Stan Tatkin on a Psychobiological Approach to Couples Therapy

Posted on by rezendevknowfully.com

A Psychobiological Approach to Couple Therapy

Ruth Wetherford: So, Stan, let's talk about psychobiological couples therapy.
Stan Tatkin: Right. It’s actually a psychobiological approach to couples therapy.
RW: What is that approach all about?
ST: When we're talking about psychobiology, we're talking, really, about the brain and the body. And we're looking at five domains—the first being attachment. And by attachment I mean infant attachment as well as adult attachment.

The second domain is arousal regulation. We focus on preparatory, or anticipatory, systems that work alongside the attachment system, and that are embedded in procedural memory. These anticipatory systems prepare us for moving toward and away from others, based on history and experience. And this is read through the body —through the face, the eyes, the pupils, the voice or prosody of the voice, skin color, temperature, movement, posture, and so on.

The third domain is neurobiological development. We take a deficit-based approach, not a conflict-based approach, meaning that we don't really focus on conflict. We don't focus on what most people —couples, at least —bring into therapy as a presenting problem: money, sex, mess, kids, and time. That is what most everybody complains about.
Rather, we look at the couple's ability to be a co-regulatory team–to be able to manage each other, particularly during distress.
Rather, we look at the couple's ability to be a co-regulatory team–to be able to manage each other, particularly during distress. How good are they during stress? Everybody has conflicts, as John Gottman says. Every couple has conflict. We're looking to see how a couple handles conflict and whether they handle it in a secure functioning manner or in an insecure functioning manner.

The fourth domain is therapeutic enactment. We work with procedural memory. We work with the body, with a bottom-up approach. In other words, rather than use interpretation, we stage experiences so that couples have an enactment, or certain state of mind, state of body, online to work with. So it's really experience before interpretation.

RW: What are some examples of these?
ST: It's using a lot of psychodrama —going back to Moreno, but also Gestalt, pulling from Satir. By basically moving people into experience, using a bottom-up approach rather than a top-down approach, we avoid tapping into higher cortical areas first, which are really good at error correcting, really good at processing, but can also mislead the therapist.

In other words, higher level cognitive processing is not as reliable as the body. So we want to get at the body first.

And then the fifth domain is therapeutic narrative. This is the therapist's own stance about why couples should be together. It has to be a coherent narrative that, along with theory, explains where the couple has been, what their trajectory is, why they are where they are, and where they're going. The narrative is grounded in secure functioning relationship, as opposed to an insecure functioning relationship. So it's very much as it is when you're working with personality disorders: the therapeutic stance is very important.
RW: This is an integrative approach.
ST: Yeah, very.
RW: Let’s dive in and talk about how we can use this. Where would you start, with a therapist who is reading the article on Psychotherapy.net, and is very intrigued and wants to know more about how to apply it?
ST: It depends on which domain we’re focusing on. With the people in my training, we focus on all five domains, each having its own set of principles and goals. But I would say one of the first ideas for therapists to grasp is: what is a secure functioning relationship, and what is insecure functioning relationship? I would say probably the easiest way to parse this is that an insecure functioning relationship is fundamentally based in a system that is unjust, insensitive, and unfair.
RW: Relational injustice.
ST: Yes.
RW: How important do you feel it is for therapists to focus on their own levels of security of attachment in their general approach to clients?
ST: Well, that's a big question, and that's more about therapy for themselves. We're talking here about theory. There are therapists who might have an insecure attachment if they were tested, say, in a proper AAI [Adult Attachment Inventory] with a reliable coder. But they could still be effective therapists and understand what a secure functioning relationship is, and follow those principles.

Here's the difference between therapist self-awareness and education, adherence, and understanding of theory. I think the very first thing is, talking professionally —and again, this is also true for couples —it is entirely possible for two individuals to be insecure but to form a secure functioning relationship. That is, their model of relationship, the principles they follow, would be considered secure functioning. What we're comparing is a two-person psychological system based on true mutuality (good for me and good for you), versus a one-person psychological system with too much emphasis on self-values or -interests, rather than on relational interest.

But there are other factors —not just a two-person psychological system —that add up to secure function. The other, in terms of a primary attachment relationship, is a mutual protection of the safety and security system for the couple.

This means that both partners agree that the relationship comes first, and that the safety and security of the relationship come first. And the reason it comes first is because, without that agreement, neither can really thrive.

Looking at the mother/infant attachment system and what we know about that system, in terms of security, a secure relationship is based on attraction, not fear or threat. Insecure models base their relational glue around fear or threat. So protection of that safety and security system is a key feature of a secure functioning relationship.

Yet another factor is a lot of mutually positive, amplified moments between the two, which are usually face to face, eye to eye, sometimes skin to skin. That is actually called primary intersubjectivity —when two people are in close physical proximity and using each other's eyes and communication to amplify positive moments, which, by the way, have neurochemical parallels to them.

And then, secondarily to that, is joint attention, wherein partners focus on a third thing to amplify the relationship. That's another quality of secure functioning. Namely, first, a lot of mutually positive amplified moments between the two people, and then —this is really important —second, that the negative experiences that partners encounter individually and collectively are mutually attenuated and foreshortened by the couples' skill at metabolizing and managing distress.

So I would say those two are extremely important for secure functioning relationships: high positives that are mutually amplified, and negatives that are quickly repaired and corrected. Distress is relieved quickly, not dismissed. When you asked the question, "How does a therapist apply this or understand this," I think we first must understand what it is, and then adhere to that idea when looking at couples. And then, of course, it's very hard, if you're working in this way, not to grow yourself, and look for it yourself in relationship.
RW: It’s everywhere.
ST: Well, it becomes everywhere, because that’s where your focus is.

Avoidant and Angry-Resistant Styles

RW: Regarding the importance of the soothing being a mutual skill, it’s a very common complaint in couples work that one partner complains that, when there is a breach of empathy, or something that moves the interaction toward an insecure feeling, one person is usually more in the role of the one who bridges that distance. And that person complains. They want the other to be less avoidant, more engaging. And typically two people are differently skilled about the extent to which, in the moments of conflict, they can self-regulate and reach out to the other.
ST: That’s right.
RW: Any thoughts about that?
ST: We're looking for couples to be able to rely more on interactive regulation, coregulation. People who are insecurely attached —that is, basically the avoidant and what I call the angry-resistant on the other side —have different styles that are wired in from childhood, in terms of how they regulate. For example, the avoidant, who comes from dismissive and derogating parenting, relies on autoregulation, which is a form of self-stimulation, self-soothing. It's not just simply a defense: it is an adaptation from very, very early, and it's wired in. So this is a default position.
RW: Things like saying a prayer, singing a song, taking deep breaths, meditation.
ST: Or masturbating, or reading. Or singing, like you said, or performing, writing. Anything that doesn't involve another person —although there are things that involve another person, with which the avoidant person could autoregulate. In Kohutian terms, that would be using that person as a self-object.
So autoregulation is normal–everyone does it–but the avoidant over-relies on autoregulation.
So autoregulation is normal–everyone does it–but the avoidant over-relies on autoregulation. And that's a sign of a one-person psychological system. The thing with autoregulation is that it's a very energy-conserved state, almost dissociative. And the problem with the avoidant is his or her inability to shift from being alone to interacting. Avoidants can shift from interacting to being alone, but not in the other direction very easily.

The angry-resistant, by contrast, focuses and over-relies on external regulation. Angry-resistants require another person to help calm them down or stimulate them. They, in contrast, have a hard time shifting from interaction to being alone, not from being alone to interacting. So you have two one-person systems that avoid relying on interactive or mutual regulation, which is what we're trying to move couples toward.

The angry-resistant will feel some fear about separations and reunions, particularly about being dropped. But both partners have a responsibility to repair these reflexes with each other, regardless of whether they are avoidant or angry-resistant. So we have a lot of emphasis on getting the couple, especially during distress, to coregulate —eye to eye, face to face —and to make quick repair, make things right as soon as injuries or distress arises. This way there's no memory of the event.
RW: What are some ways you have found that help people to engage in face-to-face, mutual soothing activities? Do you talk to people about the theory?
ST: Sometimes I do. But, basically, I suggest to my students that we push the therapeutic narrative forward by expecting a secure functioning relationship, not just teaching it. We expect one. So when people are not operating in this way, we wonder why. Don’t forget, it’s not simply the avoidant who can create a tone that is threatening, and who starts a fight. Let me just say this: “the reason most couples enter into conflicts that are problematic is because of their inability to know how to manage one another. They don’t know how the other person really works.”

Getting Couples to Manage Each Other

RW: Do you teach them skills to help them overcome their deficits?
ST: Yes. Much of the therapy is really active and experiential. I do very long sessions —two to four hours, sometimes six hours, and they're all videotaped. And the reason for this is to be able to move the couple through a variety of states, which are very much like real life.
Instead of talking about events, we try to enact them and try to make the corrections in real time
Instead of talking about events, we try to enact them and try to make the corrections in real time, while they're in that state of mind. So this becomes a part of procedural memory, which is actually why they get in trouble in the first place.
RW: I’m inferring a lot of coaching.
ST: There’s a lot of coaching, yes.
RW: Like when you've asked them to have an interaction, you read the facial expression and tone of voice a certain way, empathically. The spouse you're teaching doesn't. They're not empathic. They break right there. You'll stop the interaction there or you may note that and use it in some way to help them read the other face. I can imagine how helpful that would be if I'm reading my partner's eyes as angry when it's interest or when it's confused. If I see criticism, based on my deficit —if everything is critical, you can teach me nuance. That would be great.
ST: The idea here is that each partner is in the other’s care. They’re not in the therapist’s care. So we want to point to each partner: “Did you see that on her face? Did you notice that?” I don’t want to be the only person noticing things. I want them to be able to see things. I should say that the room is set up in a particular way, like a staging area. Everyone is on chairs with wheels. So I can see body movement. I can turn to them. They can turn to each other, and I can see them turning away, as well. “So the emphasis is to get them to read each other. They have to be experts on each other.”
RW: You identified the domains of your focus. What are some of the goals of these different domains?
ST: On the attachment level, we want to educate both partners in terms of their attachment orientation. This isn’t to say that we’re going to give them jargon, but we want them to understand from where they came and how that has wired psychobiologically into their nervous system and every cell of their body, to normalize it. This is not a pathological view of human nature. This is a very natural view of human nature in terms of attachment, adaptation. We all adapt. And the nice thing about looking at developmental theory is we can get a picture, a sense, of how someone has to adapt to certain situations. And that gives us a sense of what the person is going to do in the future.

We want people to understand who they are, really, and to take responsibility for that. For example, if the avoidant is dismissive or derogating or gets angry when his or her partner approaches, then he or she must quickly fix that and make it right. But also, we want each partner to understand the other and to know how to manage the other in the best way. When we look at attachment, we know that it isn’t so much about personality; rather, it’s about the sense of competence and agency that two people in a dyad feel they have over the other. In other words, I know that I can manage you. I can shift your state if I need to. I can move you around if I want to, without the use of threat. I can do this in the best way.

And that’s what we want. We want couples to learn who they are. They didn’t get married to be different people. They got married to be just who they are. But they want to feel that they know how to manage the other person. So the emphasis here is very different. We’re not teaching people how to manage themselves. We’re teaching the proper way, which is how to manage each other. And this, again, is borrowed from developmental theory.
RW: Don’t you think it’s both/and?
ST: It’s both/and, but too many therapies focus on self-regulation.
RW: Exclusively.
ST: Right. The way that this works is that, in a primary attached relationship, it is much more efficient for me to manage your state than it is for me to manage my own. And one of the reasons it's more effective is that, the way we're wired, at close distances you can see what's going on in my internal state, my nervous system, before I know. I can see what's going on in yours before you know. This gives us an advantage. There's a reason this is built in at close distances. At far distances, we're interested in whether we're attracted or we're dangerous. But in close distances, we're able to see into each other's nervous system and to be able to respond in this dance of mutual regulation.

So that's what we want to encourage, on the attachment level. On the arousal level, we want to make sure that couples can talk about anything, do anything, without fear of dysregulation. One of the reasons therapy sessions are very long is
I like to set fires and put them out, or make messes and clean them up
I like to set fires and put them out, or make messes and clean them up —however you want to look at it. But we want to get into areas of difficulty so that partners are not afraid, so that they know how to co-manage these situations by tensing and letting go, and never getting into a situation in which they dysregulate one another. They must know how to stay in a play zone, even when they're fighting. This is a very, very important part.
RW: That's powerful —the role of play.
ST: It is. Couples should not be afraid of anything when it comes to each other, and they certainly should not be afraid of the relationship breaking simply because they’re in conflict. So we take off the table any fear having to do with the relationship breaking or falling apart on either side of the partnership.

The Elephants in the Room

RW: So if there is doubt that the person wants to stay, and they say, "Yes, I am thinking about divorce, and I can stop saying that in the middle of a fight but it's there. I don't know if I want to stay" —how would you take that off the table?
ST: Well, in the very beginning, if that is really a very strong message and one partner, at least, is drifting or pushing in that direction, this is where it gets kind of tricky.

I will go in that direction and push it all out. In other words, I call it "bending metal" —going in one direction or the other fully. I'm not in the business of breaking people up. But if there is resistance and there's one person saying, "I don't know if I want to do this," then I will go full bore into breaking them up, for the purpose of getting pushback or blowback. In other words, I want to find out what they're really made of, and I think one of the jobs for all therapists is to clarify what's going on.
RW: That’s very important because that’s the elephant in the room that the other spouse knows is there. And if the therapist is too afraid to push on it and bend the metal, then you really can’t get to building the security.
ST: Right. One of the reasons this approach goes fast is the therapist is very active and evocative, and even a bit of a clown-at-the-bullfight kind of person. I was trained psychoanalytically; this is very different because we want to push the boundaries and see what people are made of. So if somebody thinks he or she wants out of the relationship, then we have a session on “Let’s divorce,” and we’ll go all out. And then I will look for pushback. Now, much of the time, people are using this as a way to threaten the partner to get him or her to comply. But once it’s exposed that they really aren’t going to leave, they don’t want to leave, they can’t leave, then it gets taken off the table. Because we’ve already proven that the person is not being truthful. They’re using this as a maneuver to threaten the partner. So we want to get that off the table as soon as possible, and we do that by getting them to throw down, basically.

You can see this is taking a little bit from strategic family systems, too, in that we’re being a little tricky, but always in the interest of clarification. So that’s how that’s handled.
RW: And that would apply when a person is having an affair?
ST: Oh, that’s our bread and butter.
RW: How so?
ST: A lot of people end up coming in because either they are having an affair or they're hiding one. And in this model,
we think of affairs not as attraction to a third, but an aversion toward the primary.
we think of affairs not as attraction to a third, but an aversion toward the primary. So when two people assume the office —and I think of it as an office —of primary attachment figure, it's almost like the office of Presidency. The office of Presidency has a certain valence to it. Forget who's sitting in it. And then there's the person with his or her personality, which either adds to, amplifies, or whatever, the office.

So when two people assume the office of primary, this is a very intense relationship that resembles no current relationship, only past relationships. And, as such, people become deep family when in these positions. That is why a lot of problems arise. I call it the marriage monster. As soon as people get married or they enter into the relationship with a sense of permanence, all these attachment fears coming from procedural memory and experience begin to arise. So movements away and toward each partner we see as part of the predictable trajectory, and not just as happenstance or an accident.

So, most affairs, depending on who's having them, reflect the insecurity of the primary attachment relationship, not so much the attraction to the outside third person. Ironically, many people pick, as their affair, somebody who's almost identical to themselves. And one of the common things I'll hear, and I'm sure you hear too, is "Why aren't I like this with that person? Why do I feel this way with my sister or my brother and not with you? Why my friends don't do this to me?" My thought about that is, "Well, marry your friend and then see what happens." Because it is a phenomenon of marriage or commitment that this material starts to come up.
RW: Going back to the goals, you were naming the goal of the attachment domain is to move towards security.
ST: Move towards security and to understand who each person is and how to manage him or her.
RW: And then, in the arousal domain, the goal is to promote mutual regulation.
ST: Yes, we're promoting interactive regulation, which is a close monitoring of each other's face, voice, eyes, and body. And by the way, interactive regulation in this close proximity, and mutual gaze, are how we fall in love, most of us. So it's simply going back to the way we originally began anyway. But also, the goal is to learn how to do this so that you and I, as partners, can talk about anything. We can enter into any area of importance without fear of threat or dysregulation. And that's a major, major goal.

On the developmental level, the therapist really has to discover what deficits do arise —and we all have deficits, and especially they come up in relationship —to clarify those and to hopefully help move them along developmentally. Partners need each other to do that.

If I am with you, and I discover that you've never been able to read my face, you've never been able to read anybody's face, that is going to be one of the reasons we have trouble. And I may have thought you were doing this purposely, when actually you weren't. This is a deficit. This is something you've never been able to do. That changes the game in a lot of ways. And sometimes people will never get very good at something. Other times they can get better with the help of the partner.
RW: Okay, any other goals in the other domains?
ST: In general, we're moving people towards a secure functioning relationship. And that includes, like I said, true mutuality. In other words, everything we do is based on a social contract, borrowing a bit from attachment theory and John Rawls here —a social contract that's based in fairness and justice and sensitivity. So, if the relationship comes first —not us as people, but the relationship —and it becomes the air we breathe, the water we drink, our basic fundamental engine of energy to go through the day and to brave the world, then there are things that we have to do with each other to keep each other feeling attractive and attracted to the relationship. And one of those is making sure that every decision we make is one you're good with and one I'm good with. There is no dragging you along because it's good for me, but it doesn't have to be good for you.

So we're changing really from a monarchy, or dictatorship, to a system that is fair between these two generals, who are both in charge and they have to please other.
RW: If we’re not both happy, neither one of us is happy.
ST: Neither one of us is happy. And everyone who lives below us and around us will be unhappy, too. I kind of think of this as king and queen. If the king and queen are in disorder, everyone in the land is in disorder.

So that goes with kids and that goes with everybody we interact with socially.

There’s one more part here: the management of thirds. By this I mean third things, third people, third objects, third tasks. This could be drugs, alcohol, work, in-laws, friends, children, dogs, pets, and so on.
RW: Famous triangulation.
ST: A secure functioning couple has a kind of couple bubble around it, wherein the dyad comes first, and thirds are secondary. What this means is that the couple is aware that in public and in private they protect each other at all times. They don’t allow either of them to be the third wheel for very long, at least not without repair. In this way, everybody actually fares much better. So the management of thirds is a huge deal. As therapists, we can find out right away if a couple is mishandling this by the way they address us.

One of the reasons I have them on chairs with wheels is that I can see how they’re moving and who they’re talking to and who they’re addressing. If I notice the partner is talking to me, ignoring the other, or saying something about the other without checking with him or her, then I know both of them handle thirds poorly. And not just in the therapy session, but everywhere. So, another big goal is the management of thirds, in public and in private.

It’s great fun.
RW: It sounds like fun. What are some things that therapists can take from this to translate it into tactical tips, tools, and techniques?
ST: First of all, I would recommend that someone who wants to get into being a couple therapist do it wholeheartedly, because it is very different than working with individuals and families. It's a specialty. And I think, as such, it deserves a lot of attention and a lot of focus. Having said that, I think that it is next to impossible to see a couple, particularly in the beginning, for an hour. I think the therapy sessions must be long, to give therapists enough time to relax and not be pressured. Otherwise, the therapist, him- or herself, can become dysregulated, and pressured. More mistakes are made that way.

So longer sessions to watch the couple cycle through different states, to give therapists time to think and formulate. Begin to play very, very close attention, not to content, but to micro-expressions, micro-movements. I think therapists today should be trained —whether it's Paul Ekman's material or other places to get this training —to work with the body and be able to pick up very subtle but very significant cues on the face and the voice that reveal shifting states and emotions. This is very key to working with the body. I think it's important to try to avoid getting caught up in the content of what a couple's talking about and start watching, basically, these two nervous system interacting.

One thing I do want to say before ending here is that this is a maxim that I always use and say: people do not know what they're doing. This goes for us therapists, as well.
We do not know what we're doing most of the time, and we don't know why we do what we do
We do not know what we're doing most of the time, and we don't know why we do what we do most of the time. And there's a reason for this. When we are interacting with another person, we're using very fast-acting subcortical processes that never see the light of day in terms of higher cortical areas. We're simply acting and reacting very quickly, as we should. And then, when asked why we did what we did, we really don't know. But because we're human beings and because we don't like to not know, we make it up.

I could say that this is a function of the left hemisphere that confabulates, because it doesn't know what the right hemisphere and subcortical areas are doing. But this is the flow of data through the body and the brain. We act and react much faster than our cognition, and certainly our words.

So the therapist would do well to understand neurobiology and how the brain actually works and what people are really doing. A lot of things that are happening between two individuals —and this includes individual therapy —are sub-psychological. In other words, it's biological. It doesn't even get to the higher levels that we consider psychological or theory of mind. This is our most basic nature. Our number one imperative as human beings is to not get killed. It comes before love. It comes before everything else. And we have some very, very well developed —in terms of evolution —primitive areas of our brain that are very good at looking out for our survival. They don't give a damn about relationships or anything else. If it comes down to feeling threatened, we do war instead of love. That's what I'd say.
RW: And from there is the title of your new book with Marian Solomon.
ST: That's right. Love and War in Intimate Relationships: Connection, Disconnection, and Mutual Regulation in Couple Therapy. It is available through Norton in the Interpersonal Neuroscience Division. The official publishing date is February of this year.
RW: Congratulations on that book.
ST: Thank you.
RW: What kind of training are you planning to do in the future, so that you can disseminate and spread the word and help people learn this?
ST: We do trainings in Los Angeles; San Francisco; Seattle; Austin, Texas; Boulder, Colorado. Maybe soon to be in New Jersey. We also have an international group that we do training with, as well. So it’s spreading like wildfire right now. And if people want to get involved in the training, which is a great deal of fun, they’d have to go to this web address: www.ahealthymind.org, and the click on the city that’s nearest to them.
RW: Is there anything that that I haven’t asked you or that you haven’t had a chance to say yet?
ST:

Applications for Individual Therapy

We didn't really get a chance to talk about how this translates into individual work, but it does, because we're dyadic creatures. Individual therapy is a dyad. I will say that, as a cautionary note, being an individual therapist for so many years, I now view primary attachment relationships as sacrosanct. And if an individual does come to me and is in a primary attachment relationship, I will work my darnedest to get that partner in, to turn it into couple therapy. And the reason I do that is because when we're working with the primary attachment relationship currently, we're dealing with proxies: people who represent the past. And there's no more powerful system than that system. The therapeutic relationship tries to approximate that, but really can never do that for a variety of reasons. For one, the therapeutic relationship is asymmetric. So, when we have that capacity and that exists, I think we should shift to couples therapy. If the couple or the individual is unwilling to do that, I think it's incumbent upon the individual therapist to act as an adjunct —to move that relationship forward rather than try to compete with it.

So I think there are mistakes being made now with individual therapists who are competing with primary attachment relationships. And that would be a nice thing, I think, for people to start to learn not to do.
RW: It sounds like you’re suggesting that therapists not only promote secure attachment with themselves, but also with the primary attachment spouse.
ST: Right. Instead of trying to compete with it, we try to promote the one that already exists. Unfortunately, when we see one individual who’s in a relationship, we will never, ever know the truth. One person is not a reliable reporter of the relationship.
RW: Well, there are different truths. There’s my truth and then there’s your truth.
ST: After a while doing this, you understand again the principle that people don’t know what they’re doing. That’s true for everybody. So, in this work, working psychobiologically, we want proof. We want to see it. We don’t want to hear about it. We want to see it.
RW: I know that you’re familiar with the notion that in many situations we don’t know if people should divorce or stay together.
ST: That’s right.
RW: Particularly if they are at the long line of a series of many, many injuries and don’t have any capacity for repair and a very entrenched avoidant or resistant pattern of attachment. And let’s say one is growing and is seriously wanting to think about leaving. How do you deal with that? How do you deal with those moments when you are promoting the divorce rather than the increased security attachment?
ST: I only promote divorce as a trick. I only promote divorce to test the mettle of at least one person who is drifting in that direction.
RW: And if the metal yields?
ST: Well, if the metal yields, then no harm, no foul, because clarity is the most important thing. People aren’t going to do anything because you tell them to, not really.
I have stopped being the arbiter of who should be together and who shouldn’t.
I have stopped being the arbiter of who should be together and who shouldn’t. I assume that partners will no longer be together when they are no longer together. Until that time, they’re a couple, and I’m their couple therapist. And I continue to assume that my job is not to decide whether they’re right or wrong for each other, but to move them toward a secure functioning relationship. That’s my job. If they do not make it, they’ll be better the next time for therapy. But I don’t decide anymore. Now, when I have strong feelings about the couple not being together, it’s always countertransference that passes momentarily. There are a lot of therapists who’ve tried to break up couples, and I think this is actually morally wrong.

I think nature has its own path. Primary attached relationships are very complex and very strong. We don’t understand them fully. I think people are quite capable of ending things when they’re really, really done. And they’ll prove it. Otherwise, you’re the couple therapist until that time. That’s my belief.
RW: Thank you for this interview. It was very enjoyable.
ST: Thank you.

Psychotherapy Training on Steroids: Remote Live Supervision

Posted on by Psychotherapy.net Team

Note to readers: This blog is dedicated to exploring new training tools and techniques to help us become better therapists.  May we all become “supershrinks!"

Learning a psychotherapy technique can be like a romantic tragedy.  You go to the workshop, fall in love with the technique (and occasionally the presenter), and go home with fantasies of all your therapy cases getting unstuck.  On Monday morning in your office, however, everything falls apart:  you can’t remember the techniques (despite the post-its), you can’t do them correctly, or, even worse, you do the interventions perfectly but the client responds totally differently than how the clients in the presenters’ videos responded.  Sometimes I want to yell, “No, you are supposed to cry when I say that line, and get angry when I say this line!”

Most training and supervision lacks the most important variable in therapy:  the client.  The best training occurs in an actual therapy session.  I want to know what techniques to use with my client, not the client in the case reports or videos.  But what if the expert I want to learn from lives across the country, or I don’t have a one-way mirror room?   Now, thanks to internet, I can bring him into my office.

I would like to share a new method of supervision that has been made possible by recent technological advances.  “Remote live supervision” allows a supervisor to observe a therapy session over the internet and give feedback to the therapist in real time.  The technology is inexpensive and easy to setup.  This new method has promise to greatly increase the accessibility of top-quality supervision and training across the field of psychotherapy, as therapists will no longer be limited by geographic distance. 

Specific instructions on how to set up the remote live supervision for both PCs and Macintosh computers, along with a discussion of technical issues, can be found here.

Combining the video of the therapy session with the transcript of the supervisor’s moment-to-moment comments makes for a powerful training tool, as trainees get to see the actual results of following (or not following) the supervisor’s interventions.  Another option for training is group video, where a team of trainees can observe a remote live supervision in real time.

I do remote live supervision with Jon Frederickson, MSW, to accelerate my learning of Intensive Short-Term Dynamic Psychotherapy (ISTDP), an affect-focused therapy effective for healing trauma, anxiety, anger, relationship problems and somatic symptoms.   One aspect of ISTDP that can be challenging for trainees to learn is how to identify and address the automatic, unconscious behaviors clients use to maintain an emotional distance between themselves and others (including the therapist), such as rationalizations, talking in hypothetical terms or being vague.   In a review of my work, I found that I was missing my clients’ distancing behaviors, and many sessions could go by without a significant emotional experience or change for the client.  

Of course, the client is not the only person in the therapeutic dyad who can unconsciously create emotional distance.   Colleagues in a consultation group helped me identify my own pattern of unconscious emotional distancing, especially when working with male clients who were emotional distant or angry.   However, I was unable to translate this insight into change in the therapy room.

Through remote live supervision I have been able to get immediate, moment-to-moment identification of distancing behaviors, by both the client and myself, in real therapy sessions.  Live supervision can be very challenging, especially when it addresses my own avoidance.  It is, however, extremely effective: Jon’s real-time feedback has resulted in multiple breakthroughs of sustained, heavy grief and character change in clients for whom therapy had previously been stuck.

If you have a new psychotherapy training technique you would like to share on this blog, please email me.

Rules for a Good Relationship

Posted on by Psychotherapy.net Team

1. Never go to bed angry.
Stay up all night yelling and screaming. After the way your partner behaved, he doesn’t deserve to sleep.
 
2. Don’t jump in to help when your partner is telling a joke
–unless, of course, you can tell it much better.
 
3. When fighting, take a time out.
That will give you a chance to come up with more devastating putdowns.
 
4. Don’t interrupt your partner.
You need to have all the facts in order to show her how totally wrong she is.
 
5. Don’t mind read.
Your partner might be thinking awful things about you that you don’t want to know.
 
6. Don’t dump out all your stored-up complaints.
Keep a few in reserve so you won’t be caught with nothing left while your partner still has four or five.
 
7. Restate your partner’s message.
Let him see how truly irrational it is.
 
8. Make “I” statements, not “you” statements
–except when nothing but a good “you” statement will do.

9. Don't say "always" or "never"
–except when you need it for added emphasis when your partner won't admit how totally wrong he is.
 
10. Don’t raise your voice.
You can have so much more effect by speaking softly between clenched teeth.
 
11. Don't  try to change your partner
–except, of course, for the few things that really do need changing. In fact, make a list.

Alan Marlatt on Harm Reduction Therapy

Posted on by rezendevknowfully.com

Harm Reduction Defined

Victor Yalom: We're here to interview you today about your work with addictions, and specifically your contributions to the field of harm reduction. Just to get started, the name harm reduction gives a hint of what your approach is about, but maybe you could say a few words to introduce the concept.
G. Alan Marlatt: We are basically trying to support people that have addiction problems. If they want to quit, we'll help them do that. That's our relapse prevention program. If they would like to be able to reduce their drinking or drug use-harm reduction—we want to support them there too.

Many people with alcohol and drug problems are not getting any help, and I think part of the problem is they don't want to identify as drug users, or if they're using illegal drugs, they're afraid they're going to be arrested and put in jail or something like that. They're holding out. But if you talk about moderation, many people say that's an enabling strategy.
VY: Many professionals.
GM: And others. So it’s a very controversial topic, but basically my position is, “We’ll help you, whatever your goal is. You want to quit, we’ll help you. You want to cut back, we’ll help you. We’re not going to shut you out.”
A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”
A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”
Rebecca Aponte: If somebody wants help cutting back, is that something that they can work on with a harm reduction therapist for life?
G. Alan Marlatt: With some people it's for life. Let me give you an example of a case. This is a woman that was being treated by a psychiatrist for depression at the University of Washington. The therapist called me up and said, "I've been seeing her for about three months, and today I found out that she has this drinking problem. So, I said to her, 'I can't really help you or continue to treat you unless you go into alcoholism treatment, and I don't know how to do that.'"

VY: He doesn't know how to do alcohol addiction treatment.
GM: Right. Most psychiatrists don’t know how to do that; it’s not part of their training. So he wanted me to do an evaluation of her. When she came in to see me, she’d already been to the alcohol treatment center that the psychiatrist referred her to. I said, “How it’s going?” She said, “Everybody’s telling me something different. The psychiatrist said I was probably drinking a lot to kind of self-medicate my depression.” And that was partly true.

Then, when she went to the alcohol treatment center in Seattle, they said, “No, your alcoholism is causing your depression. Unless you are into our abstinence-based program, it’s just going to continue. Are you ready?” She said, “No, I’m not ready. This is the only thing that works for me and I know it’s causing other problems, but I’m not ready to give it up.”

So she was stuck in the middle. For a lot of these kinds of people, harm reduction therapy is the best alternative. So I said, “Let’s do harm reduction therapy. I can help you keep track of your drinking, and see what’s going on.” So she agreed to do that. A lot of people at that point will drop out. If all they have are abstinence-based alternatives, they’re not going to do it.

But she agreed to do it. She worked with me for three months and we kept track of her drinking. She reduced her drinking significantly.
VY: What was her goal?
GM: Her goal was to drink more moderately and to figure out what was going on in her marriage about drinking, because her husband said, "You're a chronic alcoholic and unless you stop drinking altogether, I'm going to leave you." That made her more angry and depressed. She tried to stop drinking, and then when he would go out of town, she would get loaded—this kind of thing.

We finally figured out there was a lot going on in terms of the marriage and her anger. Then I taught her meditation, which was the most helpful strategy for her. Then, one day she was going shopping and she saw her husband in a car embracing another woman and it just made her start drinking again. She said, "I can't do this anymore."

She went to a meditation retreat center in France—Plum village, the Thich Nhat Hanh Center. You go there, you take these precepts. One of them is no use of intoxicants while you're here. She said, "I took that and I thought, 'That's it. I'm never going to drink again.'" She's been now abstinent for five years.

So harm reduction was the bridge to get her there. If you say, "You've got to stop now," a lot of people go, "I can't stop now." But if you start getting them into a harm reduction program and they realize they can reduce their drinking and begin to figure out what their triggers are, they feel a lot more confident that if they want, they could quit. That's what happens a lot of the time.
VY: Getting back to the basics of it, what do you mean by harm reduction and how did it originate?
GM: I did a sabbatical at Amsterdam in the early '80s. That's where harm reduction originally developed, because they were the first country to realize that injecting drugs can increase HIV and AIDS—so why doesn't the government provide needle exchange instead of [the addicts] sharing needles, which spreads HIV much more readily? This was when HIV and AIDS really broke out and a huge number of people died. So they said, "If people are going to use, we want to help them stay alive. We want to reduce the harm." The needle exchange program was really the first type of that.

In Vancouver, Canada, where I grew up, there are many homeless people living in the lower east side that are injection drug users, and a lot of them are overdosing and dying.

What did the mayor's office do? After some persuasion from harm reduction specialists, they opened a safe injection center. This is where, instead of shooting up in the alley and not knowing what you're getting, you can go to this site. They'll give you clean needles. They'll allow you to shoot up there. There are nurses and doctors available if they need help. Since they opened that, the fatality rate has dropped. Of course, many people say, "Why is this happening? You're just enabling them to continue using."
VY: Right. "This is illegal and the government is helping them do something illegal."
GM: Exactly. The second program in Vancouver that just started and is also having good results is basically prescription heroin from doctors. Of course, that started in England years ago. Physicians there called it the medicalization approach. If they were dealing with a heroin addict, they could say, "Look, we'll prescribe you heroin while you're doing treatment because we don't want you to overdose from buying it on the street where you don't know how potent it is." These are harm-reduction kinds of approaches.

Another example is methadone treatment; that's harm reduction because you're reducing the rate of potential for overdose fatalities.

The Bar Lab

I was interested in applying it to alcohol problems, which means moderate drinking. Mainly we’ve been working with college students who are binge drinkers, because the NIH report has been showing about 1,400 to 1,500 college students die every year from alcohol-related problems—overdose drinking, car crashes.
 
At the University of Washington, there was a recent case of a student who died. A 19-year-old freshman was living in a dormitory, and a woman that was his friend just turned 21. What do you do when you turn 21? You want to have a party because you can drink legally—even though her friends were 19 or underage. So they go, “Where can we go and not be caught by the dormitory advisors and things like that?” If you catch you drinking and you’re under 21, you could lose your room. So one guy said, “Hey, there’s a balcony on the seventh floor. Let’s bring all our alcohol up here.”
 
 So they took their vodka and rum and everything else up. There were six of them. They said, “We’ve got to drink quickly just in case—otherwise we’ll get caught.” They all got loaded pretty fast, and the guy who died was sitting on the edge of the balcony telling a funny story, lost his balance—head-first down in the cement, killed on impact. His blood alcohol level was 0.26. In Washington state, 0.08 is the legal limit. He was triple that.
 
 We found out from his family and friends that he wasn’t a big drinker in high school. Once he got to college and all of his friends were drinking, he just went overboard.
 
 So harm reduction for college students means we’ve got to train you how to drink more safely, even if you’re underage—that’s when the highest risk occurs. We developed a program called BASICS—Brief Alcohol Screening and Intervention for College Students.
We’re teaching them, “Just like safe driving, this is safe drinking.”
We’re teaching them, “Just like safe driving, this is safe drinking.” Your blood alcohol levels, what’s going on, how alcohol affects you—we teach them all that. We bring them into our bar. We have an experimental bar on campus called Bar Lab. We give them drinks.
VY: This is like John Gottman's Love Lab.
GM: Yeah. This is the Bar Lab. It's a cocktail lounge on the second floor of the psych building. What we do there is bring students in and give them drinks. They can drink anything they want for an hour—usually about 12 to 15 students. They're usually getting pretty loose and playing drinking games. Then we tell them, "Guess what? None of the drinks that you had had any alcohol in them whatsoever. They're just placebos." They go, "What?"

We tell them, "Look, when you go drinking, three things are happening: what your actual drink is, number one; what the setting is, like a bar, there's music or whatever; and most importantly, what your set is—your expectancy about how alcohol's going to affect you. Those things make for big placebo."

So, people who go through this—we call it the "drinking challenge"—end up drinking about 30% less after they go through that particular program.
VY: How do you get them to agree to do the program?
GM: They get paid for follow-ups and assessments over a four-year period—only about $200, but still. We had an abstinence-based alcohol awareness program on our campus, and they would show car crashes and things like that—people who get killed. And they were trying to say to people, "You can't drink legally until you're 21." Who showed up for that program? Hardly anybody—maybe 2% of the students.

But if we go into the fraternities and the sororities and the dormitories and others and say, "Would you be interested in a program that would help reduce your hangovers and your driving, sexual problems and things like that?" They all go, "Yeah." So you bring them in.

So harm reduction is typically user-friendly. It's not saying, "You've got to stop or we won't talk to you." People with addictive behaviors—there's so much shame and blame and stigma. They don't want to show up. Instead, we're saying, "We're going to meet you where you are. We're not asking you to quit right away. We're just saying let's talk about what your drinking or drug use is like and see what you might want to do. We'll try and help you, whatever your goal is"—rather than confronting them and saying, "you've got to quit."

Moral Objections

VY: Why do you think there's such vociferous objection to the harm reduction approach?
GM: Many people buy into the moral model of drug abuse, the war on drugs—it's called a black-and-white model. Either you're abstinent or you're using. You're an addict. There's nothing in between. So the door is pretty tight. Kurt Olkowski, the new drug czar that we just got under Obama, said that the war on drugs has failed. Thank God, because the previous administrations under Bush and Nixon said, "Lock them up. If they're using illegal drugs, punish them." We now have 2.3 million people locked up in this country, which is more per capita than any country in the history of the world. Sixty percent of them are there either directly or indirectly incarcerated because of drug or alcohol problems.
VY: It's clear you take issue with the moralistic approach.
GM: Yeah.
VY: Is harm reduction a countervailing philosophy?
GM: It’s a public health approach.
VY: Is it a more scientific, research-based approach?
GM: Yes, it is based on research, and there are more and more studies coming out that show that it is really helpful. It's working. Our BASICS program for college students is now listed on the national registry for evidence-based practices. We've got about 2,000 universities that are now using it. That's really working. People don't like to call it harm reduction. They would call it an alcohol skills training program or something.

Alan Leshner, who's the director of the National Institute on Drug Abuse, published an article last year saying, "Drop the term 'harm reduction' because it creates so much controversy. Let's call it something else"—sort of like the word "communism" or something. Up until recently, if you were presenting a paper at the APA or any other conference where there was sponsorship from NIH, if you used harm reduction in the title, it was eliminated. They said, "No, we won't let you talk about it."

I've run into this a lot. I've given talks about harm reduction where half the people walk out of the room while I'm talking. Huge resistance.
VY: Why do you think that is?
GM: They're from the moral perspective and they think all the harm reduction technique is doing is enabling people. I received an award yesterday, and one of the people that gave me the award told me he remembered when I was first talking about harm reduction and people claimed I was murdering alcoholics and allowing them to die.
…when I was first talking about harm reduction…people claimed I was murdering alcoholics and allowing them to die.


What we’re doing, like in Housing First, is trying to keep these people alive. That’s what the research has shown. So I think harm reduction is going to take off under the new administration. Ninety percent of the people who have alcohol and drug problems aren’t getting any treatment unless they’re busted for something. How are we going to bring them in? We’ve got to allow harm reduction to be a middle way. 
VY: You're not against abstinence as a goal.
GM: No. We’re for both. We’re just trying to get more people in the door.
VY: You're for both abstinence and moderation.
GM: We’re for whatever your goals are. We’re going to help you do that.
VY: If someone has a goal of moderation, but is unable—some people apparently can't control their drinking—
GM: You’ve got to put them through a program, and then they finally get to realize that they can’t do it even though they’ve had the best program. If it’s not working, they’re much more willing to consider abstinence. You’ve got to try something.
VY: Do you agree with this idea that there is a subset of addicts that just can't do moderation?
GM: It depends on the moderation program. Now there are more pharmacology treatments coming in to help people moderate drinking, and many more cognitive behavioral skills training programs. A lot of people can't achieve moderation if they just try and do it on their own. If they get into a good program that teaches them the skills, like how to use a blood alcohol level chart—if you're a male or a female, how many drinks over how many hours, what your blood alcohol level is going to be—what are you going to do instead of drinking? You want to keep your BAL lower. A lot of the young people that we work with that do binge drinking—they drink two beers in 15 minutes. They don't feel anything so they drink two more, and things like that. We tell them to slow down. Drink two beers and wait half an hour. Then they can actually feel the effects of these two beers. "I don't really need any more," this kind of thing.

We're not telling them that it's all bad. We're just telling them it can be harmful.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.You start losing your coordination. You have blackouts and other kinds of problems. What is your limit here, where one more drink is not going to make you feel any better? You learn that. You stick with it. That's been working very well.
RA: Do you see a lot of parallels between the opposition to the harm reduction approach and the opposition to anything other than abstinence-only sex education?
GM: Totally, yes. It's the same issue because they're saying, "If you teach people about safe sex and condoms and things like that, that will enable higher amounts of sexual activity, so we should promote abstinence." But those programs are not working.

It's just like the DARE program—the drug abuse resistance education—totally abstinence-oriented. Now they're finding that kids who went through the DARE program in school are doing worse in terms of alcohol and drug use. Harm reduction applies, I would think, to what we call the 3 Ds of adolescence-the three dangerous drives—drinking/drug use, dating (sexual behaviors), and driving. So if you teach people how to do those things more safely, whether it's sex, driving or drugs, you're going to reduce harm. There's plenty of research to show that it's true, but the political resistance has been amazing.

For example, one of the big harm reduction programs we have done in Seattle is for homeless alcoholics, people living on the streets who are drinking. We worked with the Downtown Emergency Services Center, which provides housing for homeless people. There was a program in Canada called Housing First where they give people housing and let them drink in their housing if they want. Compare that to what they tried in New York, in which people had to quit drinking or they wouldn't get the housing, so almost everybody got expelled or kicked out because they couldn't give up drinking.

So the Seattle program, which we received a big grant on, basically asked, "What's going on?" We wanted to compare people who got housing right away with the people who were under waitlist control. The people we looked at were selected by the King County and Seattle government; they were people that had the highest health costs over the last year. These were very sick people; the average life expectancy for them is about 42 years. So the government referred these people, who either got the housing right away or were on the waitlist. In our program, they were allowed to drink in the public housing and the opposition in the media was huge. "What? We're using taxpayers' money and letting them drink? What is that all about? You're just enabling them."

One year later, we found that the people who got the housing had reduced their drinking. For many of them, having housing gave them more reason to live. As we published in the Journal of the American Medical Association, the most important thing was the health cost savings of four million dollars over the first year. All of a sudden, people said, "Maybe harm reduction saves money compared to what we were doing before." We keep getting these flips in terms of reactions to harm reduction.
RA: I've heard you mention before that therapists can unwittingly enable their clients' addictive behaviors by ignoring the addictions that are going on: treating the emotional issues that they bring into their sessions, but not talking about their alcohol or cocaine use.
GM: Yeah. A lot of people do have both kinds of problems, and they’re using alcohol or cocaine or whatever it is to self-medicate when they’re depressed or when they’re anxious. That’s still a big split between the mental health and the addictions fields, even though many people have both kinds of problems. How are we going to approach them and teach more mental health folks to think, “Hey, there are alternatives here”?

Harm reduction is one of them, and brief interventions have become very popular now. For example, Tom McLellan, who is the associate drug czar/psychologist that everybody knows, was saying we should train primary health care physicians at general hospitals, so that when people come in with whatever their medical problem is, if they have an alcohol, smoking or drug problem, do a brief intervention. It doesn’t mean confront them, but just say, “Hey, have you thought about doing something about this? I have some information for you. Try it out. See if it works.”

They include harm reduction programs to cut back as well as programs to stop. That is very radical, but it has been happening in trauma centers around the country. In the Seattle trauma center, if people are brought in from a car crash that involved drinking or something, Larry Gentilello, a physician there, would do a brief intervention, meet with the person once their medical care is handled. “Hey, there are some programs that could help you cut back or quit drinking. Are you interested?” A lot of them said, “Yeah.” The trauma center would give them the information, and provide the referral. That turned out so well that now all trauma centers around the country have to show that they utilize brief interventions in order to get their license. That includes harm reduction.

I think we’re going to see more of it because, first of all, it works.
The research is very strong. It saves lives. It saves money.
The research is very strong. It saves lives. It saves money.It gets more people on board.

Right now, most people with these problems are just staying out. They go, “All there is is Alcoholics Anonymous. I went one time. I don’t like it, and there’s nothing else that I know about.”

Harm Reduction in Psychotherapy

VY: Let's get into the nitty-gritty of how a typical psychotherapist, who doesn't specialize in drug and alcohol use, may deal with a patient struggling with an addiction. How do you start applying these principles in the course of counseling and therapy?
GM: First of all, you’re going to ask the person what’s going on in terms of their alcohol or drug use. What are the risk factors? We adopt a bio-psycho-social model. Biologically, you want to know maybe the family history and alcohol or drug problems. You want to know about whether that’s going to increase their risk. Then you would go on to psychological issues, what we call psychological dependency on alcohol or drugs. Why do they think it’s helpful, and what are their outcome expectancies about drinking or drug use?
VY: So you ask why they think it's helpful.
GM: Or harmful. We want to look at both sides. We want to meet them where they’re at, enter their world. We use a lot of motivational interviewing.
VY: Yes, it seems very similar to motivational interviewing.
GM: So we're trying to figure out whether this person is in pre-contemplation stages of change or contemplation, or looking at possible plans of action—and matching our intervention with that. You can determine that pretty easily. Have they thought of doing anything about this? What do they think of the pros and the cons [of their drug or alcohol use]?
VY: Can you give an example of how you match an intervention to where they are?
GM: If they're in pre-contemplation, we're just going to try to talk about, "Did you know that the amount of smoking that you're doing is going to increase your risk of lung cancer and emphysema? Are you aware of this?" We try and enhance awareness of the risks. And then if they're in contemplation—
VY: Which would mean they're contemplating quitting?
GM: Or they don't know quite what to do. They're going between the pros and the cons: "Maybe I could quit, but I don't know what's the best way to quit. Maybe this isn't the right thing to do." That's when we meet them and help them look at the reasons why they like drinking and what some of their concerns are about it, and then try and move them on to the preparation and action stage.

In the BASICS program with college students, we just meet with them twice, one on one. In the first session, we give them feedback about their risks. They've filled out all these questionnaires so we know about family history and expectancies. We know about their cultural factors. We give them feedback in a friendly way. We could say, "Hey, you said that 80% of the students at this university drink more than you—actually, you drink more than 75% of the students."
VY: You're giving them some data.
GM: Giving them feedback, but in a friendly way. So they're getting a lot of feedback and awareness. And in the second session, it's the action plan. "What are we going to do about this?" We don't tell them what to do. We collaborate with them. What have you thought about doing? One young woman said, "In my sorority we usually drink and get drunk Thursday, Friday and Saturday nights. I was thinking of maybe not doing it Thursday night." We would support that—something that they come up with.
RA: Although it's not something that's necessarily spoken to directly, it sounds like this approach has a high sensitivity to the shame around addiction.
GM: Oh, yeah—shame, blame, guilt, stigma, moral issues. We're trying to let people know what their level is, how many other people have this kind of problem, and what kinds of things could help them. If they would like to quit, we'll say, "Great, we can put you in an abstinence-based program." Most of them are saying they just want to cut back. They're very positive about these kinds of skills we teach them. After we bring them in a bar lab and give them placebo drinks, then we teach them about blood alcohol levels and give them charts. We have them keep track of their drinking for two weeks so that we can see which days and what situations, whether they drink by themselves—which is more dangerous than social drinking—things like that.
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
VY: You're not coming at it from a moralistic way, but you do have some stance. You have an idea that if people are drinking in a way that you define or you think is destructive, you would like them to change that.
GM: Sure, yeah. It’s pragmatic. That’s where we’re coming from. It’s not moralistic.
VY: One thing I noticed in the video I saw of you with this black male, you got into really nitty-gritty details. He said he wanted to quit, but you really drilled down into, "What does that mean, to quit? What's your first step?" He said, "I'd go to the program." "What do you have to do to go to the program?"
GM: Right—break it all down into different steps. Also, we found that what triggered his relapses was, whenever he had cash, he'd go down to "buy a pack of cigarettes," and, "There's my beer"—these kinds of things. We're trying to teach people cognitive behavioral strategies around things that can set you up for relapse. Whether you're doing harm reduction or abstinence, there can be occasions where you just do way too much. What are the steps that lead up to that? We're using a lot of mindfulness and meditation to get people more aware of their choices.

Victor Frankl wrote this saying: "Between every stimulus and response, there's a space. In that space is our power to choose our response."So we use this idea in our work, and it's turning out to be very helpful, especially for people trying to stay on the wagon.
VY: How have you integrated mindfulness? It seems like a hot topic that's integrated into many approaches these days.
GM: Yes, mindfulness-based stress reduction—Jon Kabat-Zinn's work inspired us. I'm a good friend of his. Zindel Segal's mindfulness-based cognitive therapy for depression is very effective. Ours is mindfulness-based relapse prevention. All these programs are group-based, outpatient weekly programs for eight weeks.

We've gotten funding from the National Institute of Drug Abuse to evaluate the program, and we're finding that it's working pretty well for people with chronic alcohol and mental health problems. Of course, it's voluntary, so if people don't want to do it, that's fine, but a lot of people, once they talk to their friends who have gone through it, they go, "Hey, I'd like to do that." It's relaxing. It's stress reduction. It also gives you a different perspective on craving.

In the last study, we found that people in the control group, the more depressed they were, the more their craving went up—this was in an abstinence-based program—but if they went through mindfulness when they were more depressed, craving did not go up. The depression and craving was kind of disassociated. We're very enthusiastic about that.
VY: How do you explain that?
GM: Because mindfulness gives you a little bit of a different perspective, so you don't over-identify with situations like when you're depressed or feeling like you have to self-medicate to feel better. It gives people more of a choice. It doesn't mean they always do it, but a lot of times they do.

If you think of addiction treatment, the 12-step program, which is very popular, is basically Christian-based. The word God shows up in six of the steps, although they say the higher power could be anything. But a lot of people don't connect with that. The mindfulness program is more based on Buddhist psychology. It's a whole different approach. It's also very consistent with harm reduction—the middle way and things like that. It basically tells people there is another way. Instead of the 12-step program, you could do the eightfold path in Buddhism—right mindfulness, right activity, all that kind of stuff. So I think it's an alternative.

Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state.
Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state. Many of them are hooked in the spirits in the bottle, where they're really looking for another spiritual approach. I think mindfulness is another pathway. A lot of people relate to that pretty well.

The Disease Model of Addiction

RA: Do you have a problem with the disease model, from the standpoint that it classifies a person as an addict in a way that integrates into their self-identity?
GM: Yes. Phillip Brickman identified four models: the moral model, the disease model, the spiritual model and the cognitive behavioral model.

The disease model says, "You have a disease and it's due to factors beyond your control: your genetics and your physiology and it's all the same disease for everybody, so we're not going to give you any individualized treatment. We're going to put you in a 12-step program"—which also buys into the disease model. The theory is that there is no cure whatsoever. All you can do is arrest the development of the disease by maintaining abstinence. If you have one drink, it's a relapse. In AA, you have to go back to the beginning again.

In harm reduction, we take the attitude, "Hey, lots of people have slips. Let's look at what happened. You made a mistake. How can you learn from it?" We're not saying, "You've got to go back to the beginning."
RA: That's very shaming.
GM: It's very shaming, yeah. I asked a lot of the disease model people, "Why do you say that there's no cure?" They said, "If there was a cure, people could go back to drinking. We don't want them to do that."

Even though the research at NIAAA—the National Institute in Alcohol Abuse—shows that quite a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
… a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
They don't want to say that. The disease model says that's enabling. I'm much more in the cognitive behavioral model.
VY: So you don't buy into the disease model at all.
GM: I don't want to put people in jail and say that they're moral failures. Sure, they have a problem—but for me, the disease model is: if you're a heavy smoker or a heavy drinker, there are potential disease consequences. You could develop cancer. You could develop cirrhosis. Is what you're doing a disease?
VY: Is the act of reaching your hand out and picking up a drink caused by a disease?
GM: It's a habit with potential disease consequences. In one of my most recent books, The Complete Idiot's Guide to Changing Old Habits for Good, we talk about changing old habits for good. Habits are what's driving this. It has disease consequences, totally. We're talking a huge health problem. But just to say the whole thing is a disease—what's the point?
VY: You haven't convinced everyone, obviously.
GM: No, of course not. But we’re out there. There are more and more people coming over to the cognitive behavioral model because, treatment-wise, that’s what is most effective.
VY: So you consider your approach consistent with the cognitive behavioral model?
GM: Oh, yeah. Many people call mindfulness a meta-cognitive coping skill, so it’s consistent with the cognitive behavioral approach. Plus lots of research shows that it’s stress reducing.

The biggest trigger of relapse is negative emotional states. People are upset. They’re angry. They’re depressed. They’re anxious. They want help from the drug. So meditation is an alternative way of giving them stress reduction. That’s what a lot of the patients that we’re working with are saying: “Wow, this is really helping. I’m meditating and giving myself a choice instead of giving into my cravings.” We’re showing a big reduction, as I mentioned before, between negative emotions and craving for relapse risk.

Consumer Choices

VY: I know back in the days, they tried to study and come up with an alcoholic personality or an addictive personality, and it seemed like there wasn't too much success with that.
GM: The main kinds of personality factors that keep coming up are sensation seeking—people that crave the high, altered state—and self-medicating—what they call coping. Those are the two main personality traits. Some people have both. That does increase the risk.

There are personality models. Right now, NIDA and other people are saying, "Addiction is a brain disease. It doesn't matter what drug you're using—it's all releasing dopamine in the brain. The pleasure centers are lighting up. We need pharmacotherapies that can reduce the effects of these different drugs or replace them, whether we're talking about methadone or any of these other kinds of things."
VY: What do you think of that?
GM: It may be helpful. Some of the medications do reduce craving on the short run. I think if we combine that with mindfulness, maybe the two of them would work together.
My position is, if you think something is going to work for you, try it.
My position is, if you think something is going to work for you, try it.It could be a pharmacotherapy. It could be psychotherapy.

In the addiction treatment field, there was Project Match that came up a few years ago. They were saying therapists should match patients with a particular type of therapy that the therapist thinks would work. In Project Match, they assigned hundreds of alcoholics to get Alcoholics Anonymous, cognitive behavioral therapy, or motivational enhancement interviewing. Those were the three groups. They followed everybody up for two years. They found—guess what?—there was no difference. All three groups did equally well.

What really worked the best was therapeutic alliance: if there was a good relationship between the therapist and the client, it worked.
VY: This has been the finding in all of psychotherapy research.
GM: Yeah. So I think instead of doing treatment matching, we should switch to consumer choice. People come in: “Hey, I’m interested in getting some help. What have you got?” There are some programs that are saying, “We’ve got a lot of different programs here. I’ll show you some videos. Here’s what’s happening with 12-step programs. Here’s a cognitive behavioral program. Here’s something on moderation management. Take a look and see what you think might work for you and have a backup.” Give people a choice of pathways.
VY: Back to being pragmatic.
GM: Back to being pragmatic. "If the thing you're trying doesn't work, there are other things you can try. Don't give up." The average number of serious attempts that smokers make to quit before they are successful is twelve. Twelve attempts! So people that have tried to quit smoking and say, "I can't do it. I've tried it three times"—I tell them, "You're not even there yet. Each time you learn something."

Therapeutic Mistakes

VY: What do you think are some of the typical mistakes that therapists make if they don't specialize in working with addicts?
GM: Like the psychiatrist I was telling you about earlier, a lot of them say, “I can’t handle this so I’m going to refer you to alcohol treatment. Until you get that under control, I’m not going to see you anymore.” That happens so much. It’s the wrong thing to do. People just get stranded. They get caught. They don’t know where to go.
VY: What would you tell the therapist to do?
GM: Integrative approach: look at addictive behaviors like any other behavior issue. Read about it, get some training, take some courses and things like that; don’t leave these people stranded.
VY: If someone's having problems with anxiety, you don't say, "I don't treat anxiety. You've got to go to an anxiety program." You integrate that into the treatment
GM: Not being able to see how the addictive behavior and the mental health problem relate to each other—thinking they're separate diseases. In reality, they're often extremely interactive. One is relating to the other—like the person with depression is trying to self-medicate and he gets caught in between. I think that is the main thing.

Sometime after that psychiatrist called me, I asked him, "How much training in alcohol and drug problems did you get when you were in medical school?" He said, "One half day." Christ. Of course they don't know anything about it.
VY: That's amazing.
GM: Yeah. That's the biggest issue—even in psychology. When I was a graduate student in the late '60s, I said to my professor at Indiana University, "People are studying behavioral therapy and they're doing all this kind of work with different behavioral problems. What about drinking as a behavior problem?' He said, "You don't want to get into that field." I said, "Why not?" He said, "The addictions field is very low prestige. Why don't you get yourself a real problem like snake phobias?" That's what was going on then.
VY: As a social policy health problem, there are a lot more people with problem drinking than with snake phobias, let alone snake bites.
GM: I said to my professor, “I don’t know anybody with a snake phobia, but I’ve got a lot of people in my family with heavy drinking problems. Why can’t we do something about that?”

The disease model didn’t really look at drinking as a behavior or as a habit. The big shift was to try to move it from strictly genetic into habits. “Smoking is a habit. It’s not a disease in itself, but it causes diseases.”
VY: That is changing, that field.
GM: It’s gradually changing. When I got into the field, people were saying, “Stay out.”

I Like to Drink

RA: There are some addictions that are considered controversial, like sex addiction. From your perspective, is it the object of the person's desire that is addictive, or is it the relationship between the person and what they're going after that's addictive?
GM: The new DSM-IV revisions have been including other kinds of addictive behaviors, like gambling, sexual addictions, shopaholism, things like that. From a cognitive behavioral perspective, there are a lot of similarities. There’s a lot of craving, whether it’s sex or gambling. There are differences in terms of the effects, of course, but I see there being lots of common issues.

One of the biggest things is the problem of immediate gratification. We call it the pig problem. “I want to hit the jackpot. I want to have a sexual experience. I want to get drunk.” All these kinds of things are very similar in terms of the neuroscience of what’s going on.

So I’m totally open to talking about addictive behaviors as including ones that don’t involve drug or alcohol use.
VY: You've been doing this for a few decades now, and addictions has been a career-long interest for you. What are some things you've learned that have made you a better therapist?
GM: I think having these experiences myself. I like to drink. I have drinking problems in my family. I wouldn’t consider myself an alcoholic. Many people in the addiction treatment field are in recovery so they’re saying, “Don’t use at all.” I’m much more user-friendly to these people because I do it myself. I’m helping to teach them that there are better ways to do this.

Since I’ve been more of a Buddhist psychologist, I took the bodhisattva vow, which is to reduce suffering in people that have these kinds of problems. If I can relate to them and identify with them rather than saying, “I am abstinent and you’re using,” it works a lot better.
VY: Thanks for taking the time to meet with us.
GM: You’re welcome. It’s been a pleasure.

Trusting the Client as the Agent of Change

Posted on by Psychotherapy.net Team

After thirty-three years as a psychotherapist, I find that my insights regarding human beings and the change process are becoming simpler and easier to articulate, although I cannot establish whether this phenomenon is due to mounting wisdom or to some form of affable cognitive corrosion. Regardless of their source, my accumulating insights have provided me with a true compass that allows me to approach each client with respect, purpose, and hopefulness. I’m certain many readers have experienced the same thing.

Clients as Agents of Change

One guiding principle that emerged many years ago was a simple one: Our clients are the most essential and fundamental component of the change process. Appreciating this oft-obscured and -minimized truth of psychotherapy multiplies our options for understanding and assisting clients, and invites them to participate in the search for understanding and change, a quest that itself serves the client’s life well.

This basic idea—that clients most directly cause psychotherapeutic change—stands in stark contrast to the professional world that today’s therapists inhabit, a world dominated by the medical model, managed care, and the search for empirically supported and/or evidence-based, off-the-shelf treatment approaches, which most often attempt to match technique with diagnosis. Their resulting equations, of course, leave out essential components of psychotherapy: living human beings. Psychotherapists are expected to be capable of essentially “inserting” psychotherapeutic interventions into a human being who is nothing more than an embodied diagnosis—clients are perceived as passive recipients of our expert care. Since the beginning of my professional career, this has seemed to me to be a wholly wrong-headed approach, one that dehumanizes both client and therapist and, in doing so, neglects the most important and meaningful dimensions of human change.

A Casual Conversation

Like many, during my education and even early in my career, I maintained some ever-dwindling hope that an enchanted handbook of foolproof techniques might appear. Happily, my clients taught me differently.

A memorable example occurred approximately twenty-five years ago, when I was working as part of a rural medical practice. A seven-year-old girl was referred to me by her parents for continuing difficulties with bedwetting. While her mother remained understanding, her father had become increasingly intolerant and punitive. Although they had already set an appointment, one day they stopped by the office and asked if I would take a moment between sessions to meet their daughter, perhaps to allay the girl’s anxiety about seeing a therapist. I agreed and soon they brought the girl to my office, where she and I spoke privately. After chatting a bit about her life and interests, she told me how much she wanted to stop wetting the bed. I replied, “Yeah, I wonder what would happen if you could tell your brain, right before you went to sleep, ‘Hey, if I have to pee, go ahead and wake me up.’”

Prior to our scheduled session, about two weeks after our introduction, the girl’s parents called to cancel her appointment, telling me she had quit wetting the bed after our brief meeting. Six months later, they informed me that the change had been maintained. Her presented problem never occurred again. What was the healing factor here? Should I have copyrighted the sentence I uttered, trademarked “Single-Sentence Therapy (SST!),” and begun offering national workshops on its appropriate delivery? Of course not. The healing factor was, without doubt, the girl. She sought an answer and, in the mysterious and magnificent way that human beings often accomplish change, actively and creatively used my tossed-off sentence to forge the change she desired. Of course, at the time my utterance reflected nothing more than sincere musing on my part. Still, this experience dramatically highlighted the client’s central role in successful therapy.

Beyond my experiences, we increasingly see exceptions to the dominant narrative that therapists directly cause client change. Most notably, the work by Bohart and Tallman—their book How Clients Make Therapy Work is, in my view, a classic in the field—lucidly and convincingly makes the case that clients creatively use whatever the therapist offers in order to effect personal change, which explains why techniques have not been found to be the most influential psychotherapeutic factor.

One could argue that the seven-year-old girl’s change was nothing more than an isolated episode of kismet or coincidence, a spontaneous remission that proves nothing. However, another client with whom I worked two decades ago brought the centrality of client self-healing into even sharper focus.

Florence: A Single-Session Case

A case in which a client requests assistance in resolving an undisclosed problem sounds not unlike a patient presenting to a dentist for treatment while refusing to open his or her mouth. This was not an overly dramatic case, but it is unique in that the client shared neither the history nor the nature of her difficulties, and presented only isolated factors for my consideration, yet we achieved success after a single session of treatment.

The client was a 32-year-old unmarried Caucasian female—whom I will refer to as Florence—who lived alone in a rural Midwestern community. For the eight years before her request for therapy, she had been employed as a professional health care provider. At the time of the initial consultation, she had resigned from the facility for which she worked after accepting a similar position in a larger community two hundred miles away. She planned to relocate to her new home in five weeks.  Because she and I had both been involved in health care in the community, we were acquainted with one another on a professional basis and aware of one another’s work with patients.

Florence requested a brief consultation with me at the end of a workday. She disclosed that since early adolescence she had experienced chronic, unspecified problems with relationships and mood, and that before moving to begin her new job, she wanted to address the difficulty, allowing her to “start fresh.” Through our professional association with one another and her discussions with patients over the years, she had come to the conclusion that I was an effective therapist who would be able to provide her with the assistance she desired. She thus entered the therapy relationship with positive expectations about my ability to assist her, as well as her own ability to reach her goal.

While revealing that as a six-year-old child she had suffered a massive trauma that continued to haunt her, she stated kindly but clearly that she had no intention of revealing to me the details or even the nature of that trauma, having long ago come to the conclusion that to do so would hold no benefit for her. She further stated that after extensive research she had decided that hypnosis would help her to resolve her difficulties. She asked me to provide one session of hypnotherapy to resolve the undisclosed difficulty.

From her presentation, my options were clear: to provide the requested treatment or to refuse to do so, in which case she would simply not pursue treatment “until I find another therapist I’m willing to work with.”

Florence had grown up in a suburb of a Midwestern metropolitan area, raised by both parents and having three younger brothers and one older sister. She completed a Master’s degree, which allowed her to provide professional health care services. Never married, she indicated that she had dated in the past, but that recurrent relationship difficulties always interfered with developing a more serious and lasting involvement. Since earning her professional degree, Florence had worked for the local health care facility, where she had been a consistently reliable, popular and successful employee.

According to Florence, she had on three occasions traveled to nearby cities and consulted with therapists. After each of those consultations she elected not to return, believing that the therapists were intent on “doing things their way or no way,” and that a commitment to treatment on her part would have led to extended therapy which, to her mind, was completely unnecessary: “It would be like standing on the caboose of a train, looking backward just to satisfy the therapist. I want to focus on where I’m going. I want to be in the engine.” In particular, she had become disenchanted with therapists’ fascination with her trauma; when she had revealed in the past, it seemed to her that therapists wanted to “worry it like a dog with a bone” rather than to address her current concerns.

Although I had received significant training in clinical hypnosis years prior to our initial consultation, by the time of our session I used the approach only in cases of chronic pain management, for which it seemed ideally suited. My initial training orientation was humanistic-existential, although in the subsequent years I had availed myself of a variety of advanced training opportunities and had become increasingly flexible in my treatment of clients, although I maintained a humanistic-existential view of their functioning. I received training in a permissive, Ericksonian approach to hypnotherapy, since to my mind it was most congruent with my perception of client potential and agency. I therefore had the clinical ability to provide Florence with the service she requested. I was also positively persuaded by my clinical experience to accept Florence’s implicit challenge; I had come to the conclusion that therapy in many ways is a process of my clients and me collaborating to create “doors,” possibilities for change that clients can actively use to effect personal transformation.

In this case, assessment was indirect and decidedly not disorder-focused, instead concentrating upon Florence’s general functioning and history, as well as the presence of other factors that would inform my decision whether to provide the requested intervention. Although one could argue that her vague report could lead to reasonable hypotheses about her disorder(s), there was no way to validate those hypotheses, so basing any treatment decisions on them would have been moot. Therefore, I chose to focus upon other factors that would determine my decision.

After she signed an appropriate release of information form, I reviewed her medical file, which indicated no history of serious medical or psychiatric illness in her or her family of origin. She had not been prescribed any medication other than for short-term specific illnesses, such as infections.

Most importantly, Florence had a precise “theory of change.” She had contemplated her life problems at considerable length and reached a conclusion about what procedure would assist her in resolving her difficulties. She possessed a positive view of the clinician and an expectation for resolution that bordered on certainty, indicating a positive expectation for outcome. Despite her maintenance of a conceptual hedge around her trauma and resulting troubles, she was otherwise quite open, personable and cooperative, more than willing to undergo her preferred treatment. Thus, she appeared to embody the client whom therapy would benefit, even if the specifics of her situation remained unknown to me.

In agreeing to provide the requested treatment (hypnotherapy), the question facing me was how best to provide that treatment in a fashion that would allow me to keep front-and-center the notion that Florence was an active agent capable of using what I offered in a therapeutic fashion. In short, my responsibility was to create a hypnotic approach to treatment that would allow her to actively use both her positive expectations and creativity to change what she wanted to change. More specifically, my approach would ideally provide to Florence what Bohart has described as a “supportive working space.” It was clear: my task was to provide the canvas; she would paint the picture (and not necessarily show it to me).  What type of canvas would I provide? Since she deemed the trauma that occurred when she was six to be central to the formation of her subsequent difficulties, and because she reported experiencing her younger self as being always nearby, her construction of herself as a youngster needed to be included. Furthermore, bridging her experience of herself as a six year-old with that of her present self was important, given her connecting the two “selves” in her presentation. In short, some indeterminate flow of information and affect between her younger self and her current self needed to be invited; a bridge needed to be supplied. She would be the one to cross that bridge. Doing more than that would have been presumptuous on my part if I were to remain committed to respecting her agency and creativity.

I arranged to use a recovery room (the symbolic nature of which was not lost on either of us) in the medical office complex. I asked her to lie down on the bed, to close her eyes and begin relaxing. She responded excellently to the basic twenty-minute guided relaxation and induction process (focusing both on physical relaxation and the development of imagery). Her breathing became diaphragmatic, and I noted little to no muscle movement otherwise. I then asked her to visualize what I would describe in whatever way she chose.

While the entire session lasted about eighty-five minutes, it consisted of my providing only four basic suggestions, after which I allowed Florence to process and work with the provided images, then signal with a raised finger when she was ready for me to continue. Time between delivery of the suggestion and her signal for me to move on averaged ten minutes.

Prior to the suggestions, I asked her to visualize her current self and her six-year-old self standing face to face, and encouraged her to imagine as much detail as possible. After she indicated with a lifted index finger that she had constructed this image, I provided these four suggestions (with significant time between them):

  1. “You can tell your younger self the one thing you want her most to know, and then notice her response”;
  2. “You can ask your younger self to tell you what it is she most needs from you, and then notice your response”;
  3. “You can ask your younger self for the one thing she most wants to know from you, hear her answer, then respond to her”;
  4. “You can ask your younger self the one thing she most wants you to know, hear her answer, and notice your own response.”

Shortly after I provided the first suggestion, tears began streaming from Florence’s eyes and continued until the session ended.  Although I didn’t discourage verbal responses from her, she said nothing during the process. I ended the session by suggesting that she slowly return to normal consciousness and to remember as much or as little as she wanted to regarding what she had learned through overhearing the conversation between her current self and her younger self.

Immediately following the session, Florence indicated that already she was feeling a great sense of relief and movement, but provided no further details. We met once prior to her relocating for our follow-up session, and she reported that her mood was significantly improved and that she was viewing her relocation and new job as an adventure that she was, for the first time, regarding with optimism rather than measured dread.

Two months following her move, she sent me a lengthy letter in which she described the happiness she was feeling and the vague but confident sense that she had successfully left her problems behind her. She was no longer feeling “haunted” by what had happened to her when she was six. Although she remembered it, such remembrance seemed more voluntary, according to Florence; she was able to experience the memory “like a photo in an album, rather than the only picture on the mantle.”

After that initial letter, she sent me holiday letters for nine years. In each one, she detailed her successes not only in her profession, but in her personal life as well. Several years ago she married and, at last report, she and her husband had adopted two children and were living happily and productively.

“To this day I remain unaware of the trauma she had suffered and the resulting difficulties it caused.”

Doors of Possibility

What Florence brought to center stage, more plainly than any other client with whom I’ve worked, was the centrality not only of the client’s trust in me and the treatment I would provide, but also of my trust in the client and her inherent potential for change. For me to proceed with treatment, it was necessary to recognize the level of trust I had in Florence, specifically, and in the clients’ agency and abilities to self-heal, in general.

In attempting to understand the human beings who present for services, it is important that clinicians go far beyond the process of assigning a diagnosis and prescribing a treatment accordingly. Since the validity of most DSM-IV diagnostic categories is questionable at best, assigning a treatment approach based on that designation is at least equally dubious. Furthermore, a significant body of research emphasizes the importance of the common factors, such as the therapeutic relationship, positive expectations, and client self-healing. Both students and practicing clinicians should immerse themselves in the existing literature in these areas, providing themselves with a set of assumptions that counterbalances the medical model with which our culture seems currently enamored. By doing so, we will generate more opportunities and options for clinical intervention, the centrality of our clients’ attributes will not be reduced or neglected, and our treatment effectiveness will be enhanced as we respect our clients’ considerable gifts and abilities that, for the time being, have unfortunately been reduced to faint footnotes in our understanding of the human change process.

Florence’s case illuminated one of those simple truths that come with experience, age and attention, a truth not only about what clients bring to therapy, but also what clients most desperately need in their journey toward change. It’s not complicated.

They need doors of possibility, and they need company.

Suicide During the Holidays . . . Not So Much!

Posted on by Psychotherapy.net Team

We've all heard it on a local or national television or radio station, "And when we return after the weather, we'll examine the tremendous increase in suicide during the winter holiday season."

Well that's great, except for one small thing: It doesn't exist. In fact, the direct opposite is true.  The suicide rate generally hits a peak during April and May.   The National Center for Health Statistics placed November and December as the months with the lowest daily rates of suicide.

All major holidays with the possible — notice I said possible — exception of New Years have lower suicide rates than other days of the year with Thanksgiving and Christmas posting extremely low numbers.  Now you will invariably think I am wrong because on Christmas Day some poor soul will take his life and the media will showcase the suicide on the front page of the newspaper. Chances are you will also see it as the top feature story on the local five o'clock news. Keep in mind, however, that if this tragedy occurred on any day that wasn't on a holiday the story would appear on page 54 of the paper next to the classified ad for a Basset Hound in search of a home . . . if the story appeared at all.

The adept therapist will conduct suicide assessments everyday of the year.  Key clinical hint: If you wait until you hear Elvis singing Blue Christmas to start asking client's if they feel suicidal, then you've endangered the lives of your clients for approximately the first 340 days of the year.

It’s Over Now: Termination and Countertransference

Posted on by rezendevknowfully.com

The Dreaded Phone Call

Recently, a client of mine left the following message on my voicemail: “Hi Melissa, I just wanted to let you know I won’t be coming to my appointment tomorrow. I’m feeling fine now. I’m not coming back, but thank you for all your help. I’ll call you again if I need you.”

Of course, I called her back. It’s the age of caller ID, though, and not surprisingly, she did not pick up. Nor did she return my call, despite my delightfully supportive message wondering if we might at least have a wrap-up session.

Clients cancel appointments and leave therapy prematurely for all kinds of reasons. It’s not the first time I’ve been left by a client and it won’t be the last, but, admittedly, it had been a long time since I’d given much thought to endings.

The world of modern psychoanalysis does not put termination near the top of the training agenda. Most everything is looked at as a resistance to treatment. I like this a lot, actually—first because it puts the focus on studying the client’s unconscious, and second because it then puts the focus squarely back on mine. And it encourages studying emotional communications and unconscious obstacles to treatment with curiosity and interest, which is profoundly soothing to the part of me that tends toward self-attack and self-doubt. Looking more deeply at the challenges that get in the way of the work continuing is a good way to help the work continue.

Frankly, termination is not really at the top of anyone’s list in terms of training. In fact, much of the information out there focuses mostly on professional ethics, process, and client rights. There’s not a whole lot about what we therapists are left with when clients leave after a planned termination process, let alone when they drop out of sight without so much as a good old-fashioned goodbye.

“When clients leave suddenly, we have little recourse, but big feelings.” We pull out all of our training nuggets to help us try to understand what happened. We can figure that maybe they got what they needed; we can look back to the last session to see if we may have hit the wrong note; we can wonder if perhaps they are protecting themselves from something, or protecting us by leaving abruptly or without discussion. Perhaps they are protecting us from their rage, their hopelessness, or their discontent.

And we can think about our patients’ characters, history, patterns of functioning. Our clients might be letting us know finally how they have felt, being left in their lives—frustrated, discounted, ignored, worthless, abandoned or powerless, perhaps—which is often how therapists feel when clients leave without warning or discussion. They give it to us good over the psychic airwaves. Abrupt exits from treatment can be jarring, aggressive or even mean. The emotional communication is powerful, and while it can give us valuable information about the client, it also can be a window into our own psyches.

Therapists Have Feelings, Too

For good reasons, we therapists don’t often like to admit that we have feelings towards clients, let alone strong ones. We may be ashamed or embarrassed of our reactions, or even afraid—especially when we feel injured, abandoned, angry or stung.

Yes, of course we study the countertransference: we know we can go far enough, at least, to notice a feeling and give it a nod, to guess at where it comes from and maybe how to use it in session, for the benefit of the client. But beyond that, we hedge. Though we feel, deep down we think that we should not actually feel anything—not unless we are sure it’s in the best interest of the treatment. Not unless we have our professional head on—our dignified, composed, contained persona.

After all, we are trained to focus on the client, even when studying such ideas as subjective countertransference, when the emotional communications of the client trigger unconscious, unresolved conflicts in the therapist. For instance, when a client says that the therapy is not helpful, if the therapist has the impulse to be self-attacking or self-doubting, she may personalize the feelings, feeling anything from anger to hurt to worthless. And she may collude with the client’s desire to leave to avoid having to feel all those bad feelings.

Strangely enough, the fear that a client may leave, is, in some instances, really an unconscious wish—especially if that client brings us too many hard-to-bear feelings, or if we are burnt out or frustrated, or fear we are doing a bad job. And it’s possible that sometimes clients are onto something in us. Clients are often sensitive to emotional communication from us as well. Sometimes we may be sending the message that they are not wanted in some way. They may need much assurance that we are trained to welcome all their feelings, and help them do the same.

One client I work with wanted to stop coming because he imagined he was inconveniencing me with his weekend appointment. Another wanted to stop because she was fearful of how big her anger was. She believed I was frightened of her. Good discussions with these clients not only headed off ending the treatment, but led to all kinds of insights into their character, wishes, life experiences and patterns. And while it may be tricky to study the transferences, when it comes to endings everyone fares better when we do.

In the phone supervision groups I run, we talk a lot about termination. We debate all the ways to prevent abrupt exits, and avoid being stuck holding the bag of bad feelings. We talk about ways to help clients stay, to deal with difficult feelings differently. We discuss the merits and drawbacks of ongoing evaluation tools, professional protocol, policies, and termination letters. We wonder about preparing for discharge right from the start, checking in at each session to see how things are going in the therapy, having billing policies or not having them. But I think it’s also defensive driving. We do need to act ethically and we do want what’s best for our clients, but we do not want to be hurt. We do not want to be left. “Many of us do not think we are supposed, or allowed, to feel anything genuinely and deeply when it comes to our clients, and we most certainly don’t want to feel all the feelings that being left drudges up.” Some of us will do whatever we can to prevent bumping into abandonment, and its steadfast companion, inadequacy.

We can’t always attribute these feelings to the transference alone. Many desires are shared among therapists: to do good work, to sustain a solid income, to feel effective and accomplished, and, when possible, appreciated.

Therapists do lose sleep over these things. Our fears may get triggered when clients leave under any circumstance, but all the more so when they ditch us without so much as a “see ya.” Even planned and successful terminations can leave a therapist with a host of feelings, from loss to fear to doubt—especially if the therapist is not convinced it’s best to terminate, or does not feel that he has a real say in the decision, or if the client is leaving for external reasons like moving away or scheduling conflicts (and even these could potentially be worked out).

And if our practice is less than full at the time, or our personal finances are not what we’d like them to be, we may bump into financial fear. The fact of our business is that our livelihood is very much tied into getting and keeping clients. Many therapists fear their own financial hunger and, in an effort to prove they are not acting on their own desires, may join clients’ treatment-destructive resistance, and help them to go. I’ve seen therapists do this in a variety of ways, such as sending termination letters, bills, not returning calls when clients cancel or quit via voice message or email, or agreeing to termination without asking if the client would like the therapist’s thoughts on the decision or if the therapist has a say.

“In fact, in letting clients leave without attempting to discuss things, we may be rejecting them, or colluding with a pattern of rejection in their lives.” For some clients it may be therapeutic to help them stay; they may be relieved that they are wanted and not so readily let go of.

That’s not to say that we can’t ignore the unconscious if we’d like to, or that we don’t have and enjoy good endings, or feelings of satisfaction over good sessions and good therapeutic relationships. But let’s face it: in the volleying back and forth between occasional grandiosity and occasional inadequacy, clients who go AWOL can tip the slide downward for us fast.

"Am I Losing It?"

It’s hard to know when our feelings are safe and when they are on the edge. A friend of mine was recently angsting over some terribly good erotic feelings she was having for a client. She took it to supervision where her supervisor said lightly to her, “If they are not interfering with the therapy, enjoy them.” This permission to feel freed my pal up considerably. The erotic feelings faded and the work continues to be successful.

One therapist friend of mine says, “I feel like an emotional prostitute sometimes. I get to roll around in the all the intense feelings and then I get left alone in the chair.”

“That’s what we get paid for,” says another friend of mine. But we are so dedicated to staying contained, to reining in our feelings and our fears, that we may be cheating ourselves, not just protecting ourselves, the client or the work. What do we think will happen if we let ourselves go haywire? Not, of course with a client, but by ourselves or amongst our peers, in our supervision or personal analysis?

One colleague of mine did actually have his analyst go berserk on him. Upon my colleague saying that he would be leaving therapy soon (after 15 years and much good work) the analyst seemed to blow a gasket. He yelled, he screamed; he said that my colleague was in denial, was sick, did not even know how sick he still was. He told him to get out of his office immediately. Ungrateful lout!

When I first heard this story I hardly believed it. Perhaps my colleague friend was making it up. Perhaps he heard wrong or exaggerated, or even dreamt it? After all, this seems to be every client’s nightmare—and maybe every therapist’s. Would we really go crazy and let loose on a patient? Most likely not, but to that end, if we don’t allow ourselves to feel what we feel toward our clients, we may be missing out on a lot of good information that would benefit everyone.

But since many of us nurturers are not at all immune to self-attack, accessing our feelings may be easier said than done. Especially when clients leave us, we can be quick to accuse ourselves of all kinds of evil (especially if we ourselves are going through something difficult in our personal lives). Perhaps we really are (only and always) money-hungry, self-seeking, self-gratifying, selfish, poorly trained do-gooders? Or the opposite. What about our gift?! We most certainly could help them if they would just cooperate and let us! Why don’t they want this help? “It must be me” is the quiet tugging somewhere in our brains.

Maybe we are burnt out? Maybe we are losing our touch? Or losing touch? Maybe we are not actually helping anyone at all anymore. Maybe everyone is going to leave us. Maybe we need more training, a different approach, another certification. Were we not paying attention? Should we have been more confrontational, or less?

There may be some use in asking these questions, but it seems to me that we healers and helpers will go after ourselves in a schizophrenic loyalty to our trade before we will let ourselves have all our feelings about our clients.

Sometimes therapists tell me that they want to get rid of clients, especially the ones that are mean or demanding or frustrating, or boring, or are not making the progress they’d like them to make. On some level it’s hard for us to accept (and help clients accept) that talking itself is progressive and that we must be vigilant about not being too demanding of our clients or devaluing of our good ears.

After unpacking feelings with a therapist I work with who gives homework and advice frequently to clients, we came to understand how frustrated she feels in certain sessions—hence her urge to be more directive. While she continues to pride herself on giving resources, she is paying more attention to the words of one her patients who recently yelled at her (in itself a testament to their good relationship), “Would you stop trying to help me so much!”

Speaking Up, Pushing Back

A favorite story of mine is about an analyst I know whose patient called to cancel and “take a break” from therapy because she had to have surgery on the day of their appointment and would need a while to recover. The analyst asked if the surgery could be rescheduled for another day. At first take, this sounds ridiculous. Most of us would most likely offer up oohs and ahhs and “let me know how it goes.” But not this analyst: she works on the assumption that nothing is more important than the therapy and she does not want to give anyone’s unconscious the idea that being sick and needing surgery is ideal. She says by valuing the therapy above all else she is messaging the unconscious that it’s not okay take out difficult feelings on the body. Better to talk about them, learn to tolerate them, and live well.

The patient got angry at first. All kinds of aggression came out toward the therapist, albeit tentatively, about how the therapist was insensitive, mean, ridiculous, and odd. Funnily enough, though, the patient called back a few days later to say that the surgery was no longer necessary and she could keep her appointment.

Of course, we don’t attack someone’s defenses straight out, and sometimes a duck’s a duck, but it is interesting to consider how tightly or not we hold onto to the importance of valuing our sessions. Though we don’t always know how they will be received, our responses do send emotional messages. And since we therapists have to swim every day in the sea of a hundred feelings, we sometimes, unconsciously, may seek to avoid them by going along too readily with people’s disappearing acts.

Sometimes people really are not interested, ready, motivated enough, or are just too frightened to be in therapy. Do we forget that we have to go so very lightly sometimes, even for a while, to help people become real clients? In an informal survey among my clients who have had prior therapy, most tell me that they left without actually discussing their exit with the therapist. Some felt pushed. Many felt misunderstood and not helped, or they disliked the therapist’s style or something the therapist said. Very few recall discussing their concerns and feelings with the therapist before leaving.

A friend of mine, however, came to me for advice after doing just that. She felt her therapy was no longer helping her grow in the direction she wanted to go. She discussed it with her therapist and they agreed she should make a change. She changed, but felt that her new therapist was somewhat mean in his demeanor. She was thinking of canceling and not going back, but, reluctant to make yet another switch, she asked for my thoughts. I suggested she tell the new guy that she thought he was mean, which, bravely, she did. And in response, he told her she was right—he was mean sometimes.

My friend felt enormously relieved. It turns out her father was quite mean, but whenever she had tried to tell him so as a child, he denied it. In overcoming her fear of saying what she felt directly, and having her response validated and not denied, she believes she has made significant progress. She has decided that it’s okay to have a faulty therapist. She now takes great joy in pointing out each time she feels the therapist is being mean, and helping him to address it. And, she tells me, he is getting better. She is curing him.

The Failure Complex

When I supervise new professionals, I often find them to be blunt about their feelings, and I find myself encouraging them to say everything in supervision, and to become interested in their words and actions in sessions. When new therapists tell me, “He was so rude! I can’t stand him!” or “I’m furious with her,” I am delighted and respond by steering them toward curiosity about why they feel this way and what they may learn about the client and themselves. Seasoned professionals who I work with seem to hold back more, and are relieved to be reminded that they can have all their feelings, that clients are difficult (we ourselves may be difficult as clients), and that experience and expertise don’t negate our own need to feel our feelings and talk about our work.

And few outside the profession really understand this, I think: the constant meteor shower of feelings we encounter in our offices, this psychic holding we have to do of everyone’s feelings. Some of us fear that perhaps, even if a feeling is an inducement, we may act on it. Unfortunately, some of our colleagues do act on inducements–sometimes little ones, sometimes big ones. The number one complaint before ethics boards is for sex offenses, boundary violations. Acting on feelings. Most of us guard these borders vigilantly. “We know that erotic transferences in the treatment room are normal, and can be dealt with gently, with words and care and no action.” We may fear them, but we know they occur.

But murderous feelings? Rage? And abandonment and inadequacy? One analyst I know calls it her “Failure Complex.” Over her many years of experience she has learned that she will not be able to help everyone, that some clients will leave or punish her even when she has not made a mistake, because that’s what they do to survive. She knows that when clients leave and don’t say goodbye, it feels just like when she was a kid and her father would stop talking to her for days on end, blaming her for his reactions. She had no control over this feeling then, and felt for years that anything that happened in the treatment was her doing, her mistake. The psychic umbilical cord tying her to her father was like a straight shot back to her feeling like a lonely, misunderstood ten-year-old. Even with all her advanced training, she still wound up back there in the pit of that despair and rage. She berated herself for that, too.

After some time though, she says she has come to feel better. Her dad was just being her dad, she tells me now. And her clients are just being her clients. And she is just doing what she knows how to do. She wears it all a little lighter now.

I like the modern analysts’ idea of helping clients to say everything—at their own pace, of course—and I especially enjoy it when it translates into therapists being able to say everything in our own supervision and therapy. As another therapist I work with says, “I like to let my fear flag fly! Talking about my own stuff builds my resiliency, and then I can stay the course.”

From the Heart

Many seasoned therapists agree that part of staying the course means checking in with the client now and again, to see how the therapy is going, either with evaluation tools, or by helping clients to say everything to us about the therapy itself, and that doing so goes a long way toward preventing abrupt exits. But we have to be willing to bear our own discomfort, and keep our support systems active. When we do this, we are better able to negotiate the blurry line between discharging our own feelings in session and making good clinical interventions.

A few years ago I sat before a panel of professionals who run a regional referral service. I was hoping to be added to their referral network. I came in with my CV and my suit and took my seat. They asked a bit about my background, and then asked me what modalities I use. When one of the interviewers spoke up and asked, “What do you do with difficult clients?” I was quiet for a minute.

“I listen and I love them,” I said finally. “And I help them to talk.”

I do get referrals from them now, but I recall at the time feeling terrified. Who says that? I really was poised to talk about my training and about interventions and skills, and the things that we do that bring recovery and healing, but that’s what came out. Love. (I suppose I could have said that I get frustrated and I tolerate it. Either might be true at one time or another.)

“Here’s what I think keeps us up at night: the idea that we are not supposed to speak from the heart, the soul, or the depths of our psyches.” We may be so tied to what we think we are supposed to be, to know, to feel and to do, that we are afraid of what we really feel. And while most of the time we don’t have intense feelings for or about clients, certain clients and situations fire us up more than others (a nod to transference), like being left without a chance to know why, to heal something, or to at least say goodbye.

On top of this, many therapists imagine a domino effect: first a bad session, then one client leaves, then another, and then the unemployment line. Much as we might like to be, we are not at all immune to worry, doubt and insecurity. Even the most experienced clinicians have moods that are directly tied in to the state of their practice.

An old friend of mine who lives her life by her 12-step program likes to tell me that finding serenity, pleasure and contentment means practicing the ability to bear discomfort—that it’s ten ways to Tuesday. Whatever your discipline, training, experience or knowledge, success and satisfaction are about feeling what you feel (good and bad) without doing harm. We do get emotionally walloped once in a while in this business. Chalk it up to transference, to regression (ours and our patients’), or call it a bit of temporary psychosis when feelings get too intense.

One analyst I know continues to call her dropout patients every now and then. She leaves messages just saying hello or asking how they are. She told me that many years ago she used to worry that they would think she was just after their money or out to build up her practice. And maybe so. (“Why shouldn’t everyone make money and prosper?”) But now, she says, she thinks it’s just good practice to let clients know we are still interested, available, and open to a connection. She has a thick skin when it comes to rejection: it’s all grist for the mill. Pointedly, she tells me that some of her dropouts do return to treatment, happy that she had continued to hold open the door and hold onto the idea that they and the work were worthwhile.

Our work is fluid, frightening, fantastic, and filled with blind spots all at the same time. But I think that therapists sleep better when we allow ourselves to feel everything, to talk about everything in the company of good peers, and to find comfort in the idea that we really are not alone, no matter how crazy we sometimes feel. We can be interested, curious, and confident that we’ll be okay—and we can pass that freedom on to our clients, enriching the experience for everyone.

I am not suggesting that we never agree that it’s time for therapy to end or to pause. Certainly, there is a season for all things. But more often than not, if we are really honest, most attempts to leave treatment have some deeper meaning. And if we go along with the surface material, especially if we are only mildly in touch with what we ourselves feel, we may be helping our clients to miss out on the benefits of a meaningful therapeutic experience.

Nancy McWilliams on Psychoanalytic Psychotherapy and Psychoanalysis

Posted on by rezendevknowfully.com

Making Psychoanalytic Theory Accessible

Louis Roussel: In all of your books—Psychoanalytic Diagnosis, Psychoanalytic Case Formulation, and Psychoanalytic Psychotherapy—you're able to bring the essential features of psychoanalytic thinking into a language that is both accessible and practically useful, particularly for clinicians who are just beginning to familiarize themselves with these concepts. This is a vital project, in my opinion, particularly given the many misunderstandings and prejudices against psychoanalysis in contemporary Western culture. I wonder if you could say something about why this is so personally meaningful for you.
Nancy McWilliams: I come from a whole family of teachers, and I have had a teaching component to my career since the early 1960s if you count my years as a camp counselor, and at the college level since about 1970 in one form or another. So for a very long time, if I wanted to get people interested in the stuff that fascinated me I had to make it accessible to them.

I taught an undergraduate course in theories in psychotherapy for several years with people who had really no background in psychoanalytic thinking, and I slowly developed a kind of skill, I guess, in making it relevant to people's ordinary lives, as opposed to talking to other scholars or theorists in the field.
LR: Speaking to other colleagues and scholars in the field, I was quite struck with one comment that you made in your most recent book, Psychoanalytic Psychotherapy, that the contemporary psychotherapy field is one that is incredibly pluralistic, with many competing theories of clinical work. And there was a point where you spoke of how each of these theoretical perspectives really represents a unique understanding of very complex, multifaceted human problems and dilemmas.

And you spoke about suggesting a style of listening to alternative theories that is analogous to how a clinician might actually listen to a client in psychotherapy. I was particularly moved by that, especially given that it seems like that's not an easy listening stance to achieve, particularly with colleagues.
NM: I learned that there are a lot of identity issues involved in people becoming therapists and they tend to get organized around one theory or sensibility when becoming being a therapist. But all of us are looking at the suffering human animal and trying to be helpful, and eventually we're all going to learn similar things and have different language for talking about it.
I have tried to fight the tendencies in me that presume a position of knowing more than other people or making them the devalued other.
I have tried to fight the tendencies in me that presume a position of knowing more than other people or making them the devalued other. It's a natural human thing to do, but a lot of grief comes from it.

I've learned enormous amounts from people of very different paradigms than my own. You not only find a lot of common ground, but you find the areas where your own particular point of view has blind spots.

LR: Absolutely. As I was looking through some of your writings, there were a number of points where it seemed that you linked psychoanalysis with larger social political issues. You quoted one of the local analysts here in San Francisco, Michael Guy Thompson, when he spoke about psychoanalysis as an unremittingly subversive practice which gives voice to that which is most denied by the larger prevailing culture.

I was struck by that, because I think psychoanalysis is characterized in some ways as more conformist than I think its true essential nature is.
NM: I came to psychoanalysis not through psychology but through political science. My first experience reading Freud was as a junior in college, when my political science professor suggested I had a kind of psychological sensibility, so perhaps for my honor's thesis in political theory I'd like to read Civilization and its Discontents and talk about Freud's political theory. That's what sort of started me down this path.

I really found in the psychoanalytic movement a very subversive kind of orientation toward the world, and there were only a couple of decades where, for various interacting reasons, psychoanalysis was highly prestigious in American culture. During those decades of roughly the 1950s and 1960s, it was a quick way to prestige in the medical establishment if you were a psychiatrist. The way to get moving ahead in your discipline was to get psychoanalytic training, and that pretty much guaranteed you eventually a leadership position in the department of psychiatry. But that was sort of a fluke of the times, and it's behind us now.

I'm actually kind of happy it's behind us, because during those years a lot of people were attracted to psychoanalysis not because they loved it or they were really curious about the unconscious. They were attracted to it for narcissistic reasons, and they didn't tend to make very good therapists because they liked being right. They didn't like being surprised. They took a superior position toward their patients and talked down to them.

Many of the current troubles in psychoanalysis come from an era where people spoke rather arrogantly. They felt they were in the chosen profession.
Many of the current troubles in psychoanalysis come from an era where people spoke rather arrogantly. They felt they were in the chosen profession. I don't think psychoanalysis does very well when it's culturally at the center; it does much better from a point of view of marginality in describing things that the culture doesn't necessarily see so easily.

Therapy on the Margins

LR: That’s an excellent point. It almost seems as if the loss of prestige and the marginalization of psychoanalysis in some ways is connecting us with the beginnings of the movement. In the early days, it was quite a risk to become an analyst, and involved sacrificing more established, secure careers. Today, psychoanalytic practice is not the most popular road to go down.
NM: I do think it's very hard on contemporary students who fall in love with psychoanalysis and want to work in depth with people. Corporate agendas tend to have an awful lot of power in this culture, and it's in the interest of both insurance companies and drug companies to describe human suffering in a fairly superficial way and to apply either a drug or a short-term treatment to it.

These are hard times economically. People who want to really get to know their patients in all their complexity have to fight against some of the pressures to oversimplify things and do some quick-fix intervention. I think we've seen a paradigm shift from a cultural understanding that psychotherapy is a healing relationship in which you might use several different kinds of techniques, but the healing relationship is the definitional part of it. It's been redefined as a set of techniques that are applied to discrete disorder categories. It's moved therapists from being healers to being technicians—and often technicians at the behest of the larger culture, which has an interest in putting people in the cogs that exist in the great commercial machine, and not necessarily increasing the meaningfulness of life or the satisfactions of life.
LR: In your most recent book, Psychoanalytic Psychotherapy, you spoke of how psychotherapists in general tend to devalue what we do—activities that we view as passive and receptive, like listening, for example—and overvalue those based on doing, producing, manufacturing, achieving.

This speaks a little bit to what you were just touching on in terms of what is most valued in our Zeitgeist, and yet, what may not be in the best interest of our psychic health.
NM: Yes. I seem to be seeing more and more people lately that are coming to me for anxiety or depression or an eating disorder or something Axis I-ish, who, when I actually listen to their story, they aren't living a livable life. They're commuting one and a half hours to work. They're staying at work from 8:00 in the morning until 7:00 at night. They barely see their children.

They're trying to take care of a house, a summer house, a couple of kids, a boat—if they're people of reasonable means—elderly parents, a dog. And they're just driven. The culture seems to tell them that they should be happy this way. And of course, that's not a livable life. It's just crazy.
LR: Exactly. It’s quite an alienated existence you just described.
NM: Yes.

Psychoanalytic Love

LR: I was also very interested in something that I don't think analysts necessarily speak enough about. You spoke about psychoanalytic love, and this tension that I think clinicians face: How is it that we can basically accept someone in a very deep way in terms of who they are as a person, but still be on the side of growth and change?
NM: I don't think that being a therapist is like being a parent in most respects. But in terms of the affects involved, it's not too different. You deeply love your kids, but you also have hopes that they'll be their best self—not be satisfied with living a kind of minimal existence.
So I don't think that deeply loving people means that you have no hopes for their doing better.
So I don't think that deeply loving people means that you have no hopes for their doing better.

I think all the empirical literature on what's effective in psychotherapy, not just psychoanalytic therapy, ends up emphasizing relationship and personality. And when you talk about relationship or about the working alliance, you're talking about the two parties making an attachment to each other, which is just a fancy word for love. It certainly includes hatred and all the other affects, but it's a commitment. There's a kind of devotion that characterizes a therapeutic relationship in which somebody can grow. And we haven't talked too much about that.

We have some theories of it that are sentimentalized. You can't decide you're going to love somebody into health, but if you make a genuine authentic relationship with somebody and try to be honest with them, be honest with yourself, and help them increase their honesty with themselves, you're talking about a relationship characterized by love. You're accepting who they are, including all their darker parts. They're tolerating who you are, including all your mistakes and failures. And that sounds like love to me.

On Failure

LR: There have been some analysts who have talked about how we can't accept a patient into analysis, especially given the nature of the deep intimacy and the depth of emotional involvement unless, we have a deep sense that we like them. And yet I can think of many examples from my own experience where that feeling wasn't there at the beginning but it emerged later.
NM: Yes. On the subject of experiences where I felt like somehow I couldn’t get a therapeutic relationship really going, that’s happened many times to me, where I have failed with somebody. Sometimes I thought I failed, and many years later I find out that the patient really felt that they got something important. And other times I thought I’ve done a pretty good job, and I later find out that I missed something important.
You can’t be in this business for too many years without getting humbled about how little you really know.
You can’t be in this business for too many years without getting humbled about how little you really know.
LR: Yes, definitely.
NM: One person recently came back to me after 30 years, and I thought I had bombed with her. I was surprised that she came back to me, and, I reminded her that we kind of fizzled out. We both decided at a certain point that the therapy didn't seem to be moving. I asked her to just think out loud about what had happened.

What came out was a story about how, when she was little, her mother wanted her to be a musician, and she had no musical ear at all. Her mother's agenda was that she was going to be a great performer. She practiced and practiced, and went through excruciating performances, and tried to be good–and just didn't quite succeed.

I realized as she was talking about this that when I first worked with her, I was so excited that I had somebody that I thought was a good candidate to put on the couch and do real psychoanalysis with, that what I had enacted was, I was like her mother in wanting to fit her to a technique that I wanted to do, that really didn't suit her.

When we talked about that 30 years later, we decided that we would work face to face, and I would be more disclosing. I think we worked much better the second time around. You don't usually get the chance to undo your original mistakes.

In that case, I think that was a narcissistic thing. I wanted to see myself as an analyst, and here was a person that I thought I could put on the couch and ask to free associate. And I ended up replicating a childhood scene where the agenda of the authority didn't fit the particular inclinations of the kid—or the patient, in this case.
LR: This is so interesting in terms of having a particular valued notion in mind of what we would like to see happen, and how that can compete with how the analysis is actually meant to unfold.

I wonder if that also comes up in teaching, particularly teaching psychoanalysis. I have discovered that teaching psychoanalysis today requires a much greater level of flexibility and attunement to how students are, including some of the resistances that they sometimes come in with, related to stereotypical notions about psychoanalysis.
NM:

Teaching Psychoanalysis

I'm finding that students know a lot less about psychoanalytic ideas. Some of them have been very explicitly told that psychoanalysis has been empirically discredited, which is patently untrue. But there are a lot of academics that believe that.

Part of the reason for that is that there is an increased schism between academics and therapists at this point, for numerous sociological reasons. It used to be common that people who taught abnormal psychology might have a small private practice and know what it's like to be in the trenches trying to help suffering people. Now, it's so much harder to get promotion and tenure that they'd be crazy to do that. They have to chase grants. They have to turn out short-term studies and get a publications list.

So academics' image of therapists is often wildly off base from the therapeutic community as it actually exists. They tend to think that therapists apply their theory uncritically rather than try to adapt to every patient flexibly. So students are taught all that old psychoanalytic stuff, especially drive theory.
I haven't heard an analyst talk in terms of drive theory for at least 30 years. But the academics tend to think that psychoanalysis stopped in 1923.
I haven't heard an analyst talk in terms of drive theory for at least 30 years. But the academics tend to think that psychoanalysis stopped in 1923.

So students come in not knowing that there has been a whole scholarly evolution of psychoanalytic theory. One of the reasons they don't know this is that analysts pretty much pursue their interests in freestanding institutes and not in the academy, so there hasn't been cross-fertilization there. Analysts, I think, are to a great extent responsible for some of the estrangement with academic psychologists, because they wanted to develop in communities of their own.

So students now come to us with very little exposure to what's central to the psychoanalytic community. And we have to adapt to that. I've been asked in recent years, “What is the meaning of the term ‘transference’?” — something that any graduate student would have known 10 years ago. One student not long ago asked me what the term “ambivalent” meant.

On the other hand, as they get taught various cognitive behavioral techniques and so forth, they are often learning stuff that's very parallel to psychoanalytic learning. Some of what Marcia Linehan does is not too different from what Peter Fonagy or Otto Kernberg does. She just speaks a very different language. Jeffrey Young’s schema therapy is not too different from psychoanalytic ideas about organizing motifs in people. But students tend not to know that.

On Political Involvement

LR: Going back to something we talked about a before regarding the political and social dimension of psychoanalysis, it seems like in some ways the analyst is in a position where she or he could potentially make a valuable contribution in terms of speaking on the larger societal level, and yet it seems to rarely occur.
NM: Yes. It's an interesting thing. It used to occur. Certainly, Erich Fromm spoke a lot at that level. Robert Lifton and Karen Horney certainly did. There were a lot of social commentaries from analysts a few decades back—not so much now. Eric Erikson would be another good example, or Robert Coles addressing the problems of the poor and the marginal. But I think that was part of that European sensibility.

We're a little bit more narrow in the United States. We're a little bit more pragmatic. We're more optimistic—"let's figure out what this is and fix it."
A big part of the psychoanalytic sensibility is trying to help people accept what can't be changed. But that goes contrary to an American conceit that you can be anything you want to be, which, to me, is a pretty psychotic belief.
A big part of the psychoanalytic sensibility is trying to help people accept what can't be changed. But that goes contrary to an American conceit that you can be anything you want to be, which, to me, is a pretty psychotic belief. I might want to be a giraffe; I'm not going to get there. But we actually raise our kids saying, "You can be anything you want to be."

And that's the kind of language of a young country that has enormous resources and not too many limits. I don't think it's the best language for us anymore, but we're kind of stuck with it. The sensibility of people who've lived with more limitation than Americans have is, I think, good for us to take in.

But I have to say that an awful lot of what psychoanalysis contributed to the United States had to do with people coming over before or during the Holocaust and having a kind of broad European learning that's not that common in the United States. And that whole generation has pretty much died off now. But they enriched not just psychology—they enriched the social sciences, the natural sciences, mathematics. We had an awful lot of very, very bright people who had a more wide-ranging set of interests than is typical for the pragmatic American sensibility.

The Future of Psychoanalysis

LR: Yes, that's so true. I wonder if you could say something about your sense of the future of psychoanalysis. Since its inception, since Freud's early days, psychoanalysis has been declared dead many times, and the decade within which we live is no exception.

There are certainly many who speak about psychoanalysis disparagingly as something antiquated, as no longer relevant. And there are those who even go so far as to say that psychoanalysis has reached a tipping point and we're on the decline and facing extinction. I don't share those views, but I wonder what about your sense of what psychoanalysis's future might hold.
NM: I'm not sure. I have my optimistic days and my pessimistic days. I think psychoanalysis will endure because we help people. They know it. They tell their friends. I see many people who've tried many other things, and they eventually come for analytic therapy and they get a lot out of it. But I don't think we're going to survive in the mainstream healthcare system.

I don't see any sign of that—at least not the more intensive, long-term, open-ended work that most of us like to do in the psychoanalytic community. I think it's hard to imagine, under the current circumstances, that the culture at large is going to support that being available for anybody but people who can afford it out-of-pocket. In the Scandinavian countries it's a little different, but they have a single-payer system.

Sweden, a few years ago, decided not to offer psychoanalysis—meaning several-times-a-week psychoanalytic work—on the national health plan, and there was a kind of grassroots objection to it and they put it back in. But I can't imagine that happening in this country. And in a few years, I think it's going to be unlikely in Sweden, because although it used to be a wealthy country, it's been stressed a little bit more in recent years. And as countries struggle, they try to cut down what they offer. So I just can't imagine that intensive long-term work is going to be supported in general.

Susan Lazar's recent book, Psychotherapy Is Worth It, really documents how cost-saving it is to get a lot of psychotherapy, even intensive psychotherapy. It saves on jail time, on sick days from work, on addictions. But most of the ways we measure the cost of healthcare is very long-term.

Insurance companies ask their benefits' managers, "How much money did you save us this year?" And people change their jobs, so they change their insurance. So they don't really have a 50-year view, or even a 10-year view, of putting out money now to do prevention in the long run.

I'm quite convinced—and there's plenty of empirical data to support this—that psychotherapy and intensive psychotherapy and psychoanalysis are very cost effective for the culture, but I don't see politically that we can make that argument effectively. So I think we'll become a kind of therapy that people will get privately.

Advice to Aspiring Therapists

LR: Yes, that’s true. If you had to give one piece of advice, maybe something you only discovered through a lot of personal struggle and pain, what do you think it would be? What advice would you give to somebody thinking about entering the field today?
NM: I don't know that I can honestly say that I have had to go through a lot of personal struggle and pain. I have loved my work. As soon as I discovered you could actually make a living by listening to people and getting close to them and trying to help them, I was thrilled. I feel very fortunate to have been able to have the kind of career that I've had. And I don't feel it's been Sturm und Drang at all. I've had very good teachers myself. I had a very good analyst. As I'm older, I realize more than I did when I was younger how lucky I was about that, because if I had a person who was a bad match—it's a powerful kind of relationship, and it can do harm as well as good. But I had good supervisors, good teachers, good colleagues, a good analyst, and I've been just constantly fascinated by the work. I guess I would tell students to follow their passion: if this is what they want to do, they can make a living doing it.
LR: Well, that’s great. Yes, that’s certainly been my experience. It seems like we’ve covered a lot of ground here. Is there anything else that you’d like to speak to?
NM:

Take to the Streets

The sermon I've been giving to psychoanalytic audiences lately is get out of your offices and talk to people outside the psychoanalytic community.

We have something very precious and valuable, and we can talk to each other about it until the cows come home, but
I think we have some responsibility to be socially useful and apply some of the knowledge to social problems and to making people's lives better—not just in the consultation room, but in the culture as a whole.
I think we have some responsibility to be socially useful and apply some of the knowledge to social problems and to making people's lives better—not just in the consultation room, but in the culture as a whole.

We should be talking about things like why the teenage suicide rate has gone up so high, and what our ideas are about the obesity epidemic, and what are the strains of contemporary life. When you were asked before about people who have commented more on the social level, and I was naming people like Erich Fromm, there are a few people now.

Christopher Lasch is dead, but he was trying to talk about that in recent decades. Jonathan Lear tries to talk about it. There are people that are trying to talk to the larger public about some of the knowledge that we've accrued over 100 years of listening carefully to people and their struggles, and I'd like to see us take to the streets more than we typically do.
LR: Do you have a sense of why we don’t?
NM: Part of it, I think, is that it involves being quite visible, including to our patients, and some of our patients are terribly upset when they see us out of role. I think analysts get very conservative about what they do because we’ve all had experiences of a patient being devastated when they find out when we have a different political belief from them, or that they disagree with something, or they’re ashamed of us. I think it’s very inhibiting being a therapist.
LR: I really appreciate your talking with me. This has been very enjoyable, and I've learned a lot.
NM: Thank you. I loved your questions and it was fun to have this conversation.

What if Its All Been a Big Fat Psychotherapeutic Lie?

Posted on by Psychotherapy.net Team

In the early 90's I developed a classroom exercise to teach my students an important academic lesson. This is one of those experiential exercises where the professor feels holier-than-thou because he or sheknows the outcome in advance. First, I placed the students in groups of two's and asked one of the students to play the part of the helper while the other played the part of the client who tells a real or fictitious problem.

Next I pulled the helpers into the hallway. During the first trial the helpers were merely instructed to give the clients advice, suggestions, ask lots of questions, be extremely directive, and provide psychological interpretations. There was absolutely no empathy, warmth, or relationship building . . . I repeat no relationship building.  This session was a strict Rogerian's worse nightmare.

I then gave the helpers and the helpees about a five or ten minute session together. I then pulled the folks playing the helpers out in the hall once more and explained that during trial number two they were forbidden to give any advice, interpretations, or suggestions. They were also told not to ask the person playing the client any questions. Instead, they were merely instructed to be totally nondirective, paraphrase, reflect, and make statements that conveyed a high degree of empathy. Using the same partner with the same problem, the students were given another five minutes together.

Next using a scale of 0 to 100 (in which 0 is terrible, 50 is average, and100 is perfection) the students playing the part of the client were going to rate their helpers. Needless to say, I knew that the clients would rate their helper higher during trial two; except for one thing: it didn't happen!  The ratings for the first session devoid of empathy were significantly higher.  In fact, it was a blow-away landslide in favor of the directive approach. Say what?

I mentally scratched my head and made a joke out of the whole experience, convinced the results in this class were merely an anomaly. "Listen," I told the class, "I knew you guys were strange, but I didn't know how strange." I then explained that exercises in class often do not parallel what transpires in the real world of therapy.  Secretly, I also told myself that these were undergraduate students that most likely didn't do the interventions correctly.

There is only one problem: I have now been doing this experiential exercise (switching the order of the trials) for approximately 17 years and I can't remember a single trial when the relationship building non-directive approach won when I looked at the results for the entire class! And while no self-respecting researcher would be impressed by my experimental rigor, they would be impressed by my N; over 1000 individuals have now participated in my therapeutic scenario. Since the aforementioned first trial I've added grad students, probation and parole officers, guidance counselors, therapists in training seminars, and therapeutic supervisors, to the rank of participants.

How can this be? Many, if not most, research studies insist empathy is the most important trait for a counselor. I nearly always use what I consider a Rogerian, person-centered, non-directive, heavy on the empathy approach during my initial sessions with a client even if I plan to switch to more directive interventions during subsequent sessions. Heck, it has to be true, it says so in most counseling books, including some I have penned! So what is the explanation for these seemingly contradictory results?

1. Well, there's the rationale (or should I say rationalization?) I've been giving to my classes and in seminars for years now; simply that students and workshop participants are not like real clients and this exercise would turn out differently if we used real clients. In other words, the folks in my classes or seminars are training to work in the field or they are working in the field and therefore believe in suggestions and advice . . . no empathy necessary! The problem with this explanation is that often students are real clients, otherwise we wouldn't have college and university counseling centers.  In the case of therapists, many do seek treatment from other helpers. Indeed, if my armchair experiments are on target then relationship building, non-directive, empathy laden initial sessions, should not be used with those in the field or folks planning to go into the field.

2. Students, grad students, or helpers in the field don't really know how to perform person-centered, Rogerian slanted interventions. Maybe it's just too complicated. Although this is theoretically possible, the eminent psychologist Ray Corsini once told me that Rogers confided in him that he could teach anybody to do client-centered therapy in two weeks.

3. The paraphrasing, reflecting, and rating responses on an empathy scale paradigm we use to teach this approach actually bears little or no resemblance to what Carl R. Rogers was actually doing with his clients. Hmm that's certainly conceivable. Or . . .

4. What if it has all been a big fat psychotherapeutic lie?

As for me, well at this point in time I guess I must admit that despite a wealth of experience and knowledge, I remain a psychotherapeutic agnostic. You decide.

Bids for Emotional Connection in Couples Therapy

Posted on by Psychotherapy.net Team

John Gottman’s concept, “bids for emotional connection,” is practically a complete theory of relationships in itself. Hearing the word “bids,” we picture partners reaching out to each other in a variety of ways. Gary Chapman, in his book, The Five Love Languages, lists five such ways: words of affirmation (“That situation was delicate and you really handled it beautifully”), touch (“How about a hug?”), quality time (“Let’s get a babysitter and make a reservation at Chez Alouette”), gifts (“This scarf was so gorgeous, it had your name on it”), and acts of service (“Why don’t you take a nap while I do the cleaning up?”).
 
Partners make bids to create, increase, maintain, and re-establish connection. Arriving home at the end of a day, we ask: “How was work today?” Noticing that our partner is preoccupied, we say, “What are you thinking?” Sensing something amiss, we send out a probe: “Are you upset with me about something?”
 
“Bids” are the active ingredient in a relationship. Gottman shows how people make bids in the fine grain of everyday life, often without knowing they are doing it: “Did you hear about…,” or “You’ll never guess what my sister told me today.” A lot is going on all the time in the form of these little signals that partners are often unaware of sending. These signals—these bids—are nonverbal as well as verbal: a wink, a smile, a shoulder rub, a gentle shove, or a mutual look of understanding about a friend’s quirks. What matters, Gottman suggests, is not depth of intimacy in conversation, or even agreement or disagreement, but rather how people pay attention to each other no matter what they talk about or do. What matters is the quality of attention, as my partner, Dorothy Kaufmann, puts it.
 
What the person making the bid wants, of course, is a positive response (“Oh yes—tell me. Your sister always has such a special angle on things”). What that partner doesn’t want is an angry response (“Don’t bother me; I’m not finished with the paper yet”) or no response (grunting in acknowledgement and continuing to read the paper). Borrowing terminology from Karen Horney, Gottman labels these three responses turning toward, against, and away.
 
Gottman’s major point is that repeated failure to turn toward in response to our partner’s bids leads our partner to stop making bids. The relationship sags and both partners feel lonely. Couples frequently find themselves in a devitalized relationship without knowing how they got there. Turning away or against their partner’s bids for emotional connection is how they got there.
 
Susan Johnson’s Emotionally Focused Therapy can be viewed in these terms. She focuses on the traumatic effect of having our bids for emotional connection rejected or ignored (our partner turns against or away), resulting in our being afraid to make further bids and, instead, attacking or withdrawing (turning against or away) in turn.
 
If turning away or against is a problem, shouldn’t we try always to turn toward? Perhaps. But forcing ourselves to be nice when we don’t feel nice also leads to devitalization or to a buildup of resentment that culminates in an explosion. And we may not always be able to turn toward; the impulse to turn away or against may be automatic or overpowering. Furthermore, the original bid might have been made in a manner that provokes a negative response—that is, it might have been offered anxiously, demandingly, reproachfully, or failing to take account of what the other is doing or feeling at the moment. Gottman says that temper tantrums may be bids in some situations.
 
But maybe we can create a vantage point above the fray—a platform—from which to report that we have turned away or against. We can say, “I know I’m over the top.” Or, “Wow, you don’t deserve my snapping at you like this.” Or, “I know I’m lousy company at the moment; I’m caught up in writing this thing.” We would be bringing our partners in on our concern that we are not doing right by them. We would be turning toward by acknowledging that we have turned away or against.
 
But it is difficult to be self-reflective in the heat of the moment. It would be easier to go to our partners later and say, “I was so focused on making that last paragraph work that I hardly said hello when you came in last night. I feel bad about it.” Or, “I hate how irritable I’ve been lately, and I’m sure you hate it even more.” Or, “I know I gave you a tough time when you made me those perfectly wonderful eggs this morning. I must have been still fuming over that comment you made Saturday.” Or “I keep forgetting that when you blow up like that it’s because you’re hurt.”
 
We would be making a bid to reconnect after having previously ignored or rejected our partner’s bid. We would be reconnecting in the act of talking about how we had been disconnected. We would be talking intimately about not having been intimate—which is perhaps the ultimate intimacy and the fullest way we can join.