaborative manner.”

  • I say, “I’d like to interrupt you here because I’m afraid that we’re losing Linda; she seems to be sinking deeper and deeper into the couch”
  • Or “Let me interrupt you here to find out how Linda is doing hearing this”
  • Or “I’d like to interrupt you here because you’re making some important points but I’m concerned that they are getting lost; I’d like to repeat them and then get a response to each from Lois.”
  • Or, “In the last couple of sessions things got pretty intense when one of you laid out a number of complaints in a row, so I think when that happens this session that I’ll move in and interrupt so we can have more of a conversation. What do you think about my doing that?”
  • Or I move in after a partner has made one or two points (or has made one point but has repeated it several times) and before he or she can repeat it again or go on to make the next point and I say, “Let me work with that; you’re saying that…” Or, more simply, “Okay, so you’re saying…” or “Let me interrupt here.”

If all these various efforts fail to rein in the fight, and I feel overwhelmed and powerless and don’t know what to do, I give myself a little pep talk—that’s number seven: “Console myself.”

  • I remind myself that although I don’t know what to do at the moment, I’ve always in the past been able to come up with something a little later.
  • Or I remind myself that partners who appear to ignore or reject everything that I and their partners say, often come to the next session having made changes that show that they had heard, but just weren’t in a position at the time to acknowledge it.
  • Or I remind myself that partners who fight the whole session sometimes come to the next session saying, “We needed that—a chance to let off steam. We feel better now.”

If it looks like the session is going to end with the partners angry at and alienated from each other, I talk with them about that. That’s number eight: appealing to the partners as consultants in evaluating and dealing with the situation.

  • I say, “Given what’s happened here today are you sorry you came?”
  • Or “What does a session like this leave you feeling about what we are doing here and whether these sessions are helping or just making things worse?”
  • Or “It looks like you’re going to end the session feeling angry and alienated. Is there anything either of you can think to do in this last couple of minutes to change that, or is it something that we shouldn’t even try to change?”

Another thing I do if it looks like the session is going to end with the partners angry at and alienated from each other is to ask what is going to happen after the session. That’s number nine. I try to create a platform—a vantage point above the fray—from which to speculate about what is going to happen.

  • I say, “Given how upset you are with each other, what is it going to be like driving home together, and tonight, and the next couple of days?”
  • “How are you going to get over this and how long is it going to take?
  • “Who’s the one more likely to reach out to the other?”

By anticipating with them what is likely to happen, I am trying to keep the aftermath of the fight from being the lonely, alienating experience it usually is. The three of us would be talking about it ahead of time. I follow up the next session by asking what did happen—what evolved from last session?

In this next session, I might ask whether they want to return to the issue they were fighting over the previous session? Or do they think that’s a bad idea because doing so will just get them back into the fight? That’s number ten: attempting a recovery conversation—revisiting the issue when they are not upset. If they want to make such an attempt, I guide them through it. And I jump in quickly if it does begin to turn back into the fight. Developing an ability to have recovery conversations is a premier goal of Collaborative Couple Therapy. In a successful recovery conversation, both partner come away feeling that the positions of each made sense.

To put all this together, I move in to keep the fight from happening. If it does happen, I try to turn the fight into an intimate conversation. If I’m unable to do that, I make an elegant statement for each partner showing how his or her position makes sense. If that doesn’t turn the session around, I try to get the partners on the meta-level talking collaborative about their fight. All the while, I draw attention to collaborative moments and interrupt partners (in a collaborative way) when they belabor or amass complaints. At various points in difficult sessions, I console myself. If it looks like the session is going to end with the partners angry at and alienated from each other, I appeal to them as consultants in dealing with this problem and ask what is going to happen after the session. In the next session, and if it is possible to do so without rekindling the fight, I conduct a recovery conversation. A major goal of Collaborative Couple Therapy is to enable partners to have recovery conversations in which they turn fights, problems, misunderstandings, and glitches into opportunities for intimacy.

Fact and Fiction in Psychology

Posted on by Psychotherapy.net Team

In 1992 I was a Visiting Fellow in the Psychology Department at the University of Western Australia in Perth. For two months nothing was demanded of me other than to talk to the staff and students of the Department in a learned and wise manner, which is easy to do even if you are neither. I was asked one favour which was to give a lecture to the whole department on a subject of my choosing. Can it be any subject, I recall asking the Chairman? Yes, he said, what did you have in mind? An exploration of the psychoanalytic theories of narcissism as illustrated in Oscar Wilde’s novel, The Picture of Dorian Gray, I replied. At that time the UWA Psychology Department was staffed by hard core scientists whose idea of psychology was to do controlled laboratory experiments and high-powered statistical testing. That sounds fascinating, said the Chairman. Too optimistically as it turned out for fascination was not quite the word to describe the stunned and horrified silence that met the end of my eloquent, literary disquisition. I remember one questioner spluttering angrily that psychology was about data, about hard facts in the real world, and I was talking about a work of fiction, the last word spoken with contemptuous disdain. But why have psychologists ignored fiction? What is wrong with studying the works of good novelists and poets for the illumination they provide about the human condition?

Psychoanalysts have long recognised the value of fiction. Freud delved into Greek mythology to explicate analytical theory, the Oedipus complex being the most famous example. Narcissism, the subject I was studying at the time, is founded, as its name indicates, on the myth of Narcissus who was transfixed by the beauty of his own image in a pool, and, depending on which version of the myth you follow, faded away or was transformed into the narcissus flower. Dorian Gray’s intense fascination with his own portrait is an echo of that story. His self-obsession and relentless pleasure-seeking lead to his gruesome death, exemplifying how narcissism is, in the final analysis, self-destructive.

Like many psychotherapists I would pepper my words of wisdom with extracts from favourite novels and stories. I was fond of an episode from Lewis Carroll’s Alice Through the Looking Glass though I now think that my recollection of it may not be totally accurate. Alice is in a garden with paths leading in all directions. Her earnest wish is to get to a house she can see in the distance. She takes a path that apparently goes towards the house but inexplicably it vanishes and reappears to her right. She then takes that path but again the house vanishes and appears elsewhere. After a few more futile attempts like this she says ‘Oh blow,’ for she is a well brought up girl, ‘I shall not bother with the house.’ She turns and walks off in the opposite direction only to run straight into it.  It is a good metaphor and the great value of metaphors is that they enable us to see the world differently. However, for academic psychologists seeing the world differently was not at all what they wanted. In fact, they wanted to see the world as it is. That is, they would claim, what psychological science is about. But that too is an illusion for we can never see the world as it is. We are always looking through the prism of our ideas. Facts do not exist in isolation from our interpretations as all good scientists should know.

It can be said of a novel or story that it is not true by which is meant that someone has created it from their imagination. This is why my talk angered the UWA psychologists; the subject matter was not observable reality, the world of facts, but a story, a fiction. But truth has many forms; it is not always literal. There is truth in fiction; you only have to make sure you look at it in a certain way. In the story of Anna Karenina, for example, Tolstoy shows us how an intelligent and beautiful woman can lose everything for the sake of love that is at heart narcissistic. Towards the end of the novel, Anna is in deep despair. In a remarkable passage, Tolstoy enters her self-consciousness as she is driven to the station by her coachman, Pyotr. It is the best account of depressive, self-destructive thinking I have come across. Anna throws herself under a train. It was reading about just such an incident, of a young upper class woman killing herself in that way, that prompted Tolstoy to write the novel. A fact led to fiction which in turn illuminates the truth about certain types of relationships.

I have just finished reading Jonathon Franzen’s novel, Freedom. One its strengths is how real the characters feel; I am sorry that I shall not be there with them anymore. If I look at the novel from a psychotherapist’s perspective, I see how well Franzen has captured the way people unconsciously replay the scripts of their childhood. For example, Patty’s overweening love of her son, Joey, derives from the casual indifference of her parents to her own achievements. But just as she was driven away from her family by that neglect, so Joey is driven away by the intense scrutiny of his mother’s love. I think anyone reading this novel would learn more about the psychology of family life that they would from reading any psychology textbook. It is fiction of course but it tells a certain truth.

Working in the Here-and-Now of the Therapeutic Relationship

Posted on by rezendevknowfully.com

When clients arrive at our office, they’re hoping we can help them feel better. Often they assume it’s their outer conditions they need to change: “if only my husband would…” or,  “once I find a new job…” or, “I don’t know why I’m feeling bad because I have a great life, but…” It’s not that we don’t listen to their concerns, but these are all situations that exist outside our consulting room.
 
In order to help clients change, we have to allow ourselves to be changed by what we, in the therapeutic relationship, do together. Working in the present, in the room directly with what is happening, demands that the therapist emotionally connect with the client and not just sit back, hidden by our professional role of “helper” or “expert.” It requires emotional involvement, reflection, vulnerability, transparency, and risk.
 
Research repeatedly tells us the therapeutic relationship is the curative factor over and above all theoretical orientations. A figure commonly cited in the literature is that up to 50% of clients drop out of therapy after the first session. These figures are established regardless of finances: in private practices, agencies, and free clinics. Researchers attribute these high numbers to two things: lack of emotional engagement and failure to deal with ruptures.1            
 
If the therapist and client only talk about relationships that exist outside the consulting room, they miss many opportunities to deepen their work together. As therapists, we need not make generalizations or assumptions about what the presenting problems of our clients mean or how they came to be. These scenarios are acted out and worked with in the transference and counter-transference of the therapeutic relationship.
 
We also risk losing our clients through impasses and unattended derailments. “The first phone call can be a deal breaker before things even get started, because clients’ relational patterns begin to be reenacted from the minute they make contact with us.” If we let these moments go by and don’t address them at an appropriate time, we sacrifice the teachable moment as it’s happening between us.
 
The mutual engagement in the here-and-now of the therapeutic relationship is a deep, internal conduit for change, and it entails our clients experiencing the impact they have on us. It empowers them in personal ways we can seldom predict that speak to the uniqueness of who they are. It’s different from a prescriptive, goal-oriented, solution-focused model where we therapists are the all-knowing ones with advice and answers. It is instead dealing in the moment with things as they are, in the client, in the therapist, and the space between the two.
 

Nick: A Case Study

We can see how this way of working played out with Nick, a 48-year-old divorced man who came to treatment complaining of “loneliness and relationship problems.”2 He wanted to know why he always ended up alone and what he did in relationships that made women leave. He was also confounded by his rejection of women before things even got going. An additional problem that came up later in our treatment was his compulsive overeating. I wondered why it had taken several months for his concern about his weight to come up between us. Later I learned he had tremendous shame around his body, had been cruelly taunted as a kid about being fat, and became inured to his body as if he was destined to carry this “dead weight” around.
 
In our first session, Nick appeared overweight, with little attention given to grooming: a rumpled denim shirt, an unpressed pair of chinos, and well-worn tennis shoes. His hair was combed but hadn’t seen a pair of scissors for a while. He sat near the door, in the chair furthest from mine. As he settled, his movement seemed labored and uncomfortable, squirming in his seat, as though his body was a rough place to inhabit. It’s bound to be painful in there, I thought as I observed him.
 
“I don’t seem able to sustain intimate relationships,” he said softly, gazing down at his shoes, puzzled by his own incapacity. When I asked why he thought this was the case, he replied, looking everywhere but at me, that he didn’t know, but then mentioned he was too picky when it came to women. He realized he was a perfectionist—not that he thought he was perfect, but he always found something about the women that became objectionable.
 
“They don’t have a decent job, or we have little in common, or they’re not smart enough, they have no sense of humor, they talk incessantly about themselves…” “He said this staring out the window, as if talking to the trees. I didn’t feel like I was in the room with him.” His list was endless, and I wondered if it was the tip of the iceberg, saying more about him than the women he was rejecting.           
 
During one session after we’d been working together for a year, he shook his head and proclaimed, “Relationships are too much work.” Much of our conversation took place while he fidgeted with his clothes, his hands, or the couch. Inquiring into these nonverbal motions in the past had yielded little information and alerted us to the likely disconnect he had with his body. He acknowledged however, he thought the nonverbal gestures were about his “discomfort with intimacy.” I had seen him through two short romantic skirmishes, only to find him alone yet again.
 
“I must be afraid to get close to people, so I’m always discovering excuses to find something wrong with them.”
 
I nodded, suspecting he was on to something. “Sounds like a good insight.” Then, almost wondering aloud, “How is it trying to get close to me?”
 
He thought as his leg started kicking back and forth. “Well, it seems easier compared to others.”
 
“How so?”
 
“You’re not judging me, you accept what I’m saying, don’t need anything from me.”
 
I confess I was pleased to hear this, but suspected there was more to the story.
 
“Do you feel close to me?” I literally felt my body heating up, as if we were moving closer to something important happening between us in the room.
 
“I guess,” he said, looking out the window, fidgeting in his seat.
 
“You’re not sure?” I asked, trying to keep him present and accounted for.
 
“Well, I know we’ve talked about coming twice a week and I think I’m afraid to do that.”

The last several weeks we had been discussing his aversion to adding a session, making it a twice-a-week treatment, an opportunity for us to become more intimate. I could see him bristle at my suggestion when he mentioned “not enough time” at the end of the last few sessions. I suspected this was one version of how his fears of intimacy got re-enacted between us. “And what scares you about being together twice a week?” I asked.
 
“That you will discover something really wrong with me,” he said softly, picking at his buttons.
 
“And what would I see that’s wrong with you?”
 
He thought. “I don’t know––that I’m missing a gene that’s required for intimacy and a healthy relationship,” he said. “Maybe I have some incapacity, or I’m damaged goods, unable to be resurrected for a real marriage.” He said this with a big sigh, hanging his head, shaking it back and forth.           
 
We explored what he meant by “damaged goods.” This was a painful process with long silences and quiet tears running down his face.
 
“Once you see that, you’d give up on me, feel I’m unable to change.” He said this under his breath, choking down the tears, almost as if his words are stuck in his throat. “Maybe you’d think I’m a hopeless case, give up on me and want to get rid of me.”
 
He was barely audible. Were these new thoughts for him? My heart ached for him. Now we were getting to how fear of intimacy played out between us.
 
“Is that what you think? Are you the one who thinks you’re a hopeless case?” I asked. He was afraid I’d reject him. Perhaps this was why he rejected some women so quickly so they didn’t have a chance to reject him first.
 
The conversation segued into his first marriage failing. For the nine years they were together, it had been harder and harder to extend the intimacy, both sexually and interpersonally. Here in the room, elbows on his knees, head in his hands, he was unable to say why he had withdrawn from his wife. I also wondered about the pain he had been holding regarding his failed marriage. He didn’t understand why he felt so bad about himself; he just did. He always remembered feeling this way: not wanted, made fun of for being heavy, not feeling worthwhile or responded to. I imagined his weight, which had been with him his entire life, was an insulator for many of these feelings.
 

Ruptures

A few weeks later, Nick came rushing in late—highly unusual for him—and stormed across the doorway to my office. He appeared excited, invigorated, as he waved his arms around and stumbled hard onto the couch.
 
“I don’t know what’s going on,” he said breathlessly, “but recently I’m feeling angry—angry all the time.” My eyebrows rose as I nodded, suspecting this was a good thing.
 
He settled himself, took a breath and added, “Truthfully, I think it’s just I’m aware I’m angry.” Normally, Nick struggled to connect with his feelings and suffered with a blunted affect that resulted in a lot of fatigue and apathy. I suspected the overeating fueled the fatigue and depression and served to numb out painful feelings. “Since our work together,” he continued, “I see how there’s always been this under current of anger, but now see I’m allowing it to register. Not the usual denial of how I feel, and so I’m seeing how pervasive it is.” I can see how the food allows me to bury my frustration. He appeared animated and incredulous.
 
“Sounds like a good insight,” I said. I waited. Silence.  “Are you feeling angry now?”            
 
He considered this. “I…I don’t know. I guess I am,” he said surprisingly, almost as if to himself. I waited.
 
“Is there something you’re angry with me about?” I asked, not having anything in mind, but thinking about his being late and coming in angry.
 
“Well, no,” he pondered, “that seems like a stretch. Why would you ask?”
 
“You’ve come late today, which is uncharacteristic of you; in fact I can’t recall you ever being late, and you’re talking about being angry right now. We’re the only two here, so I thought it might have something to do with us.”
 
“I’m thinking it’s more about the spat my boss and I had this morning. I’m feeling stirred up by that,” he said, repositioning himself. After a minute, he stilled himself, focused and continued, “You know, now that I think about it, I did leave here kind of ticked off last week.”
 
He talked about his disappointment with me because I hadn’t had a chance to read an article he had written. I had told him I’d be happy to read it, but hadn’t done so between our two appointments. I certainly understood his disenchantment with me; had I been honest, I would have told him I couldn’t read the article for a couple weeks. I now realized my counter-transference had prevented me from saying anything, not wanting to disappoint him—an old habit of avoiding and pleasing people so they’ll like me.
 
As he said this, I remembered the look of disappointment and surprise on his face at the end of our last session, after asking me for my feedback on the article. I had since forgotten this moment, his facial expression being so subtle and fleeting. The moment had slipped by me; it was possible I didn’t want to see or feel his anger coming at me, a feeling that’s difficult for me.
 
“I felt unimportant and dismissed by you, not valued,” he said somewhat sheepishly, as if I were going to explain myself or make him wrong.
 
In this situation it was necessary to feel my own frustration and guilt for not reading the article, watch how this impacted my client and not collude (by evading his anger), retaliate, or defend myself. I stayed with what was happening between us to further explore his anger and frustration with me.
 
“Here was a rupture between us, and if I hadn’t made a point of contacting what was happening in the room, this incident would have gone underground.” I suspect our relationship would have hit an unconscious impasse, creating a lack of trust and distance between us. As we talked about his anger and hurt with me, he saw he could acknowledge it, feel it, express it, and that I could hear it, and we could still stay connected despite the difficulty.
 
Tracking Nick’s feelings in the context of the intersubjective field showed us how my need to please and avoid anger and Nick’s unspoken hurt and disappointment manifested unconsciously between us. Coming in late and angry, despite neither of us knowing why, acted out Nick’s feelings. I represented the “Bad Mother,” as Melanie Klein calls it, by not attending to reading his article. This re-enacted the parental relationship he had growing up. In Nick’s formative years he hadn’t had responsive parents as a mirror to reflect what his own thoughts and feelings were. This left him feeling devalued and ignored, as well as cut off from his own sense of self—a feeling that had a long and painful history and showed up in his depression, isolation and eating habits.
 
As we can see in this re-enactment, it was not just Nick’s feelings being acted out, but mine as well. In my attempt not to disappoint him, I had done just that. The disjuncture was something we’d created together, a common experience within the therapeutic relationship. As therapists, we’re going to make mistakes. The important part is how we bring the current experience to good account. This is the working through of therapy in the relationship, in the moment, in the room—the unpacking of what just happened.
 
“As therapists, it’s important to carefully monitor what gets stimulated, not only in the client, but in ourselves as well.” We allow ourselves to be moved, provoked, bewildered and, above all, impacted by our clients. What emerges in a session is a result of our unconscious subjective world colliding with theirs. We notice our personal reactions and distinguish them from our clients’ in order to help our clients with theirs. Each session is a mutual discovery. This creates a present aliveness, illuminating the issues lurking in both of us, often occurring under our radar of knowing.
 

The Past as Present

A few months later, after Nick’s hours were reduced at work, he requested to see me every other week. He said he was feeling on shaky ground with finances and didn’t want to risk spending more money at this time. Money had never been discussed between us, other than the initial payment, and I was curious what his financial situation was. He reported that his house was paid for, no alimony, and he had investments, but felt it wasn’t a “good time” to be spending additional money.
 
I understood his concerns and wondered with him if there might be any other additional reasons for wanting to cut back sessions. To ask for additional reasons beyond the cost of therapy can be a rich window into emotional issues obscured between the therapist and client.
 
“No, it’s really just a monetary thing,” he said with a shrug.
 
During the transition to therapy every other week, I mistakenly charged him for an extra session, perhaps a result of my own anxiety about money or disappointment about the reduction in sessions. Since Nick didn’t mention my mistake, I brought it up towards the end of our next session and asked him if he had noticed it.
 
“I did, but figured you were the therapist and knew best so I wasn’t going to say anything about it.”
 
I told Nick that I felt bad about my error, let it go, and imagined we had handled it.
 
But here was a reenactment. He was going to ignore his own need and accommodate to mine, a painful, reoccurring pattern established early in his life.
 
At every moment in therapy, there are multiple levels to which the therapist can respond, including the content, process, body language, affect, or relational field.  Looking back, this moment with Nick was a missed opportunity to explore our relationship. Nick had a hard time speaking up for himself and was often oblivious to his emotional needs, looking to accommodate and please others before knowing or asking for what he wanted.  We had discovered together over the months how overeating often took the place of his ability to be aware, feel and speak up about his own needs. But one missed opportunity is no reason for despair; core issues undoubtedly find a way to come around again, especially when they aren’t handled.
 
A couple months went by and Nick neglected to pay for the month’s sessions. When I billed him for them, he objected, saying he remembered writing me a check. After several phone conversations, which I found stressful, afraid I hadn’t calculated correctly, he came to see he had indeed missed the payment. The check he wrote had been buried on his desk and was never delivered.
 
The following session he came in with a check, sat quietly and finally said, “I feel the therapy is moving along too slowly and not making enough of a difference. I’m not sure I should keep coming,” he said flatly, without affect.
 
Not feeling he’s getting his money’s worth, I thought. Aloud I said, “I’m surprised to hear this since you’ve repeatedly remarked how much therapy is helping you change by speaking up for yourself, feeling more (mostly anger,) and reaching out to people.”
 
“I said those things because I figured you wanted to hear them,” he said as his face reddened.
 
“What makes you say that?” I wondered out loud.
 
“Well, I like to keep people happy… it’s automatic pilot for me and easier than figuring out what I want or think.” He’s trying to give me what he thinks I want, while dismissing how he feels.
 
Again, I suspected this had something to do with how he learned to adapt to his early caregivers. I realized I had missed the transference and might lose him–– and was not feeling good about that.
 
His anger and disappointment with me were being acted out through his non-payment. His affect and compliance had been well hidden from me. As uncomfortable as it is for me to be the object of anyone’s anger, I knew it was necessary to endure. This was another window into working with Nick’s anger that had prevented anyone from getting close to him, myself included. He’d make a decision, not always conscious, to withdraw from relationships so he wouldn’t have to deal with his own aggression, and to soothe a hurt, scared self.
 
“At times the unpredictability of the here-and-now encounter in the therapeutic relationship forces us to emotionally confront ourselves in a way that no amount of training fully prepares us for.” If I had not allowed and distinguished my own internal responses from Nick’s in this moment, we would have been more prone to an unconscious enactment. In these scenarios, one of the likeliest impediments in the treatment is therapists’ fear of their own feelings, which could potentially steer the therapy in the wrong direction.3
 

An Ending or a New Beginning

Not long after that, Nick left me a voicemail saying he was dropping out of therapy. I called him back encouraging him to come in for at least one last session to wrap things up.  He did come in, and much to his credit, he was finally able to say what was on his mind, allowing us to complete the final chapter in the therapy. This was a tremendous achievement on Nick’s part, being willing to stay connected, even if only to terminate and tell me what was going on. He felt I didn’t have any answers for him and that he couldn’t get comfortable being the only one doing the revealing. We eventually came to understand how his acting out was an unarticulated way of telling me how angry he was with me for not giving him more direction. Nick felt I was too concealing and he wasn’t happy with the relationship being “so one-sided.”
 
The vulnerability had become intolerable for him (like in his marriage?) despite the knowledge that intimacy was something he longed for. It had become too uncomfortable emotionally; he felt exposed and at risk (i.e. with money). I wondered if it was easier for him to find fault with me, as he did with other women in his life, than to take a chance being vulnerable with me. Better he reject me first than be rejected by me.
 
“How do you think this reluctance to jump into ‘risky waters’ helps you?” I asked.
 
“It keeps me safe. I can stay home in my cave, play computer games, and eat junk food rather than come here, face you and feel how screwed up I am.”
 
“I can see how courageous you are to come in and admit all of this to me,” I said, knowing how true this was. I was touched by his admission.
 
As we talked, Nick began to see how his reluctance to engage with people let him off the hook; he could retreat to his comfortable, numb solitude by reducing sessions. He would distract himself with Sudoku, crossword puzzles, computer games, etc., and saw now how this contributed to his shutting down and isolation.
 
As we continued to discuss times he had been uncomfortable with me, for instance ending a session on time even if he was in the middle of something, or initially not being able to address his food issues, “Nick came to see how he erected a “demilitarized zone” around himself so he wouldn’t be hurt and judged by me (and others).” He saw how the distance “helped” him not to have to live with uncomfortable feelings, the meaning it had, and how he was the only one who could change it. He came to see his loneliness was located inside himself—self-imposed in an attempt not to be hurt anymore.
 
As Nick became aware of his loneliness, rather than making others responsible—particularly his ex-wife, imperfect girlfriends, or even me—he saw how the pattern was an unconscious state of mind and body that protected him. Once we linked his thinking and behavior to his history, and the template of habits it created, he recognized how it had been a successful strategy for survival growing up. This unconscious strategy had helped him live through the emotional neglect of his childhood, and protected him from the constant hurts of unresponsive, dismissive parents. He realized the distance he felt earlier with his ex-wife, and now with me, was an outworn way of taking care of himself so he wouldn’t be hurt again. Staying isolated allowed him to avoid the grief, shame and anger that got stimulated in close relationships; food became his biggest comfort and companion.
 
By linking what was happening in our relationship with his history, Nick’s behavior made sense to him. This changed his relationship to himself, replacing his anger and internal saboteur with compassion. Instead of hating himself, eating to dull the pain and withdrawing from relationships, he came to see how hard he was struggling, not only to connect with others, but to himself as well. By working with the relationship in the present, we saw how his past was alive today in the present.
 
Nick also saw how his protection of extra weight helped him adapt to the deprivations of his early life. What was once a strategy of soothing and protection now became a lifetime of habits, using food, withdrawal and emotional numbing in an unconscious attempt to avoid being  hurt. We had worked for two years without any success with his weight, however, this realization was the beginning of a life-long effort and success at slow weight loss. He no longer needed the extra padding to defend himself and terminated therapy shortly after he lost 40 pounds. It wasn’t that all his issues had been resolved, particularly the relational ones; but he felt he could manage things going forward. I felt good about the work we had done together, and he successfully terminated.
 

Working with Disjunctions and Derailments

Tracking the derailments in the therapeutic relationship is a way to bring the life of the transference and counter-transference right into the here-and-now of the inter-subjective field. The disjunctions between the therapist and client have to happen so we can understand how they’ve developed. We therapists stand in for the internal object through which the client’s conflicts are experienced. And then we get to repair what’s happened between us.  Nick wasn’t used to anyone wanting to know about his needs, so he tried to stop having them. When this became impossible, he simply walked away, a pattern that left him painfully lonely.
 
The disjunctions that occur in sessions usually have a long history attached to them; making the pattern explicit, in the present moment of the therapeutic relationship, helps the client identify the pattern. Just as a mother must hold, contain and partially work through the experience her child cannot hold and work through by himself, so must a therapist help digest and metabolize experiences for the client. While the relationship creates moments of disruption, we can use our mutual attentiveness to help the client own formerly disavowed feelings.4
 
For me the challenge comes when I get caught in my own complexes, my own feelings of inadequacy, anger, helplessness, of not knowing what to do, or of wanting progress to look a certain way. I have to set my agendas aside of wanting to help, heal, or have a specific outcome. I keep my meditation practice active so I can concentrate on the here-and-now, notice my own feelings and not let them intrude on my client’s, continue with my own growth and development and utilize consultation/supervision when I suspect my own material is interfering.
 
Noting what gets acted out in the therapeutic relationship, and helping the client to articulate what this might mean, is the working through that reveals these old patterns and frees the client to make healthier choices. Staying present in the relationship helps clients release long stored up affect, integrate the disowned parts of themselves, and inhibit the reactive patterns that spoil the natural joy of being. As clients learn to tolerate and digest their internal world, their connections with themselves and their world transform. More creative aliveness becomes available. As a result of sharing and participating in the joys and suffering together, discovering what’s unknown, unfelt and unpredictable, I feel humbled, privileged, and enlivened by our encounter. We are changed by each other.

Footnotes
1 Barrett, S., Wee-Jhong, C.,  Crits-Cristoph, P., & Gibbons, M.B. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training,45(2), 247—267. 

2 I have constructed Nick as a compilation of people, events and situations to protect confidentiality.

3 Russell, P. (1998). The role of paradox in the repetition compulsion. In J.G. Teicholz & D. Kriegman (Eds.), Trauma, repetition, and affect regulation: The work of Paul Russell(pp. 1-22). New York: Other Press.


4 Riesenberg-Malcolm, R., ed. Bott Spillius, E., (1999) On Bearing Unbearable States of Mind, London: Routledge.

Molyn Leszcz on Group Psychotherapy

Posted on by rezendevknowfully.com

Core principles of Group Therapy

Victor Yalom: To get started, Molyn, can you give a general definition of what group therapy is, and what are some of the core principles of the way group therapy works? I know those are broad questions.
Molyn Lesczc: I think that the first statement to make is that group therapy is not a monolith; it is a range of different approaches that utilize the group. Some groups tend to be more skill-building and psycho-educational, for example, and use factors of peer presence support, camaraderie, and economy of scale to deliver an intervention. Then there are therapists who use the group as an agent for change, in which we aim to make better use of the processes of interaction, feedback, and learning from one another that occur within the group.
VY: That, in and of itself, is quite a different idea in terms of how we tend to think about therapy. Most of us are trained initially as individual therapists, so we think of the therapist and the therapeutic relationship as the agent of change. Here, we’re suddenly thinking the whole group is part of the change process.
ML: Absolutely. The group is an entity of its own shaped by the multiple relationships that occur between people in the group. The complexity is so much greater in groups like this, but the power comes from that as well.  The bread-and-butter group therapy is the kind of work that we describe in The Theory and Practice of Group Psychotherapy, where

The group becomes a social microcosm: an opportunity for people to learn about the interpersonal underpinnings of their psychological distress.

the group becomes a social microcosm; an opportunity for people to learn about the interpersonal underpinnings of their psychological distress; an opportunity for interpersonal learning—insight, feedback—and behavioral skill acquisition.

I see group therapy, really, as the ultimate integrative model, because it’s a treatment that provides an opportunity for people to gain insight, self-awareness, and behavioral skill and practice. It integrates cognitive, emotional and behavioral elements.
I think we’re always aspiring to do that in our work, but group therapy really delivers on that as effectively as any treatment.
VY: Right. Of course, you’re referring to the text originally written by my father, Irvin Yalom. And you came aboard as co-author for the latest, the Fifth Edition, of that book.
ML: That’s correct.
VY: He primarily espouses an interpersonal model of group psychotherapy.  Could you say a few words to summarize the core concepts of this approach?
ML:

Sure. First, let me say that the interpersonal approach has become more popular of late, and it’s important to distinguish the interpersonal approach to group therapy and other versions that have more to do with IPT—the Myrna Weissman approach to interpersonal therapy—which is non-here-and-now, but rather more skill-building and educational. I’m going to focus on the interpersonal model of group that that was really pioneered by your father. I had the great privilege of working with him, and then contributing to the Fifth Edition of this text.
In essence, what that work does is build upon a long tradition that focuses on our need, as relationally determined people, to engage, and how our engagement in our contemporary world is shaped by early life experiences.
Harry Stack Sullivan, through his influence on other people in Baltimore at Johns Hopkins, had a big role, as you know, in your dad’s view. He impacted Frieda Fromm-Reichmann and Jerome Frank. And your father took it to a remarkably accessible level. In essence, how I understand it is like this: every person operates in this world with a certain kind of roadmap, which consists of our beliefs about ourselves and the world that emerge from early life experience, and the interpersonal behaviors that follow from those beliefs.
If we are healthy and resilient with good self-esteem, then our behaviors reinforce adaptive beliefs about ourselves, and we engage a healthy, productive loop in our relational world.
VY: Right. And speaking of self-esteem, I recall some statement by Sullivan that our own sense of esteem is really, in some sense, a collective mirroring of the feedback we perceive from others.
ML: That’s right, the reflective self-appraisals.
VY: Do you agree with that, or do you think that’s overstated?
ML: Absolutely.
VY: Isn’t there also something we bring to our personhood that we’re born with?
ML:

Certainly there are constitutional and temperamental factors. How our early life environment reacts to that and reinforces that, I think, is pivotal.
You can take a highly energetic child—temperamentally a bit reckless, aggressive, assertive—and in a family that is able to corral that and harness it and see it as self-determination and strength of will, that person will grow up with a stronger sense of self and self-esteem than a child that grows up in a family where that is viewed as being burdensome, a nuisance, and something that a depressed parent doesn’t have time for.
So the pathogenic beliefs, which are the starting point of the roadmap, are shaped by early life events, the environment, culture, personal psychology, family psychology, temperament, constitution—all these things together.
But they have powerful influence, because they then shape the interpersonal behavior that follows:we seek what is familiar, not necessarily what nourishes our growth. Group therapy becomes a very powerful way to illuminate that link between pathogenic beliefs and interpersonal behaviors. And many contemporary models of psychotherapy echo that.
VY:

So an energetic, maybe excitable child in an optimal environment would be supported, maybe gradually shaped, so that he can succeed in the world; and in another set of circumstances, his development might go awry.
So, group therapy, of course—or any form of therapy—tries to deal with the situations where something goes awry, so they’re not functioning fully effectively, and also having some internal problems—distress—about what’s happening in their life.
ML: Right.
VY: If you start with this interpersonal model that asserts that we’re basically social animals, how does group address the situations when things go awry?
ML: I think the group therapy addresses that by creating an environment in which people are able to bring themselves as they genuinely are in the world at large. That’s the social microcosm. The group would not be useful if what happened in the group didn’t reflect what happens in people’s lives at large.
VY: The social microcosm refers to the idea that however people are in the world, including their behaviors that cause them problems, will get played out or enacted in the group.
ML:

And the more you’re able to get people to look at interpersonal processes and communication in the here-and-now, the more the microcosm comes to life.
If you had a highly structured group where people were given specific tasks, you’d have much less opportunity for people’s interpersonal style and interpersonal processes to emerge. I’m sure you’re familiar with the background at National Training Laboratories, the original work by Kurt Lewin in the late ‘40s.
VY: It was a bit before my time, but I’ve heard of NTL.  Weren’t they referred to as T-groups, or training groups?
ML: Yes, they were training groups for executives. In essence, they were being taught how to be better leaders. At the end of the day, all of the facilitators would meet and talk about the group dynamics, and how hard it was to get this guy to see things from other people’s perspective and the like. What emerged then is that executives found out that they were being discussed in the evenings. They said, “Give us access to that information.” So that really became the start of the encounter group mentality, where people were given feedback in the moment, rather than a focus on the transmission of content material alone.
VY: And I assume they found that feedback useful.
ML: Well, they found it useful and challenging.

Working in the Here-and-Now

VY: Getting back to the social microcosm, say I have a client who’s aggressive, has difficulty maintaining relationships, or another client who is a people-pleaser, never gets his or her needs met. A naïve reaction might be, “Well, we don’t want them to repeat that behavior in the group. We want them to change it.” But this model is saying, “First, we want to see what that behavior looks like.”
ML: That’s right. It begins by manifesting itself. We obviously don’t want it to persist, and we’re looking for every opportunity for change. But people are more likely to make changes when they have hard evidence for what the problem is.A classic example is the man who reports in the group how his wife is always hard on him, critical, and he doesn’t feel he gets a break. In fact, it’s illuminated even in the Schopenhaeur Cure video to a certain degree, with Gil and Pam. If you’re not careful, the group may sympathize with him and give him advice such as, “You’re married to a miserable woman. Get away from her.”

Whereas if you look at what’s happening in the here-and-now and ask this very powerful here-and-now question—if you asked the women in the group, “Based upon on what you know of this man, in his time in the group, what would you think it would be like to be married to him?”—then you get the feedback about what it would be like being married to an inanimate object:”He seems like a decent guy, but if I was married to him, I’d be withering on the vine because he’s so unresponsive and gives so little of himself.” It’s an intervention that your dad has used, and I’ve used many times.

VY: You’re referring, of course, to this video demonstration that we’re just releasing, which was an enactment of the characters in my father’s book, The Schopenhaeur Cure, which occurs largely in the context of a therapy group.
ML: Exactly. So

making things come alive in the here-and-now is, I think, the most important skill a group leader can develop.

making things come alive in the here-and-now is, I think, the most important skill a group leader can develop. It’s the most challenging aspect of the work, but I think once you’re able to do that, I think you really are able to move things to a very effective level in which, I think, people really make meaningful change.

VY: You’re describing one of the core skills of group therapists—according to this model, at least—which is how to bring the group into what’s called the here-and-now. Now, that’s a term that’s been bandied around a lot from Fritz Perls onwards. But in this model of group therapy, it has a very specific meaning.
ML: Yes, it does. What is meant by that is moving away from people telling their stories into talking about the experience of telling their stories—getting the group to reflect on itself, and the members’ experience with one another.So, for example, instead of you and I doing this interview in this way—you asking questions, me making comments, you making comments, me responding—a here-and-now approach would be, “What do you really think about my answers? How am relating to you?”

In a chapter I recently wrote I used the example of walking down the street and asking someone for directions. That’s a simple transaction at the level of content. But if we were working at that at the level of a here-and-now, what we’d be looking at is the following:How do I feel asking for directions? Am I concerned that my wife, kids, girlfriend will have a negative reaction to me for needing to ask for directions? When I ask somebody for directions, of all the people passing by, what am I using to determine who I will ask? What is it about their demeanor, about how they carry themselves that leads me to ask them the question?

VY: So if you take that lens of looking at group interactions, you’re thinking of how people engage in the group. Do they monopolize? Are they quiet? Are they assertive? Who are they drawn to? Who are they distant from, or afraid of?
ML: Exactly. What is the meaning of their behavior? What is driving them? And when I talked earlier about the roadmap, I believe that a group therapist needs to have a very good sense of each person’s roadmap in the group. I aspire to operate in this way:that,

in a moment-to-moment fashion, I’m thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.

in a moment-to-moment fashion, I’m thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.

VY: Can you give an example of that?
ML: A woman came into a group, and the important elements of her story were that when she was a youngster, her older sister was diagnosed with leukemia. And the family was concerned, understandably, that this daughter would die. So, they threw all of their resources into caring for this daughter.My patient grew up with the sense that no one had interest in her; no one was invested in her; that her job was just to make things better for others, and not to ask for anything for herself.

So she comes into treatment with a history of disappointing relationships; failure to advance at work; chronic depression and self-harm. And at the heart of it is her belief that she is to be seen and not heard. In the group, that becomes the important focus of her work.

VY: How is that visible, then, in the here-and-now of the group interactions?
ML: Because she’s always helpful to other people. She rarely asks for time for herself. When somebody is crying, she is crying. When somebody is laughing, she is laughing. So she becomes like a Greek chorus rather than a person there in her own right, with her own entitlement.
VY: Now, I imagine that this is a likeable trait in some way, at least initially. People like someone who’s attentive to them.
ML: There’s a lot of positive reinforcement for her. But ultimately, you have to ask the question, “What is it like for you to be in this group, always giving support and not asking for much back? How do you think others in the group feel about you doing this? What’s it like for you coming to the group knowing that that’s what’s going to happen? What would it be like for you to actually ask for some time? Compare and contrast meetings where you’ve asked for things from us, and how you felt in the evening afterwards with those meetings where you come and just look after others.”
VY: So all of those are ways of getting her to focus on process—her experience of being in the group.
ML: That’s correct.
VY: And you do this with other people to give her feedback. Although they may like her attentiveness at first, I imagine they grow tired of it. They don’t feel like they ever get to know her.
ML: Exactly. And ultimately, it begins to feel inauthentic.Another incident occurred recently in a group—a man who had been badly sexually abused as a child came into a meeting feeling very annoyed, angry at how upbeat everyone was about the idea that the group leader presented. This was an early-stage meeting of a group that I supervised. The group leaders proposed that one task of the work in the group therapy was to emancipate themselves from the past. And everyone had been excited about that. But this man was then plagued that whole week with a resurgence of flashbacks and re-experiencing phenomena of the sexual abuse.

He came into the meeting saying, “I have to tell you how angry I am at you that you think it’s so easy to escape from the past. I’ve been reliving my past every day for the last 30 years.”

First, that was important because that was the opening for him to talk about the sexual abuse. It was also important because what he went on to say was that he was terrified that expressing his disagreement with us, disagreement with those in the group, would lead to attack. That was his experience, always. Whenever he protested the abuse, it resulted in more abuse.

So that was the first part. And this leads us to the next issue, which is the corrective emotional experience. Once you bring people into the social microcosm—once you illuminate their interpersonal processes, once people begin to push against their roadmap—it’s important then to reinforce that, and create an experience that this confirms their pathogenic beliefs, by virtue of insight and a relational experience.

Though with this man, we dived into what was it like for him coming to the group today, knowing that he was going to tell us he was angry with the way the meeting had gone the week before? Who did he think was going to be supportive? Who did he think might be challenging? What does he feel about the job that he’s done in protesting his opinion in the meeting today? And so on and so forth.

VY: These are, again, all process-oriented questions.
ML: All process-oriented questions.
VY: And this is done by the leader.
ML: It’s done by the leader, and ultimately, as the group matures, it’s done also by members of the group.
VY: So you’re shaping the group to start doing that work on their own.
ML: That is correct. The mature groups are able to do that on their own.
VY: And the corrective emotional experience you referred to is what? How does this help him?
ML: It helps by virtue of reinforcing the risk-taking, helping him to actually see that although making a protest in his youth led to a crushing attack, the group welcomes it now, and we do not want to silence him or marginalize his experience; we’re very interested in the meaning of things for him. And that taking this risk, in fact, makes him better known and closer to us, rather than the opposite—which is his fear that it’s going to lead to further abuse.

Training Group Therapists

VY: Let’s back up a sec. You’ve been training group therapists for how many years now?
ML: Thirty years.
VY: And I think you probably run, at the University of Toronto, perhaps the largest group therapy training program anywhere in the world?
ML: I don’t know about that. I’d be reluctant to say that because I can’t measure it against others, but we have the largest psychiatric residency program in North America, the second-largest in the world. We train about 25 to 30 residents in each of five years of training.
VY: And in your program, how many groups are going on at any one point in time?
ML: I think residents are doing groups of different sorts all over. It would be hard for me to estimate, but I would probably say residents are involved with maybe 30 groups a week.
VY: Let’s start with the skill of helping groups get into the here-and-now and talk about their experiences in the group with other members and their feelings about each other. This is a challenging skill to learn—both for beginning therapists and even experienced therapists who aren’t group therapists.
ML: It sure is, yeah.
VY: What does it look like actually getting the group to work that way? You’ve given a lot of examples of the types of questions you ask, but how does that happen, and what’s hardest thing for group therapists to learn in terms of doing that?
ML: I think that it’s difficult work. And one of the projects that I worked on in the last several years—through AGPA [American Group Psychotherapy Association]—was the creation of a document of clinical practice guidelines for the practice of group psychotherapy. What we’ve tried to compile in that are all of the elements that I think go into proper running of groups, and hence, proper training of group leaders.To run effective groups, you have to plan for them wisely, and you have to have support—of the system, of the administration. You have to be aware of how to use the therapeutic factors in group therapy—the importance of cohesion, and the principles that help to achieve and sustain cohesion. You need to be able to select wisely and prepare people properly. You need to be aware of the developmental stages that groups go through. You need to work well with group process. And you need to know how to use yourself effectively as a group therapist, and be mindful of the ethical demands of doing the work.

VY: I just read through this document and it’s quite comprehensive. And it does address initially a lot of the institutional challenges of getting groups going—administrative challenges. Just getting enough referrals, if you’re in a private practice setting, to start a group—that’s a real challenge. What are some of the key considerations and challenges to actually forming groups?
ML: People’s resistance to group therapy.
VY: Both patients and systems?
ML: Yeah. I think that there’s a general undervaluing of the effectiveness of group therapy. And group therapists suffer because their work is efficient; and people assume if it’s efficient and economical, then it’s going to be of lesser quality.

The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.

The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.

VY: And in terms of that, patients think, well, if there are eight people in the group or nine people in the group, I’m only going to get to talk an eighth of the time, so I can’t possibly get as much out of it as if I had the undivided time of the therapist.
ML: Right. They don’t have an appreciation yet—and that’s where preparation comes in—about how the group works, and how the synergies in the group can make that 90 minutes relevant. Each minute can be relevant to each person.Also, many of the people who really need group therapy don’t have positive experiences in their social groups. They haven’t been the most popular kid in high school. They’ve often felt, earlier in their life, that relationships were hard; or, because of depression, relationships have become hard. So the group is daunting for them.

Take a look at how groups are portrayed in the media and TV and movies. There’s a lot of the theme that we throw people out of groups. All the reality shows have to do with people getting extruded. It really feeds into people’s apprehension about being the weakest link, or being the first one thrown off the island.

VY: So those are patients’ fears. Then there are challenges of getting patients referred your way. Now, if you’re working in an institution or a setting where there are lots of patients, it’s easier. But if you’re in private practice, if you’re just relying on your own referrals—unless you have an extremely healthy practice—it’s quite challenging to get enough suitable people to get a group going.
ML: For sure. So you weigh it. You think, “Well, I can see these people individually and get paid for each of them by the hour rather than put them together into a group.” Groups are not necessarily more lucrative for practitioners in private practice. There’s great interest in their applicability in institutional settings, where there’s a high volume of patient flow. But it’s challenging to get started.
VY: So what advice would you have for a therapist who is, say, in private practice and really excited about doing groups, but doesn’t know how to get them off the ground?
ML: I would say get as connected as possible with other providers who will see you as an ally and a resource—whether it’s family physicians, primary care providers, or other mental health professionals. And think of a group that has something useful, both as a stand-alone, and also as something to be applied conjointly with other interventions. But you have to be deeply connected.Something else that I tell all of my trainees is, whenever somebody asks you to see somebody, whenever you have a consultation, make sure you send a note back to the referring professional. Those things really cement the relationship, and increase the likelihood of that person remembering to send people your way.

VY: I’ve always done one or two groups in my private practice, and always with a co-leader, for a couple of reasons. I enjoy the process of co-leading. So much of our work as therapists is solo, it’s been a richly rewarding experience to be able to share and learn from another therapist. But also, just logistically, if we’re both drawing on our own referrals, it’s been a lot easier to maintain the group over the years.
ML: That makes great sense.
VY: Let me just add one more point. As you well know, in major metropolitan areas, there’s a lot of competition among therapists. I’ve found that doing group therapy is one way to distinguish yourself, since not that many therapists in private practice are offering that.
ML: I think that’s a great point. At the University of Toronto, at my hospital, we get a real flow of referrals, because people recognize this is the place where people will be seen and get a good group therapy experience. In our hospital, I typically get 10 or 12 referrals a month for group therapy. So we’re able to start each year probably five or six time-limited groups, with eight or nine or ten people in them.
VY: I would guess if you’re doing that many groups, you have some different types of groups, or groups that are for people who are at different levels of functioning, so you’re able to assess people and place them into appropriate groups.
ML: Right, we do about five or six groups a year, time-limited, interpersonal group therapy. In addition, we run groups for trauma, groups in our day hospital program, groups in the inpatient setting, groups in our geriatric program, women with post-partum depression in our perinatal mental health program. We have a whole range of groups.And one of the things about groups is that they’re very malleable, that you can change your focus and emphasize homogeneous concerns. So I’ve done lots of groups with seniors with depression; with medically ill patients, women with metastatic breast cancer. We just published an article about using interpersonal group therapy to help people with alcohol abuse to maintain sobriety, and we showed that by dealing with these psychological interpersonal vulnerabilities effectively, we’re able to reduce heavy drinking and substance abuse.

VY: So even though many of these are what you called homogeneous groups—in that they revolve around a topic, a symptom, a life challenge—you still put a heavy focus on interpersonal here-and-now relations in the group.
ML: That’s right, absolutely.

Group Selection and Preparation

VY: Can you say a little about the selection and preparation of group members, because that’s so important to developing healthy, sustainable groups?
ML: I think a shorthand answer is to funnel everything that you do through the therapeutic alliance. The therapeutic alliance is the best predictor of outcomes, across all kinds of psychiatric treatment and psychotherapy. What we look for is the degree of agreement, between the treater and the patient, about the goals of treatment, the tasks of treatment, and the nature of the relationship.
VY: You’re doing that in the first assessment meeting?
ML: Yes, that’s something we’re doing right from the start. If their goals are not in sync with our goals, then the group’s not going to be an effective experience for them. They may need to be in another kind of group.Now, what do people need to be able to do to engage in the tasks of treatment? They need to be able to come reliably. They need to be able to sit in the group. They need to be able to speak. We’re talking about having the logistical, intellectual, and psychological ability to actually make use of what the group provides.

So I find it very helpful to be able to ask and answer the question, “Do we have convergence on the goals of treatment? Do you have convergence about the tasks of treatment?” Then I talk a little bit about what they can expect from me in terms of the therapeutic relationship and from the relationships in the group.

VY: But if someone is coming to you or your clinic because they’re depressed, for example, and you’re suggesting, “Gee, rather than go into individual therapy, I think you might really benefit from a group,” you need to explain to them how a group works, and how it might be helpful.
ML: Exactly.
VY: What are some ways you do that?
ML: Well, I think virtually everything that we’ve talked about in the interview so far, Victor, I would share with them:the research that shows it’s an effective modality of treatment; how it would work; how I think it would work for them specifically, with regard to understanding how their difficulties—with passivity, assertiveness, anger, self-esteem—contribute interpersonally to the difficulties that they’re having in their life at large; and that the lens that we’re going to look through is what’s happening at the level of interpersonal relationships.Then I’ll talk about the microcosm of the here-and-now, interpersonal learning, the corrective emotional experience.

VY: So you really lay it out for them—how the group works, how it might benefit them.
ML: Absolutely. There is an appendix in the Fifth Edition, of a preparation document that therapists can give to their clients. You can personalize it, but it really covers and nuts and bolts of what we feel needs to be communicated to people.And

there’s robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they’re more popular group members and much less likely to drop out.

there’s robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they’re more popular group members and much less likely to drop out.

VY: Right. And dropouts can be a big problem in groups—not only for the clients who drop out, but it can be demoralizing, or threaten the very existence of the group.
ML: Yeah. It’s very hard, in particular when people are beginning to do group therapy, to have dropouts. The residents that I supervise are heartened by two comments. One is that dropouts are inevitable, and that no one in the literature, even in the most experienced hands, is able to eliminate dropouts, and the range is anywhere from 10 to 40 percent.The other point is that if you never have any dropouts, then it means you’re setting the bar for entry into your group too high, and you’re like a surgeon who only operates on people without any risk factors. And it means that you’re missing the opportunity to be helpful to a lot of people who would otherwise benefit from treatment.

VY: But if the bar is too low, and you let a lot of people into the group who don’t stay very long, it can be disruptive and demoralizing to the group.
ML: No question.
VY: You talked about preparation and the research showing how important that is. One thing I’ve heard about in some institutional settings people are doing intake over the phone and are sent to a group without much screening or meeting with the therapist. That seems like it can cause a lot of problems.
ML: I have to say, I understand the pressures that some organizations are under; but to me, it’s being penny-wise and pound-foolish. If you want preparation to really take hold, it should be provided by the person who is actually going to be doing the group. Part of the rationale for preparation is to begin to establish the therapeutic relationship, and you want to screen people in a more meaningful fashion. So I think if you cut the front-end short, you end up paying at the back-end.

Co-Leading Groups

VY: Another problem that I’ve heard about is interns in agencies being matched up with a staff member, a more experienced therapist—which is great, in theory. I mean, most of the time in our training we’re thrown in the room alone with the client, and we don’t have the chance to learn directly from working with experienced practitioners—which is how professionals generally are trained, whether in fields of law or surgery or accounting.But it often seems that interns are thrown into co-leading a group, and there isn’t sufficient time allotted to meet with the senior therapist for several sessions prior to starting a group to make sure they’re on the same wavelength. Or they may not have time to meet after the group to debrief. And there can be tensions between the group leaders that aren’t worked through.

ML: All those things happen, but I think they are by and large avoidable if people, number one, are working in good faith, and if there’s a commitment on the part of the more experienced group leader to promote the growth and development of the trainee. And the only way to enact that good faith is to actually have time to meet before the group and after the group. If you’re not doing that, then you’re not giving yourself a chance to be successful.
VY: In your training program, is there a lot of co-leading that goes on? Do you pair residents with staff or with each other?
ML: Mostly with each other. But for 30 years, I’ve led at least one or two groups a year with the residents. I often tell them that my first real experience leading a group involved, I think, the greatest gradient imaginable between my experience level and the experience level of the person I was co-leading with, which, of course, was your dad.When I began to do groups with your father, at the beginning of my fellowship at Stanford, I had had very little experience in groups. And I remember vividly—and I tell this story often—that one of the groups I co-led with your dad that he brought me into was a group he was leading for mental health professionals, all of whom had done group work. Some of them were even teaching group therapy.

I remember one group session when somebody came into the group with The Theory and Practice of Group Psychotherapy that they were using in a class that they were teaching. And I felt really de-skilled, small and marginalized, which was a very uncomfortable feeling.

But I talked about it with your dad, and he responded, in essence, “This group is too dependent on me, and that’s why they’re not making any room for you. It’s not good for you, it’s not good for them, it’s not good for me. So look for an opportunity.”

Ultimately, after several weeks, I identified that I felt no one in the group was paying any attention to what I had to say. And this goes to show you that there is an unconscious—I meant to say that people were just waiting and deferring for this “wise old therapist,” in reference to Irv.

But I didn’t say wise, I said wizened, and I didn’t realize it! Irv, afterwards, when we rehashed it, had a great laugh

But I didn’t say wise, I said wizened, and I didn’t realize it! Irv, afterwards, when we rehashed it, had a great laugh and teased me about the Oedipal strivings that were evident in that slip of the tongue.

I think in co-therapy you have to anticipate competition, rivalry, tension. But hopefully, as I say, if people are working in good faith, these don’t become insurmountable problems, but, in fact, become learning points.

I often tell residents, if you are a passive co-leader with a more active co-leader, what message does that give the quiet members of the group? It models for them that it’s okay to take a backseat. And that often has a powerful impact.

I think most people are also heartened to hear that I was able to address the gradient of my limited experience working with your father at Stanford in 1980. If I can do that, they can do what they have to do here.

VY: I hadn’t heard that story before from you, but we share that experience, because I led a group with him very early in my training, and certainly had similar experiences—that I knew very little and felt I had little to offer. It was a challenge for me to speak up and feel that I did have something to contribute.
ML: Absolutely. It’s part of the consequence of the very large shadow that your dad has cast.
VY: Indeed.You’ve trained many, many therapists over the years, group therapists. What are some of the things that are most challenging for them to learn about being effective group therapists?

ML: I would say the most difficult thing has to do with learning how to use oneself effectively as a therapist, and how to use language effectively—how to be able to communicate meaningfully with our patients; the risks that we need to take sometimes; how to be appropriately transparent, including the limits of transparency.
VY: What kind of risks?
ML: The risk of giving feedback to a patient. Oftentimes, especially young therapists are very reluctant to do that, because they feel that it’s going to fudge the boundaries.
VY: Do you think there are still some vestiges of the blank slate?
ML: Still some—and now with the added overlay of, “If I’m too personally present in the group, is that a slippery slope that’s going to lead to some boundary issues later?” Still dealing with the aftermath of the ’90s and all the focus on boundary crossings and boundary violations.
VY: What’s your take on that?
ML: I think that it’s impossible for a person to be in a room with another person and not to disclose. So I would rather be proactive and mindful about it rather than think it’s not happening.
VY: Rather than think that the way to avoid the possibility of some kind of inappropriate behavior is just to set a hard-and-fast rule that we’re neutral and we’re impartial bystanders.
ML: Exactly—to be stilted, distanced. I think fundamentally group therapy is a human experience, and we have to be humans in it.I think that probably the best line that a patient ever articulated in a group—this was a senior person who was close to leaving the group, who was welcoming somebody new into the group—she said, “You know, you’re beginning now. Likely, you’re going to be skeptical about this, the way I was skeptical for the longest time. My first impression was that the group was a very natural place for unnatural things to happen. And then,” she said, “with a little bit more time, I realized that, in fact, the group is an unnatural place—it’s constructed for this purpose—but that what happens here is very natural.”

A real endorsement of the meaning and the value of the relatedness.

VY: Yeah, because it is a contrived situation. People are paying money to be there. And yet the nature of the relationships, and the events that occur in the group, become extremely meaningful to people in a successful group.
ML: Incredibly so.

I’ve had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.

I’ve had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.

In fact, one woman in a group that I run commented that she holds onto images of people in the group during the week to help her deal with adversity. And when that woman graduated from the group—a very successful ending; she was leaving to get married, having previously—a woman in her thirties—having never had any sexual contact—one of the other members of the group, who is an accomplished artist, gave her, as a going-away gift, these beautifully crafted popsicle-stick figures of each of the group members, made out of material and wood and painted. Just a beautiful embodiment of the internalization of the members of the group. Touching.

The Best Kind of Work to Do

VY: And, needless to say, as this has been the focus of your professional life, it can be a deeply rewarding experience for a group therapist.
ML: Absolutely. I think it’s the best kind of work to do.
VY: How has it been rewarding for you?
ML:

I think that we grow as our patients grow. You can’t do this work and be static.

I think that we grow as our patients grow. You can’t do this work and be static. All of the things that I’ve learned about people, about the world, have shaped me in very constructive fashions. Even dealing with people who are facing death—our metastatic breast cancer research—has made me more existentially aware; the meaning of their experience, I think, has added meaning to my experience.

Your father has written extensively, of course, about existential approaches to psychotherapy, and I think there is enormous value in that. Life is short. Make use of it. Author your life in a way that is meaningful to you; you’re personally responsible for authorship.

I often tell the story of the woman that I first encountered in the metastatic breast cancer group who subsequently graduated from that group. She is one of the long-term survivors from that group. Most of those women died within a year or two. This woman was diagnosed with metastatic breast cancer when she was 26, if you can believe it, and she’s still alive and thriving twenty years later.

I saw her September 12, 2001, right after 9/11—and she comments to me what a terrible tragedy the World Trade Center attacks were. But it crystallized for her that if she had been in the World Trade Center on 9/11 and had died, she took heart from the fact that she would not have had one moment’s regret of how she lived her life on September 10.

I think that’s something that I aspire to, and I think, if we’re able to help our patients aspire to that, then we’re going to help them a great deal.

VY: Well, I think that’s an inspiring and encouraging note to end on. I want to thank you so much for taking the time to share your wisdom and passion about group therapy.
ML: If we speak for a moment, too, Victor, about our here-and now, it’s a remarkable sequence. I’ve benefited so much from my relationship with your father, and to be able to talk about that work with you in your career, in this way, feels like another good loop.
VY: It feels absolutely that way for me. And that’s an example I can’t help noticing from a process lens:when you shifted the conversation away from the content—group therapy—to making it a personal connection between you and me, I found myself moved in an emotional way that I hadn’t previously in this conversation.
ML: I feel that, Victor, and I’m glad that it touched you in the same way. I would have not wanted our conversation to end without making the comment.
VY: Thank you very much.

Interacting Sensitivities in Couples Therapy

Posted on by Psychotherapy.net Team

It is a typical night at Tom and Betsy's house. Tom has his nose in a newspaper.  Betsy is leaning in the door of his study trying to talk to him, getting more and more frustrated at his periodic, vague “Uh huh.” After a few minutes of trying to entice him into a conversation, Betsy starts complaining, and then criticizing him for being cold. Tom snaps, “Can't you just once leave me alone?” Betsy yells, he withdraws further, and Betsy stalks out, thinking, “I'll give him all the alone time he wants!” 

Tom and Betsy are caught in “interlocking vulnerabilities” (Carol Jenkin’s term) or “interacting (or reciprocal) sensitivities” (my term). Each partner responds to having his or her sensitivity inflamed in a way that inflames that of the other. Tom is sensitive to criticism and responds by disengaging; Betsy is sensitive to disengagement and responds by criticizing. Michele Scheinkman and Mona Fishbane call this pattern “the vulnerability cycle.” Scott Woolley calls it “the EFT (Emotionally Focused Therapy) Cycle.” Robert-Jay Green calls it the “problematic couple interaction cycle.” “Pursuer-distancer” (coined by Thomas Fogarty) and “demanding-withdrawn” (researched by Andrew Christensen) are earlier ideas out of which the notion of interacting sensitivities developed.
 
My purpose here is to distinguish two major subtypes of interacting sensitivities—“pursue-withdraw” and “attack-withdraw”—and to describe how the pattern of interacting sensitivities plays out in the couple relationship. Awareness of this pattern will help the therapist follow the flow of the session and enable the partners to appreciate what they are caught in.
 
In “pursue-withdraw,” one partner is sensitive to the other’s withdrawal (feels ignored, shut out, abandoned, rejected, lonely, uncared for, unloved, unlovable, or just not as close and connected as he or she wants) and responds by pressing for connection (time together, intimate talking, affection, sex), and the other partner is sensitive to pressing (feels engulfed, smothered, suffocated, bombarded, besieged, flooded, controlled) and responds by withdrawing (disengaging, abandoning, shutting down, closing off). The self-reinforcing nature of this exchange is clear. The more Bob disengages, the more Gloria needs reassuring contact. The more Gloria presses, the more Bob needs to disengage.
 
In “attack-withdraw,” the other major form of interacting sensitivities, one partner is sensitive to attack (complaint, blame, criticism, anger, reproach, scolding, demands, sarcasm, rejection, disapproval, humiliation, exposure) and responds by withdrawing; the other partner is sensitive to withdrawal and responds by attacking. Again, the self-propelling nature is clear. The angrier Ben gets, the more Alan withdraws. The more Alan withdraws, the angrier Ben gets.
 
In a fight, the withdrawn partner typically seeks to end the fight or, at least, take a time out. He or she is the one more aware of the destructive and stalemated quality of the fight. The pursuing partner typically wants to keep talking. He or she dreads ending the exchange without a resolution and on bad terms.
 
In practice, “pursue-withdraw” typically morphs into “attack-withdraw.” At some point, and in some cases very soon, the pursuing partner becomes frustrated and shifts from pressing for connection to reproaching for failing to connect: “Why are you so defended?” “How come you never talk to me?” “Living with you is like living alone,” “Hello, are you alive over there?” Such reproach creates an “attack-withdraw” pattern (unless, of course, the other partner responds with anger rather than with withdrawal, which would then trigger an “attack-attack” pattern.  I’ll get to that in a moment). Here is an example of the shiftfrom “pursue-withdraw” to “attack-withdraw”.
 
Sally (inviting): What do you say we go for a walk?
Tom (vaguely): Maybe later.
Sally (encouraging): Come on. Let’s go now, while it’s still sunny out.
Tom: I want to read this book.
Sally (pressing): You can do that when we get home. Come on. You’ll feel different once we’re out there.
Tom: I’m really into this book.
Sally: (pressing): Well, okay, we don’t have to walk. Why don’t we just hang out and talk for a while?
Tom: I’m not in the mood.
Sally (shifting to attack): You’re never in the mood.
Tom (shrugs)
Sally (blurting out a hidden fear): Admit it—you just don’t want to do things with me anymore; that’s it, isn’t it…
Tom (looks up for a second): That’s not true.
Sally: Well, it is true. You’re like your father—the way he treats your mother. You’re getting to be more like him all the time.
Tom (Looks down at his book)
Sally: Aren’t you going to say anything?
Tom: I don’t know what I can say.
Sally (sarcastically): You could say, “Sure, let’s go for a walk. What a great idea! Thanks for suggesting it. You always make things such fun.”
Tom (looks unhappy)
 
Such “attack-withdraw” can go on for some time. At some point, and with some couples very soon, the attacking partner thinks, “I’m tired of being angry,” or “Oh my god, I’m sounding like my father,” or “This is starting to go nowhere fast,” or “I hate how whiny and needy I sound, even to myself,” or “You can’t change people, especially some people” or “You can’t get all your needs satisfied by just one person; I’ll call my sister,” Thinking such thoughts, the attacking person joins the withdrawn partner in disengaging. The result is a “withdraw-withdraw” pattern.  
 
At times, the pursuing partner purposely withdraws, creating what looks like a “withdraw-withdraw” pattern. He or she secretly hopes that the withdrawn partner will miss the engagement and start pursuing. But the withdrawn partner is usually just relieved by the decrease of pressure and doesn’t pursue.
 
While one partner has remained withdrawn, the other partner has shifted from “pursue” to “attack” to “withdraw.” At some point, and in some cases very soon, the latter partner again becomes distressed by the lack of emotional connection and again starts pursuing, which triggers a repeat of the three-part sequence. Couples can go on for years repeating the sequence of “pursue-withdraw,” “attack-withdraw,” and “withdraw-withdraw.”
 
At some point in this repetition, the pursuing partner may become so resentful about the withdrawn partner’s lack of engagement that he or she bypasses the “pursue” and goes directly to the “attack.” From then on, the partners shuttle between “attack-withdraw” and “withdraw-withdraw.” The “pursue-withdraw” has dropped out. At yet a later point, the “attack-withdraw” may drop out, too. The attacking partner becomes so discouraged that he or she gives up, and the couple slips into a chronic “withdraw-withdraw” devitalized state.
 
The discussion so far portrays one partner as remaining in the withdrawn state even when the other gets angry. In some cases, however, the withdrawn partner responds with anger of his or her own: “Why do you always have to get so angry about every little thing?” “Don’t yell at me!” “You could use a crash course in anger management—my treat.” In some cases, the withdrawn rather than the pursuing partner is the first toburst into anger: “Stop trying to control me,” “Get off my back!” “Give me room to breathe,” “Back off,” “You never let up, do you?” “Can’t you do anything by yourself?” “You’re the neediest person I’ve ever known.”  When the withdrawn partner attacks, the result is the pattern of “attack-attack” (if the other partner fights back), “attack-pursue” (if the other partner continues pursuing), or “withdraw-attack” (if the pursuing partner is now the one to withdraw).
 
Withdrawal and attack are not always clearly distinguishable. When you give your partner the silent treatment, you appear to withdraw. You relate to your partner in a grim, wooden, disengaged, monosyllabic way. But all the time, you are communicating anger. You are simultaneously withdrawing and attacking.
 
In summary, interacting sensitivities (the vulnerability cycle, interlocking vulnerabilities) has two main forms: “pursue-withdraw” and “attack-withdraw.” If the withdrawn partner remains withdrawn, the couple repeatedly passes through “pursue-withdraw” “attack-withdraw,” and “withdraw-withdraw.” As time goes on, the “pursue-withdraw” may drop out as may also the “attack-withdraw.” If the withdrawn partner doesn’t remain withdrawn, but instead attacks, the couple shifts into “attack-attack,” “pursue-attack,” or “withdraw-attack.”
 
We customarily think of a couple as being a particular type—for example, volatile, withdrawn, or pursuer-distancer. But if we look at what actually happens moment-to-moment, we see that couples often shift among several phases.
 
Knowledge of this shifting helps a therapist follow the flow of what is happening in the couple and understand how the partners are triggering each other—how, for example, Alex pursues because he feels abandoned and Judy withdraws because she feels cornered, which leads to mutual accusation, and, in an effort to avoid further damage, to mutual withdrawal. The therapeutic goal is to enable the partners themselves to observe their relationship in this way: to give them a compassionate vantage point above the fray—a platform—from which to monitor and manage their relationship. Such a vantage point is created by developing the couple’s ability to hold recovery conversations in which they go over their alienating interactions and appreciate how the position of each made sense.

The Lake Wobegon Effect

Posted on by Psychotherapy.net Team

How good a therapist are you?

Odds are, you think you’re pretty good. A recent study[i] of 129 therapists found that over 90% self-rated their psychotherapy skills at the 75th percentile or greater.  All of the therapists rated themselves above the 50th percentile.

In his fascinating new book on therapy outcome, Michael Lambert calls this positive self-assessment bias the “Lake Wobegon effect”. While it is true that the overall industry-wide effectiveness rates for psychotherapy are very good, our blindness to our weaknesses is dangerous.
 
Lambert points out that 30% to 50% of our clients don’t improve in treatment. Even more alarming, roughly 8% of clients get worse in treatment.  (Deterioration rates of children and adolescents may be as high as 12% to 24%.)
 
If all of us are above average, then who is causing the problems?  

Lambert cites a study in which 20 experienced therapists and 20 therapist trainees were asked to predict the progress of current clients in their caseloads. Of the 550 total clients, the therapists in the study predicted that only three were deteriorating. The actual number of clients who got worse was 40.

Notably, none of the experienced therapists predicted any of the clients in their caseload getting worse, even though they were reminded at the beginning of the study that the industry-wide average deterioration rate is 8%.

How can we fix our blindness towards our weaknesses?  The traditional method of addressing therapist deficits is supervision and consultation, but those only work when we can correctly identify which clients in our caseload are deteriorating.

Lambert proposes using an intriguing actuarial model, in which the clients’ session-by-session data on outcome measures is entered into a computer program. Using a large database of client outcome data, the program is able to alert the therapist when the probability of client deterioration is high. In his book, Lambert cites a few studies that indicate promise with this method.

Understandably, many therapists will be loath to make clinical decisions based on a computer’s calculations. But then how else do we overcome our self-assessment bias and seriously deal with the risk of client deterioration? Whatever tool we choose, this is an important question for our field to address.


[i] Walfish, S., McAlister, B., O’Donnell, P. & Lambert, M. Are all psychotherapists from Lake Wobegon?: An investigation of self-assessment bias in mental health providers. Submitted for publication.

Eysenck, Rogers and Psychotherapy Effectiveness

Posted on by Psychotherapy.net Team

In the 1970s I worked as a psychology lecturer in Hans Eysenck’s department at the Institute of Psychiatry, London. He was a controversial figure, quiet and introverted when met face to face, but on the academic stage a formidable and ruthless opponent. Rod Buchanan’s recent biography, Playing with Fire:The Controversial Career of Hans J Eysenck, nicely captures the complexity of the man, part prolific scientist, and part inveterate showman. Whether it was race and IQ, cancer and smoking or the effectiveness of psychotherapy, Eysenck did not hold back from taking the unpopular position. His 1952 paper challenging the effectiveness of psychotherapy triggered off a fierce debate that resonates today. How do we determine that psychotherapy works? Many therapists believe the question is either meaningless – like asking if medicine works – or has been loudly answered in the affirmative following thousands upon thousands of research trials. But the question is not as simple as it sounds.

In the 1970s I recall researching into Encounter groups that were all the rage then and coming across a statement by Carl Rogers. He claimed that a positive consequence of a successful Encounter group was for the members to become aware of their psychological problems and go on to have individual therapy for them. So the measure of success in Rogers’ terms was (a) having a problem and (b) going into therapy, the opposite of what most people see as psychotherapy’s goals! What Rogers claim illustrates is that any notion of outcome is based upon a set of values. For him authenticity was paramount and therapy was not a means of getting rid of symptoms but a chance to explore oneself, a process of self actualisation that was the key to the well-lived life. To be happy was not to be free of problems but to feel comfortable in oneself and to relate to others in a genuine and empathic way. Attractive as this philosophy may be, it is not one that the researchers into the effectiveness of psychotherapy have adopted. On the contrary, a quasi-medical model has been all powerful. Researchers have sought to prove that any specific therapy works in terms of making people feel better and enabling them to get rid of depression, anxiety, addictions or whatever ‘illness’ they are deemed to have. The problem I have with that it does not describe psychotherapy as I know it. Most psychotherapists realise that these simplicities mask the truly interesting part of therapy which is determining what the client’s problem actually is.

In my memoir, The Gossamer Thread. My Life as a Psychotherapist, I describe my first therapy case whom I call Peter. Peter’s problem was a phobia about using public toilets. His anxiety would rise exponentially when any men came in so he avoided public toilets altogether and led a restricted social life. I took over the therapy from another clinical psychologist (who went on to become a distinguished researcher into psychotherapy) and plugged away at Wolpe’s systematic desensitisation, first in imagination then in reality. The reality I chose was to see Peter in a bar where we would chat and drink beer in a way that is unthinkable today. In the course of these conversations I got to know him well, and he me, since I had no idea about boundaries being young and totally inexperienced. The result was a great success but it was in Rogerian not quasi-medical terms. When by chance two years later I met Peter again, he was a changed man, relaxed, happy in himself, content in his career. When I asked him about the original problem, at first he looked puzzled and then said, ‘Oh, that. I still have it but it doesn’t bother me anymore.’ There was a lesson to be learned about what psychotherapy outcome really means but it took me many years to learn it.

Psychotherapy outcomes: The best therapy or the best therapist?

Posted on by Psychotherapy.net Team

I’m often asked, “What’s the best therapy for anxiety/depression/trauma/etc?”  CBT, EMDR, ISTDP, ACT, DBT – the alphabet soup of therapies – how do we (and our clients) choose?  Research shows that psychotherapy outcomes often vary more between therapists than therapies, suggesting that picking the right therapy may actually be the wrong approach. In other words, choosing the most effective psychotherapist is more important than choosing the most effective therapy.   

How can our clients pick the most effective therapist? They can’t. There is no industry standard for tracking and reporting psychotherapy outcomes. This won’t last. Regulators and consumers are going to demand public accounting of treatment effectiveness. If I have the right to ask my surgeon for their success rate, then why can’t my clients ask for mine?

In a recent panel, the eminent psychotherapy researcher David Barlow noted the “inexorable trend” toward outcomes measurement. He believes it will bring “enormous benefit for all of us,” by improving the connection between clinical research and the effectiveness of actual clinical practice.

Many therapists, however, dread the movement towards measuring outcomes. They raise important concerns about the ability of outcome measures to assess subtle nuances of psychotherapy in long-term treatment. Other concerns include paperwork hassles, and the danger of “therapist profiling” by outcome. (You can join a lively discussion of these concerns in the forums here.)

However, the benefits of embracing outcomes far outweigh the concerns. I’d like to suggest four major benefits to tracking psychotherapy outcome:

  1. Measuring outcomes will help us become better therapists. How else can we know if all the workshops, trainings and supervision we do are actually helping?
  2. If we get out in front of this movement then we will have a stronger hand in designing it. If we resist the push towards accountability, it will be forced upon us. (For example, the Los Angeles Times recently published a report outcomes of public school teachers in Los Angeles county, by teacher name.)
  3. Online therapist-review websites (such as yelp.com or healthgrades.com) lets one or two disgruntled clients hurt your reputation. A public system for reporting outcomes gives a fair perspective of your work.
  4. Most importantly, our clients deserve to know about the treatment they are getting. Research consistently shows that most therapy is very successful. Dodging accountability can foster the impression that our failures are more common than our successes.
One good example of a therapist who has embraced outcome measurement is Allan Abbass. He tracked and reported his therapy outcomes for his first six years in private practice, and then published the results.

How can a therapist start tracking their outcomes?  I use the Outcome Rating Scale, which takes about one minute at the beginning of each therapy session. The free scale and instructions can be downloaded here  and here. There are also three online services that help therapists track their outcomes: myoutcomes, oqmeasures, and core-net.

[This blog is dedicated to exploring training tools and techniques that help us become better therapists. Please email me at trousmaniere@yahoo.com if you have any feedback or new psychotherapy training techniques you would like to share.] 

Preventing Psychotherapy Dropouts with Client Feedback

Posted on by Psychotherapy.net Team

“You understand me thirty percent of the time.”

“I need to you to slow down.”

“I was sad and you cut me off.”

These words of dissatisfaction are from my clients. They weren’t easy to hear, but they have changed how I practice psychotherapy and have significantly reduced my dropout rate.

Anne: A Case Study

I had been treating Anne, a Latin-American woman in her early 20s, in psychotherapy for six months. She presented with weekly panic attacks, daily cutting, severe sleep disturbances, a range of somatic symptoms that she attributed to her anxiety, and persistent interpersonal difficulties. She presented as attentive and likeable, though beneath her mask of smiling and compliance she clearly hid a tremendous amount of pain. Anne has a history of sexual abuse by multiple family members over a six-year period starting before age four. Her mother had been a prostitute for most of Anne’s life, and both her biological father and stepfather are in prison for sexual assault. Despite these and many other challenges, Anne demonstrated tremendous resiliency and had just graduated from college with a very strong GPA.

Anne had been in individual and group therapy for much of her childhood and teens, but by her own report she had never really tried to make it work. After graduating from college, Anne decided she wanted to find a solution to her anxiety, sought out individual therapy, and found me.

Anne’s treatment progressed well at first. In the first few months her panic attacks stopped, her general anxiety decreased, she stopped cutting, her somatic symptoms decreased, and her sleep gradually improved. Anne’s interpersonal difficulties, however, persisted. We had been digging into that material for a few months but had made little progress. In fact, her social and romantic life was getting worse. Anne was becoming restless and frustrated. I pulled out my two favorite “getting therapy unstuck” tools: consultation groups and additional training. Neither helped. As a dynamic therapist, I knew what I was supposed to do: work in the transference, bring insight to the dynamics in the room, monitor my counter-transference, and above all hold the frame. But “the frame of a therapy case cannot be stronger than the frame of a therapy practice, and mine was starting to splinter.”

Existential Threat

In the same month that my treatment of Anne was getting stuck, I had two new clients drop out after one session in the same week. I knew about the research that we are all told in graduate school about how the modal number of psychotherapy sessions nationwide is one, and how not every client and therapist is a good match, and yada yada. But for a new therapist trying to build a practice during a recession, having two new clients drop out in one week is an existential threat. I decided something had to change.

On my commute home one evening that week, I listened to a recording of Scott Miller’s presentation at the 2009 Evolution of Psychotherapy Conference regarding his pioneering work on feedback-informed psychotherapy. Scott got my attention when he referred to dropouts as the “largest threat to outcome facing behavioral health” in the United States and Canada. He was talking about my practice! I realized that I was not the only therapist with a dropout problem, and there was no reason to hide it out of embarrassment. I resolved to seek counsel from my colleagues and mentors.

The Ubiquitous Scourge

In the first, difficult year of building my private practice, I ate a lot of lunch. Networking lunches are like lottery tickets: one in ten results in a few referrals, and every referral was worth its weight in gold in that difficult first year. I enjoy networking lunches, because it’s fun to meet senior clinicians and hear their war stories. They tell me that they enjoy the lunches because they get to pass on the gift of mentoring that was once given to them. Senior clinicians are a generally calm, relaxed and self-assured bunch; they have established referral sources and can easily afford to lose a client here and there. Want to make some highly regarded pillars of the therapeutic community stop eating their free lunch and sweat a bit? Ask about their dropout rate. It’s as if you’re asking what sexually transmitted diseases they may have. It’s not polite. Never mind that dropouts are one of the ubiquitous scourges of our profession, affecting all diagnoses and treatment modalities. Therapy dropouts are the dirty secret of our profession: everyone has them yet few want to talk about them. Unfortunately, avoidance has not proven to be an effective solution to the problem. With few exceptions, the overall psychotherapy dropout rate is as bad now as it was fifty years ago, despite decades of treatment research and empirical certification.

What Counts as a Dropout?

For 2010, the overall dropout rate for my private practice was 37%. Unfortunately, it is hard to know whether this number is good, average or poor, because there is no general consensus in the literature on what exactly constitutes a “dropout.” The average psychotherapy dropout rate has been reported to be from 15% to 60%, or higher, depending upon whether you define dropout as quitting therapy before all treatment goals were achieved, terminating without the therapist’s agreement, or a variety of other definitions. For my own practice, I define dropout as any time a client terminates therapy without telling me that they are stopping because they have achieved enough positive results. I chose this definition because I think it points most directly to the problem I want to resolve: clients who could benefit from more therapy but choose to not be in treatment with me anymore. Of course, this definition is not precise and won’t work for all therapists. If a client terminates due to factors that make continued treatment impossible, such as moving out of town, then I do not count it as a dropout; but if the given reason is that he or she cannot afford therapy anymore, but isn’t interested in talking about a sliding scale, then I do count this.

Of course, there are many reasons a client may drop out. Most of the research on dropouts has focused on what we call client factors, such as the client’s diagnosis, demographics, rate of progress in therapy, etc. But this research doesn’t help my dropout problem because I’m trying to keep my practice full, and I don’t have the luxury of excluding clients who are at high risk of dropout. So instead I have to focus on therapist factors: what can I change about how I work to reduce my dropout rate.

Insisting on Feedback

“Of course I ask for feedback from my clients. I do it every session!” Every therapist believes they ask for client feedback. True for you too? Then tell me why your last three dropouts happened. Sure, we ask for feedback, in the same way that my previous dentists asked—as an offhand, pro-forma fly-by at the end of the root canal. “Was that ok?” And the information we get is usually as meaningful as the effort we expend asking. “Yeah, that was great,” or “You’re a great therapist,” or “I’m really feeling better.” Vague and general; even worse, polite. Just enough for the client to think that they have satisfied the therapist and just enough for the therapist to keep the specter of dropout in the closet. It’s a mutual con-job—a wink and a nod to accountability. But if we don’t embrace accountability in the therapy room, then it will make itself known in dropouts.

Sure, some clients are tripping all over themselves to give you feedback. Sometimes you can’t stop the feedback. But those aren’t the clients I’m worried about losing to dropout. Maybe some therapists are able to get meaningful information through informal soliciting of feedback, but I’ve found the hard way that if I don’t make a Big Formal Procedure out of it, I end up with empty, vague generalities.

Another fruitless session had just ended with Anne, and I was pretty sure that she was about to drop out. I handed her a feedback form and asked her to complete it. “She looked at the piece of paper, snorted and said, “Are you kidding me?”” As a beginning therapist, I have a lot of practice hiding my nervousness. I replied, “I need your feedback in order to learn how to help you better, but also to become a better therapist overall, so I appreciate your time and candor in filling this out.” Anne snorted again, rolled her eyes, and completed the Session Rating Scale, an ultra-brief tool that measures the working alliance along four dimensions. She handed the form back to me and I saw that our working alliance, as I would have guessed, was a sinking ship. I asked what specifically I could do to help her better. Anne replied, “You could listen.”

I said, “More specifically, tell me how I don’t listen and how I can help you better.”

She gave me the look clients give you when they’re not sure if you really mean what you say or if you’re just doing a canned intervention. “You understand me thirty percent of the time,” she said, visibly angry. I asked for an example. “When I mentioned my cousin you cut me off,” Anne said. “That was important.”

I couldn’t remember Anne mentioning her cousin. “What else?” I said.

“You tuned out two or three times this session. I can always tell you’re tired when we meet this time of day.” I thought I had managed to hide my mid-afternoon fatigue.

“What else?”

“There are times when I am sad that you really don’t understand how I’m feeling—even though I can tell that you think you do.”

None of Anne’s feedback struck me as accurate. Above all, I pride myself on accurate empathy. What kind of therapist am I if I don’t feel a client’s sadness?

Four Rules for Receiving Feedback

We all have areas of known weakness. Take cultural diversity, for example. I am a straight, white, middle-aged male. Anne is a young bisexual Latina. I would expect for her to tell me about culturally based misunderstandings. This would be ego-syntonic for me and not cause anxiety. But tuning out or missing sadness—that’s not me!

The feedback I get from clients that is confusing or seems inaccurate is the most important feedback I get. “Why is it that we trust our supervisors to point out our blind spots, but not the people who are actually in the room with us?” It’s odd how we spend so much effort and money getting feedback from peers and experts, yet so little effort on getting formal feedback from our customers.

I’ve come to see that there were two major problems with how I had been using feedback. First, my collection of feedback was pro-forma. I wasn’t invested in getting it, and my clients could tell. Second, I interpreted the feedback. I conceptualized it as part of the therapeutic process, which meant that it was ultimately about the client, not about me. Of course, getting and using feedback affects and informs the therapeutic process. I needed to learn, however, to set aside the process for a moment to accurately hear the feedback as it pertained to me.

Since then I have developed a four-step feedback rule. First, I make a Big Deal out of it. I use a paper form (the Session Rating Scale) because the act of pulling out the paper and pen serves as a symbolic shift in focus away from the client’s process towards my performance. If a client always gives me high marks on the form, or responds with platitudes like, “Tony, everything is great,” I’ll say, “Well, there’s always something I can improve. Can you give me one or two specific ideas on what I could be doing better?” In therapy, it’s all about the client. In feedback, it’s all about me—I’m downright selfish!

The second rule of feedback is that I don’t interpret. If I make the feedback about the therapeutic process then I am missing the actual feedback. As a dynamic therapist, all my training was telling me to interpret Anne’s response as transference or a projection: she was reliving her past pathological attachments in our relationship. But I’m convinced this approach would have caused Anne to drop out, because she would have seen (correctly) that I was ignoring her.

Scott Miller calls this kind of attribution “burden shifting”—when we misattribute our mistakes to client factors. He warns therapists that blaming dropouts on client demographics or diagnostic categories can block our insight into our own mistakes.

The American Psychological Association is moving towards requiring trainees to learn how to collect clinical outcome data. Likewise, Michael Lambert1 and others have developed tools to predict and reduce dropout by tracking clients’ session-by-session clinical progress throughout treatment. This data is valuable, but still focuses on client factors, and thus can miss important information that only the client has on what the therapist is doing wrong. I need to know my part in the story so I can stay ahead of potential dropouts. Without session-by-session feedback, when a client drops out, it is already too late to find out why.

As therapists we claim clinical legitimacy by using empirically certified treatments. We advertise our professional trainings and certifications proudly. But just as important are our personal treatment data, including our dropout rate, which we generally hide in the closet. Krause, Lutz and Saunders2 have argued that instead of having empirically certified therapies, we should have empirically certified psychotherapists. As public health providers, assessing outcome is an ethical responsibility. If we continue to hide to our mess then we run the risk of others exposing it for us. (For example, teachers’ unions across the country are getting clobbered for their resistance to incorporating meaningful outcome evaluations into their work.)

Incorporating Feedback

How do I actually use feedback? Sometimes it is easy. For example, in response to Anne’s feedback, I moved her appointment to a time of day when I wouldn’t be tired. (Now I use her previous time for a midday nap, so other afternoon clients are benefiting from Anne’s feedback as well.) Other feedback can be harder to use, especially when it is about my own unconscious behaviors. Anne insisted that I cut her off when she had brought up her cousin, but I couldn’t remember doing so. Likewise, I had no awareness of avoiding her sadness. While I did want to take her comments seriously, I also didn’t want to automatically assume her perceptions were correct.

However, feedback that points to my unconscious behaviors is also the most valuable. This is the third rule of feedback, which is the hardest rule to follow: to “focus most on the feedback that seems inaccurate, confusing, or anxiety-provoking. This is where the treasure is buried. “

When I’m unsure about the accuracy of the feedback I am getting, I use a strategy I call perspective triangulation. First, I videotape my sessions with that client and review the video myself. I then review it with colleagues in consultation groups. Comparing the perspectives of the client, myself and my colleagues usually results in a definitive answer.

In my experience, the client’s perceptions are correct at least two-thirds of the time, and I make consequent course corrections in their treatment. It is important to note, however, that even when I think the client’s perceptions are incorrect, I still have to substantively address their feedback, or else there is a growing risk of dropout.

My review of the video showed that, yes, I had cut her off. Colleagues in a consultation group watched the video and pointed out multiple instances where Anne was about to have a rise of sadness, but I had blocked her sadness by refocusing on her anger. (Later sessions revealed that the two were in fact connected, as her sadness was about being unable to protect her cousin from abuse.) This was the hardest feedback for me to receive; I never would have believed it, had it not been clear as day on the video. Investigation of videos revealed that I had an unconscious pattern of re-directing from sadness with a range of other clients in addition to Anne. I never would have found out had I not insisted on feedback.

The fourth step in my feedback process brings it back to the client. If I agree with their comments, then I make appropriate course corrections in our work. If I disagree, then we discuss our different points of view. Either way, I make sure to be clear and transparent in my process, and to let clients know that I take their feedback seriously. So in this case Anne and I had a discussion about her feedback. I agreed to be more attentive to not cutting off her sadness. She agreed to let me know, in the moment, if she saw me doing it.

I was trained to get a review of my clinical weaknesses from my trainers and supervisors. Now I also get it from my clients. They have given me an amazing gift: an empirically validated list of my clinical weaknesses. I can’t think of a better resource to prevent dropouts.

Now, six months later, Anne has made significant progress on her interpersonal challenges. She has improved her relationships with friends, roommates and employers. She started setting firm boundaries with previously abusive family members. Her sleep, anxiety and somatic symptoms all continue to improve. Every session Anne teaches me how to better help her.

Before using feedback, I had one to three dropouts per month. Since getting serious about feedback, I’ve had only one dropout in over three months. While this is too soon to draw definitive conclusions, the results so far are very encouraging.

The client sitting across from me knows something about my dropout problem that I don’t. All I have to do is ask, and listen.

2011 Update

 I am pleased to report that my dropout rate for 2011 was 18%, one-half what it was in 2010. I'm confident that getting serious about client feedback contributed to this improvement. This raises the question: how low can a dropout rate realistically go? Besides improving as a therapist, what else can help lower the rate further? (One of my clients recently suggested offering coffee in the waiting room for night sessions!) Hopefully we will find answers to these questions from future research.

Footnotes

1. Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients' progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.

2. Krause, M.S.; Lutz, W. & Saunders, S.M. Empirically certified treatments or therapists: The issue of separability. (2007). Psychotherapy: Theory, Research, Practice, Training. 44, 347-353.

Further Reading

“When I’m good I’m very good , but when I’m bad I’m better”: A New Mantra for Psychotherapists. by Barry Duncan, PhD and Scott Miller, PhD.