Ron Kurtz on the Hakomi Method

Posted on by rezendevknowfully.com

“Who are you?”

Serge Prengel: A lot of people in our audience know Hakomi, and many have been trained in it, but some people may not know. Would you define what Hakomi is?
Ron Kurtz: Hakomi uses several particular, unique approaches to helping people study themselves.
We believe–or I believe, anyway–that self-study, as it’s practiced even in the East, is about reducing the unnecessary suffering that comes from not knowing who you really are.
We believe–or I believe, anyway–that self-study, as it’s practiced even in the East, is about reducing the unnecessary suffering that comes from not knowing who you really are. In fact, Hakomi means, “Who are you?” So, the way we do it is to establish a safe relationship–a “bubble,” we sometimes call it–within which the therapist helps the client feel comfortable, safe, and cared for. That’s done by training therapists to be in the right state of mind when they work, and that state of mind is very similar to what Buddhists might call compassion. We call it a loving presence: to have a loving feeling about the person, which you actually practice developing, and to be totally present.

To be totally present is to be aware of the fact of the moment, to be aware of what’s happening–actions, physicality. That relates us to body psychotherapy; we’re constantly aware of the bodily signs of the client’s present experience, and we’re interested in accessing the client’s implicit beliefs–the beliefs that are operative through the client’s habits. We see the signs of those behaviors; we even see the signs of some of those beliefs in the person’s present behavior.

We don’t generally think about taking a history; we don’t listen very much to what people try to explain to us about themselves. We just use this method to help the person realize who they are and how they organize their experience.
SP: So it’s really “Who are you?” in the sense of how you organize your experience.
RK: Yes, and how you do it unconsciously, automatically—things that go on, as John Lennon would say, while you’re doing something else. There are wonderful new books about the adaptive unconscious, and that’s an essential part of my thinking.

SP: That most of the processes happen unconsciously, and that there’s a reason behind that.
RK: Yes. There’s usually a habit that was learned as an adaptation to a situation, and these habits are not necessarily verbalized or even made aware; we have to bring them into consciousness. Sometimes they come in as a memory or an emotional reaction, and then we have to spend a little time getting the verbal descriptions of it. A child will learn the grammar of its native tongue by the time it’s 18 months old. It could not tell you about nouns and verbs, but it uses them perfectly. That’s the kind of adaptation I’m talking about.

And we work with the surface indications of those adaptations. I’ll give you a very simple example: there are people who interrupt themselves when they’re speaking, as if they had an editor who was watching what they said and would stop them and make them change their words. Well, that’s an indicator; that’s immediate behavior that happens with this person all the time. It’s an indicator of something like trying to avoid making a mistake because they were punished for making mistakes. So we can go right to that. If I can just listen to a person for a minute or two, I can see that behavior.
SP: So really what’s happening is you’re not paying a lot of attention to the story of people’s lives, but focusing on how they are and tracking what you call “indicators.”
RK: Indicators, exactly. [Wilhelm] Reich said that the client’s history walks in with him; it’s the way he shakes your hand and holds his body. The adaptations are written in the posture; they’re written in the muscle tension. The kind of posture where a person looks at you with a slight angle of their head, they don’t look directly at you–that’s an indicator, a postural indicator. As in Bioenergetics and Reichian work, locked knees are an indicator of orality, or a puffed-up chest is an indicator of a psychopathic personality. So all the character patterns, to me, are a subset of indicators. And these indicators are indicators of implicit beliefs, like the puffed-up chest: “I have to be tough, I can’t let people in, I can’t be honest with people.” All those things are written in the posture; you just have to know how to read it.
SP: So what the posture tells you, it’s an embodiment of the belief.
RK: Yes, but the belief doesn’t come first. The adaptation comes first. The belief may not even be conscious. It may never have been verbalized. When I give feedback, they’re shocked that these beliefs are there, but they recognize them.
SP: So this unconscious belief is a result of this unconscious adaptation, and it takes a special kind of attitude on the part of the therapist to notice it.
RK: And the client.
The client has to be devoted to this idea of self-study. They have to be willing to allow the therapist to experiment, which will evoke some of these early, painful situations.
The client has to be devoted to this idea of self-study. They have to be willing to allow the therapist to experiment, which will evoke some of these early, painful situations. They will just come up as emotions first, where the person will get very emotional and not know why, and then a little while later they start to have a memory that fits that emotion. It takes courage to be a client.

Assisted Self-Discovery

SP: You used the word “experiment”–do you want to talk a little bit about this concept of “experiment”?
RK: Absolutely. For example, I was giving a talk at a psychology conference in Vienna one year, and there were maybe two or three hundred people, Germans and Austrians, in the audience. I asked them to become mindful; I gave them some time, and I helped them work themselves into mindfulness. First, though, I told them that I was going to give them a statement while they were in mindfulness, and I told them what the statement would be. I was going to tell them that each was a good person–in German, “a Mensch.” And I asked them, “Tell your neighbor what you think your reaction will be when I say that to you when you’re in mindfulness.” So they talked about that, and then they got mindful. And out of two hundred people, 80 percent or more had incorrectly predicted it–they hadn’t known what their reaction would be. About 60 percent of them got suddenly sad; some got teary-eyed; some felt relief.  It’s because there’s an implicit belief in those cultures that “we’re not good people.”

So that’s an experiment. I study a person, I study their indicators, and make a guess about what their beliefs are. From that guess, I create an experiment that I hope will evoke a reaction that has significant information for that person about who they are.
SP: So that’s very much related to that notion that Hakomi is about, “Who are you?” And by creating the experiment, you give the person a chance to actually realize the belief that they carry inside.
RK: Sometimes they call it “self-discovery.” Assisted self-discovery–that’s how I like to think of it.
SP: That’s a very different approach from the more medical-oriented model of pathology.
RK: Yes, it’s totally not a pathological model. It’s a model of, “You want to study yourself? I’ll help you.”

Teaching Mindfulness

SP: You mentioned several times the word “mindfulness,” and that it’s very much a part of the experiment function. Could you talk a little bit more about mindfulness?
RK: Traditionally, mindfulness is the method for self-study and meditative practices.
Mindfulness is a state where you’re focused and concentrated on the flow of your experience moment-to-moment, and, as much as possible, without interfering with it.
Mindfulness is a state where you’re focused and concentrated on the flow of your experience moment-to-moment, and, as much as possible, without interfering with it. For example, it takes years of practice, but some people can watch their breathing without interfering. That’s mindfulness. And the smart way they train mindfulness is to have you pay attention to your breathing. The idea is that there’s no organization around controlling it. You’re not controlling it, so if I say something while you’re in that state, it directly evokes a reaction. You’re not protecting yourself against it; you’re allowing these things to happen. And that’s one of the reasons that there has to be this connection with the client, where the client understands and feels the compassion of the therapist.
SP: So in the example you were giving earlier of this talk where you had asked a question to the audience, and their inability, in most cases, to predict how they would feel, the reason is that they had not been connected to themselves, and in mindfulness, they suddenly had the raw experience.
RK: Yes, you could say that. That’s true. And the reason I chose that statement, “You’re a good person,” is I understand that culture doesn’t promote that. The culture promotes original sin, and “You’re the bad guy,” so I just guessed that that would work.
SP: Yes, and as you said, when you’re dealing with the client you pay attention to who the client is through these indicators.
RK: Absolutely. And then the statements I offer to clients, or other kinds of physical experiments I do, are designed particularly for that client at that moment.
SP: You mentioned that in order to reach that moment where the client is able to be in a mindful state, the attitude of the therapist includes compassion and a loving presence. How do you help somebody who is not trained in mindfulness to become mindful for these experiments?
RK: Well, almost everybody can do it for a moment or two. Almost everybody. You’d have to be quite wired up and nervous not to notice something, and so most people can do it. Of course, it gets easier for clients once they have practiced a little bit. The key to it is what you might call “limbic resonance”–by timing and pacing, by being silent when the client needs you to be silent, by noticing simple things.  
What I train my students to do is, when you sit down with somebody, study them for what you like about them, for what makes you feel good, and that will be reflected in everything you do.
What I train my students to do is, when you sit down with somebody, study them for what you like about them, for what makes you feel good, and that will be reflected in everything you do. So they’re trained to do that: to look at somebody and know to just start liking this person and see how beautiful they are. They’re all beautiful, somehow. Everybody was somebody’s baby.
SP: So what I’m hearing is that if we are making mindfulness something that’s intimidating, it’s going to be difficult. But if we focus on the fact that most of us can access mindfulness for a few seconds, then it’s much easier. And what happens is that the therapist actually eases the client into that mode by limbic resonance–by focusing on what they like about the client.
RK: Yes, that’s true. And I may not even mention mindfulness to the client. I may just say, in a very soft voice, something like, “Well, why don’t you just get as calm as you can get, and I’ll say something and you notice what happens when I say it.” Just as simple as that, and it works. They don’t have to know about mindfulness; they just have to get calm and study their experience.
SP: Very much that sense of just being in the moment and creating the present experience.
RK: Yes, exactly–studying reactions for information, what it tells you about who you are. And there are people who are too nervous–they had too much coffee or something like that–and they can’t get into mindfulness right away. So they have to get a massage, take a hot tub, something like that. But I’ve only run into maybe two or three people in a 30-year career who couldn’t. That’s how easy it is.
SP: Maybe it’s a testament to how wired we are to resonate with other people, that the therapists themselves are able to create some of that.
RK: Absolutely. Sometimes we’ll trigger a traumatic memory, because you have no idea what’s going to pop up when you do an experiment–you’ve got an idea about an indicator–and the person can go right into a traumatic memory. And in times like that, I talk very softly and gently and calmly to the person; I have them look right in my eyes, I hold them with my vision and my softness, and I talk to them, this human hijacked by a memory, and I say, “You know you’re really safe right here, right?” It’s an appeal to the rational mind. And that seems to help them come around, quite a bit.
SP: So instead of talking about relationships, you are in a relationship at a very basic, limbic level.
RK: That’s true.

Building Loving Presence

SP: What is it that helps therapists practice being able to offer this kind of loving presence?
RK: That’s a good question. For me, it popped up many years ago when I was working in Germany. I had done nine straight days of therapy sessions in a group, over and over, and I was exhausted. I was so tired I couldn’t think very well, and I just stopped thinking for a while, even though I couldn’t tell the client. I didn’t interrupt the client; they were just talking and I sort of went blank.
In this blank state, looking at this person, I saw a certain kind of beauty in them. And I realized if that person knew that I was seeing this, they would feel it.
In this blank state, looking at this person, I saw a certain kind of beauty in them. And I realized if that person knew that I was seeing this, they would feel it. And I realized, “It shows. I’m looking like I’m feeling this.” And I had the person look at me (he had his eyes closed). He looked at me, and immediately his process changed into something deeper and emotional. And that’s when I realized, “Oh, yeah, that’s the basic engine of the relationship: it’s just appreciating this person to the point where you feel compassion and you feel loving towards them. And that will move the process by itself.”

I get plenty of that for myself, too. I have a wonderful family that supports and sustains me.
SP: So, in other words, it would be very difficult to offer this sustaining sort of presence to clients if you didn’t experience it yourself and in your own life.
RK: Yes, you have to find a source for all that. You have to find a beauty in everything. You have to be really careful about getting hung up on what’s wrong with the world, because there’s a lot.
SP: Maybe that’s also related to mindfulness, in the sense that it’s about the ability to focus or not focus on some things.
RK: Right. Sometimes it’s called “concentration training.” It’s the ability to focus in the present.

The Missing Experience

SP: So you, as a therapist, have this sense of loving kindness; you are tracking the client’s reactions, discovering indicators, conducting experiments. What is it like for the client to go through that? You mentioned earlier there is a certain sense of courage, and it must take a certain kind of client to take this–or is it something that’s applicable to everybody?
RK: I think almost everybody. But in self-study, there has to be a willingness to take an honest look at yourself. The experience for clients–we think of it this way: if they adapted to a situation that is still painful to them in some way, or still running them in some way, defensively, compensating, they didn’t get the kind of emotional nourishment that they needed. There was something missing. We talk about the “missing experience”–and “missing” because either they don’t believe it’s possible, or they feel like they have to defend against it.

For example, we can do an experiment where I ask a person to be mindful and to watch me as I move my hand very slowly towards them and touch them, and then to notice their reaction. Well, that will trigger a memory; if they have been abused, this typically will trigger that. What’s missing for them is this perfectly gentle, sweet touch. When they realize that, they become emotional, and then they can allow the hand to touch them and they can feel the sweetness; they can feel what’s been missing for years and years. That missing experience is so delicious, and so healing, that once you experience it–or even if you just see it happening with somebody else, like when I do therapy intensives and there’s 25 people out there watching me, five of them are going to be crying in somebody’s arms when I’m done. The people watching get moved because they have similar issues; these issues are very general. The nourishment that was missing is just like the Germans.
SP: That’s something that I want to make explicit: we’re talking about something like an experiment and using an analogy with a scientific process, but at the end of it, the moment of change, the moment of healing is the emotional healing that happens when people connect to that missing experience.
RK: Exactly.
SP: The emotional healing you just described happened in a workshop. Could you give some experiences and other recent examples of an experiment and the kind of missing experience that it revealed?
RK: Very often, I’ll tell somebody, “There’s a little bit of technique involved here, to invoke these memories and to invoke these emotions.” I remember working with somebody–a psychiatrist, or I think she was just a medical doctor–who had been severely abused. We worked together for several sessions until she reached a point where she was containing her rage and couldn’t release it. It would just choke her up in her throat. And I said, “Okay, why don’t you come back tomorrow, and I’ll have people here to assist me, and we’ll contain you.”

So she came back; we brought her right to the same edge, and they were holding her very tightly because she would contain herself if she was alone. But when she reached a point the second day, I had people hold her very tightly so that she could feel safe enough to compress herself. She went into this rage, and I don’t know how long it lasted. I have a tape of it; it probably lasted at least five or ten minutes. Afterwards, after this explosion, she lay down with her head on one of my assistants’ laps, and she was feeling really great. She had released the anger and went into kind of a sweet melancholy about it all. Then she looked at me and said, “I never did this before.” She had never let herself be comforted; she had never rested her head in somebody’s lap before. That’s delicious, it’s wondrous. I forgot the question, but that was the answer.
SP: Yes. I was asking you to relate an example of that, and what’s become very apparent in this example is the role of containment and support, including physical support.
RK: Exactly. It’s still part of the body-centered aspect of it.

Taking Over

SP: So, where other people see things in terms of resistance, you actually support people.
RK: Yes, I see it as emotional management behavior, experiential management behavior. So I’m going to help them manage it. I’m going to support their behavior so that they can relax a little bit, let me help them. Then what they’re managing has a better chance of coming through as expression.
SP: In other words, you don’t go into a battle with the clients, describing a behavior as dysfunctional, but you see it as a way they are managing their behavior. And as you help them, something else happens.
RK: Absolutely. It’s amazing. We call that technique “taking over.” We take over a person’s management behavior. For example, if I give somebody a probe that says, “You’re a good person,” and they have a thought that says, “No, I’m not,” we’ll have somebody take that over because that’s a management behavior. They’re managing their fear of thinking of themselves as a good person, and that’s not a good idea. I have somebody take that over by saying a few times, “You’re a good person,” and having an assistant of mine say, “No, I’m not.” Then the person is again in mindfulness. And as we do this two or three times, there’s a memory; a memory comes up about where they learned this adaptation. And
once you’ve got it in memory, it’s changeable. Once they see why they did it, they have some more control; they can change it, they can change that behavior. But they have to understand it first. You can’t force it to change. It changes through insight and practice.
once you’ve got it in memory, it’s changeable. Once they see why they did it, they have some more control; they can change it, they can change that behavior. But they have to understand it first. You can’t force it to change. It changes through insight and practice.
SP: The words “insight” and “practice” are very evocative also of Buddhist practice.
RK: Absolutely.
SP: And I assume that is an area where some of that wisdom, some of that approach, has permeated your approach and your methods.
RK: It was there from the beginning. I was enamored with and studied Buddhism and Taoism long before I started doing Hakomi. It’s part of the inspiration for the method.
SP: I would like to use the word “inspiration” to say that this has been an inspiration. Unfortunately, we’re coming to the end of the interview, but I would like to suggest to people who are hearing this to carry with them some of this compassionate and experimental attitude in their work.
RK: A loving presence.
SP: Thank you, Ron, for your loving presence.

Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy

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The Interview

Chanda Rankin: I’m Chanda Rankin, and it’s a real pleasure to have you here for this interview today with Psychotherapy.net. Earlier you mentioned you were born in Vienna, Austria. I wanted to know how much sociocultural influences at that time affected and influenced you to go into the field of psychotherapy and analysis.
Otto Kernberg: To begin with, I left Austria when I was ten years old. My parents and I had to escape from the Nazi regime. We did so at the last moment and immigrated to Chile. I trained in psychiatry at the Chilean Psychoanalytic Society. I came to the States for the first time in 1959 on a Rockefeller Foundation fellowship to study research in psychotherapy with Jerry Frank at Johns Hopkins. Then in 1973 I moved to New York, where I was at Columbia. Now, I'm Director of the Personality Disorders Institute where we're carrying out the research of personality disorders.

Certainly my cultural influences are Austrian, German, and that has influenced me in many ways. But my psychiatric training was integration of classical descriptive German psychiatry and psychoanalytic psychiatry/psychodynamic psychiatry. Later I became immersed in ego-psychology and Klein's work. I also visited Chestnut Lodge where I became acquainted with the culturist orientation, Sullivanian, Frieda Fromm-Reichman as well as the ego/object relations psychologists, Edith Jacobsen and Margaret Mahler. So it was natural to try to synthesize an object relations approach between the great ego psychological Kleinian and so-called British 'middle group' or independent approaches. Then many years later, to this was added a certain influence from French psychoanalysis.

Kernberg’s Gold Mine

CR: I’ve always been very curious about what is it about working with personality disorders do you find so compelling that you’ve made this the focus of your life’s work?
OK: It was a combination of various influences. First of all, perhaps the most important one was that the psychotherapy research project at the Menninger Foundation that I joined and eventually directed consisted of the treatment of 42 patients—21 treated with various types of psychotherapy from a psychoanalytic basis, and 21 patients were treated with standard psychoanalysis. Now, it so happened that many of the patients sent to the Menninger Foundation suffered from severe borderline conditions. Severe personality disorders, right now called Borderline Personality Organization…the concept had originally been developed there by Robert Knight and his coworkers. Many patients with severe personality disorders were included in that project, and the diagnosis was made very, how shall I put it, tentatively or fleetingly. When the project started in 1954, there were no clear-cut criteria being used. It was very helpful because it turned out that half of the patient population on the therapy side, and half of the patient population on the psychoanalysis side suffered from severe borderline conditions.
CR: How fortunate for the researchers.
OK: Yes. And each of these cases had typed process notes of each session, of treatment over many years. Big fat books. So by the time I got there, I had 42 cases studied in detail, and it was just a gold mine! I noticed regularities about what happens in the treatment, what would have facilitated the diagnosis, so I combined my interest in object relations theory with the interest in clarifying this group, to develop some hypothesis about treatment. We then did the statistical and quantitative analysis of the project. It provided me with important confirmations and disconfirmations of the hypothesis.
CR: And this population was not well understood at the time.
OK: No, so I was very lucky to have this patient population. And when I started out, I wasn't aware myself that I was getting into a very interesting subject.
CR: How did you become involved with the study of narcissistic personality disorders?
OK: Just by chance. One of the patients who I saw in a controlled analysis while I was a student at the Psychoanalytic Institute in Santiago, Chile, had been diagnosed as an obsessive-compulsive personality. I was unable to help him—he didn't change one inch over years and his memory persecuted me. Then, I perceived that he was very much like other patients I saw at the Menninger Foundation. Hermann Van Der Waals, who had written an important article on the narcissistic personality told me, 'These are narcissistic personalities.' Nobody had described these characteristics in the literature well.

I then took another patient into analysis, exactly like my previous one, and on the basis of my then-developing psychoanalytic knowledge, I developed a particular thesis on how to treat that patient. And this is how I developed the treatment of narcissistic personality, the diagnostic observations, the differential diagnosis between narcissistic and borderline typology, the generalization of the concept of borderline personality organization. So it was a combination of luck and interest.

CR: A very rich time, and a confluence of things coming together to make that happen. What or who influenced your clinical style which seems to be neutral in many ways but not passive or impersonal?
OK: One individual who I have not yet mentioned, who is very little known at this point, although he was a leader of American psychiatry, is John White, the Chair of Public Psychiatry of Johns Hopkins when I was there. He developed a method for clinical interviewing that inspired me for developing structural interviewing. He was the best interviewer I've ever seen. He would start talking with the patient, and the interview would go on until he had a sense that he knew what he wanted to do. It went on for two or three hours. John White had a way of putting himself into the background, disappearing, so to speak. He was very direct, very honest, and understood something about people, in depth. No showmanship. Just raising questions that permitted the development of the patient. He had a tremendous capacity to permit the patient to develop his present personality, rather than asking what happened 50,000 years ago. That also influenced me in interviewing. Sharpened my approach to the study of the present personality.

But, perhaps also what has been very important to me is the excitement with the fact that there you have these patients with severe distortions, that ruin their lives. No doubt about it. This is not phony pathology for wealthy patients who have nothing to do but to go to a psychoanalyst. These people have not been able to maintain work, a profession, a love relation. And with the psychoanalytic psychotherapy and psychoanalysis you are able to change their personality, improve their lives. I think that is an extremely important contribution of psychoanalysis. And we need to do empirical research on this. One of the things that I have been very critical about is the lack of systematic and empirical research within the psychoanalytic world.

How People Change!

CR: Do you think that there’s any one specific thing, if at all, that contributes more than any other thing to change with a personality-disordered patient?
OK: People change in many ways with common sense, with friends, with help, with luck, with good experiences in life. I think that psychoanalytic psychotherapy and psychoanalysis are probably the methods that promote the best changes in case of severe personality disorders, through the mechanism of analyzing of the transference, the split off, dissociated, primitive object relations that determine and are an expression of identity-fusion, bringing about normalization of the patient's identity, integrating his self and concept of significant others. In that context, permitting the advance from primitive to advanced defense mechanisms, and strengthening of ego function in terms of increased impulse control, moderating affective responses, and facilitating sublimatory engagements.

So I think that's probably the best approach nowadays to bring about fundamental personality change. There are indications and contra-indications; not all patients can be helped. I think that the prognosis depends on the type of personality disorder, on intelligence, on secondary gain, on the severity of anti-social features, on the quality of object relations, on the extent to which some degree of freedom of the sexual life has developed or not. So there are many features that make indication, contra-indication and prognosis for the individual cases different. We are in the middle of trying to spin all of these out.

“Psychotherapy Training is Going Down the Drain”

CR: You often emphasize the importance of training, really making sure that the therapists know what they are doing and what they are dealing with in terms of the patient. Can you speak to that issue?
OK: First of all, yes, I am very critical of chaotic gimmickry in treating patients based upon chaotic theory. Each person who invents a treatment method invents his own ad hoc theory for treatment. I find that this damages the field, the treatment, the patients. It's bad science, on top of it. One thing I like about psychoanalysis is that it's an integrated theory of development, structure, psychopathology, that lends itself to develop a theory of technique of intervention. I'm not saying it's the only one, but that's one of its strengths.

I think that when people apply various techniques from different theoretical models, they cannot but end up in a chaotic situation in which transference and countertransference is going to drive the relationship in one direction or another. I'm not saying that you can't help patients with this. But you cannot learn how to develop a certain approach. I've seen so many bad consequences from that. Because then you don't match technique with the needs of the patient. And you don't give patients as much. So I prefer to have a cognitive-behavioral therapist, let's say, a well-integrated general theory that applies to his field, rather than one of these esoteric schools everybody has. In this field there is so much voodoo and so much fashion and quackery. It's paid for, and of course, it requires research. Now, unfortunately, most of the research that's been done on short-term psychotherapy done by non-therapists with non-patients in university settings, to grind out papers… so the real treatment that is done clinically has only been researched in a limited way… I think that's our major task. And I believe that we need to develop manualized treatments for long-term psychotherapists, whatever their background. And test them scientifically.

So, regarding training, I think that training should focus on theory of personality, personality change as a basis of technique. And then, apply it to clinical situations.

CR: What do you think of the impact of managed care on psychotherapy?
OK: Psychotherapy training is going down the drain in this country, under the corrupting effect of managed care, this terrible system for profit that goes under the mask of 'managed care,' but really it's managed cost. Under its pressure, long-term psychotherapy is now reserved for those who can pay for it privately. So we are depriving a significant segment of the population of treatment. I trust that that system is going to explode by its own corruptive effects and structure. This is already occurring. And that in the long run, our knowledge and our scientific development of psychotherapy will restore an optimal level of psychiatric practice and psychotherapeutic practice. I think that in the meantime we live in a happy-go-lucky, democratic fashion in which everything goes. Which creates distrust in the public, cynicism in the profession, and is not healthy to patients.
CR: Have you considered ways to reverse this trend?
OK: I think the solution is, in the long run, scientific research.

In my own Institute of Personality Disorder, we're trying to contribute in a modest way by carrying out empirical research. We have randomized three groups of 40 patients each, all of them with the diagnosis of Borderline Personality Disorder. One group to be treated with transference-focused psychotherapy, which is a psychoanalytic psychotherapy that we have developed and tested. The second group by DBT, Dialectical Behavioral Therapy, developed by Marsha Linehan for suicidal Borderline patients. And third, supportive psychotherapy based on psychoanalytic principles. We're going to compare these treatments, not simply in a kind of horserace, but we're trying to study what process mechanisms are connected with what mechanisms of change.

I don't believe that one treatment is 'better' than the others, but there are specific types of patients who respond better to one or another or that treatments may be equally good on the basis of different mechanisms of change. In this regard, I'm very critical of the assumption that non-specific aspects of psychotherapy are by far the overriding cause of its effectiveness. Because all the studies on which these conclusions are based are short-term psychotherapists of very questionable nature. Nobody has studied yet the comparison of long-term psychotherapists from the solid bases, as I have tried to define.

Critiquing the Media and Pop Culture

CR: To go back to something we were talking about earlier, I was wondering if you could say something about psychotherapists portrayal in the media? What are your thoughts on how psychotherapists are portrayed in movies and television? Along those same lines, you have noted how eclecticism in the field is leading to a diffusion and misrepresentation.
OK: In general, psychotherapists are portrayed in simplified and almost caricatured ways in movies. What is very fashionable in this country right now is the so-called intersubjectivist approach, in which the therapist lets 'everything hang out' and people are impressed with how real the therapists are. I think that reflects a dominant culture of doing things quickly, immediately, the culture of faith, good faith, warmth, belief in the human being helps everybody along. Which is different from the reality when we treat patients who suffer under severe regressive conflicts, whose major need is to destroy the therapeutic relationship, who envy the therapist's capacity to help them—those kinds of cases we don't see in the movies, except that by the time we see that kind of patient, they are shown as monsters and people get horrified. And there is a strong cultural critique of psychoanalysis that is not new, but now takes the form of "psychoanalysis is lengthy, expensive, hasn't demonstrated its efficacy and effectiveness, and patients can be helped by brief psychotherapists." Often they present psychotherapy as shamanism.

At the same time, the combination of the important development in biological psychiatry, the financial pressures reducing availability of psychotherapeutic treatment, the cultural critique of subjectivity and wish for quick solutions, adaptation—all that has tended to decrease the participation of psychodynamic psychiatry and psychodynamic psychotherapy and the training of psychiatrists. It has brought about the old-fashioned split between biological psychiatry (centering on basic research and psychopharmacological treatment) and psychotherapy (pushed off to other professions and being disconnected from medicine and psychiatry). I think that's unfortunate. That leads to a kind of mind/body divide when they should come together.

CR: Can you say more about this mind/body divide?
OK: The impact of the new neurosciences on psychotherapy is very misunderstood. I think there is a lot of premature, reductionist excitement with all these new findings. We have important new findings of the central nervous system, as an effect of psychotherapy, correlations between psychiatric disorders and brain functioning. But these new developments do not, as yet, have any practical implications in terms of both theory and technique, technical interventions, so we have to keep that in mind.
CR: How do you view issues of the mind/body applying in the clinical situation?
OK: Of course you could say that it applies insofar as psychopharmacological drugs derived from our better understanding of neurotransmitters. That is certainly true for the case of schizophrenia, major affective disorders, syndromes of depression and anxiety in general, but it's not true for personality disorders, the many sexual difficulties and inhibitions that go with them. And, to the contrary, there, medication has a very limited symptomatic effect on anxiety and depression, but not at all on the basic psychopathology. The illusion that eventually everything is going to be cured by a pill is an illusion that has existed for a long time, and I think that there are good theoretical as well as practical, clinical, reasons to question it.

The Question of Love

CR: I want to turn to a different interest of yours which you explore in your new book Love Relations: Normality and Pathology. I was very curious how that came about, and in the body of all your other work to be writing a book on love seemed like such a drastic change. What was the impetus for this book?
OK: As I mentioned in the Introduction to the book, I have been accused of being only concerned with hatred and aggression, so I thought it would be fun to write about love!
CR: Was it fun to research and write this book?
OK: It was fun, but it was also difficult, because when I got into the subject, I realized how complicated it is, and how I had to renounce exploring many areas that I would have loved to explore. So the book has important limitations. I observation that the degree of pathology of the personality disorder, of one or both participants of the couple, does not permit us to establish a prognosis of how the couple would do. Two perfectly healthy people get together and it's like hell on earth; two extremely troubled people get together and have a wonderful relationship! So that clinical observation created my curiosity, because of course it's a problem that borderline patients face—establishing couples, getting married.

I also became interested in the subject of sexual relations, because I found out there were two types of borderline patients—I'm using the term loosely to mean severe personality disorders. One with an extremely severe primary inhibition of all sexual capacity, no capacity for sensual activation or enjoyment, no sexual desire, no capacity for masturbation. These patients had a bad prognosis because in the treatment, as everything was consolidating, more repressive mechanisms inhibits that sexuality even further. On the other hand, you had those with wild promiscuous sexuality—polymorphous perverse, invert, pan-sexuality, with masochistic, sadistic, voyeuristic, exhibitionistic, fetishistic, homosexual, heterosexual, everything…those with such a chaotic sexual life seem to have a terrible prognosis, but the opposite was true. These patients did extremely well, once their personality was functioning better. So it raised my interest, why this extremely severe sexual inhibition, what could be done about this? And, also, a more basic question about how much a couple can contribute to inhibit each other or to help each other to free themselves sexually. That's it, in a nutshell.

What are Good Therapists and Analysts Made Of?

CR: Do you have any thoughts about personality characteristics that an analyst or a therapist needs to have in order to work with severe personality disorders, or even mild personality disorders?
OK: That's a good question. As I look at our experience, we've trained many therapists. We've had 20 years of training and supervision. I think that people with very different personalities can become very good therapists. I don't have anything deep or new to say about this that couldn't be said by anybody with some experience in this field. I think it's important, first of all, that the therapist be intelligent, it helps. Second, that they are emotionally open. That they be a personality that is sufficiently mature, on the one hand, and open to primitive experience, in contrast to someone who is extremely restricted. It helps not to be excessively paranoid, infantile, or obsessive-compulsive. Although, I'm saying excessive because we have all kinds of therapists—all basically, honest with themselves and others, with a willingness to learn. Therefore, it helps not to have too much pathological narcissism. If you are too narcissistic, you don't have the patience to work with very troubled patients, and your capacity for empathy is limited.
CR: But it also seems like you need a healthy dose of those things.
OK: Yeah, some of us are exploring that. I really don't have a good answer to that. But there are some people who have a talent for it, like people have talent for playing piano. I don't know whether experts would say, what personality does it take to play the piano? There are some people who have the talent. Some people are able to do it almost without any training. It's almost frightening that they know things before we teach them. It's bad for our self-esteem! I've had therapists with whom I've had a sense that there is such an inborn capacity that with little…they would flourish. And others who never learned, even though they were intelligent and hard-working. And I'm not able, at this point, to spin out what it is. But, we can discover it.

Very simply, we tell people who want to train, "Bring us a tape. The best tape you have, of any session that you are carrying out, a videotape with a patient in treatment." And we have developed methods of the psychotherapeutic interaction by which we can sort out who does have the talent for doing it. We can evaluate very quickly with manualized treatment whether the therapist is able to adhere and whether the therapist is competent. Competence is seen by the therapist talking, focusing on what is relevant, focusing on what is relevant with clarity, doing it relatively quickly and in depth. Relevance, clarity, speed, depth. The combination of them tell us who is a good therapist. It's terribly simple, and it works.

And I'll tell you, some experienced psychoanalysts are terrible; and some young trainees are very good. This creates the problem: does one have to be a psychoanalyst to do this kind of treatment? I would say it helps to have psychoanalytic training, but it's not indispensable. There are some people who have so much talent they can do it without psychoanalytic training, although, a personal psychotherapeutic experience always helps, particularly if people have a kind of "blind spot" in a certain area. Sometimes a psychoanalytic treatment or psychoanalytic psychotherapy helps.

CR: You have written about the importance of therapist safety. It really hit home with me, and I had not actually heard anyone articulate that clearly before. The ability to be able to sense when safety is an issue seems so primary. So all the things that you’re talking about—your own self-awareness, to be able to have the insight into these areas, to know when something is a problem. It’s very important for safety as a therapist and also the amount of safety you can provide for your patient.
OK: Exactly right. It permits you to maintain the frame of the treatment. It's absolutely essential. The therapist has to maintain the control over the therapeutic situation. The therapist has to be in charge. There is a realistic authority of the therapist that has to be differentiated from authoritarianism, namely, the abuse of that authority. There is kind of a cultural move toward "democratization" of the psychotherapeutic relationship. I think that's just silly. Because patients come to us because of a certain expertise, otherwise they wouldn't come to us, and they shouldn't. There's a difference between authority and authoritarianism. And part of the authority of the therapist depends on the therapist's being able to maintain the frame of the treatment. And our own safety is essential in this regard. When you treat severe personality disorders it becomes crucial…physical, psychological, legal safety, in this country which is so litigious. It's the most paranoid culture that I know within the civilized world. I've not been in the jungle…
CR: We might be close!
OK: Perhaps so, we live in a very paranoid culture.
CR: Thank you so much for your time.
OK: You're most welcome.

Michael Hoyt on Brief and Narrative Therapy

Posted on by rezendevknowfully.com

The Interview

Victor Yalom: I’m really pleased you agreed to join me today for this conversation. I’m going to try to pick your brain in the short time we have, to really find out about you as a therapist and as an innovative thinker in this field.
Michael Hoyt: I appreciate the opportunity to meet with you. I wanted to start by asking you a question, if I could: What was your particular interest in inviting me to participate in this exciting series?
VY: My vision for this interview series for Psychotherapy.net is to present therapists that are doing really innovative yet practical work, despite the pressures that we are all facing on various fronts. I’m most interested in those who are finding a way to be excited about what they’re doing. I’ve had a sense from your work that you fit in that camp.
MH: Thank you. I’m delighted to be included. I’m very excited to participate.

Narrative Constructivism: Is it All in the Mind?

VY: So, you’ve written a new book.
MH: Yes, it’s called Some Stories Are Better Than Others. It was just published two weeks ago by Brunner-Mazel Publishers.
VY: How did you come up with that name? Obviously, it has a lot of meaning for you.
MH: It does have a lot of meaning. I’ve become, in the last several years, more and more interested in what is sometimes called narrative constructivism, how people put their story together. Rather than having the idea that we discover our reality, or that it’s an objective thing that we find, we are oftentimes creating it. How we look at things affects what we’ll see; and what we see affects what we’ll do. I think that as people live their lives, they may generally be doing fine, but when they get stuck it’s often because they’re telling themselves a story or constructing a world view or a narrative that isn’t satisfying to them—it isn’t self-fulfilling in a good way, but instead it’s frustrating. And people will come to therapy looking, in essence, for a new story, a new way of understanding, a new perception—which can lead to new behaviors and new outcomes. So some stories are better than others—because some stories give people more of what they want in life, where other stories will be more self-limiting. My recent influences include the work of Don Meichenbaum, Michael White, and Steve de Shazer, and other constructivist thinkers going back centuries.
VY: Just this morning, I was reading a book by Zerka Moreno about her late husband Jacob Moreno. That’s what he said about psychodrama—that it’s used as a way for people to construct their life. Existentialists thought the same thing: we’re here, we have to create our meaning, we create our lives with the resources we have. In that way, you’re following yet another tradition.
MH: It’s a long tradition. As I begin to say a few names of the people who’ve influenced me recently, I begin to think of all the people I haven’t mentioned, including Irvin Yalom, George Kelly, and a whole host of people. I think it’s important to realize, though, that this idea of narrative or story is not the entirety of people’s experience.Some people have misunderstood constructivism as meaning “it’s just in your mind” or “that’s your opinion.” Yet, it’s very important to recognize the realities that people are living in. To use the title of one of Michael White’s books, Narrative Means to Therapeutic Ends: the narrative is a means, it’s a vehicle

VY: There is a quotation in your book; something to the effect that social constructivism does not mean that external reality is irrelevant.
MH: Yes. As obvious as that is to say, there’s been a lot of misunderstanding, I think, and it’s become a kind of tiresome argument. We’re not saying that there’s nothing outside. We’re saying the knower has to know the reality, and that knowing involves construal, construction, mean-making, and so on. It gets filtered, mediated through our consciousness, and that we can affect consciousness The situation that people are in can be very significant.Existence determines consciousness as well as consciousness determines existence. Salvador Minuchin has spoken a lot about this. Take the example of people in terrible situations of oppression and poverty—a radical constructivist might say it’s all in the way they’re looking at it—but that would be an absurd position to take, not really appreciating the horribleness of their situation. So obviously we have to take into account social and economic issues, not just internal, intrapsychic processes.

VY: What you are saying, and relating it to the current reality of the therapy world, and what’s driving the idea of this website, is exactly this. Many therapists feel very oppressed, very disillusioned by the phrase, “realities of practicing therapy today”—managed care, a glut of therapists in many urban areas, lower fees. And the story that some therapists tell about themselves is that “we’re in the wrong profession at the wrong time, and there’s not much opportunity.”
MH: I’ve seen and experienced some of that personally as well. There’s a lot of demoralization. I think at the extreme psychotherapists are somewhat of an endangered species. On the one hand, there’s the pressures of managed care: Get it done real quick, keep it on the surface and get it done quickly. Then there’s the pressures of biological psychiatry: Use medication and you don’t have to talk too much about it. It’s a very hard time. It’s an interesting coincidence that we’re meeting here at the Evolution of Psychotherapy Conference. “Evolution” requires pressures in the environment, and some kind of genetic variability, and then some new things can emerge. You don’t want to become extinct; you want new things to emerge.I wrote a different book, in 1995, called Brief Therapy and Managed Care. At that time, I expressed the view that there are ways of working with managed care. And I still think there are ways of working with some managed care, but more and more I’ve heard too many horror stories that have impressed me with how much difficulty managed care—especially in the for-profit sector—has been thus far in the world of psychotherapy. Managed care has not yet produced the promise we were hoping for, of being more efficient and distributing services to more people.

It seems managed care has mostly been cost containment, which has meant cutting people off, rather than finding new ways to help people.

The Archaelogy of Hope

VY: How does your recent book shift your focus?
MH: Well, the reason I called my new book Some Stories Are Better than Others is because I think we’re going to need to have a real shift in the field, in many directions, including looking more for clients’ strengths and resources, not just focusing on their problems, pathologies, and pain. The “archeology of hope” (to borrow the subtitle of the 1997 book Narrative Therapy in Practice, edited by Gerald Monk et al.) involves looking for competencies, strengths, overlooked possibilities, latent joy, and other little nuggets that we can pluck and bring forward. So when I say Some Stories Are Better Than Others, I think it’s going to be incumbent upon therapists more and more to see the whole person, not just the problems. I think it’s going to be much better if we’re competency-oriented, more collaborative, somewhat more future-oriented.
VY: I think, going back to Freud, the model is “what’s unconscious is usually bad.” A seething pit of conflict and aggression. While those things certainly exist, my experience has been that some of the most powerful changing moments in therapy are when people discover positive things about themselves that they didn’t know, that may have been repressed, or forgotten, or dismissed. Often therapists are looking for problems, they’re looking for pain and conflict, rather than helping the client develop the capacity to sit with positive feelings which is no easy feat either. If a client comes in with something happy or joyful, the therapist may redirect them into the pain, rather than help them sit with it and explore and really experience something positive, at a deeper level–almost running from the joy. Yet, staying with the positive can lead to profound awareness shifts and life change.
MH: As one of my colleagues quipped, most of the people in this field have been trained as “mental illness professionals,” not mental health professionals. We spend so much time pursuing illness and pain. Somebody will say, “I had a couple of good days, but then some bad things happened.” “Well, tell me about the bad things.” If somebody mentions pain, or sorrow, or looks sad or angry, we feel that’s where the meat is. We’re supposed to go for that. It would be interesting to me, not just to take a history of the present problem, but to take a history of the person recovering. “What in your past, what little clues or keys might help you deal with this better?”
VY: Or simply, “How have you overcome difficult circumstances in the past?”
MH: “How have you dealt with difficult circumstances? How have other people? Role models? Parents? People in your ethnic history? Are there examples you can draw upon? Ancestors you can call upon? Can you project yourself into a time in the future when things will be better? Imagine that time, and how are you going to get to that time? Thinking of times when things are better, a time that inspired you, can that give you some energy, some courage to go toward that?”

Some Stories Are Better Than Others

VY: Can you think of your work with a client where you helped them get to a better story?
MH: I’m thinking of a woman, I’m thinking of how to respect her privacy and confidence, thinking of how to say this – OK, a woman I’ve known for some time who developed a terrible case of multiple sclerosis. Over a number of years she became very incapacitated, to the point where she’s barely able to speak, incontinent, bed-bound. At one time she had been a fashion model—quite a lovely young woman.
VY: Pretty heartbreaking.
MH: Very heartbreaking, but that’s not the whole story. There is a lot of sorrow there, and we cried together over that. But if we see her as only an “MS victim,” then she’s really stuck. Then she’s been terribly delimited. I began visiting her in her home when she couldn’t come to the office. She has cats all over her house. So we started talking about the cats—they’re sitting in my lap—and I found out that even though she’s very limited, she’s doing animal rescue. She’s a phone counselor and helps place animals. I also discovered that she has a whole world of artistic and aesthetic interests. So we were able, over time, without denying the medical reality, to at least enlarge the picture. That she’s not just somebody with MS, but that she’s an animal lover/activist, she’s an art appreciator.She sent me a Christmas card last year—her condition has even worsened—in which she said—if I could think of the exact words it would be better—I’m so choked up thinking about it that I’m blocking on it. It will come back to me.

VY: What’s the feeling of being choked up?
MH: he feeling is that of being deeply moved. I love heroism, and heroine-ism. People triumphing over adversity. People who somehow, despite the odds, find a way to be happy. I met a kid recently down the street, a little boy who had some serious medical problems and he was in a wheelchair. In one way, you could look at him and see all the physical problems he had. And this little boy was laughing, and he had a balloon, playing. He was, at that moment, in a certain way healthier than I was. I was fussing and worrying about something, and he was experiencing the joy in life. I’m very interested in finding ways to bring out that joy for people.And sometimes it’s very hard. And it’s getting harder for therapists. Most of us, I think, went into this crazy business—this wonderful, strange business—for very good reasons. We want to make the world a better place, we care about people. And oftentimes we get suspected: “You’re doing this out of some neurotic need,” “Aren’t you co-dependent?” or “You’re on a power trip” or something like that. The term “countertransference” has gotten to the point now where therapists are sometimes concerned about themselves too much. (See references for Hoyt, 2001a, 2001b, 2001c 2002.) I think it’s very important for us to keep remembering the positive reasons we’re in this field. Otherwise, I think it’s a sure burnout.

VY: I think one way of doing that is to really be able to celebrate the triumphs with our clients. Were you able to emotionally share that joy with the woman you just so movingly described?
MH: Yes, and we both experienced it as a natural, genuine human encounter, not as a technique It’s very important for us to anchor, reinforce, praise, acknowledge, celebrate—whatever terminology you like—our clients’ successes and forward movements. In this case, our relationship has become very important to both of us. She had sent me a note and I wrote back thanking her for the session. I told her that there had been a couple of times that I had been very worried about something, and I thought of her example and it gave me courage.She inspired me: if she could find a way to live her life meaningfully and have joy in it, given the challenges she has, then that inspires me to do the same in my life. And for me not to tell her that would have felt inauthentic and incomplete.

VY: That’s wonderful! I think one way to avoid burnout is to give yourself permission as a therapist to really be human. So much of the training in our profession runs counter to this and teaches us to hold back so much of ourselves.
MH: It’s a fine line. Because I don’t want her to feel that she has to take care of me, or “I can’t tell him I’m having a problem because he’ll be disappointed,” so I think we have to be judicious.
VY: Yes, we don’t want to self-disclose simply because it feels good. You always ask yourself “Is it for the benefit of the client?” In this case it seems like a no-brainer that sharing your joy about her triumphs is a good thing to do.
MH: Yes. I can see ways it would not be if it became her obligation; if she needed to prop me up somehow. But most of the time I think we’re much too invisible; if we’re a blank screen then we’re not real. A colleague of mine, David Nylund, and I have developed an interesting exercise. It’s in my new book. We interview therapists, but we interview them as if they were one of their patients. So, you would interview me as though I had been this patient. And you would ask, “What was it like working with Michael Hoyt? What was helpful and what wasn’t helpful? What did he do that was really good for you? Did you ever let him know that you appreciated him?” There’s a whole series of questions which are useful in evoking the internalized client that we all carry around. We’ve used this in a lot of workshops, and people often say it’s a breath of fresh air, or “it’s like getting a different take on myself.” Particularly if we make it very real, if we start to ask a lot of specific questions. We all internalize our parents, our clients, our friends—all sorts of people. And I think they’re a source of revitalization. You can be reinvigorated if you can find a way to access what inspires you. And this particular young lady really inspires me.Hey, now I remember what the card said: “Memory is what God gave us that we might have roses in December.”

VY: My – how very sweet.
MH: Yeah!

Goals and The Discovery Process

VY: I want to go back to some of the other things in your work, in the brief /strategic/solution-focused types of therapy. One of the concerns I have involves the emphasis on goal-setting. How the hell can you set a goal with a client in the first session, when it is often the case that clients don’t really know what they’re there for? Their presenting problem is often so vastly different than what you’re working on four sessions later.
MH: I think that most clients do know what they’re there for, at least initially. And so I might say, “What’s your goal at this time?” or “As we start today, what do you think would be helpful? What would you like this to be like? How will you know this has been useful?” And then, now and then in the course of the therapy—whether it’s one-session therapy or 10 sessions or 100 sessions—I’ll ask “How’s this going for you? Where are you at now? How have we done in terms of the initial things we were talking about? What should be our focus now?”
VY: “How are we working together?”
MH: Yes. And “What’s next? Do you feel this has been adequate and sufficient? Do you think there are other things?”I think there’s a danger that we can act as though we know more about the client, or what’s best for the client, in ways that actually dis-empower the person. Jay Haley wrote a great paper many years ago called “The Art of Psychoanalysis.” You can keep saying to the patient, “You think that’s the problem, but there’s a deeper level.” Oral interpretations trump. You can always go “deeper.” You can say it was pre-Oedipal: “You’ll have to have years to absorb me, because we can’t even talk about it.” And you can kind of undermine the patient’s sense that they really have autonomy, and they really know what’s best for them. I think sometimes people come in and it’s not the goal I would pick; it seems to me too superficial. Or it’s just skimming the surface. And I’ll ask them, “Does that work for you?” And if they say it really does, I’ll say it’s fine. I might say—if I think they’re taking a solution that’s not really in their best interest — “I was thinking some other things that might be of some interest to you. Does that sound like something you might want to look at?” I might try to open some space. If the person says, “Nah, I don’t think so” or “Maybe someday,” I’ll say, “I just want to let you know it would be available. I’m not necessarily saying it’s good for you, or even true for you, but it might be something to consider.” I don’t want to give people the message, “You think you’ve dealt with this, but you really haven’t,” where you keep undermining their sense of self-control and autonomy.

Often times I think we’ve had the idea that we somehow have superior knowledge. And even if in some ways we know a lot, I think by following the client closely, rather than leading the client, in the long run, the person will become more empowered and more of a person.

You become a “person” by making “personal” decisions.

VY: I agree with a lot of what you say. We can’t know more about our clients, regarding the content of their lives, or in terms of what their actual goals should be. What we bring to the table is that we’re process experts. We can see ways that they’re holding themselves back, how they’re defending themselves. And we have real skills to help deepen their awareness, to deepen their inward searching abilities.
From another angle, one limitation of the question, “What are your goals?” is that it’s a cognitively framed question, and you’re going to get a cognitive response. A few sessions later the goals and the awareness can get larger if they’ve explored new territory and are starting to think and feel differently about themselves or their body.
MH: Yes. We’re using certain metaphors: “superficial vs. deep,” “cognitive vs. in your heart.” And they can be useful metaphors, sometimes. So my deconstructive mind says, “What do we gain and what do we lose?” I’m familiar with the “deep” concept, and I sometimes think that way. I might, even in a brief therapy, say, “Does that solution fit all the way through? I know it sounds good in the ‘top of your head,’ but how does it set in your gut?” or “Does it fit all the way in your life?” or “Is there any part of you that doesn’t feel right with that yet?” We have all sorts of language—we say “the tapes are playing,” there’s an “unconscious,” and all these different metaphors. They all can be useful. I think it’s critical, to try and stay as much as I can in the client’s frame, in the client’s phenomenology.I am not an expert at everything by any means. But I am something of an expert at asking questions. We want to help create a discovery process, and we can ask questions that will open vistas, that will get people to look at things differently, without necessarily directing them. Not “You should do this and this and that.”

For example, you might say to a depressed client: “What you call depression, what else might you call it? Some people would call that sadness. Or some people would call that oppression rather than depression. Is something putting you down or holding you back?”

Managed Care… Or is it ‘Mangled Care’?

VY: Let’s switch to some practical issues. You’ve worked at Kaiser, a large HMO that gets a lot of bad rap from psychotherapists, as any HMO or managed care company does. How have you dealt with that? Obviously you care passionately about the field, and it’s clear from this conversation that you do deep, meaningful work. And yet I’ve heard so often that at Kaiser you have to average 5-6 sessions or less per client. Also, you might see them for the first session, and then your schedule is so booked you can’t schedule a follow-up session for three weeks. How do you work within such a system?
MH: I’m not here as a Kaiser spokesperson, but let me respond to several things you said. It’s true I’ve worked at Kaiser for 20 years, and I’m certainly aware of people’s comments, that it’s “get them in and get them out.” I think the pressures of managed care are affecting everyone, unless you have private pay patients and their income is such that they don’t have to worry about the economics of it and can come as often as they want. There is a major distinction between the for-profit HMOs, who generate most of the complaints, and the not-for-profit HMOs, of which Kaiser is one. No system can be everything for everyone, but it’s the for-profits that rake a large profit off the top rather than putting it back into services. Many years ago I coined the phrase “mangled, not managed care” to describe what some companies often wind up providing. According to all the polls—Time andNewsweek and U.S. News and World Report and various newspapers—Kaiser has actually gotten excellent ratings within the HMO world.There’s also a conflating or confusion between the idea of length of treatment and depth of treatment. There are some patients that I have seen once or twice or three times and it was “deep” or “heart” work or whatever one would call it. And other patients I’ve seen for long periods, it never really had much soul or passion in it. So I don’t think that length of treatment is always the indicator of what is better.

What I have tried to do is a number of things. I’m fascinated with people, and I’m almost an anthropologist at times. I’m curious how people got to be who they are, what makes them tick, what their hopes are.

VY: How does that work in your brief therapy?
MH: For me, the hallmarks of brief therapy are the development of a collaborative alliance and an emphasis on clients’ strengths and competencies in the service of an efficient attainment of co-created goals.In brief therapy, people can get unstuck, or get back on track, get their process going, but I usually don’t get to hear the whole story. I might get to hear one or two chapters or an interesting pivot or turn and then they carry on and do their work without me. I think it’s one of the differences between more traditional longer-term versus briefer treatment. At the risk of oversimplifying it, with the former, the therapist goes well down the road with the patient, around lots of turns, with this shared idea that, “eventually we’re going to terminate.” Whereas the brief therapist, as soon as things really start moving, they’re saying, “We’re only going to meet a couple more times, let’s talk about relapse prevention.”

VY: So you can do some very useful things within the constraints of the system. And certainly it is better than no progress at all. But in terms of what feeds the soul of the therapist, and prevents us from getting burnout, that may be harder. We have a lot of difficulties in our professional life. We’re dealing with lots of people with pain. We’re not making as much money as a lot of other equally intelligent professionals. So we want the emotional gratification/satisfaction that the work brings.
MH: Freud said somewhere that the therapist should have the most satisfying personal life that he or she can have, so they won’t look to their patients to make their life meaningful, to give them satisfaction. And I think some therapists have a strong need—I don’t quite call it “addiction” or “co-dependency”—but there’s some emotional reliance on the experience of getting close and being trusted. It’s beautiful when it’s happening. But sometimes I would ask, “What and whose needs are really getting served? Is it my need to be a long-term therapist for the gratifications—maybe not financial ones—
VY: —or maybe financial.
MH: Yes, maybe financial. I think there are some monetary incentives as well.
VY: Of course it cuts both ways. Clearly, as a private practitioner, there are financial incentives to keep patients long term. There’s no way around that. And, conversely, in managed care, where someone has a pre-paid health plan, or a capitated contract, it’s to the institution’s economic incentive to keep the treatment shorter. So the economic incentives are there; we live in a free market economy; we know the impact of prices and money. And I think private practitioners need to be aware of the point you just raised, just as managed care needs to be aware of the converse dilemma.
How do managed-care therapists and companies deal with this? Weren’t you in the management end at one point? How do you deal with that? To know that you’re doing that right thing, and not being coerced by economic pressures from up above?
MH: As well as being a full-time clinician, I was the director of adult services at a large Kaiser facility for many years. I stopped being the director a few years ago because I had some other interests I wanted to pursue. I think it’s a complicated question. I address it at length in two chapters on likely future trends and attendant ethical dilemmas in my book, Some Stories Are Better than Others. There are lots of thorny issues, and 40 or 50 pages of discussion. I think we have to find ways to continue to function as professionals, with the intertwined implications of competency, autonomy, responsibility and ethicality.
VY: We certainly have to try to.
MH: As much as we can. And there is the fact that “he or she who pays the piper calls the tune,” to some extent. Although it’s true that that we are economic animals, that we’re trying to make a living, we have to safeguard what we think is best for clients, whether we’re working in fee-for-service, managed care, or in whatever arena.This long pre-dated the managed-care issues. Imagine if a patient came into a private practitioner’s office with a long list of issues and problems that obviously required long-term intensive treatment. And imagine he or she says “But I don’t really have any money—I can only pay you $300 total.” Many well-intentioned practitioners would say something to the effect of, “Well, I can see you two or three or four times.” They might do sliding scale, and maybe pro bono for awhile. But sooner or later they would also say, “If you can’t pay, I’m not going to be able to give you professional services on an ongoing basis.” So sometimes I’ve wound up in a situation discussing with patients—whether it’s in an HMO or in a private setting—”How do you propose to pay for this? This is a professional service. For consideration of a certain amount of money you’ll get a certain amount of service.” It becomes a very complicated thing, because you don’t want to just cut people off—but you also need to make a living

Hoyt Under Pressure

VY: Let me put the pressure on you a little bit more.
MH: Good!
VY: I know that at HMOs like Kaiser, and others, in their benefits they give up to 20 sessions per year, and then if you read the fine print, it says, “As needed per medical necessity” Where do you draw the line? Five sessions versus 17 sessions? And what’s “medical necessity”? It’s not really a medical treatment to begin with.
MH: I have a big objection to the term “medical necessity.” I much prefer to call it “clinical necessity.” And they have defined clinical or medical necessity in terms of four dimensions, in general: One is a legitimate DSM-IV Axis I diagnosis. A second is “likely to show significant improvement,” meaning “it’s necessary because it will really help.” A third is “necessary to avoid a worsening,” meaning that if we don’t do it, the patient is going to wind up worse. And the fourth, which has a lot of slimy politics around it, is that some companies are using the DSM-IV, Axis V, the Global Assessment Functioning, just setting a number: they have to be below a 55, or below a 50, or below a 60.
VY: Whatever that means!
MH: Whatever that means. It’s semi-operationalized. But, how low do they have to go? How sick do you have to be? It’s counterproductive and, in my mind, stupid, to say that you have to really fall apart, and then we can start therapy.
VY: There’s an incentive for therapists to make the person look worse! An incentive to game the system.
MH: Right. What happened a long time ago is that we, as a field, made an alliance with the medical model. And insurance has been treated as an entitlement: “I’m entitled to my 20 sessions,” or “I’m entitled to as much as I want.” Whereas it has been written, in contracts, that only if it’s a diagnosable “illness” and a “necessity” will treatment be covered.
VY: By doing that we signed a pact with the devil, if you want to call it that. But whoever bought into that is saying, “I’m going to agree that this is the illness model, the medical model.” I agree with you: If we’re going to go for that, we play by those terms.
MH: And then we’re in the language of DSM pathology, the language of the medical model, and then we’re into “Axis I,” “presenting complaint,” and “symptom resolution.”
VY: And all that jazz.
MH: I do think it can be useful, to a point, at times. It depends what we’re doing therapy for. When people are having panic attacks, and it’s turned into panic disorder, it’s a fairly circumscribed thing. Sometimes diagnosis is not a bad thing. Other times, people want to come to therapy for a kind of growth therapy, or personal enhancement. I’ve been in therapy for those reasons, more than once. It’s a question about whether insurance should pay for it. “I wasn’t there to treat DSM IV, I was there to grow Michael Hoyt.” Insurance is for one thing, but this was a different process. HMOs and other managed-care companies are needing to specify what will and will not be covered, and for how long. (Hoyt, 2000, Some Stories Are Better than Others, Ch. 4, “Likely Future Trends and Attendant Ethical Concerns Regarding Managed Mental Health Care” and Ch. 5, “Dilemmas of Postmodern Practice Under Managed Care and Some Pragmatics for Increasing the Likelihood of Treatment Authorization” (with Steven Friedman); and Hoyt (2001d). Also see “The Squeaky Wheel: Don’t Let Managed care Shortchange Your Clients.” Family Therapy Networker, 25(1), 19-20.)
VY: But that’s such a hazy line. When you talk about the woman with MS, you talk about despair and hope and inspiration. Where is the line between treating illness and symptoms, and growth?
MH: Yes, and one of the ways that treatment was justified to the insurance company was that there is some well-known research, with 50 or 60 replications, that good psychotherapy services reduce unnecessary medical utilization. That’s one of the ways to sell it to the HMOs, showing them the bottom line. And so, if she could have some visits with the psychotherapist, there weren’t going to be so many visits to the internist and the emergency room and the internist. We may have to be “bilingual,” so to speak.I could articulate “symptoms” and “enhancing coping” when I had to, but when I was with her, I wasn’t doing medicine, I was doing humanity.

Words of Wisdom

VY: Before we stop, any words of wisdom or advice or inspiration to the hordes of therapists, many of whom are feeling disillusioned with the field? What do you say to them?
MH: I hope these are words of wisdom; they’ve been wise for me, and they may fit for somebody else. I think it’s good to get more training and read books and go to workshops. I think that’s helpful, but what we really need to do is remember why we came into the field, and honor it. We need to come from our heart. We need to come from our soul. We need to follow our passion, as Joseph Campbell used to say. Sometimes there is a lot of pressure and unpleasantness. That’s true. But don’t let the bastards get you down.Don’t let them define your reality completely. Work hard and keep hope alive—right livelihood is worth it.

I think another word of wisdom is that it’s important to be multi-theoretical, to have different lenses you can look through. The other word is “eclectic,” but I don’t like that word because it sounds like “chaotic” and “electric” in the same breath, like when you throw techniques at someone and you don’t know why. But I think it’s important to be “multi-theoretical.”

We’re in this wonderful, strange business: we go into small rooms with unhappy people and we try to talk them out of it, so to speak. We’re here at the Evolution of Psychotherapy conference. The first speaker was brilliant and right on. And the second speaker was brilliant and right on, and completely contradicted the first. And the third said something really brilliant and right on and had a very different perspective—and each of them and their proponents have helped thousands of clients. Not everything is equal, but there are different ways to go, and nothing works all the time.

I think when you’re stuck — and we all get stuck every day — we don’t quite know what to do or the therapy isn’t going anywhere—the first thing I’d do is consult my client. “How is this working for you? What am I missing? I don’t think we’re looking at this the right way. What are your thoughts and ideas?”

VY: Instead of peer consultation?
MH: Yes, I would start with the client, rather than assuming the resistance is in the client.The first place resistance exists is in the therapist. We have a resistance—we are looking at things a certain way that doesn’t let things go forward. I would start with the resistance being in me, than I would look at the resistance in the interpersonal field, that is, something not working between us right. And finally, and only finally, I might ask, “Is the resistance in my client?” Too often, when it’s not going where we want it to go, we say “”Oh, they were Axis II,” ‘or “There’s secondary gain,” or “They didn’t really want to change,” or “They really like suffering,” or “They’re too attached to their negative affect because of their early experiences with abuse.” We’ve come up with something to explain it, as though the other person is the problem rather than the difficulty is in our understanding them better.

VY: “If it doesn’t work, it’s their fault.”
MH: Right.
VY: “And if it works, it’s our doing.”
MH: Yes. There’s an old saying, “When you point a finger at someone, there are three of them pointing back at you.” So I would take this and say, “What’s going on with me? What am I missing?” That’s one thing I would do.I would also suggest talking to people who have a different theoretical orientation than oneself. If you’re psychodynamic, go talk to a cognitive behaviorist. If you’re a cognitive behaviorist, go talk to a Jungian. If you’re a Jungian, go talk to someone who does biological psychiatry, and so forth. Because the way you’re looking at it, your lens, your frame, your conception, may not allow you to see the client and to see solutions in a way that’s going to be helpful for this person. We often want to go talk with someone we really trust, someone we went to school with, because we had the same professors and the same books are on our shelves. Sometimes it’s like talking to a mirror. You almost know what they’re going to say; they’re going to confirm your pre-existing beliefs, because they have the same frame. It’s OK to do that, because sometimes you get ideas. But if you’re not getting the ideas that are going to move the therapy forward, it’s time to talk to someone from a different orientation. How you look influences what you see, and what you see influences what you do. And if you’re not seeing something helpful, get some new glasses. Some stories are better than others.

VY: Thanks, you’ve helped expand my perspective and greatly enriched my understanding of what your work is all about.
MH: I really appreciate your interest, trying to follow some passion and bring some energy and life into the field by interviewing different people about what turns them on. I would encourage people to look at this whole set of interviews, not just the people they may already be acquainted with. All the people who are going to be interviewed have something to say; if you can hear it. It’s important to stay curious.I used to think that if something didn’t turn me on, it meant that it wasn’t good. I have now discovered that if it doesn’t turn me on, and (especially) if it turns lots of other people on, maybe it’s something I’m not hearing.

VY: Again, the three fingers are pointing backwards.
MH: Thank you for the opportunity.
VY: Thank you so much.

Susan Heitler on Couples Therapy

Posted on by rezendevknowfully.com

The Interview

Randall C. Wyatt: Dr. Heitler, it’s good to have you here. Let’s start with how you first got into conflict resolution and marital therapy work?
Susan Heitler: I think this is a profession I have been in since I was 3 or 4 years old. When I was just a child, my parents would battle and I would be the one that would step in and bring some calm or reason to the situation.
RW: Were your parents a high conflict couple?
SH: My father was a high conflict individual and my mother would react but was somewhat clueless about what to do.
RW: So what did you do? How did you intervene as a 3-year-old?
SH: I have a sense of myself as having my two hands up – one facing him, one facing her, standing in the middle like, "Cut it out." Cut it out would be too strong; "enough," "calm down," "Stop, listen, listen!" would have been more like it. (Laughter…)
RW: As you grew up did your parents listen to you much? Did you get them to stop or quit arguing so much?
SH: I think on the whole they did. It is a little bit amusing now that they are elderly, 91 and 86. And when my mother introduces me, she will typically say, "This is my daughter, but she thinks she is my mother." I must say, though, that she was a marvelous, marvelous mother.

RW: Wow! That’s pretty amazing. We have interviewed several master therapists of all stripes on Psychotherapy.net and that is the earliest beginning we have heard. What began to influence you to get into couples work?
SH: I don't recall a single course in couples work being offered at NYU graduate school ('75) nor at my internships, where I got otherwise excellent training. The phenomenon of couples work just didn't exist like it does now. I was fortunate to work with a doctoral fellow from Israel who was studying at Denver and he knew a lot about family therapy and the beginnings of couples work. He suggested readings and we did cases together. And then the rest of my training has been either from seminars and workshops or from listening very closely to couples. Also, conflict resolution theory and techniques have mainly originated in the realms of business negotiation, international relations, and legal mediation, which I have incorporated into my work.

Conflict Resolution and Marriage

RW: When did conflict resolution enter the picture?
SH: I had the notion that what I was doing seemed to be about helping people to resolve conflict, both intrapsychic and interpersonal.

Yet the only time I heard about it was from a one-hour lecture by an organizational psychologist who talked about the new literature on conflict resolution in the world of business. It stunned me that here we were helping people resolve their conflicts and yet not a single therapist that I had met seemed to know squat about conflict resolution. So I filed it in my mind that maybe, someday, I would learn all I could and one day write a book about it, which I did – From Conflict to Resolution.


RW: In the business world, conflict resolution and communication skills are much different then when people are in love or married. Lovers and married folks can be very touchy and can quickly regress, suddenly losing all the communication skills they have ever learned
SH: Yes, I think it's a sad state of affairs that most people behave far more maturely at work than they do at home. Now, the good news is that means most people are bilingual. They do know how to talk in a civil way and, even if they are beginning to get agitated, they will calm themselves down and resolve conflict in a fairly cooperative way. The bad news is how sad it is that we use a lesser language – the language of arguing – at home.
RW: Why do you think it is that lovers, married folks – who begin with such caring and consideration – find they can’t talk about hard things without arguing or withdrawing? They become their worst selves.
SH:
Why do people become more degenerate, more argumentative, more agitated, and more aggressive at home than at work?
Why do people become more degenerate, more argumentative, more agitated, and more aggressive at home than at work? Early on we see the difference. Many children fight a lot with their siblings and yet when they go to school virtually never have a fight with anybody. Even in abusive situations, many abusive spouses handle work conflict in a more collaborative way. There are three main realms where we learn the language of interaction: interacting with siblings and parents, and watching our parents interact. And, there are many more decisions that need to be made in a family.
RW: At home, it becomes a matter of the heart too and the stakes seem that much higher.
SH: Well, the stakes are higher and decisions need to be made about so much: money, whether to have kids, where to live, intimacy and sex, how to treat in-laws, how to treat children, how to spend leisure time, do we watch the football games on TV or do we have people over for dinner, or do we spend a lot of time going out together. Multiply that over and over again about all the decisions involved in making a life as a team, yoked together as partners. Those decisions are not only more quantitatively frequent but they are qualitatively different.

At work, you know for the most part who has power and what the expected roles are. At home, that needs to be negotiated. So, in families where everything becomes an issue, there are often underlying issues about how much power do I have, how much am I listened to? Or does he love me? Does she really care about me? We know that the more emotional intensity there is, the more likely people will regress in their collaborative dialogue skills.

RW: Clearly, as you point out, love is not enough since most couples love each other to begin with.
SH: Shall I give you the good news?
RW: Yes, the next question is: What can be done about that? What can you offer them?
SH: That's exactly what I was thinking about. I have come to see maturity as a function of skills. For example, as a tennis player, I have observed that there are plenty of people who just go out and play tennis. They never raise their skill level. There are others who go out and get some instruction or watch good players on TV or play with better players. Those people are definitely elevating their skills. It's much more fun for me to play tennis when I play better.

Living well as a couple means living with an excellent skill set – a skill set for dealing with conflicts, for dialoguing and sharing information effectively, for relaxing and enjoying life, and also skills for emotional self regulation. So, instead of getting agitated and angry, people stay calm and are able to use their skill sets to deal with difficult issues.

RW: It is nice when someone can communicate directly and calmly, but this seems unrealistic to expect people to just talk so directly and rationally. Some people tend to be more passionate, emotional, and some people are more private, more casual, shy, and some are super rational. People seem to have different ways of arguing and different ways of solving problems. Plus, there is a great deal of cultural variation in communication styles. How does your approach account for all these different ways since a lot of therapies want people to “speak directly, be clear, be rational,” yet that does not seem to fit everyone’s style so well.
SH: Right, there are certainly cultural variations, many of which are harmless. They are like the multiple flavors of ice cream. There are other cultural variations that have a major impact on how collaborative a couple is going to be or how likely they are going to be split off into separate realms. In some cultures, the roles between men and women are more defined and problems are dealt with indirectly instead of through direct communication. In most American couples, however, there is a lot of necessity for husband and wife to be able to make shared decisions, to function as a team. If the goal is to have a collaborative relationship, then there are certain principles of information flow.

I like to tell my patients I work on flow. A good analogy is traffic flow. Cars crash if the traffic is flowing too fast which is the equivalent to too much emotional intensity. Cars also crash if people don't follow simple traffic rules and guidelines.

RW: I have read that if traffic is going less than 30 mph there will be a traffic jam.
SH: This is exactly right. If you never get on the roads at all, you are not going to get where you want to go which is a mistake that many people make. They never even bring up the issues and talk about what is concerning them.
RW: Going another step: people seem to use communication skills and I-messages when they are calm but lose it when stressed out.
SH: The pivotal factor is that the more important the issue, the higher the level of agitation and emotional intensity, and the harder it is to have good communication.
It is just like driving a car, where speeding takes more driving skills but someone with excellent driving skills can still manage 90 mph. In terms of communication skills, most of us can go up to 30-40 mph with ease but we are in trouble when we go faster.
It is just like driving a car, where speeding takes more driving skills but someone with excellent driving skills can still manage 90 mph. In terms of communication skills, most of us can go up to 30-40 mph with ease but we are in trouble when we go faster.
RW: So what should we do when our emotional speed is too hot and we are traveling out of control?
SH: I teach couples that as soon as they are beginning to get out of their effective zone, just take a break and get a glass of water, learn to calm oneself, and then we go through this step by step. I teach each person this shared choreography so they don't feel like the other person is walking out on them. The agreement ahead of time helps monitor their emotional intensity. And, each person is responsible for calming themselves down and rejoining the discussion.

Heitler takes on Gottman’s Unresolvable Problems

RW: And what has your success been in working with couples to teach them these skills and resolve their problems?
SH: A significant proportion of my clients are referred by divorce lawyers. I also get newlyweds and people who are beginning to have some problems. I really like getting the 'last chance' cases. That's what I am known for in Denver, I am sort of the court of last resort. I would say, of those cases, the vast majorities end up with great marriages; they just never had the skill set.

What I hear over and over again is, "I wish someone had taught us these skills when we first got married. All those years and all that dreadful modeling we have done for our children wouldn't have happened. All those years of suffering, all those years of portraying how to make each other miserable wouldn't have happened if we had just known how to interact more maturely, more effectively."

Now does everybody do better? The reality is some people would rather stay how they are. My approach is a kind of a coaching approach to therapy and just like some people will prefer to stay beginners on the tennis court, some people aren't interested in learning in their marriages.

RW: So is learning the skills the whole of it for these couples?
SH: What you said earlier is very true. Once there are deeply felt issues, it evokes strong emotions even if people take breathers, that when they return they become so emotionally reactive on those issues or to each other that they will have a hard time using the skills. So a combination of skills training and therapy is really important.
RW: How and where does therapy enter into your couples work?
SH: In therapy, as people are getting hot, I would be more likely to help them see where their initial issue came from, their own marital issues or family issues from their past. I agree with the research that says skills alone won't work with difficult couples. First, the guidance of a coach who knows the skill set and, secondly, also knows traditional therapy skills of accessing family-of-origin material.
RW: You have questioned Gottman’s findings that often there are certain interpersonal problems couples have that will not be resolved, rather that over the years they will come to manage or work around these repetitive problems. How do you differ from this view?
SH: Yes, Gottman and I have had some dialogue in this regard and I have given him my books From Conflict to Resolution and The Power of Two. He has looked at them and said, "Yes, that's very interesting." I have been told by others that he refers to my work on conflict resolution in a positive way.
I have continued to hear Gottman say that some conflicts can't be resolved, that conflict resolution is an unrealistic goal. I take great exception to that.
I have continued to hear Gottman say that some conflicts can't be resolved, that conflict resolution is an unrealistic goal. I take great exception to that.
RW: Let’s hear it.
SH: Gottman and others have contributed excellent research on marital communication skills, but his writings do not include the advances in the conflict resolution theory that enable fights to transform into cooperative problem-solving and conclude with mutually satisfactory, win-win solutions – this is where my work is focused.

If there are conflicts between two people who have the cognitive flexibility to really listen to each other and work together till they can come out with win-win solutions, then those conflicts can be resolved. Of course, I would say that we all know some people aren't willing to learn the skills of win-win conflict resolution, but that is the exception. For example, I get conflicts about whether to have children or how many children to have. I have had a number of those cases in my practice and they have always come up with excellent win-win solutions. You would think either we are going to have a baby or not have a baby and that should be a zero-sum game, right? Wrong! It's how you decide to have a baby or if you decide not to have a baby. So even that is quite amenable to a win-win conflict resolution.

Hot Buttons: Geography and Religion

RW: You and Gottman seem to agree that some couples don’t solve their problems, but you emphasize that with the motivation to learn, most issues can be worked through. I would like to see this debated with Gottman, but, for now, what are the most difficult conflicts that you find couples having?
SH: There are some conflicts that are inherently more difficult, the two most difficult issues being geography and religion.
RW: I thought it was politics and religion.
SH: Right now, politics – I have found, that if people have very good skills, that most people can listen to the underlying concern and let it go after awhile.
RW: So then what about geography and religion?
SH: There are deep attachments that people often form not only to their family that might live in a certain area but also to the land. Now, I do think the more mature and more flexible people are, the easier it is.

I am thinking of one poignant couple, for instance, where she was rather a brittle person who felt very much of a New Englander. Now, myself coming from New England, I can identify with that. She grew up in an old small subculture there and she felt safe there, she felt she belonged. Unfortunately, her husband, a lovely fellow who had been very successful in business, went through 3 or 4 years where he was unemployed. It was terrifying for him since he wanted to support his family. Finally, he got a job in the Southwest and she tried to move with him but just couldn't do it. She wasn't able or willing to make new friends. She strongly missed being away from her parents and felt they needed her since she was the only child. It was multi-dimensional and a very difficult issue to find a middle ground on.

Now, remember conflict can be at a shared decision making or conflict resolution level. Shared decision making is what we call the process if it's going smoothly. We call it conflict resolution if the couple is getting oppositional. In this case, they were going beyond oppositional to desperate because they each felt so strongly wedded to their own concerns and unable to embrace it in a broader way to take into account the concerns of their partner.

RW: A very difficult situation, certainly. I saw a couple recently where the man felt strongly that they should move to the country so the kids could have a more peaceful life in a small community. And his wife felt they should stay in the suburbs near her friends and family. They both believed strongly that God was leading them to follow their own path in this matter and they went round and round on it.
SH: With religion too, that is double trouble.
RW: Since they were so adamant, I said, “Maybe God wants you to get divorced, the way things are going.”
SH: And then that would pose problems for me because I see myself very much as a pro-marriage therapist.
RW: My comment was tongue in cheek, said to make the point that they were falling into a trap of using God to support their personal preferences as a fixed solution that they had both become entrenched in; yet it was not merely an either-or solution.
SH: So this situation is extremely difficult.
RW: They actually share many of the same values and goals, but have different ideas about how to accomplish them. Understanding their shared values brought the conversation to a manageable level.
SH: Excellent! And again, if they are flexible, they would find some way to go to the country for the summers and live in the city during the school year.
RW: Yes, they are going in that direction for now at least – they live in the suburbs and go hiking and camping more often.
SH: And that takes both cognitive flexibility and financial flexibility that some people realistically just don't have. So, are there always options? Yes. Are they always within what the couple realistically can do? Once in a while, you find a real difficulty.
RW: Can you speak briefly on religion and marriage?
SH: Religion brings on non-negotiables. For instance, if you are an orthodox Jew, you just don't drive on Saturdays. You don't eat certain foods in certain places. You don't bring certain kinds of food into your home. As a reformed Jew, you can have greater flexibility in these matters. Basically the choices are doing things the more religious person's way, or finding someone whose lifestyle is more like your own. Now even that's not 100% true because there are plenty of orthodox Jews who think flexibly and creatively, who have married less observant spouses, and they find some way to accommodate each other's needs.

Changing the Argument Cycle

RW: You have done lots of consultations with therapists and trainings. What do you find are common mistakes therapists make in working with couples
SH: I see the same pattern everywhere. First, even experienced therapists are quite clueless about how to do conflict to resolution approaches. Second, virtually everyone takes too long to intervene with couples. So when I demo a case or when people watch my video that demos a case, one of the first comments I virtually always get is…
RW: I have seen the video, so it is striking to see how quickly you intervene and interrupt the arguing.
SH: If I am on my toes, they would never argue in my office because I intervene preemptively. Do you intervene after a car has rolled off a cliff or do you intervene when it begins to hit the soft shoulder? In fact, I intervene when they are just beginning to cross the line where there is still a little place before they go on the soft shoulder.

If a couple is accustomed to arguing, that means a lot of intervention. Intervention not just after they have argued but lots of setting them out to do it right. So, for instance, one person starts to says something… I can see the "b" of the word "but" forming on their mouth so I would interrupt them right there and offer alternatives.

RW: What is your thinking behind interrupting them and stopping their argument? Many couples therapists and writers will let them go on but try to help them argue better?
SH:
Well, I don't know what they mean by "argue better." It's an oxymoron from my point of view. Effective dialogue is almost always collaborative. Emotion and passion are fine but only up to a point.
Well, I don't know what they mean by "argue better." It's an oxymoron from my point of view. Effective dialogue is almost always collaborative. Emotion and passion are fine but only up to a point.

I am referring particularly to what I call crossovers when people are labeling others or speaking for the other person versus people speaking for themselves. Are they listening to take in information or they are listening like a hockey goalie to bat it away? Did they digest what the other person said out loud or do they just move on to their own thought? So there can be a perfectly civil collaborative tone but each person ignores what the other says rather than what I call breathing the dialogue. The couple needs to have a positive experience versus just repeating what goes on at home.

Also, many people don't know how to ask good questions. In other words, the alternative to you-messages is not just I-messages, it's good questions. Good questions almost always begin with "What?" or "How?" and many people don't know how to ask those questions. Lastly, many couples lock into a tug-of-war over "I want X," – "No, I want Y." Many people don't know how to switch levels to the underlying concerns that fuel such tensions.

Sharing Therapist Reactions in Couples Work

RW: Couples therapy involves the couple’s relationship and you have a relationship with them too. Are there times when you share your own reactions, personal feelings, your own life stories with clients?
SH: Well, I assume you might have noticed already I get tearful easily, so when I am touched, I am not going to fight it – it shows. And couples have often given me feedback later that my getting tearful in response was meaningful to them.
RW: What about anger coming out or other emotions that are not so tender?
SH: I do have anger. I am a human being and anger is very, very important as a feeling to know when something is wrong. So I use my feelings of anger to validate for myself when I feel that a couple or an individual is getting off track. For instance, I recently found myself getting very angry with a teenager in a family session with her parents. Did I act in an angry manner towards her? No! Did she hear some built-up tension and the firm manner of my voice? Yes! You could label her borderline or you could just say she had real difficulty self-soothing, very quickly misinterprets what is going on, and becomes angry and provocative; she had controlled her parents forever in this way.

So I used my anger in service of the work by allowing myself to feel my own anger and express my experience with her parents… that this girl evoked that response in me and does so with others as well, but the parents continued to enable this oppositional behavior. I essentially told them they needed to address it, talk quietly with her about this, and help her learn skills so she would not continue to be provocative in that way. But I showed them how anger could be used well instead of just going head-to-head with her.

RW: That is nice. It seems more and more therapists of various orientations are using their own reactions to bring about more immediacy in the session, which seems to lead to a more real and effective therapeutic engagement.
SH: That is a very good question for therapists: when and how do you share aspects of your life? The technique I most often use is if there is something in my own life that is relevant to them, I will talk about it in the third person or from a general perspective. At the same time, it's a little too complicated and risky to talk about oneself. But I don't have that as an ironclad rule. There are times when being able to share something about my own world facilitates the normalization of what they are experiencing. At the same time, it's their therapy, it's not my therapy. So that's got me wondering: do I not want to talk too much about myself?
RW: Too much or too little would be a problem.
SH: I think one can't err very often on the side of too little. If you never talk about yourself, I think that's fine. There are moments when something in my own experience could be very relevant and very helpful.

Saving Marriages

RW: Let’s go back to what you meant by pro-marriage. You said that you are pro-marriage and your website states that you specialize in saving marriages.
SH: Correct. Marriage happens to be good for people and there is very good research now out. For example, Linda Waite and Maggie Gallagher summarize the research very well. The research shows that people who are married are more fortunate than those who are not in terms of money, sex life, happiness, as well as physical and mental health. Now there are some exceptions to that. In general unmarried women do better than unmarried men. But, on the whole, marriage – particularly a good marriage – is a great blessing in people's lives. I think it's important to therapists to be unequivocal that marital health is good for people and marriage is a great blessing. And even the average kind of marriage seems to be far better for couples for the most part and particularly for men than a divorce.
RW: How does getting divorced or being single play into it?
SH: It's one thing to be single and it's another to be divorced. It turns out that people who have always been single adjust fairly well in life. More and more research is coming out showing not only negative consequences of divorce for the children, but also physical consequences for the couple as far as 20 years down the road. So, you can see why I am pro-marriage. 'Marriage friendly therapist' is the going term now. There is a new website at marriagefriendlytherapist.com.
RW: Marriage friendly therapist?
SH: Yes, my approach is friendly and supportive of marriage and I am dedicated to teaching people how to do it better. At the same time, nothing is simple. It is one thing to be rigidly against divorce and I certainly would not put myself in that category. There are definitely marriages that should be terminated. All people have the right to be safe in their marriage.
RW: So that’s what I was going to ask you, do you ever see couples and think, “Why did they even get married?” or “They should get a divorce.” What do you then?
SH: I lay it on the line to them. For instance, I remember one couple that I worked with over a period of months. She was a very fast-talking, highly energetic woman from New York, a very successful entrepreneur. He was a slow-moving guy, nice looking but kind of laidback Appalachian kid who had grown up in a dirt-poor environment. They had economic clashes plus educational, lifestyle and income differences. She was doing fabulously. He could barely hold a job. They used to argue a lot about everything since his way was radically different from her way.

Yet I was able to teach them some skills and help them to see their family of origin and cultural roots in context. But no real progress was made,
and at some point, I said to them, "I hate to admit this but I truthfully can't see how I can help you make a real marriage out of this. I can't see how to bring the two of you together. I see on each issue that we discussed such radical differences. I don't see how it can work."
and at some point, I said to them, "I hate to admit this but I truthfully can't see how I can help you make a real marriage out of this. I can't see how to bring the two of you together. I see on each issue that we discussed such radical differences. I don't see how it can work." I apologized to them.

To my surprise, they came back the next week and said, "Thank you so much. That was so helpful. We have stopped fighting." They came a few more times and I did not see them for years. I ran into her downtown one day and she told me an amazing story. She said that about three months after they finished therapy, she was diagnosed with breast cancer and he was an angel to her. His real mission in life… this story still makes me cry when I tell it now…was to care for her. And he was so loving, so marvelous. That's really why she made it through. It makes me tear up just to think of them.

RW: It seems you’re admitting how difficult their situation was and your sense of helplessness gave them a way to look at reality and do something about it. Plus, they rose to their life crisis in a way that transformed their lives.
SH: Absolutely. And this was maybe 10 years ago. I saw them recently and they said that they have continued to have a marriage where they both feel very blessed to have each other.
RW: What touched you so much about this couple?
SH: I think probably the limits of my own or of any therapist's ability to know what's good for another couple. They knew at a deep level that they were somehow meant to be together. So I could do what I could do, teach them a few skills, help them see the differences in their background and implications of that. I could go part of the journey with them and that was okay. And such a single limit of my… oh no I will start to get tearful again… of my ability to have to do more there, that there are bigger forces than therapists in the world and fortunately they take care of these things.

Now, at the same time, there are couples that the research would certainly say they ought to get divorced. If couples are fighting a lot, the research is unambiguous that it's better for the children for them to disengage; a climate of war in the house is not conducive to child rearing. Medved and Quayle partnered on a fine book called The Case Against Divorce where they outline 9 factors where divorce is indicated.

What to do with Secrets in Couples Work?

RW: What is your approach to seeing couples together and individually, and how do you deal with secrets?
SH: That's a very important question. I have written an article, Combined Individual/ Maritial Therapy: A Conflict Resolution Framework and Ethical Considerations, that sets me at odds from the conventional wisdom in the field. If a couple is in individual work with another therapist, I make it my policy not to see them in couples therapy unless the individual therapy is done with me. The individual and couples work needs to be under the guidance of one person or else it just doesn't work. If the therapy is split among therapists, they are almost inevitably going to have two different databases so that the therapist becomes a source of iatrogenic doctor-induced damage.
RW: I would think this is even more so with high conflict clients, though yes, it goes against the grain in the field.
SH: The therapist is unable to correct the distortions because they can't see for themselves what the other person is doing. The client in individual therapy presents as being so perfectly nice, very warm, very nurturing, very interested in changing… you see their healthiest side. Many times I saw this in working with just one person then was stunned to see what happens when they are interacting with their spouse.
RW: How do you set up who comes in to see you?
SH: If they are in a relationship or married, we encourage them to come in from the very first session as a couple. Then we will work out to what extent they do individual work, couples work, or some combination of both. Also, when you are stuck in the couples work, switch to individual and you will find out what the 'stuckness' is about. I recommend that they each do a similar number of individual sessions. The client is able to relax and speak more freely, take in new information, or experiment with new stances in a way they may not be allowing themselves to do while the other is watching. Then you have more leverage with that person when you return to the couples work. In real troubled couples, I will consistently see them both alone and together.
RW: What about keeping secrets and confidentiality in this flexible approach?
SH:

It is very important that a therapist have a policy and state it clearly in the first session. The prevailing policy seems to be that there are no secrets: if you tell me something in session, I have the option of disclosing it to the other.

I am truthfully horrified by this no-secrets perspective because it means that if one person really does have some information they don't want the other party to know about for whatever reason, they are not going to disclose it to me.
I am truthfully horrified by this no-secrets perspective because it means that if one person really does have some information they don't want the other party to know about for whatever reason, they are not going to disclose it to me.

After laying out the foundation of confidentiality, I turn to each of them and say, "When I work with either of you alone, the confidentiality that I am bound by limits keep me from saying to your spouse what we have talked about. Each of you can trust in that privacy." Then I explain that they are free to speak with each about their own therapy or to play the session tape because I audiotape every session and give them the tape so they can listen to it. I am the only one that's bound by confidentiality. The tape, by the way, radically increases a therapist's effectiveness since patients benefit greatly from listening to the session.

RW: Many experienced couples therapists I know take an approach that gives each person confidentiality in their own sessions. But I agree with you that the no-secrets approach seems to predominate in graduate training. New therapists are afraid of keeping any secrets for fear of becoming confused about who said what. My experience has been that people keep private things all the time in life and people appreciate it in therapy as well. You don’t necessarily tell one good friend what another friend said about them. With tact and permission, I find that most people want to bring out important issues in the couples session as well.
SH: Exactly. And people tell their spouse information and they don't expect them to tell others. Privacy and maintaining boundaries of privacy is an important maturity skill. I think I learned this lesson years ago when I saw one of my first couples and, sure enough, it was a situation where the man was having an affair. I don't know why it happened that he spoke alone with me at some point, but we had one session on the affair. Through that session, he realized, "I don't want to be having this affair. I want to get out but feel so stuck in it," which is so common. And so we role-played how you end such a relationship and he learned that skill set. He ended it and we subsequently went on to deal with their problems and concerns which we handled virtually immediately.

I saw them some 15 years later when I was downtown.
remember thinking, "Thank heavens I disobeyed the conventional wisdom of the time and did not insist that everything come out in the open."
remember thinking, "Thank heavens I disobeyed the conventional wisdom of the time and did not insist that everything come out in the open." My guess is he has never told her; it was one of those stupid mistakes people do. They have a wonderful relationship. They never wished for Humpty Dumpty to fall apart. And I at least have no responsibility for whether he told her or didn't tell her. I care that they have raised five wonderful children and have a great marriage.

Heitler’s Husband and Tennis Coach Teach Her Some Things

RW: On a different note, what have you learned from your own relationship and marriage to help you in being a couples therapist?
SH: A lot. If it doesn't work at home, I am surely not going to teach other people to do it. My husband has been my accomplice or coach in this whole practice of learning about what principles keep data flow moving comfortably, playfully, effectively. He's been wonderful about that.
RW: Do you have an example?
SH: There is the classic therapist dilemma which is when I know the rules and he doesn't in terms of effective dialogue. It's not going to work for me to coach him when we are in the middle of the discussion because that's what I call a crossover, telling him what to do. And what my husband taught me to do was use my own ideas with him. I can talk about myself or I can ask about him. But it's not for me to either examine his way of talking or tell him how to talk or what to feel or think. So all I can do is model it or ask "How?" and "What?" questions myself.
RW: What about for therapists who are married to one another; often people think they should have some perfect relationship…
SH: And they should.
RW: Really?
SH: If they can't do it at home, what are they doing talking to other people? Would you want a tennis coach who can't play tennis?
RW: We would want a tennis coach who can learn from his mistakes and could correct them, but I think therapists can overanalyze things to a point where it gets in the way of living life. Indeed, some coaches are so good at their sport that they become perfectionists and can’t coach beginners well. Some of the best coaches are just fair players.
SH: That would not be enough for me if he really wasn't good at the game. But yes, some great players have forgotten what beginners do. So I think one doesn't have to have a perfect relationship. One does have to have a good strong skill set, like my current tennis teacher, Charles, who I am very fond of.
RW: I can tell. What makes you so fond of him?
SH: He is a dear of a person, has a marvelous eye for what the next technique is that would move me to the next level of playing. And part of the fun is that although he is a good player, I can still win some points off him. He reminds me of what it is like to be a great therapist.
RW: Let’s hear more about that. What about his coaching is like being a therapist?
SH: As long as I feel like I am learning every single lesson from him, I feel like I still want to be taking lessons from him. He is actually a very unusual tennis coach in terms of where he came from in life. He is an African American fellow in his 20s who grew up in a very poor area where for years he was doing all the riskiest things in his life. But he has always been a very good athlete who had a great tennis coach. Eventually, the head coach at my tennis center found him and said, "Hey this guy is a gem," because he has strong skills and has an engaging charismatic, fun personality. Charles just lets himself be Charles out there. He is upbeat, full of enthusiasm when I do things well, like he really cares how I do. He's really in there, connected with me. So I think what I am saying is that therapy too should be skill-based work and fun.
RW: Good coaching and good therapy have lots in common. What other advice would you give for young to mid-ranged therapists?
SH: You can't coach if you have no skill sets, so a therapist has got to really be well-schooled in at least the main couples techniques that I set out in my book The Power of Two. To me, those are the skill sets that one needs to be a quality therapist.
RW: What about the ability to form a positive relationship or working alliance with couples, to be able to approach problems in a collaborative way?
SH: The ability to have an alliance with a couple is a function of therapist attunement to the couple. If you are only listening without also being a person there commenting on what you hear, then you don't have attunement or a relationship. So I spend very little time at the outset of therapy worrying about building a relationship. I build a relationship because I am an attuned and responsive human being as we talk about their problems. Within the first five minutes of seeing a new patient where we are interacting, I am in there with them.
RW: You are not building a therapeutic relationship, you are having one.
SH: I love that way of describing it.

Heitler's Hats
Coaching Hat: Teach people the skills that enable them to have successful relationships. These intrapsychic and interpersonal skills facilitate self acceptance, coping with stress, emotional self-soothing, and soothing of others. Couples can learn these skills, be prompted, and can reinstate them after failing to use them in a tense situation.
Healer Hat: Use traditional therapy skills to understand the patient's past, family-of-origins issues, understand depression, anxiety, anger, obsessive compulsive and addictive disorders and know how to reduce or eliminate the symptoms.
Mediator Hat: Walk people through their intrapsychic and interpersonal conflict. Help them to tolerate emotional exploration while using the dialogue and question skills that enable them to keep moving forward in the three steps of conflict resolution: express initial position, explore underlying concerns, and create mutually satisfactory solutions responsive to all the concerns of the participants.





Still Having Fun

RW:
SH: Obviously after more than 30 years in the field…
RW: Obviously you have kept your enthusiasm in the field and it shows. What is it that still excites you about the work?
SH: Like with my tennis coach, I enjoy my clients and the work. I am playful, we laugh a lot, we have a good time. I don't think therapy has to be this deeply serious thing all the time. Certainly, there are issues that carry more emotional weight and need to be given their due. Even more than that, when I think of all the next generations that are benefiting from their parent's growth, because the skill sets get passed on from generation to generation. We therapists are very, very fortunate to be able to have this kind of impact on our world and the generations to come. And it's also a great fortune to be able to spend one's life making other people's lives radically better.
RW: Thanks for sharing your work and yourself with us today. I agree it has been fun.
SH: I have enjoyed it as well, thank you.

Kenneth V. Hardy on Multiculturalism and Psychotherapy

Posted on by rezendevknowfully.com

Trained to be a “pretty good white therapist”

Randall C. Wyatt: Hi Kenneth. Today I want to talk to you about your work in ethnic studies, diversity, and social justice with a particular emphasis on how that impacts the work we do in psychotherapy. But I want to start with something basic: What originally got you into the field of psychology and diversity?
Kenneth V. Hardy: Good to be here Randy. Well, at a very early age I started noticing differences in human beings and mostly my own family. I became intrigued just by how was it that my brother and I could grow up in the same family, two years apart, and yet be so incredibly different. I think some piece of that curiosity extended to things like these broader social concerns. I have vivid memories of going home in Philadelphia and asking my parents and my grandmother why there were so many people sleeping on the streets. Despite their best efforts to provide me with what they thought were pretty cogent answers, the answers they gave me didn’t make much sense. I had this insatiable curiosity about how we ended up in circumstances in life. Long before I even knew what to call it, I had some passion for it. I just knew that I was interested in this unnamed discipline that would help me understand human beings better.
RW: Where did you end up going to school to get your psychology degree?
KH: I did my undergraduate work at Penn State University, a Master’s degree at Michigan State and got my doctorate degree in clinical psychology at Florida State. So I did a little bit of globetrotting.After getting my PhD, I hung around in Tallahassee, Florida for a bit, worked, stayed on at the place where I’d done an internship. Left there, took a job in Brooklyn, New York, at an outpatient psychiatric clinic, and there some of my interests around issues of diversity and race began to crystallize.

I realized after working at the outpatient psychiatric clinic that

my training had prepared me in a way that I was a pretty good, decent white therapist

my training had prepared me in a way that I was a pretty good, decent white therapist. I was in NY and there was great diversity in the clients I was seeing: immigrants, African Americans, poor, and so on. I realized at that point that I was poorly trained and oftentimes challenged very directly by clients of color about the ways in which they felt I was not understanding or appreciative of their experiences; that was very enlightening for me.

RW: Say more about what you mean when you said you were a “pretty good white therapist.”
KH: What I mean is that I had gone to predominately white schools. I struggled with how to take the theories and conceptual models I was exposed to and massage them to apply to individuals and families of color; I was pretty much left to do that myself. There wasn’t someone to oversee, guide, and mentor me for that. I was introduced to ways of thinking, ways of conceptualizing human behavior, problem formation, and solutions from a more Euro-centric point of view. And I don’t think there’s anything necessarily wrong with Euro-centrism. It’s just that not everybody is of European descent.
RW: Much of your career has set out to change that emphasis and broaden what psychologists and psychotherapists study and who they work with. We will get to more of that in a minute. What did you do next in your career?
KH: I left New York and took a faculty position at the University of Delaware for a short period of time, and then I then went to Washington DC to work for the American Association for Marriage and Family Therapy as a senior executive. I also worked rather assiduously there to keep my fingers in academia at Virginia Tech on their campus in Fosters, Virginia. And then after almost ten years at AAMFT, I left to go to Syracuse. There was a program specializing in family therapy and social justice that drew me there. I helped to get the PhD program started and to help solidify the emphasis of diversity and multicultural social justice.I recently moved back to a program in Philadelphia Drexel University where there is a strong emphasis around diversity and social justice. And my last book was on youth and violence (Teens Who Hurt: Clinical Interventions to Break the Cycle of Adolescent Violence) and sadly and unfortunately, Philadelphia has a major problem with violence, in particular, youth violence, and so it’s an important place to continue my research in that area.

Social justice and diversity

RW: How do you describe and differentiate diversity and social justice?
KH: I’m glad you ask because lately in lectures I’ve been suggesting that we as a discipline need to tease out a bit some of the nuances and distinctions that exist between diversity and social justice. I think that they’re first cousins but they have different emphases. With diversity, it means acknowledging and finding ways to appreciate differences. How do we include? How can we be more inclusive?Social justice has more to do with critiques around power and the inequitable distribution of power. The more diversity-oriented orientation would be one that would embrace some piece of the ideology, “I’m okay, you’re okay.” This presupposes that we’re all situated equally. I think a social justice perspective, while it appreciates differences, also attempts to look at the ways in which we are situated differently and the ways in which everyone possesses power but not everyone possesses it equally. Social justice is about, in one sense, rectifying fractures and ills that may be attributable to the inequitable distribution of power. Social justice is about recognizing that some voices are louder than others, that some people have greater access to power than others, and then what do you do about that. What is your resolve to alter that?

RW: Can you give an example of social justice from something that’s happened or that you’ve noticed?
KH: At this workshop I was just doing here in Berkeley on various isms (Building Inclusive and Multi-Culturally Competent Health Organizations: A Healing Approach to Addressing the Isms), we’re thinking about how to bring people together across any kind of divide—whether it’s race or gender, sexual orientation, class, blue states and red states. We are bringing people together to constructively engage and question the conventional wisdom predicated on the notion that everybody has equal opportunity, equal voice, equal power. I think that’s a fundamentally flawed position, because I think when you bring people together, for example, people of color and whites, there’s a way in which people of color and whites are not situated equally in those situations. It may be an equal resolve to have the conversation, but one group historically has had more power, has enjoyed more privileges and had greater access to resources than the other. So to freeze frame it in this moment and treat it as if everyone is equal, I think disadvantages the group that’s been historically disadvantaged.Now, I used people of color and whites in my example, but I certainly could argue that the same would be true if we were trying to cross a gender divide.

RW: How does it take shape with men and women?
KH: Men historically have had more power than women have. And so that if you’re trying to problem solve, it doesn’t make sense to start from the point of view that presupposes that men and women are on equal footing. That is in keeping with what I think the social justice position would be. What it means is that power and distribution of power is being factored into the analysis of relationship dynamics.
RW: I can see what you are saying and it makes sense – the importance of taking power and history into account. How then does an awareness of that different distribution of power make a difference in a conversation between people?
KH: It can play out in many ways, but I think that what the whites would refrain from doing is turning to people of color and asking them in those settings to teach them, forgive them, accept that they’re unique or whatever.
RW: Like, “Hey, accept that I’m the good white guy.”
KH: Yes. What that does is draw upon these narratives from history, which is what the person of color is in—same would be true for a woman—that they almost immediately get into sort of a caretaking role. And so, like what I would expect from you as a conscientious white person, who’s aware, that even if we were in a group together and you saw me beginning to do this thing, which is caretaking of you, that you would have some consciousness about what’s going on and use yourself in a way that you didn’t collude with me around that.I’ve developed this model which outlines what the tasks of the privileged are in these conversations and what the task of the subjugated are.

RW: So let’s hear your basics on what these tasks are.
KH: If you’re in a privileged position—and it doesn’t matter to me by virtue of what race, class, gender, sexual orientation—I find a much more useful way to have these conversations than to get bogged down in the fine distinctions between these issues. The underlying process is the same no matter what the context is, whether I’m in an organization talking about how to bridge the gap between senior management and laborers, it’s the same process. They’re privileged; they’re subjugated.So one task of the privileged, for example, is to make a critical differentiation between intentions and consequences, because I believe that when one is in a privileged position, one almost invariably talks about intentionality.

RW: “I meant well” or “I was trying to help, trying to do the right thing.”
KH: Exactly, that’s right. You can mean well, have pure intentions and still do harm. And so, conversations between the privileged and the subjugated—whether we’re talking about blue states and red states, or men and women, or poor and wealthy, or races—break down when the person or group in the subjugated positions is principally concerned about consequences where the person in the privileged position is concerned with intentionality. And because the person in the privileged position has power, they have a greater opportunity to frame the discussion around the purity of intentions rather than honoring consequences.So for example, if you said something that I considered racist and I said to you, “That upset me, it was racially insensitive, etc…” This type of consciousness about privilege and subjugation from the social justice perspective would hopefully inform you to address the consequences of what you said rather than providing me with an explanation.

RW: Pay attention to how what you did or said affected the other person versus just defending or explaining yourself.
KH: Yes, I understand how it happens to defend and explain but it’s not a useful conversation. It doesn’t allow for a deepening or an advancement of the dialogue. If I’m stating to you an infraction that I have experienced and your retort is about the purity of your intentions and how I’ve misunderstood it, you see, then that conversation becomes a conversation about what your intentions were rather than a harm that I thought was done to me. Does that make sense to you?
RW: Yes it does and it is quite poignant with significant implications for relations between people and in therapy. Can you tell me why you think this is so crucial?
KH: I believe that an explication of these tasks are important and a necessary prerequisite to bringing people together to have these conversations. I think that these issues around theisms are so explosive and so laden with heavy meanings that it doesn’t make a great deal of sense to me that we can simply bring people together who have been in a tense relationship and just suddenly have a conversation because there’s the will to have it.

I think will is important, but I think you have to have will and skill.

I think will is important, but I think you have to have will and skill. And sometimes, even the best of us have will but no skill, or it’s possible to have skill and no desire to do it, a lack of will.

RW: Will and skill, that’s nice. Let’s go back to the consequence and intention. It seems both would have to be attended to for each person to feel it works in the conversation. The person in power that made the offensive comment or unintentionally offensive comment would have to communicate “I didn’t mean to do that and I am sorry that it hurt you.” The person who felt hurt, offended, thought it had to do with race, let’s say, or whatever, would have to know that their pain and hurt was understood and not dismissed or explained away.
KH: I certainly understand what you’re saying with that, but I don’t think it’s necessary in the midst of an infraction or offense for the person in the privileged position to even get into clarifying intentionality, because that’s designed to take care of them. It’s not on behalf of the relationship. And so when I’m in that position, if a woman is saying to me, “You know, you just said this thing, Ken Hardy, and I’m offended. It did not feel good to me as a woman.” What I need to do is rather than say, “Oh, wait a minute. You misunderstood me. That’s not what I meant. You know, I meant this or that.” What I need to say is, “I’m sorry that I said something that was hurtful to you.” I appreciate the conversation because what I believe is that when you’re in a subjugated position, I don’t think it makes much difference whether it’s intentional or not.
RW: Okay, let’s hear why you think that and why this is so important.
KH: Say that in my haste to go to the bathroom, I step on your foot and break your toe. Your toe is broken whether I intended it or not and that what I need to do is to attend to that first and foremost before I get into any explanations. Let me just think about how ludicrous that would be, that I’ve broken your toe and I’m taking the time to explain to you how it was not intentional and that I’ve never done this before, because what I imagine is that what you’d be most concerned about is getting your toe attended and this whole piece about “I didn’t mean to do it” is not attending to you; it’s attending to me.
RW: This example is right to your point, certainly. I would think it does matter a great deal if a person broke my toe intentionally or not but I would say in support of your point that attending to the wound basically shows that you care about the person and implies that it was not intentional. I’ll go with you on that. Historically there has been too much room for explanation of intention and not enough for the consequence. When there is a crisis going on or a person is wounded, such explanations seem almost superfluous or dismissive.
KH: Yes, and especially because of the history of inequities.
RW: So what are some examples of the responsibility or tasks of the subjugated?
KH: One example has to do with reclaiming one’s voice, because I do believe that when one is in a subjugated position, one typically becomes silenced. Say a woman colleague of mine is offended or feels hurt by something I’ve said but she does not say anything to me, and is quietly resentful and that resentment erodes our relationship. So she’s walking around with something that’s developing, swelling up in her for three weeks. Now she is further upset because I am walking around as if nothing happened. Well, from my perspective, nothing did happen. And so she can’t hold me accountable for that, which she hasn’t shared with me. And so, I do think

that part of the task of the subjugated is to give voice to one’s experiences.

that part of the task of the subjugated is to give voice to one’s experiences. The same would go for me if I was offended at something a white colleague said to me. It sounds simple but I think it’s very complicated because I think that the very socialization process of the subjugated is one that orients them toward silence, a kind of voicelessness.

Another task of the subjugated is to really overcome having to take care of the privileged in very sophisticated ways, often involving self-sacrificial behavior. “I’m not going to say what I believe and I am not meaning what I say,” for example, would be a way in which I sort of protect the privileged because I don’t want to be thought of in a certain way, and so that I end up compromising myself.

I always know that if I’m doing a workshop and if there’s what some might call a “radical militant gay person” in the group who’s challenging heterosexism in a way that makes straight people feel uncomfortable. Invariably what happens is, there’s usually another gay person in that group that’s going to challenge the more radical, outspoken gay person.

RW: Interesting. What do you think is behind this reaction and what are you getting at here?
KH: I see it as a very sophisticated form of taking the privilege. I think dynamically that there’s some inherent fear that people in the subjugated position have about the privileged being taken to task. Sometimes bad things happen when the privileged get challenged. I think historically whites have done that with people of color. I think men have done that with the woman who says more than we think she should say. And so it’s not like it’s necessarily something broken in subjugated people; it is a reflex reaction. It is learned behavior that has to be unlearned in order to be able to constructively engage in these discourses in a way that I think is necessary to move forward.
RW: I get how the one gay person may speak their truth, their experiences and…
KH: Can I interrupt you for a second? Because for me, it’s “radical gay” in quotes. It may not be a person I necessarily consider radical but is being perceived in the group that way.
RW: Okay. I would think if the second gay person was trying to help them be more constructive, that would be valuable. But my guess is you are speaking of times when the second person is trying to soften the blow, to make nice, to avoid the issue, so to speak. Is that it?
KH: I am glad you said that, yes. When one person is trying to almost undo what the other subjugated person has said. I do also think that when you are suffering from ways in which your voice has been muted and when you are in a process of coming to have your own voice, that the voice that you are evolving toward is a very primitive unrefined voice. It’s raw.

Silencing rage versus giving voice to rage

RW: That is a powerful distinction, that the person whose voice has been muted, historically silenced, is finding their voice, and an expectation of some super constructive expression is unrealistic and not really looking at the reality of the situation.
KH: And also, in the interest of the relationship, I would hope that the person in the privileged position—in this case, me—would be able to hold that sometimes-belligerent raw voice, to not issue preconditions, because there’s something about the issuance of preconditions that has the net effect of silencing again.
RW: I’m reminded of a client, an African-American male, who came in with his white American wife because their child had been kicked out of school for fighting. And the father had gotten in trouble for spanking his kid, CPS had been called, and they’d been referred to me. The mother came in quite calm, wanting to know what to do differently. The man was quite angry, very angry and the wife was getting very uncomfortable, trying to calm him down: “You’re in a professional office, and CPS is after you. Bring it down.”
KH: That’s a tough situation, what did you do?
RW: Now what I did, and hopefully I was getting at what you are saying, we’ll see what you think. I said to her, “Why don’t he and I meet together for awhile?” Because he was going off and I had not made much of a connection to him yet. And so she left and he kept going on, so I thought I’d kind of join with him instead of trying to silence him, by saying, “It sounds like you’re furious at this situation that’s happened, you’re tired of it.” And trying to get his voice to come out more rather than less.
KH: Right. That’s right. How did he react?
RW: He seemed to appreciate that. I brought up the issue that I was a white male and how he now was sent to see the man. I asked him, “Do you have any thoughts about that?” He said, “You seem okay, but you know, yeah, you’re right. I didn’t want to come here.” And then the third thing I tried to do was kind of even go one more step, which felt a little risky, but I said, “I’m wondering, you know, what’s going on with you disciplining your kid and they’re saying you’re too much, that you’re out of control – I’m wondering if you’re trying to protect your kid from getting in trouble. That’s why you’re doing this. That you see what is happening with so many black kids and you don’t want that to happen to your kid.” And he said, “Yeah, I’m spanking him more for a reason. I don’t want him to get into fights and like a lot of black men end up in jail. I don’t want my kid to go through that, nothing scares me more than that. ” I felt I was out on a limb in a way, but it felt right and he softened and we went deeper in the session.
KH: That is precisely what I’m getting at, with his anger and his rage—it was counterintuitive—that rather than try to cap it, you moved toward it almost implicitly, encouraging him to go there. I think it did a sort of counterintuitive thing for him; he actually calmed down. I think if you tried to suppress that affect by sitting on top of it [pushes hands down] you press down, it goes up.You know, what you did was,

you were able to sort of get him to calm down by basically almost encouraging him to sort of rage in your presence, and that’s precisely what I’m talking about.

you were able to sort of get him to calm down by basically almost encouraging him to sort of rage in your presence, and that’s precisely what I’m talking about.

And I think that that type of intervention or technique if you think of it that way, I think is within the province of the privileged to do that. I think that when I’m situated in interactions where I have the power and privilege to do that I want to do just that.

I would say that I’m not one of these folks who are out trying to eradicate the world of privilege and dismantle all privilege, because I don’t think that privilege in and of itself is necessarily a bad thing in all circumstances. I think what we ultimately do with privilege determines the valence that’s attached to it, and so that I think it’s possible to have privilege and use privilege responsibly. I think it’s possible to have privilege and use privilege abusively.

RW: I like that you don’t divide people into such either/or categories in that it depends on the situation. Would you say that you’re privileged as a therapist, as a professional, a doctor?
KH: Absolutely. As a man, as a heterosexual, in many ways. And so what I hope for myself is that I use the privilege that I have in a very conscientious, respectful way that helps to promote the kind of change that I hope for rather than using it to exacerbate preexisting differences.
RW: Silencing.
KH: Yes.
RW: Now I want to go back to something you said because I want your take on it. You said that what I did was a good technique, how I got him to express his rage and I gave voice to it and it counterintuitively calmed him. I would have to say I thought he had some valid points, and some of his rage was valid, that yeah, “There’s a reason you’re really trying to manage and help your kid. Maybe you’re going overboard at times but I can see how much your care about your kid.” I didn’t think, “Oh, I’m just going to do this to calm him down.” This is not a technique to appease him, it’s vital and real. I meant it.
KH: Right. Yeah, I appreciate that. There’s no way for you to know this, but just yesterday in my workshop, I’m saying to folks what I believe is exactly what you’re saying. That there’s a piece of what I’m suggesting that looks like a technique although I don’t think it is simply exclusive technique. That if that were just a technique for you, it probably wouldn’t have worked. It was as much ideology as it was technique—there was a way in which you looked at the world that helped that technique to be effective. Even to the point where you say, “I wonder if you’re concerned about your son out there.”Now, I’m telling you, any time any white therapist says that to a black male client, it says so much more than those few words state.

If you’re saying that to me and I’m your client, what I’m thinking is, “Damn. He understands. You know, he understands the reality of the world out there.”

If you’re saying that to me and I’m your client, what I’m thinking is, “Damn. He understands. You know, he understands the reality of the world out there.” I mean, you didn’t have to name it anymore explicitly than you did, but if I’m that client, I’m thinking, “He gets it.”

That’s the part that has virtually nothing to do with technique as such. It has to do with a piece of consciousness, a piece of a world view that you have that you bring to this, and I think that, when I talk about the task of the privileged, responsible use of privilege, that that would be the embodiment of it.

Talking about diversity concerns in psychotherapy

RW: Let’s go to psychotherapy specifically. You started out by saying you were trained to be a good therapist for white people. What is the difference between a therapist practicing therapy as usual versus a therapist practicing therapy informed by racial sensitivity and multicultural concerns?
KH: Well, I think the major difference is that psychotherapy as we’ve known it, as we’ve practiced it, has been one where the focus has been around the, for lack of a better term, the psychology of one’s being… to look inside of me and make some broad generalizations, determinations about what’s broken inside of me. The unit of inquiry really centers around the individual, the intrapsychic processes, and maybe one’s interpersonal processes depending on what you’re doing.I think operating from a culturally informed, multicultural perspective is the recognition that psychotherapy is not just about one’s psychology but also, broadly speaking, about one’s ecology. I’m not just concerned about how is it that this person’s family of origin impacts the client you talked about earlier. There’s a difference between looking at how his family of origin impacted his parenting practices and what society would consider abusive discipline habits—that’s one way of looking at it.

The other way of looking at it, for example, would be to raise questions about what impact his lot in life out there in the world as a black man has on his parenting practices, in addition to his family background and inner world. I’m as interested in one’s ecological context broadly defined and how it shapes behavior, as I am about one’s intrapsychic, psychological processes. So I think that the point of examination is a wider lens.

And I also think that the other piece of it is that it’s not just about having capacity to see it and conceptualize it, but also having a requisite skill to talk about it.

RW: In your experience, how does it play out in talking about diversity and culture in therapy?
KH: In any number of ways. I think in having the willingness and the foresight and the skill to name it. I’ve had people watch me do therapy and be very critical of the way I do therapy. Let me give an example from one of the Psychotherapy with the Experts therapy videos1 with an interracial couple. She’s Chicana, he’s African-American and a stepfather to her two boys by a previous marriage, also an interracial marriage. The boys who are his stepsons, are failing in school, and are into rap music. And he really struggles with that. Now part of my hypothesis is that he may struggle with this because they are more identified with urban black hip hop culture than he is comfortable with.Afterwards some of therapists watching this session say, “It seems like there’s a lot of discussion about race and I don’t know why that was necessary.” And so that to me, that’s a difference in their perspectives and I think that’s how it translates in therapy.

There’s a wilderness of creative space in the therapeutic dialogue for the recognition of race and class, how they inform who we are, decisions we make or decisions we fail to make.

There’s a wilderness of creative space in the therapeutic dialogue for the recognition of race and class, how they inform who we are, decisions we make or decisions we fail to make. Because there’s no aspect of our lives that aren’t, I believe, shaped by the nuances of all these issues—race, class, gender, all of those things.

RW: Why not? I mean, you can almost turn it around and say these are part of the fabric of life, the threads, so it would seem unusual or troubling to not be noticing their relevance. Yet, for years we didn’t.
KH: That’s right. And some today still don’t because they don’t see the utility of doing that.
RW: Let’s say, some may not see the utility, but maybe many also think there’s a danger or a fear, or that it could be offensive, or that it could stir up things and cause a greater problem.
KH: Yes, I think that is true. I think that these fears are impediments to talking and yet I think there’s a greater likelihood to be a problem when it doesn’t come up than when it does come up. And I’m not just talking about bringing up race with clients of color. I’m not just talking about discussing gender with women. I mean, I think it’s important for us to have these conversations with clients across the board and have an openness to look at them. See, I guess that’s the difference. I’m keenly interested in knowing how one’s life and relationships are informed by all of these issues, no matter who’s sitting in front of me. Because I think they do inform our lives though we may not always be conscious of it.
RW: If they are brought up in a constructive way, people seem to love to talk about such things and it brings more meaning to the conversations.
KH: That’s right. And particularly people for whom it’s a major core aspect of their identity and their lives, I agree with you. I think, when properly executed, it does provide a deeper level of richness to the conversation and to the relationship.
RW: I mean, I come from an Italian-American background and if my therapist didn’t know that my grandfather came from Italy, I would feel like he didn’t know about me.
KH: That’s right. I, as your therapist, after having that piece of information would then be curious about your name.
RW: My last name is Wyatt, which is my father’s name. His family came out west from Missouri in the dust bowl and he was mostly English and some Cherokee Indian. My mother’s maiden name is Acquistapace which is Italian. So if my name was Acquistapace, people might see me differently.
KH: That’s absolutely right.
RW: So many people say, “You can’t be Italian.”
KH: Right. They’ll tell you.
RW: Which I’m sure comes up even more so for mixed race, black/white or other mixed race folks.
KH: Yeah, it’s the audacity of it that people can make a claim on somebody else’s identity, and that’s why what you said just cracks me up because I’ve heard so many times, “You can’t be that!”

The psychotherapist as the broker of permission

RW: Can you talk about other ways that discussing racial issues can play out in therapy? Let’s say you’re seeing a white client. Usually most of the books on multiculturalism and psychotherapy are written to the white therapist and say how we can be more informed about ethnic minorities. So very few books are written to the black therapist or the Asian therapist or the gay therapist about how that therapist can work with cross-cultural issues. Yet, since people from diverse groups and identities are becoming therapists more often now, that is changing some. What goes through your mind when you see white clients? What issues have come up for you?
KH: First, as you said, there is a dearth of information about therapists of color with white clients, I think that needs to be addressed more. I also think part of the reason is because it’s part of the psychology of being a minority. When you’re a minority, you have to know about the majority group, so I think that’s part of the reason why that gap exists there.
RW: That minorities live in two worlds.
KH: And where your very survival is predicated on your knowledge of the dominant group, to have to know what to say, when to say it, what not to say.But to come back to your question about therapy. My guess would be that you could interview 100 therapists of color and 90 of them would report anxiety and discomfort about that walk to the waiting room for the first time seeing a client—it comes up in workshops all the time. I’ve experienced that when I have white therapists who refer white clients to me they find it necessary to let them know I’m a therapist of color. So they’re forewarned about that.

RW: Before you go on, it’s fascinating that you mentioned that. When I told people I was interviewing you, one person brought up the question of therapists notifying the client about the therapist being Black. I wondered if this was as common as he thought it was.
KH: It happens all the time. For some therapists I know they routinely and naturally describe people that way, their gender, race, etc, which I don’t have a problem with. But, if it is selective for one race that is problematic. I’ve found myself anxious about what reception I will receive and I don’t think that would be true for you. So either the client is already forewarned that they’re going to see a black person: “You need to know this before you go” or they are not told and are surprised to see me.

I’ve watched clients get paralyzed. “I’m Dr. Hardy, your therapist,” and they cannot move; they are so utterly shocked by it, by the whole race thing.

I’ve watched clients get paralyzed. “I’m Dr. Hardy, your therapist,” and they cannot move; they are so utterly shocked by it, by the whole race thing.

I also think that in situations like that, when it’s cross-racial therapy, it’s really important to me to name race very early in the process, which I often do. I’ve written about the importance of the therapist being the broker of permission. And I think that that permission to acknowledge and talk about race has to be given before it ever happens because the rules of race in our society is that we don’t talk about it. So I use myself to do that. I will make reference to myself in therapy. “Well, as an African-American” or “as a black therapist,” which is my way of saying to you, the white client, “I’m okay acknowledging race. I’m even okay if we talk about it.”

RW: The way you introduced it there was in a subtle way, putting it on the table.
KH: I believe that permission granting maneuver requires some subtly.

I don’t agree with the strategy where white therapists ask clients of color, “How do you feel about being in therapy with me?”

I don’t agree with the strategy where white therapists ask clients of color, “How do you feel about being in therapy with me?” I also don’t agree with me asking a white client that because of power. While I believe the white person is generally in the racially more powerful position, in that context of therapy, I’m in a more powerful role. And so I would be asking this person to engage in a level of self-disclosure about a very difficult topic while I’m not revealing anything about myself. And so I think—again, back to social justice—your privilege also brings a greater responsibility.

It’s my job, the way I see it, to put my views out there about it and not require an answer. It’s up to the client if they want to pick it up and go with it. But my putting it out there is not contingent on them picking it up and going with it. So it’s not like a chess game.

RW: It’s an invitation. It doesn’t need a response, but it’s there.
KH: Absolutely.
RW: Your approach adds a different way of looking at why these types of questions often backfire. I’m glad you brought that up because a lot of cross-cultural psychotherapy books and supervisors across the country are saying to their white interns, you know, Ask the client, “How do you feel about me being white?” or “You’re black, and I’m white.” Or “You’re this, and I’m that, how does that make you feel?” I don’t think it works well that way.
KH: To take the race risk, no it does not work well in that way.
RW: It reminds me of former colleague of mine, John Nickens, an African-American man who was going for his postdoc in psychology after a successful career in management. He went for a group interview and the white interviewer said, “Well, we’re wondering how you feel about coming to work here with, you know, mostly white therapists.” And he said, “I want to work here. I’m wondering how you feel about having me here. I’m okay with being here, that’s why I applied.” I think they were trying to be sensitive but it did not make him feel comfortable. John has a way of cutting right to the chase on these matters.
KH: I personally don’t think that it’s a useful strategy where I’m asking a person to disclose to me because I think the conversation’s too volatile that way. There’s an inequity of power. So you were asking earlier about social justice; that would be an example that’s informed by this difference in power between client and therapist.
RW: Can you give an example with a white client when they did talk about it, when a difficult issue came up?
KH: Well, I am reminded of a young nine-year-old white child who I wrote about. He did not want to continue with me because he believed that white therapists were better and smarter than black therapists. He felt like he was being shortchanged by having me as his therapist and essentially told me that. I first tried to deal with it clinically, but it just exacerbated the situation. He became more egregious and more insulting and assaultive in his interactions with me. I think he was pissed off that I wasn’t releasing him from the therapy. And, he had these well-developed emotions about why it was unacceptable to him to have a black therapist. It had to do with somehow he was being disadvantaged by having me as his therapist.Other times issues have come up where I’ve had a client who has used a word like “nigger” for blacks or “spic” to refer to Hispanics, not just Puerto Ricans but Hispanics. When I address that, it’s almost like it’s a wake-up call to them that I’m a person of color. And it’s, “Oh, well…” It’s like they sort of excuse me because I’m a therapist, but I always feel it necessary to raise issues like that anywhere they come up and sort through them.

And then there what I consider subtleties of race, microaggressions, where my clients talk about not wanting their daughter to date a black guy. And they say to me, “It’s nothing personal, Ken. It’s just too hard out there. You know, I worry about her.” So those conversations eek up in therapy a lot, and it’s almost like sometimes with white clients, it comes out before they realize it. And it’s, “Oh my, he’s black…”

Doing work with adolescents, I often get referrals from white families who are referring their children to therapy, mostly boys, because they think they sometimes act too ethnic. They say their white sons act too black, so they send them to me to help them with that.

RW: And how do you think about and approach these situations with clients?
KH: Well, for the family that refers them for acting too black, I’m always curious about what that means. What does it mean to act black? And I have my own thoughts about that, so I don’t pretend. I engage the parents in, “What is the difficulty with some of this behavior that’s being so pathologized?” because I do believe that in our society when kids of color act white, they’re considered good kids, and when white kids act like kids of color, they need therapy. And so, I try to make that part of the conversation.With the father who didn’t want his daughter dating a black guy, my general approach in therapy is to try to open up the conversation and dialogue with him. I think that we often times, in and outside of therapy, so quickly move in ways that we shut conversations like that down when I think we should be opening them up. I try to respond in ways so I don’t go into the challenge of, “Why? Why not? What’s wrong with you!” I try and get into their world and understand how they’re putting all this together that it gets him to this place where he has a well-developed position against his daughter dating an African American.

In working with racial or cultural issues, I think it’s important to create a space for a conversation rather than me issue a cease-and-desist order.

In working with racial or cultural issues, I think it’s important to create a space for a conversation rather than me issue a cease-and-desist order.

RW: Instead of silencing them. Because that person could feel silenced, too.
KH: Absolutely.
RW: I think white people ”I don’t think it’s the same thing as silencing a subjugated group” but I think we should address it. I want to hear what you have to say about the fear of being called a racist. It’s a Catch-22 in society and especially in forums where diversity and racism are discussed. On one hand, let’s be open about racial issues, let’s talk about ethnicity, about that it’s a culture with racism in it, and people should be aware of their own prejudices and privileges. Yet if somebody is defined as being racist, they’ll get really defensive, they may lose their job, other people will see them as really out there.
KH: Well, that’s why I try not to ever use the term “racist” to apply to someone or to refer to someone. I personally don’t find it useful, and I think that it’s a conversation stopper, a conversation blocker. It doesn’t facilitate, because it’s so totalizing in a sense. I was consulting to an organization that was already one year into an anti-racism initiative. I was never quite comfortable with that term because it has a way of implicating people in a way that it doesn’t allow for some wiggle room with people who are trying to find a way to grow. More often than not what I see is that the person who’s been called a racist gets into defensive mode about why they’re not a racist, and that becomes the conversation rather than this belief I have about why my daughter shouldn’t date a black man or whatever.

Of course, white therapists can be challenged with things from clients of color as well. The question is, how to deal with those issues from a curiosity mindset instead of becoming defensive or pathologizing, and how to bring them up in a way that allows for discussion.

RW: I am thinking of one situation where the issue of race came up but in a indirect but powerful way. I remember one time a black woman client of mine was very upset because she was being discriminated against at work, mostly by white supervisors. And she said she felt very angry about white people and saw white people on the train and looked at them very intently as if to look right through them to scare them. So at a certain point, I said, “Well, you know, how does it feel you telling me ”I’m white, you are feeling lots of anger toward white people, how does it feel to tell this to me here?” And she talked about it very freely as we had a strong trusting relationship. In that state of hurt and anger that she was in, she generalized beyond those who had hurt her. She said she struggled with that because it didn’t make sense to her. She didn’t hate white people. She had grown up with many friends that were white and appreciated people of various backgrounds. But in that moment it transferred there.
KH: Yeah, absolutely. Yes, it makes. Where did this lead you in term of your relationship and your work with her?
RW: I saw her for years in therapy and years later she told me, “When I first came to see you, I didn’t think you could understand my culture, my life, but I gave you a try because they referred me to you and I like to give people a chance in life.” She said that over the years her view of me had changed, “First I saw you as a white guy. Then I saw you as a doctor. Then later I saw you as a pretty good doctor. I came to see you as a friendly doctor, and then I saw you as a person and a friend who was a doctor.” And that kind of blew me away and sticks with me to this day.
KH: Wow. That is profound. And it seems to be reflective of just, I mean, the incredible piece of work you’ve done with her, the deepening of the relationship together. I mean, it says it all. You know, you’ve gone from “white person” to “person and friend who happens to be a doctor.” I mean, that’s so amazing.
RW: So much so that when my father died, she wanted to pay her respects to my mother. She said it was just what people did where she was from. She had also heard stories of my father and what a fair man he was. She let me know she was going to contact my mother since my client was in her town on business. At first, I was fairly reticent due to unusual nature of this request in our traditional therapy culture. I consulted with a colleague, raising the questions of her interests, cultural background, and potential therapeutic benefits and drawbacks. After discussing it more with her, I decided to let it take its natural course, since I also trusted both of them implicitly. She then called and visited my mother who is a very warm welcoming person as well. They visited for a bit and hit it off and both appreciated the visit. I was touched myself by her grace in the matter.
KH: Amazing. That’s unbelievable. Did it fit in any way that you understood her background and culture, I am just wondering.
RW: It felt like it was culturally congruent with her background. She was from a big close knit family back east, one of many siblings, the oldest so she had a lot of responsibility. And every year she’d have a pie for a holiday or something for my family. After her visit, there was no fallout. She appreciated and enjoyed paying her respects, honoring what happened, as she called it. She came back and told me the story and then it was part of the background and a good experience.
KH: Perfect. Looks like a match made in heaven. I struggle with this stuff because I just think that somehow, sometimes the work that we do is so incredibly boundaried that it blocks, or at least minimizes our capacity to promote healing in clients. I mean, like who’s to say that her doing that wasn’t as healing, transformative, therapeutic as anything you’ve ever said to her sitting in the office? If she gets to reach out to your mom and felt like she was giving something back, maybe that interaction was transformative for her.I remember I had a client, a poor black woman I was treating, and she had very few marketable skills as society would record them, but she was an avid baker. And I remember I happened to mention in passing one day my love for brownies, and so around the holidays she brought a dozen brownies. And she said,

“I baked these for you,” and her hands were literally shaking because she wasn’t sure about the appropriateness of it and was worried that I was going to reject it.

“I baked these for you,” and her hands were literally shaking because she wasn’t sure about the appropriateness of it and was worried that I was going to reject it. And when I took the brownies and ate one in front of her, her face lit up in a way I’d never seen before and she sat there, teared up, “Dr. Hardy, a doctor eating my brownies…”

You could tell what that meant to her. I thought about the depths of her own sense of devaluation, the fact that this powerful figure in her life could find something valuable that she did, I thought was important to her.

And despite all the worries in psychotherapy and the caution about that, there was no spillage over into other parts of the relationship. I mean, it was, you know, it was simply that she brought in the brownies. I accepted and appreciated them. We moved on. I mean, I thought trust was built in our relationship. It wasn’t anything that I usually read about in books where you take the brownies and next the person brings you a Rolex watch or keys to a Jaguar. The drama didn’t play out that way at all.

Are we not all just basically human?

RW: I teach diversity and clinical psychology myself and a common refrain that’s a challenge to diversity studies is “It’s good to study about ethnicity, race, prejudice and racism, but are we not all just basically human? Shouldn’t we be focusing on what brings us together and makes us all human? Isn’t that the way to bring justice and peace to the world?”
KH: Yes, it’s true, we’re all human. But we are so many more other things than just human, and so, yes, I want us to appreciate and hold our humanness but I also want us to hold all the other threads of who we are. So, no, we shouldn’t take that view. I think that’s something that romance novels are made out of, that belief, that ideology.I don’t know why this is a common belief that our humanness should trump all the other places and spaces where we stand to give meaning to our lives. And even what makes us human. I’m not so sure it is the same thing for each of us. Because I would say that the pain and suffering that I have experienced in my life as an African-American has helped to tremendously, significantly humanize me, that there’s a piece of my humanity that is specifically borne out of my suffering and that piece of suffering is inextricably connected to being black in this society.

I’m not convinced that we could all get together and come up with some uniform answers as to what makes us all human, because I think we’ve all traveled different paths and those paths have been significant.

I’m not convinced that we could all get together and come up with some uniform answers as to what makes us all human, because I think we’ve all traveled different paths and those paths have been significant.

And so I don’t think that the problem is paying attention to differences. I think the problem is that we—as we often do in our society—attach differential values to differences. And so the problem is not with diversity. The problem is with hierarchical dichotomized thinking, I think, that one group of people is somehow better than another based on color, gender and so on.

RW: What about the flipside, which you hear in multicultural studies where it is, explicitly or implicitly, stated that “race, ethnicity or the color of one’s skin is the most important factor and life and power should be always looked at through the lens of race, ethnicity or color.”
KH: I think those issues are contextual. I think that race has greater salience in U.S. culture in particular. But I don’t necessarily agree with that sentiment in totality. I believe that we all have multiple threads of diversity that makes us who we are, that we have to pay attention to all of them. And within any given moment or a freeze frame, it may be that race is more salient than some others. I would say race and gender, women and people of color were the only two groups in our society that historically weren’t born with the right to vote, and other built-in forms of racism and sexism, which elevates those issues to a whole different level of significance.But I generally don’t like to even get in conversations that rank isms. It’s enough to recognize that all these issues are all valuable in their own ways.

RW: You’ve done dozens of diversity trainings and a videos, including Psychological Residuals of Slavery. How do people take to your ideas? What’s your general take about what people take well to and where there’s some resistance or tentativeness or anxiety?
KH: I think that what people generally appreciate is the opportunity to discuss these very complex issues. There are very few venues in society where we can get together in cross-racially, cross-cultural, heterogeneous groups and have open, candid, in-depth conversations about things that really matter.

The anxiety is about having the cross-cultural conversation, so I think people find the greatest gift of it, the greatest attribute, is also the thing that’s most anxiety-producing.

The anxiety is about having the cross-cultural conversation, so I think people find the greatest gift of it, the greatest attribute, is also the thing that’s most anxiety-producing.

RW: Let’s take whites, blacks, Asians, Hispanics. What might their anxieties commonly be?
KH: I think that whites, some whites have anxiety about being blamed, being called racist, saying the wrong thing. Those are always concerns that whites have. They come, but some whites worry that they come to be dumped on. That’s the anxiety of whites. Blacks tend to have anxiety about having wounds reopened, being on display and at the end of it, nothing changes.And I think Asians and Latinos often have had anxieties about the binary notions of race being so rigidified that there’s no place in the discussion for them, that somehow the conversations get calcified, if you will, around black/white issues and they’re left somewhere in between.

And then if they’re Asian or Latinos or others who are not U.S. born, they tend to have some anxiety about where they fit into this conversation because you have people coming here from countries where they were not thought of as people of color and come here and become a person of color.

RW: So it becomes important to facilitate Asians, Latinos and other minority groups to feel they have a voice and are part of the dialogue beyond the white/black focus.
KH: That’s right. And it creates a space for them to externally explore what feels internal, because to express one’s experience and have other people hear it and validate it is liberating and uplifting.

Cultural genogram

RW: Can you talk about the cultural genogram that you’ve developed and the role of that in diversity training and other groups?
KH: I took the standard genogram which is usually a three generational diagram that’s focused around family of origin and modified that to a cultural genogram. And so the way it’s set up is that the therapist, trainees, and participants use colors to depict the various ethnic, racial groups that comprise their family of origin and their three-generational family.You mentioned earlier that you were Italian, and so that you might say, “Well, I’m going to give Italian red.” And then, you know, if your dad was English and Native American, and your mom was Italian, then they would get different colors. So you see all these colors on the genogram, which depicts the various ethnicities that comprise a family.

So if you were doing one, as an Italian, what are the major organizing principles in Italian culture? What are the things that comprise core values for Italians across the board? What makes you most proud as an Italian, what are those things? What are things that make you feel shame about being Italian? List all of these on the board. And so the idea behind it is to help each of us become more acutely acquainted with our cultural selves, what we’re proud of and what we feel shame about. I think that, particularly for us as therapists, when we have parts of ourselves that we attempt to disavow because of shame, they inevitably come back to haunt us therapeutically.

I’m also thinking with the cultural genogram that it’s a way for every trainee to practice talking about race, class, gender, ethnicity, all those things, because all those have to be depicted on the culture genogram. And then, it’s helpful, finally, to help the person trace generational patterns that are informed by culture. So it really is designed to help the person become more knowledgeable of who they are as a cultural being.

The personal and the professional self are one

RW: You make a point in your writing to emphasize the importance of developing skills and ways to approach diversity and social justice concerns, but also personal growth and self awareness. To quote your writings: “It’s hard to separate the personal from the professional lives of the therapist, that the process of becoming sensitive begins with how each therapist lives his or her life. Once change occurs on this level, it will be manifested within the therapy process.” You said it so well there that I don’t know if you can elaborate, but can you?
KH: I solidly reject this notion that this is me out there, this is me in here. I think that we are who we are. I always tell therapists that I’m training and in my role as a professor that what we’re doing here is training you, teaching you how to be a different kind of human being and if we succeed in that, you’re going to be fine as a therapist. And so, it’s how do you embrace your own sense of humanity. Doing that is the beginning of embracing the humanity of others as a therapist and a person.
RW: Indeed, that is a lot of what psychotherapy is about. It really is foundational.
KH: Yes it is.
RW: Kenneth, I want to thank you so much for having this conversation and sharing your ideas and challenging us to go beyond the expected in therapy and life, professionally and personally.
KH: Thank you Randy, it has been a great pleasure. You brought out nuances of these questions that have made me think about them in new ways.

John Gottman on Couples Therapy

Posted on by rezendevknowfully.com

The Interview

Randall C. Wyatt: Welcome, Dr. Gottman. Thank you for being with us today and sharing your insights and work with our readers at Psychotherapy.net. Many therapists are familiar with your couple’s and marital research, which you have written about extensively in several books and articles. Today I want to focus more on the therapist’s end of it as much as the couple’s end of it, because this is going to be going out to therapists of all stripes. You have often quoted Dan Wile, who said that when you choose a marriage partner, you choose a set of problems, a whole set of difficulties. That doesn’t sound very hopeful. Is that as pessimistic as it sounds?
John Gottman: Well, it's interesting. It changes the way you think about marital therapy.

When we brought couples back into the laboratory four years later to talk again about their major issue in their marriage,

69 percent of the time the couples had the same problems, same issues, and they were talking about them in exactly the same way
69 percent of the time the couples had the same problems, same issues, and they were talking about them in exactly the same way, so that the instability in the marital arrangement was enormous. Still, 31% of the problems had been solved.

When we looked at the masters in marriage, how did they go about solving these solvable problems? That's when we discovered this whole pattern of really being gentle in the way they approached solvable problems – a softened start-up, particularly guys accepting influence from women, but women also said things to men, it was a balance, they both were doing it. The ability – again as Dan Wile says – to have a recovery conversation after a fight. So it wasn't that we should admonish couples not to fight but that we should admonish them to be able to repair it and recover from it. That became a focus of the marital therapy that I designed.

In terms of the unsolvable or perpetual problems, we found two kinds of couples, and the optimistic part is we found a lot of couples who really had sort of adapted to their problems.

It's not that they liked it but they were coping with it and they were able to establish a dialogue with one another about it. Okay, you're not happy about it but you learn you can cope with it, have a sense of humor about it, and be affectionate even while you are disagreeing, and soothe one another, de-escalate the conflict. And then the other kind of couple who is really gridlocked on the problem. Every time they talked about it, it was this meeting of oppositional positions; there was no compromising.

The Myth of Active Listening

RW: Many couple’s therapists, as you know, recommend “active listening” and “I messages,” and that’s pretty much the bedrock or the history of couples therapy in this country. Satir and Rogers, among others, advocated these approaches yet you’re critical.
JG: Well, I used to recommend it. The history of where it came from is that Bernard Guerney took it from Carl Rogers' client-centered therapy. Most of the techniques of marital therapy have come from extrapolations from individual therapy. Carl Rogers would be accepting and understanding and genuine and the client theoretically would grow and develop and open up.
RW: So each member of the couple could then be a therapist to the other person?
JG: Yes, suggesting that the same thing could be applied to marriages is a big leap because, first of all, there's a hierarchical relationship between therapists and client. The client is paying, the therapist isn't paying. Usually the client is complaining about somebody else, so it's very easy for the therapist to say: "Oh, that's terrible what you have to put up with, your mother is awful, or your husband, or whatever it is. I really understand how you feel."

But in marriages, it's different because now you're the target, and your partner is saying: "You're terrible," and you're supposed to be able to empathize and be understanding. We found in our research that hardly anybody does that, even in great marriages. When somebody attacks you, you attack back.

RW: “I feel you’re a jerk,” instead of “You are a jerk,” so the I statements are covert attacks?
JG: But that wouldn't really put the kibosh on active listening, because even if people didn't do it naturally, you could train people to do that. In the Munich Marital Study, a well controlled study, Kurt Hahlweg did the crucial test and he found that the modal couple after intensive training in active listening were still distressed. And the ones who did show some improvement had relapsed after eight months. It was the worst intervention in the Munich Marital Study! I'm not against empathy,
I'm just thinking active listening is not a very good tool for accomplishing it.
I'm just thinking active listening is not a very good tool for accomplishing it.
RW: Tell me why, in particular?
JG: Well, it kind of makes sense. Let's say my wife is really angry with me because I repeatedly haven't balanced the checkbook and the checks bounce. I keep saying: "I'm sorry, and I'll try not to do it again." So finally she gets angry and confronts me in a therapy session. What would it accomplish if I say: "I hear what you're saying, you're really angry with me, and I can understand why you're angry with me because I'm not balancing the checkbook." That's not going to make her feel any better, I still haven't balanced the damned checkbook! So I've got to really change – real empathy comes from going: "You know, I understand how upset you are. It really hurts me that I'm messing up this way, and I've got take some action." Real empathy comes from feeling your partner's pain in a real way, and then doing something about it.
RW: Doing what you can do?
JG: Yes, doing what you can do.
RW: You may not be a good accountant but you can try.
JG: You can try, right. So I think it's really kind of artificial to just say: "I hear what you're saying, I can understand that, that makes sense to me, and then we switch back and forth." Have you really engaged in empathy?
RW: You might have to work a lot harder to show somebody you understand, that you know what they’re talking about, and that it matters.
JG: So here's what the secret is, I think here's what couples do who really are headed for divorce. They take the problem and they put it on their partner: "The problem is you, and your personality, your character; you're a screw-up." That's an attack, and that's the fundamental attribution error that everybody's making: "I'm okay, you're the problem, you're not okay." So then their partner responds defensively and denies responsibility and says: "You're the problem; I'm not the problem."

What the masters do is they have the problem and it's kind of like a soccer ball they're kicking around with each other. They say: "We've got this problem. Let's take a look at it, let's kick it around. How do you see it? I see it this way, and we kick it around." And all of a sudden I can have empathy for your position because you're telling me what you contribute to the problem.

RW: One person has to break the cycle and then –
JG: And move that from defense mode into a collaborative mode.
RW: So have you found that if one person does that, some momentum starts going and things start changing?
JG: Rarely. It usually has to be both people. So one person is admitting fault and saying "I'm sorry" all the time, the other person is saying:
"Yeah, you're a screw-up. No wonder you're apologizing, you need to apologize, you should get down on your knees and apologize."
"Yeah, you're a screw-up. No wonder you're apologizing, you need to apologize, you should get down on your knees and apologize." And then eventually that person who's saying I'm sorry all the time feels pretty angry and pretty much like it's not fair, it's not balanced. There has to be a real balance, I think, or has to be a perceived balance, it has to feel fair.

"Yes Dear" and What Men Can Learn from Bill Cosby.

RW: I remember Bill Cosby having a father-son talk on the old Cosby Show. His teenage son said: "My girlfriend is still mad at me, I screwed up! I said I was sorry, but she won't forgive me. What can I do, Dad? I want her back more than anything." And Cosby says in his Cosby voice: "Son, you're not done til' she says you are done." His son dejectedly says: "Well, how many times do I have to keep apologizing, Dad?" And Cosby says: "Until she begs you to stop." This sounds similar to what has been called your "Yes, Dear" approach, which has been lampooned on the Politically Incorrect TV show. It sounds cliche, but what are Cosby and you really getting at?
JG: There's this great Ogden Nash poem that I think gets Bill Cosby's point, and I'll paraphrase it:

To keep brimming the marital cup, 
when wrong admit it, 
when right shut up!

It's a great line. It's about respect, it's about honor, and the idea of giving in, of saying I'm sorry, that really honors both people. So what we find is that, first of all, just like Bill Cosby said, the husband is really critical in this equation because women are doing a lot of accepting influence in their interaction. That's what we find and it doesn't predict anything, because many women are doing it at such a high level. But there's more variability in guys. Some guys are really in there and these are the masters. They're not saying: "Yes, dear." What they're really saying is: "You know, I can see some points in what you're saying make sense to me. And there's other stuff you're saying I just don't agree with. Let's talk about it." Now that husband is a different husband from the husband who says: "No. I'm not buying any of this!" Then the husband becomes an obstacle.

If you don't accept some influence, then you become an obstacle and people find a way around you and you have no power. So the violent guys that Neil Jacobson and I studied, they're always saying: "No!" to offers to communicate better. No matter what was said, they would bat it back like baseball players at batting practice. Wham! And they turn out to be enormously powerless in their relationships. I think that's one of the reasons they resort to violence, because they have no influence in any of their personal relationships.

RW: And in couple’s therapy, oftentimes when dealing with the aggressor, they’re told to basically give up all their power, both illegitimate and legitimate, and so then they’re powerless again, and the cycle begins anew.
JG: That doesn't work either. Morihei Ueshiba, the Japanese genius who invented Aikido, had that very point, his whole approach to negotiating conflict, which is you need to yield to be powerful.
RW: When pushed, pull, when pulled, push, and roll.
JG: That's right. So it's not that the guys were saying: "Yes, dear," as the parody went, and, sure, "I'm sorry, I'm sorry, anything you say." They were saying: "I can see this point; let's kick this around. Here's my point of view. I accept some of what you're saying but not all of it." Usually the wives will be saying a similar thing. And then they really start persuading one another and compromising and coming up with a solution.
RW: You’ve used “masters” several times, by that you mean?
JG: I just mean people who stay married and kind of like each other. I have a low criterion for mastery, and I actually do have a lot of awe for these marriages. We've studied couples who have been together 50 years. We've looked at masters from the newlywed stage through the seventies, the transition to retirement people who are 70 and 80 years old now. When I say they're masters I really sit down and watch them, and my wife and I try to learn from what we've learned in the research and acquired in our own relationship.

What Gottman Learned from His Own Marriage

RW: I was curious about that. In your own relationships in marriage and life, have you applied what you have learned personally in working with couples, and vice versa?
JG: Absolutely. For example, when Julie and I do our workshops with couples, one of the main messages we give is that we've found that really good marriages, people who are really happy, have terrible fights, where they're thinking at the end of the fight: Why did I marry this person?
RW: Not right before the workshop, I hope?
JG: Well, sometimes we have. We've had a fight the morning of the workshop and we're not talking to each other before the workshop. So one thing we did in the workshop is we processed our earlier fight in front of the audience. One time I got up in the morning and my wife had had a really bad dream about me. I was a real rotten guy in her dream. She was mad at me! I was being really nice to her in real life but in her dream I was a rotten SOB. So I try to be real understanding but she is still mad. And then finally I said: "You know, this isn't really fair because I didn't do this stuff" and so I got angry with her. She went in the shower and she's crying, and so I got in the shower and tried to comfort her. She wouldn't be comforted by me because now, I'd really made her angry. We talked about this in front of the audience for the first time: "We've had this fight, and this is not unusual. Periodically we have disagreements, stuff like this happens, and here's how we talk about it."

My wife and I once had a disagreement that took five years to resolve. It started out as a perpetual problem, a real big difference between us that wasn't reconcilable. We worked on it and we talked about it every day and we finally made a compromise. But it still wasn't fully resolved and five years later we actually solved this perpetual problem. It stopped being a problem, which happens occasionally in our research, too. But most of the time they don't get resolved at all. And somebody in the audience said: "Well, that's amazing that it took you that long. You guys, you're teaching this workshop." And we said: "Well, this is the way it is in good relationships."

RW: Why did it take so long? You’re both smart people, I am sure.
JG:
But she's so stubborn. You don't know what I have to go through. And that's what she says about me. That's what people are really saying.
But she's so stubborn. You don't know what I have to go through. And that's what she says about me. That's what people are really saying.
RW: It seems there are three issues: prevention of fights when possible, how to argue when you do fight, and how to recover when it gets away from you.
JG: Exactly!

When Compromising Too Soon is a Problem

RW: You brought up the need to compromise. Dan Wile (see Couples Therapy: A Non-Traditional Approach) suggested that sometimes people compromise too soon even when they feel strongly about an issue. By the time they talk, neither one of them will compromise anymore. Each person has already compromised once, though their partner does not know that or appreciate it. And then both people come across as more stubborn then they actually are.
JG: Right, I think that's a very good point. I think Dan Wile is a very wise person, a wonderful therapist, and most of his insights are supported by the research I do. We have him come up to Washington every year and do a workshop for our therapists at our marriage clinic. I think one of the great things that Dan Wile said is people shouldn't compromise so much.
RW: Yes, that sometimes compromise is a solution that becomes a new problem.
JG: A lot of times they're giving up their ideals, they're giving up the romance and passion of their selves. They've giving up something really essential. That's what the secret is to ending the gridlock in these perpetual problems; to realize that there's a reason why people can't compromise. They have a personal philosophical ideal that they're holding on to and it's very essential to who they are as a person.

And

if you can make the marriage safe enough, you can take those fists and really open them up, and there's a dream inside of each fist, there's a life dream.
if you can make the marriage safe enough, you can take those fists and really open them up, and there's a dream inside of each fist, there's a life dream. When people see what the dream is and what the narrative story is, what Michael White would call the narrative behind it, the history of this life dream, usually both people want to honor their partner's dream.

RW: They may not be able to go along with it all, but honor is different than just kowtowing.
JG: Exactly. There are many ways of honoring someone's dream. You can support it, understand it, financially support it, or you can talk about it.
RW: Here’s another area where you go against the grain of couples’ therapy tradition. Often couples therapists begin their books criticizing romantic pop songs or idealistic romance movies or novels. You say “Don’t give up those dreams, don’t give up your fantasies, you may not get them all but don’t give them up.”
JG: I'm basing this a lot on the work of Don Baucom who has looked at this idea: Is it true that we have too high of standards and that's why we're unhappy and so should we lower our standards? He found just the opposite. He found people who have idealistic standards, who really want to be treated well and want romance and want passion, they get that, and the people who have low standards, they get that. It's better to really ask for what you want in a relationship and try to be treated the way you want to be treated.
RW: You’ve critiqued two pillars of the couple’s therapy accepted truths. Active listening is not the be-all/end all to accomplish empathy, and romance and hopes should not be cast aside as merely wishful thinking. So how do therapists respond to this? Are they shifting? What’s your perception?
JG: I think there's a certain kind of therapist that's real interested in what I have to say, those interested in scientific validation for ideas. Not every therapist finds it appealing. I've tried to create a psychology of marriage from the way real, everyday people go about the business of being married, instead of taking it from psychotherapy.

What Works in Couple’s Therapy?

RW: You’ve done in vivo research, looking at couples in their homes, in the lab. Now you are doing the outcome studies. How does it look?
JG: We're now doing the outcome studies to see whether it will work. What came out of this way of studying normal couples, everyday couples as well as the masters of marriage, was a theory, and I think that's what therapists find useful. Pieces of it have some evidence, but it still needs more confirmation. For example, if you know that the basis of being able to repair a conflict is the quality of the friendship in the marriage, then
you can individualize therapy for each couple and that's the task that every therapist is confronting.
you can individualize therapy for each couple and that's the task that every therapist is confronting. We confront it every day in our consulting rooms.

We look at three profiles in every marriage – the friendship profile, the conflict profile and the shared meanings profile – which is creating a sense of purpose and shared meaning together. Then on the basis of that we think: Well, they need this kind of intervention and that kind of intervention, but it really emerges from the process in the consulting hour from what the couple brings.

RW: Many therapists want more than a cookie cutter type of therapy? they want to individualize their work with couples vs. using only one theoretical model.
JG: That's right. The interesting thing to me is that my research supports a systems view, that really is husband affecting wife and wife affecting husband in a circle. The existential view is supported because you can't just look at what these gridlock conflicts are about; you have to look underneath at what the life dream is. Then these dreams have narratives, so narrative therapy is supported, and they usually go back to the person's childhood and they go back to have symbolic meanings about the way they've been traumatized in other situations, so a psychodynamic point of view is also supported. You get a behavioral view supported because you find when you look at the evidence that often the best way to effect change is changing the behavior rather than trying to change the perception of a person, and perception often follows behavior. So all these different kinds of therapies are supported by this research.
RW: There’s something for everybody to be happy with.
JG: You have to really take a little from everybody to do good couple's therapy.
RW: When you went into couple’s research, you had certain views of marriage and relationships. Which ones were debunked, and which ideas do you still hold on to, despite the research?
JG: Well, I went in with an open mind. When Bob Levenson and I started doing this research, we decided on a multi-method approach. We thought perception must be important, so we showed people their videotapes and interviewed them about what they saw on their tapes. We interviewed them more globally about the history of their families – multi-generational perspective must be important. Asked about their philosophy of marriage, how they thought about the conflict and what their worldviews were about their relationship, what their purposes were. And we thought emotion must be important, so we scored facial expressions and non-verbal behavior and voice tone. We tried to look at everything. We looked at couples in all these contexts, whether they were conflicting or talking about how their day went or a positive situation, with no instructions at all, and we tried to see what would emerge from the data.

I thought active listening would be powerful. People just didn't do it. For a long time I thought we were getting evidence that it was happening, but it wasn't until I started doing workshops with clinicians that I couldn't find any examples of it. I went to my observational coding team: "Help me find some examples," and they went: "Oh, God, we don't know how to break this to you but we haven't found any examples." And I said:

"Why didn't you tell me?" and they said: "Well, we didn't want to hurt your feelings." So I was blown away by it.
"Why didn't you tell me?" and they said: "Well, we didn't want to hurt your feelings." So I was blown away by it.

RW: Researcher and assistant bias?
JG: That's right. So my staff was really protecting me. I saw that I was wrong about this and had written about it in print. I really had to eat my words. I think it's important to do that, to find out these things. I also thought that what would really work in conflict is people being honest and direct. Confronting each other saying: "You know, you do this and it really makes me angry," and the other person would not get very defensive. Boy, that wasn't true. The masters were not doing a lot of this clashing and confronting stuff. They were softening the way they presented the issue and giving appreciations while they were disagreeing.
RW: They can also hear some feedback. They weren’t just closed to it.
JG: They weren't closed to it, because the partner was using humor: "I appreciated you taking that drive, it was so nice and I know you were tired." And the other person wouldn't see that as gratuitous flattery, and say: "Thank you very much," and really appreciate those comments.

Happy Marriages: What are They Made of?

RW: Is this something that is in these happily married people before they were married? Did they learn it? It is part of their family background?
JG: Well, we know a little bit. We know that personality, the enduring qualities that people bring to their relationships accounts for about 30 percent of it, how conversations begin could be a moodiness and so on.

But then there's the fit between two people. Let's say I select somebody to marry and she's kind of a moody person, but it doesn't really bother me that much, I don't take it personally and we fit in terms of this. If she had married somebody else and if she comes in moody and all of a sudden they take it personally, that doesn't work.

Nathan Ackerman talked about this a long time ago in the thirties, saying that two neurotics can have a happy marriage if they don't push each other's buttons and they're respectful about what Tom Bradbury calls enduring vulnerabilities.

That's one thing we do in our therapy is really try to find out what are the enduring vulnerabilities in these two people, how does the marriage respect that?
That's one thing we do in our therapy is really try to find out what are the enduring vulnerabilities in these two people, how does the marriage respect that? How can we, in this marriage, not trample on those sensitivities so that person doesn't go nuts?

RW: It sounds like there’s sensitivity to each person’s vulnerabilities and meanings and not just an open-ended kind of experiential therapy. In the same way, how can the therapist appreciate what works for the couple already? It reminds me of – it will sound far afield, but since you mentioned baseball, stay with me – the old Boston player Carl Yastremski used to have his bat way up there, and some coach tried to change it. Maybe he holds his bat funny but it works for him. For couples, I fear that sometimes therapists have a view of just how things should be. The couple’s doing fine, it’s not a problem for them, and yet we’re trying to fix it, the problem that doesn’t exist.
JG: I think that's true. I think a lot of us come in with a sort of model of what good communication or intimacy should be, and it doesn't fit what this couple wants or desires or needs. We have to be very flexible and be able to move from one system to the other, and really speak in their language as well.

Future Breakthroughs?

RW: What’s your next challenge in research? I see you have a book out on domestic violence and what works in couple’s therapy (When Men Batter Women: New Insights into Ending Abusive Relationships). What’s the next breakthrough on the horizon?
JG: The real challenge, I think, is to try to develop a therapy that fits certain kinds of people so that we're not doing the same thing for every couple. So we can do an assessment and say: "Oh, we need this kind of therapy for that couple, and this other couple doesn't need that, they need something quite different." We need to modify therapy to fit each particular couple.

And preventing relapse is the other challenge. We're trying to develop preventive approaches. We're doing things like arranging birth preparation classes to prepare people for what's going to happen for when the baby comes, because 70 percent of the time marital satisfaction goes down the tubes. We know marital conflict increases by a factor of nine.

Extra-marital affairs are another area where there hasn't been a single controlled outcome study, trying to help couples get over non-monogamy. At least if you're on the science bus you want more research-informed therapies. You can select from the clinical literature but it's hard to know which treatment approaches work best. Shirley Glass's is the one I really favor because it's based on more research. Another issue is co-existing problems like depression and marital trouble, or alcohol. O'Farrell and MacCready have approached alcoholism and marital distress and created an integrated program focusing on both issues in the same therapy; both were more effective.

RW: What is the most gratifying part of your work as a researcher, couple’s or marital therapist?
JG: I'm really in this for knowledge. The deal I made with God is that I wanted to understand things: how relationships work, how to make them work, and I'm hoping that eventually this knowledge becomes widespread and well known. Just like we don't know very much about the guy who invented Velcro, we just use it. One of the things that I've really learned in the past five years is to make research and therapy a two-way communication. That's what needs to happen because up until now therapists have been on the firing line – developing these ideas in isolation.
RW: One thing that people enjoy about your books and your work is that it does bring research from the ivory towers of academia to therapists, to other people, in an everyday language.
JG: I think it's absolutely true that if the people come alive from the theory, then you know that it makes some sense. If you can actually use the ideas and put them into practice, in some concrete way in your own relationships and in work with clients, then you know that maybe it makes some sense, it's useful.
RW: That would be a good thing. Thanks for taking the time to talk with us today.
JG: Thank you.

Nick Cummings on the Past and Future of Psychotherapy

Posted on by rezendevknowfully.com

A Psychotherapy for the People

Victor Yalom: Well, Nick, good to have you here at the Brief Therapy Conference in San Diego, 2008. I believe you’ve long been a proponent of brief therapy and intermittent therapy throughout the lifespan.
Nick Cummings: Correct. In fact, I started that in the 1950's.
VY: Really? Tell me about that.
NC: I was trained as a psychoanalyst and went into a psychoanalytic practice in San Francisco. I did this for a number of years and decided that if I were lucky—I had an epiphany one night—that by seeing patients four times a week for seven years, in my entire lifetime, if I live long enough, I might touch 70 lives. And it occurred to me that that's not why I became a psychologist.
VY: Now, for some people, touching 70 lives deeply would seem like a good thing.
NC: Well, in those days there was no prepayment, so it was essentially treating the diseases of the rich–people who could pay. And to pay for four sessions a week, you had to have some money. It occurred to me that there was a great need out there among working people that didn't have these services available.  If they had mental health issues—in those days all you had was psychoanalysis—they didn't go into it. Minority groups—for example, African-Americans—turned to religion when they had distress, because psychotherapy wasn't available to them. We were the first program to make it available to them for free. And the idea that African-Americans didn't go into psychotherapy turned out to be a myth, because when we provided it, we had many African-Americans in the late 1950's in our program in San Francisco. So after practicing psychoanalysis for a while, and butting up against the psychoreligion of the San Francisco Psychoanalytic Institute, which was absolutely rigid in those days, I decided this was not what I wanted to do, and I was wondering what I was going to do. 

My wife said to me one day, "Kaiser Permanente is looking for a chief psychologist." So I applied, found out there were some 56, 58 people that applied, and I made the final cut of half a dozen finalists. In my interview with the founders of Kaiser Permanente, which was very young in those days—Kaiser Permanente was formed post-World War II—they said to me, "If you take this job, you've got to agree that for the first six months we can fire you with no questions asked." I found out later I got the job because the other five finalists said, "No way," and they withdrew. To me, that was like waving a red flag in front of a bull.

VY: You liked the challenge.
NC: I loved the challenge. "I'm going to take this job and I'm going to show you that I can succeed." After I started, I found out why they had made this challenge: my predecessor had been Timothy Leary. Do you remember Timothy Leary, the High Priest of LSD? He was the chief psychologist of Kaiser Permanente before me.
VY: Wow, who would’ve thought that?
NC: This was before he went to Harvard and got into LSD and so forth. But he was so interested in doing research that they couldn't get him to send one of his people over to the hospital to do a bedside consult. So one day, Sidney Garfield told me—Dr. Garfield was the founder of Kaiser Permanente—he came to work and the second thing he did was hang up his coat. The first thing he did was pick up the phone and fire Tim Leary. And then he decided that he didn't want anything more to do with psychologists. They went for a couple of years without them, but then decided they couldn't get along without them. And Dr. Garfield, interestingly, although he was a physician, didn't want the department vested in psychiatry. He wanted psychologists doing the work, because Kaiser Permanente was beginning to realize that a lot of the so-called medical conditions were really emotional problems translated into physical symptoms. And they said, “A psychiatrist is ultimately a physician”–wearing white coats in those days—“and it's just going to ingrain in the patient that this is a physical issue.” So he wanted it done by psychologists. Two years later he decided he was going to try again; I was interviewed, and I stepped into that post.

Throwing out the Couches

VY: You’ve had obviously a long, illustrious, and sometimes controversial career; we could spend hours going through all of it. So to be brief, what were a few of the things you did at Kaiser that you thought were instrumental?
NC: The first thing: in those days, you never started therapy until you did a social worker intake. Then, after the social worker intake, you did a battery of tests. Those were absolutely mandatory before therapy could start.
VY: Was this just at Kaiser?
NC: No, this was the United States! And the battery of tests were the ubiquitous Wechlser Intelligence Scale, Rorschach, Thematic Apperception Test, the Bender Gestalt, and the Machover Draw-A-Person. You had to do those five tests—it was written in the bible of psychotherapy in those days.
VY: Wow. I had no idea.
NC: Before you did the battery of tests, you had a social worker do an intake interview. By the time the therapist saw the patient, the patient had told his or her story two other times. Now this was the third time. We eliminated the first two. Everybody said, "They're going to be sued up the kazoo. This will not work." We never got sued. The first person to see the patient was the therapist.
VY: Makes sense.
NC: Which is what we do now! That was radical in 1957. It worked. So that's one of the things we did.

I had the power to hire eleven psychologists, twelve of us in all. And I had my own psychoanalytic couch, being trained as a psychoanalyst, so I ordered eleven more psychoanalytic couches, all with nice tufted black leather, just like Freud's. We started seeing plumbers, carpenters, bus drivers, restaurant servers…
VY: How many times a week? Would you see them more than once a week?
NC: We insisted in the beginning we had to see them twice a week at least. And we'd ask them to lie on the couch, but they were uncomfortable. They'd want to get up off the couch. So I had another epiphany.

I saw a working class man that had back trouble. He’d exhausted all 33 orthopedic surgeons at San Francisco Kaiser, and they all decided, "This is all in your head; go see the shrink." I asked him to lie on the couch. He said, "Sure, Doc," and he lay on the couch face down. I said, "No, no, you don't understand. I want you to lie on your back." He turned over and said, "Sure, Doc, but how are you going to examine my back if I'm lying on it?" I said, "No, no, no, I'm not going to examine your back." He said, "What are you going to do, Doc?" I said, "We're going to talk." "Oh!" He jumped up off the couch, grabbed a chair, put it opposite me, sat down, and said, "OK, Doc, what do you want to talk about?"
It suddenly hit me that everybody in the world knows that when you talk to people, you talk face-to-face–except psychoanalysts.
It suddenly hit me that everybody in the world knows that when you talk to people, you talk face-to-face–except psychoanalysts. You have to sit behind the couch so the patient can't see you.

So we decided to get rid of the couches. We called up Goodwill and when they came out to pick them up they looked at them and said, "What are these? Nobody can sleep on them: they slope. You can't sit on them because they don't have a back. We don't want them." They refused 12 couches! So I called up the Salvation Army. They came out and they said the same thing: "These are ridiculous, what are we going to do with these?" So I called up St. Vincent de Paul. And I told them we had 12 nice black leather tufted couches that we wanted to give away. I got my staff—we were on the third floor—and I said, "We're going to take these couches and we're going to carry them in the elevator and stack them up on the street on the corner. And I'm going to stand out there." When the truck pulled up at the appointed time, they said, "We don't want these." I said, "They're yours. I'm going to walk away, and if I have to call the police that you're littering the sidewalk… Because they're yours, you agreed to take them." That's how we got rid of the couches! So we started seeing patients face-to-face. I was immediately declared a traitor from psychoanalysis.
VY: So your traitor status started early in your career.
NC: Very early in my career–actually much earlier, before I became a psychologist, but anyway, that's another story.

Your Therapist for Life

So we started seeing patients face-to-face, and instead of asking them to free-associate, which working people didn't know how to do… See, up until that time, the only people we treated were the educated class who had read about psychoanalysis and were eager to try it. So when you'd say, "Free-associate," they would do it. These people didn't know how to free-associate. They knew how to talk. We started listening to them and began to develop focused, targeted therapy addressing the problem. Do you remember a man named Michael Balint?
VY: Heard the name.
NC: Michael Balint helped found mental health in the British universal health system after World War II. In his 1950 book, The Doctor, the Patient, and the Illness, he said that physicians have to become more like psychologists, and psychologists have to become more like physicians. He said that the idea that a psychologist is going to treat a patient so that for the rest of his life he will never have another neurotic symptom is insane. It's crazy. Physicians don't practice that way. You come in, you have the flu, you're treated for the flu. After the flu is cured, you're dismissed. But two or three years later, you may come in with a leg injury, with a fall, with whatever. And you're treated for that. Psychologists should treat people for the condition that brings them in.
VY: There’s no magical, comprehensive cure.
NC: That's right. So we started doing that, and the hostility was enormous. We never terminated a patient. When we got to the place where the patient said, "Gee, Doc, I'm feeling great, do I have to come in?" I'd say, "No, we're going to interrupt our treatment. Just like you go to your doctor for your physical problems, you come here if you ever have another problem that you can't solve yourself."
VY: People don’t have the idea if the doctor cures an illness or a virus, that that’s the end of their relationship with the doctor.
NC: Exactly. We extrapolated that into psychotherapy. This was absolutely heresy in those days. I was attacked, not just by psychoanalysts, but by colleagues. And it worked because the patient could come in for life. We began calling itbrief intermittent psychotherapy throughout the life cycle. "I am your doctor for the rest of your life." And the interesting thing was we found out it was transferable—that patients who might not have come in for four years would start talking as if they'd been in last week.
VY: Kind of like old friends: if you don’t see a friend for a long time, you pick up where you left off.
NC: Exactly. I might not remember the last conversation that well, but they did. And it worked. Now, they didn't know that there were other forms of treatment, but for what we were doing, it worked. And Kaiser said, "How do we know that these people are doing well?"–because calling them up and asking them "How are you feeling?" is unreliable.

Kaiser got interested in psychotherapy because they found out that 60 to 70 percent of their physician visits in primary care had psychological, not medical, conditions. So we decided to follow these people the year after they'd been in, the second year after, the third year, and see what their overutilization of health care was, because they would be running to the doctor when they actually had psychological problems. We found that we were reducing medical overutilization by 65 percent within five years after the initial contact, with no further therapy. And that's how the medical cost offset attracted the National Institute of Mental Health, the Veterans Administration, and so forth. We started a series of research.

The acceptance in medicine was terrific. The acceptance from government in Washington was terrific.
The rejection from my colleagues was intense. I was accused of destroying psychotherapy singlehandedly.
The rejection from my colleagues was intense. I was accused of destroying psychotherapy singlehandedly. And I said, "Well, it's just a pleasure to learn I'm that powerful." But nonetheless, this is what I had to put up with. I contacted Michael Balint and asked if he could come to San Francisco and spend a week with us. And I wanted him to meet with our psychologists and physicians. He asked, "Can I bring Alice?"—his wife. Victor, we got both of them for one week and we would go from morning, have dinner, and go into the evening. We got him and Alice for one week, not counting airfare and hotel, for $1000. Both of them, in the late 1950's.

He convinced us that we were going in the right direction. A lot of my staff was beginning to chafe under the attacks, but all of this bolstered our resolve and we kept going, and we'd write about it and we'd publish. All of us became consultants in Washington, D.C. over this. For example, I became a consultant to Ted Kennedy when he was head of the Senate subcommittee on healthcare. At the same time, I was in private practice.

So this is how we developed the model of brief intermittent psychotherapy throughout the life cycle. Later we changed it to focused intermittent psychotherapy because our adversaries had made such a dirty word out of "brief." We decided to call it "focused" or "solution-based" or whatever.

Strange Bedfellows at the State Capital

VY: Now, how did you get from there to starting the California School of Professional Psychology, the first independent professional school?
NC: I found out, in talking to students in the late 1960's, that the same conditions were extant with them that were there when I went through a doctoral program. Clinicians were not allowed to join the faculty. They had to have lots of publications, etc. etc.—all things clinicians don't do, because clinicians are busy seeing patients. So I started working with the education and training board of the APA to try to change the rules of APA accreditation to allow clinical faculty to be brought on board with the same status as nonclinical faculty. I utterly failed. Finally, one night in the middle of the night, I couldn't sleep and I had another epiphany. I said, "I have to start our own school." I was president of the California Psychological Association at the time; Don Schultz was our executive officer. The next morning I could hardly wait to tell Don my idea. And Don started saying, "You know, Nick, you're working a little bit too hard. I think you should maybe take a rest." I suddenly realized Don was treating me like I was having a psychotic episode or something with my idea.
VY: It seems work is what drives you and keeps you alive.
NC: It's invigorating. Especially if it's innovative.
I have to change careers every seven years because once I succeed at something, administration bores the dickens out of me.
I have to change careers every seven years because once I succeed at something, administration bores the dickens out of me. I have to go out and create again. This is why we're forming this new program.
VY: We’ll get to that in a second.
NC: So anyway, Don says, "How are you going to pull this off?" Ronald Reagan was governor of California in those days. No friend of psychology. But Reagan was having a fight with the University of California on the Board of Regents. And I knew that he might listen to this idea, not because he liked psychology, but because he wanted to do something to the Board of Regents.
VY: They say politics makes strange bedfellows.
NC: Absolutely. He had an administrative assistant named Dr. Alex Shariffs who had been Dean of Students at Berkeley, and I knew Alex. So I called Alex up and said, "Can you give me an appointment with the governor?" "Oh, what's this about?" When I told him, he said, "Hey, that sounds like a great idea!" So he arranged it. When we walked in, the governor said, "Dr. Cummings, today is very busy." They were having the eruption on the San Francisco State College campus.
VY: Yeah, late 60’s.
NC: Yeah. "You've got 20 minutes." We were there for almost two hours. Once he heard it, he kept asking questions. Finally he said, "Dr. Cummings, I'll make a promise to you. You get a first-class faculty, a first-class library, you get an endowment and a curriculum that makes sense, and I will order the head of the department of education in the state of California to accredit you."
VY: That’s a dramatic story.
NC: I thought, "How do I get a first-class library? This takes millions of dollars." I discovered in my research that any Ph.D. in the state of California had complimentary access to the Berkeley and UCLA libraries. So I got a card and all of my students got duplicates. And they all used the University of California libraries, using my card.
VY: So they were all using Nick Cummings’s card!
NC: We got it later amended that any doctoral student could use the state facilities. When we got it changed, they had their own cards as bona fide doctoral students. So we solved the library problem. We got a first-class faculty because I got 200 psychologists to volunteer to teach for free for 18 months—they would all teach one course. And they loved it. And this was sort of like our endowment. Teaching free for 18 months launched us, because we didn't have the money up front.
VY: That’s a lot of free labor.
NC: A lot of free labor, but it was very productive free labor. They loved it, and they loved interacting with our students. And we had a very innovative program.

Originally we started with the San Francisco and Los Angeles campuses. The San Francisco campus was above a machine shop.
VY: I heard about that. I heard there were pillows on the floor and all the students had to be in group therapy.
NC: Yep, absolutely. But when the big machines were running on the first floor, the whole second floor would shake and vibrate. The Los Angeles campus was in a condemned Elks Lodge, and the building was right on MacArthur Park and was due to be torn down. We got it for nothing. But the problem was, right in the middle of class there could be plaster falling off the walls. But within a year we got enough money, got our own facilities, and moved out of these. And then we founded the San Diego and finally the Fresno campuses. And this launched the professional school movement in the United States. So today, even though the APA has accredited doctoral programs, there are clinician faculty members in universities.
VY: Before we get to the new program you’re launching, what are your thoughts on the status of professional school education now?
NC: It has failed.
VY: How so?
NC: I formed the National Council of Schools of Professional Psychology—NCSPP. And I had set it up with Washington, the department of education, that it would be the accrediting body for the professional schools. Remember that our first classes at CSPP were in the 1970's; I founded it in the '69-'70 school year. We held our first meeting, and I said, "I'm doing the last thing for the professional school movement." We had to ratify the articles of incorporation, etc., etc., and elect a president. They elected Gordon Derner, who was my mentor at Adelphi. Gordon had run three times for APA president and lost, and he wanted APA respectability. He talked the group into going for APA accreditation, which was the biggest mistake–they signed their death knell at that point because the APA made them hire full-time faculty. Now, I could get ten to 12 part-time faculty to teach 12 courses for the same cost of hiring one faculty member who taught two courses. So we had created the business basis for the professional schools to succeed even though they were tuition-dependent. But once they had to get full-time faculty, they couldn't make ends meet. What they're doing now, unfortunately, is turning out hoards of master's-level practitioners and PhDs. They're accepting 900 GRE scores—it used to be if you weren't 1600, you couldn't get in. And they're flooding the market because they need the tuition. In that sense, they've failed.
VY: You’re known for making strong statements, and to say “failed” seems… There are certainly lots of good programs, and lots of good psychologists coming from these programs.
NC: And there are lots of very poor psychologists coming from these programs.  I say about them that some of the best psychologists I've ever worked with came from the professional schools, and some of the worst have come from these same professional schools. The range of ability is incredibly large.  The old saying that you can't make a silk purse out of a sow's ear also applies that you can't make a sow's ear out of a silk purse. The bright students do well, and they flourish in the professional schools. And then there are students that limp through.

The New Behavioral Health Providers

VY: Jumping ahead, you’re starting a new program this coming fall: the Nicholas Cummings Doctorate in Behavioral Health. What’s the idea behind this?
NC: The idea behind this is we have launched a plethora of professions out there. We not only have psychologists; we have social workers, we have MFTs, and we have MA-level counselors. All of these organizations fight each other. And when the newer organizations are looking for licensure, the older organizations fight them, just like psychiatry tried to prevent psychology from getting licensure. We tried to prevent social work from getting licensure. We now try to prevent MFTs from getting licensure, master's-level counselors from getting licensure. So we have created a very antagonistic atmosphere with a profession called psychotherapy that is fractionated into organizations that are fighting each other.

Also, we have drifted so far away from health care that we have created two silos. We have a huge silo called health care, and it gets a trillion dollars a year. And over here we have a tiny silo called mental health that gets the crumbs. In the last ten years, where we've passed parity in 44 states, the portion of the budget that goes to mental health has dropped from 8 percent to 4.5 percent—almost half.
VY: Parity hasn’t helped.
NC: Parity has done nothing, because when you pass parity, the managed care companies either create more herculean hurdles for mental health and for physical health, or they drop mental health altogether from their package. So we have declined by almost 50 percent in funding; the mental health silo's getting smaller and smaller. The American people pay for health care. They do not pay for mental health care on federal funding. That is an afterthought; it's the crumbs.
Until we become an integral part of health care, we will always, always get the crumbs.
Until we become an integral part of health care, we will always, always get the crumbs.
VY: So how are we going to do that, and how is your program going to help with that?
NC: Our program trains master's-level psychotherapists who've been in the field for several years and are savvy. They've been up against the world of hard knocks; they know what it's like out there. They know that psychotherapy has declined by 40 percent in the last decade. They are ready to upgrade and learn a new profession called behavioral health provider, to work in medical settings side by side with primary care providers, with equal status. You can't work in a medical setting unless you're called "doctor"—there is that chauvinism.
VY: So how are they going to get equal status? Even psychologists don’t get equal status.
NC: Psychologists go into medical settings and they make fools of themselves. They don't know a type-II diabetic from a type I-diabetic. They make so many errors, they don't know what medical protocol is, and they don't know how the health system works–they've been isolated in this other silo. So they're not accepted. Then they become defensive. They see that medicine is relegating us to a lower status. When we integrate behavioral care providers into primary care settings on a ratio of one BCP to six PCPs—BCP being behavioral care provider, PCP being primary care physician…
VY: One behavioral care provider to six physicians?
NC: In some systems they've loved it so much they've upped it to three—twice as many as our original model.

You always have to have at least two BCPs in every medical setting, because one is doing the treatment while the other is doing what we call the “hallway handoff.” When a physician is seeing one of the 60 to 70 percent of her or his patients that have severe psychological issues, instead of writing out a prescription and getting the heck out of the office—because they've learned that if this patient opens up and collapses and cries, they're stuck there for the next hour, and they have a waiting room full of patients—they can say, "You know, Mr. Smith, Dr. Jones, my colleague down the hall, I think can help us with your case." And the physician walks Mr. Smith only a few steps down the hall to Dr. Jones's office. And Dr. Jones is a behavioral care provider. The physician introduces the patient to Dr. Jones, and they sit down–the primary care physician doesn't dump the patient–they sit down, but only for a couple of minutes. And then he excuses himself, goes back to his office. The BCP takes over and does a 15- to 20-minute interview. They have been trained to engage the patient in treatment.

Now, Victor, the amazing thing is, we've done this with the U.S. Air Force, we've done this with several VA centers, we've done it in TRICARE [U.S. Military Health Plan], with returning veterans, and in community health centers. I named it the hallway handoff and the term has stuck. Eighty-five to 90 percent of patients who experience the hallway handoff will follow up and get into treatment, whereas when the physicians makes a referral to an outside therapist…
VY: They’ve got to first have the courage to call the person, set up an appointment, go across town.
NC: Only 10 percent get there.
VY: Wow.
NC: Literally only 10 percent. So this increases our patient flow by 900 percent! It's amazing. And it's consistent. Cherokee Health System in Tennessee has adopted this model. It's going great guns. Native Americans are really getting engaged in treatment because there's no stigma. This is a seamless part of the health system. You're not being abandoned by your physician and thrown into a mental health system where, "Oh gosh, my doctor thinks there's something wrong with my head." Even if they know this is a behavioral care provider, they see it as part of the health system, and the stigma is gone. It solves access, for crying out loud. You know, I have decided that we perpetuate stigma and access in our current practice, inadvertently.
VY: How so?
NC: Patients have a hard time getting to us. They have to call, make an appointment, go across town, leave the health system, go into a mental health system. The stigma becomes an issue, so they deny their own access because they don't want the stigma. We make it harder for the patient to get to us because psychologists do not congregate in health centers. If you look, physicians are herd animals. Every community has a medical plaza.
VY: They have a hospital and a medical office building next to it, or in the hospital.
NC: That's where podiatrists practice; that's where optometrists practice. Psychologists are across town in a solo office.
VY: Well, a lot of psychologists don’t think that they’re medical providers. We’re having conversations, as you said, with people about life—about their relationships, about their family, about their work.
NC: That's why we get the crumbs: because the American financial system pays for health care; it doesn't pay for psychosocial care.
VY: You said earlier that when professional schools joined with APA, I forgot your wording, but it was something like they made a pact with the devil. Don’t you think that, by identifying ourselves as medical providers when we’re really not, in some sense we’re making a pact with the devil, despite the financial gains of it?
NC: You just mentioned the fallacy. You said, "Wouldn't we identify ourselves with medical care?" There's no such thing now. When you talk to a nurse, they're not in medical care. They're in health care. When you talk to a podiatrist, they're not in medical care. They're in health care. Every health care profession recognizes that: "Oh, no, we're apart. We're not going to be medical care." Psychology has not caught up to the fact that, in 1985, the Supreme Court ruled that health care was subject to the same anti-trust laws as every business, and medicine lost their stranglehold on health care. You have these independent professions. And you know who figured this out first?
VY: Who?
NC: Nurses. Nurses used to be the lapdog of physicians. They'd do all the scutwork. Nursing now has established nurse practitioners. Only two percent of physicians go into primary care because that's not where the money is. The money is in specialties. Within 10 to 15 years, the primary care physicians in the United States are going to be nurse practitioners. Nurses know this. So the 26 nurse practitioner programs and nursing schools in the country this fall, 2008, upgraded their nurse practitioner program from an MA to a doctorate, because they're getting ready to be the primary care physicians. They've already done that. They own emergent care. You go to a doc in a box, it's going to be a nurse. The nurses are going full-blast, because they say, "It's not the medical system anymore! It's the health care system, and we're going to lead the way in health care."

The Hallway Handoff and other How-tos

VY: Let’s get back to your program in behavioral health. What are people going to learn in this program, and how are you going to teach it?
NC: They're going to take survey courses in the basic sciences. They're going to learn chemistry, they're going to learn physics, they're going to learn biochemistry, they're going to learn organic chemistry—not to the extent that they’re proficient in these, but they have a working acquaintance.
VY: In a year and a half they’re going to learn chemistry, physics?
NC: The mission of this program is to train skilled practitioners who are intelligent consumers of science—the opposite of what the APA does.
The APA trains scientist-professionals. So while they're trying to do both, they end up with second-rate scientists and piss-poor professionals.
The APA trains scientist-professionals. So while they're trying to do both, they end up with second-rate scientists and piss-poor professionals.
VY: Don’t mince your words, here.
NC: I'm not! I'm not. You know that.
VY: Tell me how you really feel!
NC: So for once, we say, "Let's do what all the health care professions do." We train skilled professionals that are intelligent consumers of science. That's what medicine does, that's what nursing does, that's what podiatry does, that's what optometry does, that's what dentistry does. Psychology hasn't figured this out yet.
VY: OK. So they’re going to get some survey, some general understanding, and what else? What are they going to do with this?
NC: During those 18 months, you spend two days a week in a medical setting and you rotate from outpatient to hospitals to cancer clinics, on and on. You learn the lingo of health care. Psychologists do not know the lingo of health care, and this is why they're fish out of water when they try to work in medical settings. They're going to become proficient in working like physicians work, but on the psychological side.
VY: So you’re assuming that these people–they’re master’s-level therapists, they’ve had quite a bit of experience–they have good therapy skills already.
NC: Yes.
VY: So you’re not there to teach them more therapy skills.
NC: No, we are not.
VY: So they know something about science; they learn about the medical system.
NC: Yeah.
VY: What do they need to know that they don’t know already? In other words, how do you take your existing clinical skills and modify them so that they work? Because I assume they already know a lot.
NC: They don't know how to do the hallway handoff.
VY: So what are three keys to doing the hallway handoff?
NC: They're chained to the 50-minute hour. The managed care companies always pay us on what we do in a 50-minute hour. And the more they squeeze the fee on that 50-minute hour, the more they squeeze us. So number one: abandon the 50-minute hour. It is archaic. As I say in the foreword to my latest book, the 50-minute hour is outdated in our nanosecond generation.
VY: Well, I’d say in that kind of setting I can see the disadvantage. But for ongoing depth, life-changing therapy, it works pretty well. And a lot of people do still want that.
NC: Then we're going to do what David Barlow recommends: that we should have a health care when we're part of health care. And that's called behavioral care. Then we have something called psychotherapy that continues to do what it's doing. But it's going to have to figure out how it gets paid, because under health reform, medical necessity is going to prevail, not life change. Americans are not going to pay taxes to fund a life-change system.
VY: Makes sense to me. So back to the hallway handoff: break the 50-minute hour. What else? What are the other skills?
NC: Role modeling. When you start, you sit in and watch an experienced person do the hallway handoff.
VY: Right. So what does the experienced person do, what do they know, that therapists need to learn?
NC: It's a skill that's hard to describe in words.
VY: I’ve never seen you at a loss for words, so do your best.
NC: There's no word for it; you are actually role modeling. And by role modeling, you learn to zero in very rapidly on the patient's presenting problem, which is something physicians do routinely because they have seven minutes with a patient. The average PCP visit in America is seven minutes. And in that, they've got to make a diagnosis and a treatment plan and so forth. We're not asking students to do it in seven minutes. We're giving them 15 to 20. But they learn to do it. And third, you learn what physicians need to do their job. And that's when they become so dependent on us that we achieve equal status.
VY: Well, this sounds good. It sounds like there’s a need for that.
NC: We're trying to respond proactively to where we see health reform going.

The Pits

VY: You’ve been a visionary in our field, an innovator, so let’s get you on record here. Where do you see health reform going?
NC: I see that
psychotherapy's either going to have to become part of the health system or lose out entirely.
psychotherapy's either going to have to become part of the health system or lose out entirely. Medical necessity will prevail. Marriage and family therapy, marriage counseling, occupational counseling is out. Look at the federal parity law that was passed last month.
VY: What you’re saying is it’s out of being paid for by tax dollars.
NC: Yes. MFTs are out. As David Barlow has seen, he said there are going to be these two systems: the traditional system, which we'll call psychotherapy…
VY: So that’s going to continue.
NC: That's going to continue, but they're going to have to figure out how to fund it. And it'll have to be funded out of pocket because it's not going to be part of health care. So if you want a life change, pay for it. Now, if the American people want it badly enough, they'll pay for it out of pocket, just like they do for alternative medicine.
VY: And there will still be some form of community medicine and various nonprofit counseling centers.
NC: Absolutely. But it will not be the golden age of psychotherapy that we've had in the past.
VY: When was the golden age?
NC: I'd say the 1950's.
VY: Private insurance was paying for it then?
NC: No. Private insurance came later.
VY: So we’ll be going back to the golden age, then.
NC: In the golden age of psychotherapy, there was a tremendous shortage of psychotherapists. People would wait sometimes for weeks and months for an interview.
VY: A golden age for therapists! Not for the public.
NC: Not for the public, absolutely not. I'm thinking you're asking me, "What's the fate of psychotherapists in the future?" And I'm talking about how the golden age is over. The competition is fierce. We now have 700,000 licensed psychotherapists in the United States. We only have 750,000 physicians! So we have almost as many psychotherapists as we have physicians, and they're all competing for a declining number of patients.
VY: So, in economic terms, you think we have an oversupply?
NC: Terribly. I call it a glut. A glut is more than an oversupply. I talk to students nowadays; they graduate and they can't pay their student loans.
VY: Yeah, it’s tough. But you’ve made some dire predictions before. When I started graduate school, I heard you speak, and you said something to the effect of, “Private practice is dying.” And it doesn’t seem to be, although the economics is not as attractive as it used to be.
NC: Now what year would that have been, Victor?
VY: That was about 1984.
NC: Because the book I published–I'm trying to remember the name of it–but at any rate, it predicted the decline of solo practice and why we had to succeed in doing group practices, which we didn't succeed in. Consequently, we're working at the same fee scale that we had in 1980, 1990.
VY: Exactly. So in real dollars, fees are half what they used to be.
NC: So my prediction—OK, it didn't die, but it sure is limping. It's the walking wounded.
VY: Right. Now, as I said, you’ve been a visionary and you’ve started a lot of new things, but let me be devil’s advocate for a minute.
NC: Oh, you can't do that, Victor.
VY: Sounds like you made some great changes at Kaiser, but if you look at where Kaiser’s at now, they provide very limited mental health services.
NC: Absolutely.
VY: If people are suicidal, they can get in. If not, it will take a few weeks, and they may not get back in for a month. And they’ll get a few sessions in most places.
NC: Correct.
VY: I imagine that must be somewhat disappointing for you.
NC: Terribly. But we're now in the third generation from the founders of Kaiser, and each succeeding generation becomes less like the Kaiser Permanente vision and more like the managed care routine.
VY: All right. You started the professional schools and you’ve said they’re a failure.
NC: Yes.
VY: You started American Biodyne, which was an innovative managed care organization.
NC: It was the only managed care organization where it was completely run by psychologists.
VY: Right. And that was bought out by Magellan. And what’s the status of it now?
NC: It's the pits!
VY: It’s the pits. So, you started three great things with great promise, and they’re all the pits. What makes you keep going and trying something new?
NC: I'm very proud of the fact that clinicians can be on faculties in psychology. I'm very proud of that. Maybe the professional school movement went astray, but there were some gains there. Kaiser Permanente is in its third generation; it doesn't have the vigor and vitality of the founders. I mean, Sid Garfield and Morris Collen, those people were fantastic physicians who saw that psychology was more important than psychiatry, and so forth. Naming a psychologist chief of mental health for all of Northern California was unthinkable.
VY: Thanks for balancing out your record. You’ve had some lasting successes as well.
NC: Yeah. So at any rate, there have been great disappointments because people tend to—what should I say—return to the mean.

I Hate Golf so I Can’t Retire

VY: So you told me at the beginning that you’re 85 years old.
NC: Yes.
VY: You look fantastic.
NC: Well, thank you.
VY: You still have a great deal of energy.
NC: Thank you.
VY: What keeps you going?
NC: Productive work. I love it.
I hate golf, and when you hate golf, you're not allowed to retire, because all retirees have to move to Florida and play golf.
I hate golf, and when you hate golf, you're not allowed to retire, because all retirees have to move to Florida and play golf. I hate golf so I can't retire. But I joke about that. I really, really enjoy productive work. This month, my 47th book is coming out.
VY: Wow.
NC: All my books do well. Eleven Blunders That Cripple Psychotherapy in America: A Remedial Unblundering is shaking up the APA. People are reading it. I get invited all over to talk at meetings and state conventions and so forth on the subject. So maybe I was put on this earth to be an agent provocateur. I don't know. But nonetheless, I am proud of my profession. I love this profession. I have never left it. I want it to succeed. It dismays me that we've created a profession that is full of economic illiterates. They don't think that private practice is a business, yet they have a product called psychotherapy. They have a place of business called their office.
VY: A unique skill set.
NC: A unique skill set. They collect a fee. They pay taxes on that fee. It has all the attributes of a business but they say, "No, no, I'm not in business."
VY: I heard recently that a lot of psychotherapists are reluctant to accept credit cards because they feel they’re enabling their clients to get into debt, rather than use the preferred method of payment in this country.
NC: Hippocrates said it is the obligation of the physician to do no harm, and he lists a number of things that the physician has to do. Then he talked about the obligations of the patient, and the first one was to pay the fee. Now, that was Hippocrates in 300 B.C.! And psychologists haven't learned that. You go to a physician's office, and when you check out, you pay the fee. At many physicians’ offices now, you pay the fee when you check in. Psychologists haven't learned that, and they say, "I didn't become a therapist to make money."
When I ask them, "Did you become a therapist to lose money?" they don't know what to say.
When I ask them, "Did you become a therapist to lose money?" they don't know what to say.
VY: So what parting words of advice would you have for young psychologists, students wanting to get into the field, people in mid-career to ensure their continued success?
NC: Pick your graduate school carefully.
VY: OK. If you’re going to graduate school, pick it carefully
NC: Make sure that they are teaching business courses, teaching you where the profession is going and how you have to evolve to keep up—all the things that most ivy-covered professors have no idea about. And drop your anti-business bias. Drop your guru worship. We're at a conference right now that is founded on guru worship. There was a time when we worshiped our leaders because we had no evidence-based therapy. If you wanted to prove something, you'd say, "Well, Sigmund Freud said…" or "Anna Freud said…" or "Carl Jung said…" Now, under health reform, if you don't do evidence-based therapy, you won't get reimbursed. So pick your graduate program carefully. I would say most of them are worthless. Again, I'm mincing my words, I know.
VY: You mentioned evidence-based treatment. What’s your general thought about that, and manualized treatment as well?
NC: The problem with evidence-based treatment as it's going now—it's very recent—I refer to the three E's of psychotherapy. We need to do what the IOM has told medicine it has to do–we have to catch up to that.
VY: What’s IOM?
NC: The Institute of Medicine. Their "Closing the Quality Chasm," one of the greatest reports ever written about health care, alludes to this: that there's too much non-effective treatment going on out there. But at any rate, Chambliss has called our attention to the need for evidence-based, the first E. Barlow has come along and he said, "Now wait a minute, what often works in the laboratory doesn't work in the treatment room. So we also have to look ateffectiveness. Does the evidence-based that worked in the laboratory work now in real life?" That's the second E. And the third E was developed by some guy named Nick Cummings, and it stands for efficiency: that we not only need evidence and effectiveness, but we also need efficiency.

Let's take an example in medicine. There was a time when everybody got a coronary bypass: expensive, intrusive. It took months to recover. Now we find out that a lot of the people can be treated with a stent instead of a coronary bypass. That's efficiency. The coronary bypass was effective, but it wasn't efficient. Psychotherapy does not look to develop efficiency. And this is one of the things we're doing in this program: we're creating the kind of efficiency that goes from getting 10 percent of the patients referred to 90 percent. Those are the three E's that I use. Stopping at evidence-based would be a mistake. It has to be proven in the field.
VY: And what about manualized therapies that are being taught? How do you manualize a human relationship, especially given that everyone is different?
NC: At American Biodyne, we had 68 proven group interventions or therapies–all time-limited, manualized psychotherapy. And they were guidelines; they were not cookbooks.
Ultimately, therapist ingenuity, insight and decision trump the manual.
Ultimately, therapist ingenuity, insight and decision trump the manual.
VY: I’m glad to hear you say that.
NC: Too many manuals are considered sacrosanct. That's a mistake. The word "manualized" to me is a dirty word because it denotes, "Here's the bible that you can't deviate from." I don't believe in that. The guidelines we had for our programs were based on our research. For example, if I can give you one innovation that was just absolutely fantastic…
VY: Sure, why not?
NC: Borderline personality disorder—the scourge of all therapists. If you see borderlines, get ready—someday you're going to be sued, as Bryant Welch, who defends psychologists all over the country, said. We developed a program for treating borderlines. We created an esprit de corps where the borderlines would police each other, which a therapist can't do. And we created an atmosphere where, "If I can't do this, I'm not going to let you get away with it."
VY: These are in groups.
NC: These are in groups. And our research showed how effective this was.
VY: Was the group identified as being for borderlines?
NC: Yeah.
VY: So they accepted their diagnosis?
NC: "You're a borderline." The first such group we did we called the "last-chance group." We had a group of borderlines that, for one of the Blue Cross plans, were so egregious that Blue Cross was considering dropping their health insurance. And I said, "Give me one more chance." They were all borderline women. See, male borderlines are scarce in psychotherapy because they go into the criminal justice system. They do things that get themselves in jail. Female borderlines disrupt the mental health system, not the criminal system. So most of our borderlines were women. And we called this the "Losers Group." "If you flunk this therapy, you're out of the health plan. I have prevailed upon the heads of Blue Cross Blue Shield to give you one last chance. I want to let you know that I have a side bet that you're all going to flunk. It's a sizable bet and I don't think I'm going to lose, because I don't throw my money away." So they're motivated: "I'll show this SOB." But then you create an atmosphere where they police each other. And then from there—and we would only have 20 group sessions, two hours each—they start to be able to form boundaries for themselves for the first time. And then we allow them brief intermittent psychotherapy throughout the life cycle. "Whenever you can, come back." It works. My therapist said, "I'm terrified when I have one borderline in my office. You want me to have eight??"
VY: Well, that could get into a whole other discussion about why there’s so little group therapy going on when it’s such an effective mode of treatment. But before we wrap up, getting back to words of wisdom, one was for therapists to pick their grad schools carefully if they’re going; the second was, if they’re practicing, to think of themselves as businesspeople. Any more words of advice?
NC: Be flexible and innovative. Unfortunately, too much of psychotherapy has been carved in stone. It is turning itself into obsolescence. Patients are ultimately our customers. The main characteristic of a customer is if they don't like your product, they don't buy it. And that's what we are now. Patients have been misled into now saying psychotherapy takes too long. They accept medication.
VY: I don’t know that they’re not buying it. I think the demand is still there and probably stronger than ever. I think its more an oversupply, as you said.
NC: That's one. But the actual number of referrals for psychotherapy have declined by 40 percent. Let me give you a very concrete figure. In 1995, 92 percent of all patients discharged from a psychiatric hospital were referred for outpatient psychotherapy. In 2005, it dropped to 10 percent. Ten percent!
VY: They’re not being referred–not that they’re not wanting it.
NC: They're put on a medication regimen. They're not being referred, but… If a customer wants the iPod, they're going to get it. If they really wanted psychotherapy, they'd get it. They say they're satisfied with the medication. Psychotherapy is not in its golden era; we would see articles in 1950 that psychology was going to solve the world's ills.
VY: And in the 60’s, drugs were, and in the 70’s, encounter groups were; and then it was the decade of the brain. Hope springs eternal.
NC: Yeah. But if a product keeps up… Nobody is going to buy a 1980's Apple computer.
If Apple hadn't kept up, if they hadn’t made the iPod, etc., they would have gone out of business. We also have to innovate.
If Apple hadn't kept up, if they hadn’t made the iPod, etc., they would have gone out of business. We also have to innovate.
VY: You’ve certainly walked the walk in your life. It’s been a pleasure to review your lifetime of innovations, creativity and contributions, even if they occasionally disrupt things and annoy people. It’s been a great pleasure talking with you, so thank you very much.
NC: Thank you very much, Victor.

James Bugental on Existential-Humanistic Psychotherapy

Posted on by rezendevknowfully.com

The Interview

Victor Yalom: I’ll get this started with the question you always ask: are we live or are we on tape?
James Bugental: Good question. Now, can we edit the interview?
VY: I’ll have someone type this up, and then I’ll e-mail it to you, and then you can look through and see if there’s anything that you don’t like or things you want to change, and I’ll honor whatever requests or deletions you have. It will be a joint project.
JB: And this is not on video, so I can be as sloppy as I'd like.
VY: Sure. And thanks for reminding me I want to get a couple of candid photos of us to put on the website, before we stop. I recall when we made the videotape of you, "Existential-Humanistic Psychotherapy in Action." In the introduction you started off by pointing out the actual reality of the situation—that even though you were doing a real session with a client, you wanted to acknowledge that there were other people in the room influencing the situation, the videographer, and the sound crew, the lighting, etc. It reminded me of your maxim "Everything is Everything,"—that is, we must take into account the real context of any situation.
JB: It's astonishing to me even now how often people join in a conspiracy to deny that there's a camera or a camera crew—that it doesn't count.
VY: The reason I mentioned this is I wanted to acknowledge the context of our interview, and recall that that video project was the genesis of Psychotherapy.net, which we’re just launching; and I’ve invited you to be the first featured therapist of the month. For that reason, and also because you’ve had such a profound impact on my life personally and professionally, I thought it was suitable that you be the premier therapist of the month.
JB: I feel that with real appreciation.
VY: So you wrote a new book, another book, this one called Psychotherapy Isn't What You Think. Tell me about that title.
JB: What do you think it is?
VY: What do I think the title is?
JB: Yes, or what do you think psychotherapy is, either way you like.
VY: What do I think?
JB: Uh-huh.
VY: I’d like to hear from you about that title.
JB: Well, I think—see how that word just pops up over and over. What's that word doing in there? Why do I put it in? Well, I think I put it in, see, that's the way, sort of crossing your fingers, saying: Don't hold me to it too tightly; I'm tentative; I want to see what I say, how it sounds and whether I want to stand behind it. And so much in our personal intercommunications is of that order.

VY: Hedging our bets?
JB: Yeah, by not putting all our chips on it. And so much of our lives we live that way: I had my fingers crossed, it didn't count. Think of all the different ways in which we say we're living tentatively for the moment.
VY: What do you think you’re getting at with that title, Psychotherapy Isn’t What You Think?
JB: See, that's what I was just answering when I took you on this little side trip about thinking and so on. What we do is tentative, we don't want to be held to it too tightly, and particularly in the therapist's office we need to be free to sort of speculate, to think, but not commit. But also we need to know there is a difference. Psychotherapy isn't what I think. It's what I live, when it's the best—when it's the psychotherapy you really want to believe in.
VY: In this book and in your previous one, you attack a lot of the fundamental, the traditional thinking about kind of a logical, or as you say a “detective” or problem-solving approach to psychotherapy.
JB: The whodunit school of psychotherapy.
VY: Then what should psychotherapy be?
JB: It's the pursuit, it's the process of always leading somewhere beyond to somewhere fresh.
VY: And making that process fresh?
JB: Yeah. Well, you, I'm sure, like me, sometimes you get into a rut with a patient; if you listen for some time you realize you're stuck in a familiar pattern, and that pattern is what you think, not what you live. That's why it's so important to feel alive in the therapeutic hour, to be aware of what we're living in the actual moment.
VY: When you look back in your life, what are the things that have really helped you become more alive?
JB: That's a tough question.
VY: Well, the reason I ask is that the thing that most impresses people about you when you’re talking about or demonstrating psychotherapy, is not just the concepts you espouse about being alive and being present, but how you put these principles into action, how you embody them. So I’m wondering….
JB: How did I get there?
VY: Sure, maybe how you got there. What do you think helped you with that?
JB: That's an intriguing question. Let me chew on it a minute. Well, I'll tell you some of the things that come to mind. I don't know whether they're a complete answer. My parents were for some time very into Christian Science, Unity viewpoint, all those sorts of things, quasi-religious I guess you'd call them. Very well-intended and not without merit, but for me it seemed that we were just saying the words. I'm sure this happens in any religious system. You say the words in the absence of genuine presence to the words. I don't want to just indict Christian Science. It has many good things, and other things have similar sets of words, all of which is often very benign, even useful. But somehow the magic, the dynamic has slid away from the living experience of the person, and become words.
VY: Which for you weren’t truly alive?
JB: Well, for me, and I think for many others. But I don't even want to make that sharp a distinction between saying the words and what is truly alive. I think it's a gradient.
VY: But you started upon this topic in explaining how you got to be more alive.
JB: Good point, thank you. Now right there is an example of what I teach about psychotherapy: by bringing attention to my process, you helped me stay with what's more alive right now.
VY: I’ve learned a few things from you.
JB: Thank you, that moves me. It's so hard as a human being in an interaction with other humans to be open, to receive and give communication without some of the communication replacing the living. Does that say it? You know what I mean.
VY: Yes, yes.
JB: I think being alive involves constantly finding a balance for being in and out of relationship. Being in front of an audience, boy! it's easy to get sucked totally out of full aliveness. You complimented me a minute ago that I often can be alive, but I have to be wary because, once I step away from myself and realize "Hey, I'm doing it now," then I'm already not doing it. It's a very slippery slope.
VY: But sometimes you can revel right in the moment, being self-aware, and at the same time appreciate what is happening.
JB: That's right, and that's the best countermove. You know, when I step out of myself to comment on it, that can be losing my footing or regaining it.
VY: I’m going to ask you the third time, Jim. Can you think of what are some things that have helped you personally to become more alive, more embodied?
JB: My experience with the quasi-religious sects that my parents were in and….
VY: S-e-c-t-s?
JB: S-e-c-t-s (laughter). Well, let's play with that for a minute because I think in sex you have the same thing, in physical, bodily sex—that if you're feeling very sexy, if you start trying to talk about it, and describe it, there is one point at which it augments the excitement, and then another point at which it dampens the excitement. That's really an intriguing thought, isn't it?
VY: Are you avoiding talking more about yourself personally, or do you just keep getting sidetracked?
JB: I feel these were very personal things I just said.
VY: No.
JB: No?
VY: Oh, they are, but not in terms of my original question of what do you think helped you to become more alive or embodied. You mentioned Christian Science. Are you implying you reacted against this, and were propelled to find another way?
JB: Rather I would say, the various kinds of religious, quasi-religious, semi-religious experiences I have been exposed to have helped me tremendously to experience the difference between the word, the information, and the living experience.
VY: So early on in life this is something you were very aware of, this distinction?
JB: No, not very early on. I would say about high school. By that time I was beginning to be aware of it. It wasn't a sudden boom; it was a very gradual process. I suspect it's still going on in a way. I don't suspect, I know that's so, now that I say it.
VY: You’ve focused so relentlessly on this topic of presence and the importance of the human subjective experience for the last 40 years or so.
JB: If you don't have presence, what have you got? What are you working with?
VY: You’re preaching to the choir, of course. I’m convinced that this is important, but I’m wondering if you have some sense of why this particular topic held such a grip on you.
JB: Well, I think that goes back to things like the quasi-religions. I don't know why I keep insisting on putting "quasi." They are religious groups.
VY: What’s held your interest and fascination with presence for all these years?
JB: My reaction when you ask that is: Without that, what have we got? I'm surprised how can you ask that question. Without that it's all mumbo-jumbo, or – what comes into my mind – you know when you get a package, it's got these little plastic things that fill it in so the contents won't break.
VY: Styrofoam peanuts?
JB: Yes. Without that we're reduced to Styrofoam peanuts to subsist on.
VY: I can see in your facial expression that presence is just as important to you right now as it has been for the last 40 years.
JB: I'm not sure if I can quantify it like that.
VY: In either case, it’s still very important.
JB: Very important, oh, yeah. What have you got if you don't have presence?
VY: Styrofoam peanuts?
JB: Exactly, and too many therapeutic interviews are filled with Styrofoam peanuts. Don't you think?
VY: Yes.
JB: But sometimes you do depend on those peanuts. I wouldn't get rid of them.
VY: I've often had the impression that for you living through the Depression profoundly impacted your life.
JB: True, absolutely right.
VY: Anything more about that?
JB: It's such a broad question, I don't know. Let me think just a minute. See, so many of my formative years as one approaching adulthood…
VY: How old were you…
JB: I was just trying to think of that.
VY: …during the Depression?
JB: Well, 1929 was the crash. In 1929 I was what… 13, 14 but we didn't feel it totally for several years. Let's see, when was my brother born? I don't remember. He's nine years younger, so he was born by that time but was very small. And for a while my dad couldn't support us, so we went to live with my mother's mother.
VY: Where was that?
JB: In a small town in southern Michigan, Niles, Michigan. That was important, first not having Dad there. Dad's a whole other chapter, a whole other story. But, second, because it was a small town. Mother gave piano lessons and that brought us a little income, and then she got a job playing in the movie theater.
VY: Playing the piano or organ?
JB: Playing piano, and also she took organ lessons and played organ for the Catholic Church I think when their organist was ill, and that brought in some money. I always remember that the movie theater where she played most, once in a while I could slip in and sit on the bench with her while she played, and that was fun, you know. And she just improvised as she watched it. Sometimes it came with suggestions for the pianist.
VY: She’d improvise to the movie?
JB: Yes (laughter). And I'm not sure this is true – you know how some memories you're not sure about – but that was the movie that also had—oh the name just slipped past me, "Flaming Youth," or something like that. It had scenes about bad young people who danced and pulled their skirts up and things. It was sexy in a very cautious way, but you might even see the girls' thighs or something. But I never got to go sit on the bench when that was playing, although I was always trying to. Frustrating. Maybe Mom wouldn't have let me. Those were times, perhaps because my grandmother was such a dear lady, who pitched in and supported us for a while but who was a very staunch Methodist or Baptist or Presbyterian, one of those, in a way that my family was not. And she was amazingly progressive about my not going to Sunday school every Sunday. I went a lot of times, though.
VY: How do you think the Depression impacted you—then and later on in your life?
JB: Oh, God, so many ways. The splitting up of the family, the whole family for a while, and then when we finally were able to get back together, that was such a wonderful thing. Not without its problems, though. When we first went back, you know, we went by train, of course, in the coach in the cheapest way, and it was three days and two nights, or something.
VY: That’s from Chicago?
JB: No, we went to Chicago and then out to California. Dad had come out here to L.A., and so Mom packed food in a basket and we ate sandwiches and whatever she'd put in the basket. When the train was in station, she ran off and got some more supplies, and then we were sleeping in our seats, of course, and it was a big adventure. Also in the car with us were a couple of advance men, I guess they were, for the L. G. Barnes' Circus, and I got acquainted with them and they were young, and I don't remember much detail except they were very friendly to me. I think of those times with sadness and with joy. There was lots of both, and I think what it did, thinking more in terms of your question, I think those times demanded that I grow up in some way, not be so dependent as I might otherwise have been. Dad wasn't there, Mom had her hands full trying to earn some money and take care of my brother, who was much smaller, and be there for me as well.
VY: Just the two of you?
JB: The two boys, uh-huh.
VY: No girls?
JB: No girls. But what it did was—I never thought of it quite this way—it demanded I be a separate person, more than if the family had been intact and in an intact home. One thing that helped very much was Boy Scouts, after we came to California. Let's see, you had to be 12 in those days to join, and I was born in 1915, so that would be 1927, actually 1928. And I had read novels about Boy Scouts and studied about them, and, oh, I was so eager for that. Now, what was so big about that same time was doing papers. I sold papers on the street corner.
VY: Where?
JB: In Lansing.
VY: Michigan?
JB: Uh-huh. And that was good. I earned practically nothing, I know now…
VY: How much would you make?
JB: Well, they were daily papers so we sold them every day, and my guess is I might make 50 cents, but that's only a guess. It wasn't any big money. After we came to California I had a paper route, bigger stuff, regular. Had to have a bicycle, which I loved. Oh, I loved my bike.
VY: Did you have enough to eat?
JB: Yeah. Sometimes it was scrimping, and I vaguely knew in the back of my mind that my mom wasn't taking as much, that she was shorting herself some. Hard times. Dad always had such grand plans, and they mostly didn't pan out, you know. But I learned from him optimism because he'd bounce back wonderfully. The only thing, sometimes he'd go off on a binge and get drunk, and he wasn't mean but he was unavailable.
VY: Do you think the deprivation or fear of the Depression lingered with you and impacted you later in adulthood?
JB: I'm sure it did, yeah.
VY: How so?
JB: Well, to always be concerned about income, and my earnings from my paper route sometimes helped us tie over. Both of my parents felt bad about that, and Dad went back to Chicago, didn't come to Michigan because he and Grandmother didn't get along very well. But he gradually was able to earn more, send us some money, until we finally could come to California. That wasn't the end of the money worries, though. There were federal projects, you know. I can't remember the details now. He did some things on a work project, and Mom did some teaching on a federal project. It's so amazing looking back how kids can know and not know so much of what's going on with the adults.
VY: Despite that economic uncertainty, you chose to go into psychology, which I imagine was by no means a guaranteed income in those days.
JB: Well, actually, it was pretty good. Now, we came to California about 1931, and 1932, I guess, was the Olympics in Los Angeles, and I got a job as an usher, and that was neat.
VY: Do you remember anything from those Olympics?
JB: Oh, yes.
VY: What stands out?
JB: Well, the first thing to pop up was not really because of the Olympics. There used to be, every year – I guess it was called the Electrical Parade. All the major movie studios would have floats, and there were marching bands from USC and UCLA. And I guess PG&E, maybe, and some other industries would have floats. The thing I remember most about that [laughter] was that the studios, the big movie studios often had floats with maybe a Grecian scene, or something, with starlets or would-be starlets with very little clothing on them.
VY: You keep getting back to that.
JB: Yeah, keep getting back to that. I always loved that. And the ushers would always get people seated, and then when the parade came and when those floats came in, we all got down in the boxes and looked up [laughter].
VY: So you’d get the good view?
JB: So we would get the good view.
VY: Those seem to be the memorable moments in your life?
JB: That's one of the memorable moments (laughter). And also I guess there was a flood. I think it was in the La Crescenta, Cucamunga area, and I went up there with a group of boys and we helped people dig out or helped them in various ways, and I was beginning to feel some authority because as an older boy they reported to me, and I worked with the officials. That's a little more grandiose than it was. I might have said "Hey, Kid, have you got anybody that can run an errand?" and so on.
VY: Do you remember the first client you saw?
JB: Oh, you're jumping way ahead. Am I taking too long?
VY: That’s okay.
JB: Don't hesitate to tell me. I'm enjoying reminiscing. Let's see. Got through junior college, worked some, I can't remember doing just what now. Oh, I worked for the Bank of America Trust and Savings Association, which we called Bank of America Mistrust and Slaving Society. That taught me I didn't want to stay in the banking business. And then in the meantime, I'd say about 1935, I got married. No, it would be later than that, early 1940s. I got married to a girl I'd been going steady with since junior college. In the meantime, we both graduated from junior college and she went to UCLA. Her family had more money so they could do that. I worked, and now I can't unwind it all, too many strands all mixed in. Anyway, she was from Texas, that was it, and at some point her family invited us to come back there, and a distant cousin was the Registrar at Western State Teachers' College. He said "We can get you in here." My grades were not good enough to get a scholarship, I'm sure, but somehow or other I got in and finished up my last two years of college in one calendar year, by taking extra courses and so on. And then I did well enough to get a scholarship to Peabody—do you know Peabody?
VY: In Georgia?
JB: No, in Nashville, Tennessee. It's now affiliated with the Vanderbilt University School of Education. It had a long, excellent history, particularly in psychology. Names we don't hear much any more: Garrison and Boynton and so on. so think we were getting support from my wife's family, we must have been. Oh, by that time I had been in and out of the Army, that's right, so I had the G. I. Bill. I was only in the Army, God, I don't know – 11 months, 13 months, right around a year.
VY: Did they send you anywhere?
JB: Virginia. In the meantime we moved to Atlanta. I don't know just how that came about now, but I got to know the chief psychologist at the Army Hospital there, and so when I went through my training he requisitioned me. I went through basic and I was assigned there, and had the great fortune to be put with a Gray Engleton, who had been for many years a psychologist in the New York City schools. Gray, I remember him. He was such an encouraging, sponsoring, teacher. He opened up my whole vista on what a psychologist was and what they could do.
VY: You’re getting emotional when you talk.
JB: Yes, I do.
VY: What’s the feeling?
JB: It's hard to identify. It's sadness, great appreciation for him. He opened a door that I didn't even know existed within the practice of psychology, what it means to be a psychologist.
VY: You were in the Army then? If you hadn’t met him, you might not have become a psychologist?
JB: No, I'd already taken my Master's in psychology, but I might not have taken the path that I did, I don't know. Someplace in there my second child, James, was born, and the war ended. Without trying to detail just the sequence, the thing was that with two children and having a year of service, I became eligible for discharge. I don't know, something about that—I don't think it was the discharge. It was the change in my life. In a relatively short space of time, five years – I'm just grabbing the number, it's not precise at all- my whole vision for myself, my whole vision of what was possible, what the world was going to be, radically changed. I began to think I wouldn't have to be a salesman like Dad, that I might be able to do something more. I always wanted to be an author, to write fiction. Well, I'm getting too caught up in details here.
VY: No, not at all.
JB: That's okay? And then I got discharged and went back to Georgia Tech to the counseling center; but in the meantime a former professor of mine at Peabody, had become the director of the counseling center, and with his encouragement I began casting around and looked for fellowships and scholarships or something. Ohio State accepted me, and I liked Carl Rogers, who was there, and it sounded like the place I should go, so, without worrying about the details, I accepted that, and we moved there.
VY: You entered the PhD program?
JB: Um-hmm, and we moved to Columbus, Ohio, even as Carl Rogers was moving to Chicago. So instead of studying with Carl Rogers as I intended, I found I was with George Kelly, and it was the luckiest break of my life. No, not the most, but one of them. George is not well known but he was a splendid teacher, encourager, and he'd brought Victor Raimey, another name you probably don't know, but Vic was one of Rogers' Ph.D.s and was at the University of Colorado. Vic was so encouraging. I was his first graduate student, his first doctoral candidate. Let's see, I passed all the tests the night before…. what? I don't remember – before something or other, maybe passing my orals, that was it, and I guess somehow we were in a celebratory mood and Victor came by my house and picked me up and we went out, and he got drunk and I had to take care of him (laughter). But I was his first candidate, and it was too much for him, I guess (laughter). Oh, he died too soon. Nifty guy. I had my basic degree by that time. New Ph.D.s in Clinical were very sought after and you could almost name your school, and name your price within reason, and UCLA meant coming home in a way, so I took UCLA. And the rest is history. Why did I go through this whole thing? What did you ask me that set me off?
VY: I asked you if you remember your first client.
JB: My first clients were counseling clients, some who we really did brief therapy with, though we didn't know it by that name then, but therapeutic counseling. I set up the counseling center at Georgia Tech—no, not Georgia Tech, but UCLA – I don't know. Anyway, I found I loved to do that.
VY: Despite that and your desire for economic security, you did the bold thing, quitting a tenured position at UCLA?
JB: That's right.
VY: To go into clinical practice, whatever that was.
JB: Al Lasco, do you know Al? He and Glen Holland and I were all teaching at UCLA, and we started a practice on the side, Psychological Services Association. Good academics that we were, we'd have regular staff meetings, and we'd study books together, sometimes bring people in to teach us. It was a very rich diet, out of which we all three eventually left UCLA and developed our practices.
VY: I’ve heard you say that at the time all the books on psychotherapy, including psychoanalysis, fit onto one bookshelf.
JB: Oh, yeah. Not even a full shelf. I can't remember them now, but there were a couple from the twenties that still had some currency, and of course Carl Rogers' books, a couple of those, and just one or two others. There just was hardly any literature in the field.
VY: Were you aware of being real pioneers?
JB: Yeah, to some extent, uh-huh.
VY: Exciting?
JB: Oh, yeah, yeah. And a lot of support, too. Not only the two people in practice with me, but at that time we were starting the Los Angeles Society of Clinical Psychologists in Private Practice. There was another group practice, three guys that we had very congenial swapping relations with, and then maybe a half dozen others in town in solo practice, most of them having some other connection, as private practice wasn't supporting them solely. But rapidly that changed and new people came in. LASCPIPP, that's it, Los Angeles Society of Clinical Psychologists in Private Practice, and it's still very much in existence. And there's the Southern California Psychological Association, which overlaps with them.
VY: Any memories that stand out of a particular client you’d like to share just as you were kind of learning how to do this thing called therapy?
JB: Also a guy I'd known in high school, we'd been in high school together, was a psychiatrist, and I think he was in training analysis, and we got together and I used his office some and he gave me sort of coaching. I don't know whether we ever had a formal supervisory relationship. I don't think so, but just sort of coaching and he taught me about some of my work and he'd tell me about some of the things that he was learning, and that was very helpful. My whole understanding of the phenomenon of resistance traces back to Jerry Saperstein. I'm moved now and I can't think quite why. We weren't big buddies or anything, we were just good friends, our paths only sort of bumped together for a while, but it was congenial.
VY: Are there some moments with clients that stand out when you look back and think: Here’s where I learned some important things about therapy?
JB: There are a number of them. There was Mildred, who was an older woman, who—how would you characterize Mildred? Very needy. Looking back I know how much I fostered her need. I needed her to need me, and I think I did a lot to help her, but I didn't do much that was forward looking. I didn't know about that even. I gave her support. It taught me a very important lesson, not just to soak in positive transference, not just to feed it and feel that everything's going great.
VY: What about the therapy with her helped you learn that you needed to do more than support? Did you get to that point with her where you started to do more?
JB: Oh, yes, and she fought it, hated it, and then I'd slack off. I think the thing I learned most importantly was that it's not too hard to get a positive transference if you don't keep setting limits and having a formal sense of what you're doing. It doesn't have to be stiff and distant, but just yielding to the neediness of the client is not therapy, and I'm afraid that's a lesson many of us have to learn probably not just once. I struggled with that a lot.
VY: Therapy isn’t what you think.
JB: You got it [laughter]. Now where do you want me to go from here?
VY: Before we move on, you said several came to mind that you thought of, clients who have helped you learn about what therapy is.
JB: I mentioned Jerry teaching analytic concepts and particularly about process as opposed to content, one of the most fundamental things I learned. Oh, someplace in there I went into analysis myself. That was a very important learning experience, five times a week.
VY: How so?
JB: Oh, the analyst I had, and I think many others too are very disciplined, very formal, and somehow in that respect very evocative. I know many new therapists are hesitant to be formal and disciplined and so on, feeling that they will drive the client out, but that formality, those limits, actually can encourage intensity. That was an important discovery.
VY: What did you learn about yourself in psychoanalysis?
JB: About myself? I think I learned my neediness, my emotional neediness, and how important it was to not suppress it but give it some structure.
VY: We all have a lot of neediness.
JB: Structure and ethics, because I think one of the most important things for a therapist to learn, and one that I worry that too many of our younger therapists don't get to understand, is the reciprocal relationship of affect and form.
VY: What do you mean, they don’t understand? What don’t they understand?
JB: That affect itself, the display and release of it….
VY: Catharsis?
JB: Yeah, catharsis unbridled is not psychotherapy. Catharsis bridled—the bridle is a good metaphor because you steer with it. Catharsis bridled is a powerful therapeutic vehicle. It's not therapy, it's a vehicle for therapy. Emotional discharge is incidental to therapy, not prerequisite for therapy, but without structure affect is counter-therapeutic actually.
VY: You don’t really believe that affect is incidental? Don’t you need to get to some point of strong affect?
JB: Oh, sure, but affect with structure. Affect provides the engine, but the engine doesn't know where to steer.
VY: I’d just to like shift for a final part to taking a look at where you are in your life now. A lot of the theoretical existential literature talks about death, death anxiety, and how it impacts one’s life. You’re getting old.
JB: I used to just have great terror around death.
VY: Yeah?
JB: Oh, yeah.
VY: When was that?
JB: At a guess, I'm saying the 1940s and '50s—that's a guess. Probably when I was in my thirties and forties. That's not very precise. Just god-awful. I couldn't breathe.
VY: You were worried about dying?
JB: Not about dying. About oblivion, nothingness.
VY: What do you think that was about, looking back?
JB: It was about oblivion and nothingness [laughter]. I think that's what it was about. It was about confronting how limited is our knowledge and our purview, about confronting that finally I had the Ph.D. and I'm a psychotherapist and I'm the president of this and something of that, and I don't know where the escape hatch is. I'm still going to die, and I still don't know what's happening to me. I think that's finally the existential reality coming home, and I didn't welcome it.
VY: And now?
JB: It's funny, no not funny, but in an odd kind of way those things are still true. The feeling I'm discovering even as we talk is very difficult to put in words. What comes to mind though, is a celebration of the not knowing. That's got too many overtones that I don't want, but it's something like that. It feels right that I don't know. I hate it that I don't know, all at the same time.
VY: It’s not terror then?
JB: Not terror. But I can see terror back of it a ways, like it's waiting, it might come back. But there are other things in back, too, so I don't think I'll just be captive of it.
VY: You complain about your memory a lot.
JB: That's a pain in the ass. If you press me on what year was that, or where were you living at that time, or informational, factual, objective information, I just can't do it.
VY: But right at the moment you’re still very lucid and present?
JB: Yeah, that's the saving grace.
VY: Maybe letting go of that helps you to be even more present?
JB: Oh, I think, yeah, very definitely. If I grapple with that, I'm not present. I'm off in a private wrestling match.
VY: Any awarenesses about life….
JB: Endless.
VY: ….that you could share with me that will save me a little pain?
JB: Nope. That's one important awareness!
VY: What are you going to do the rest of the day?
JB: Well, probably I'll alternate between trying to find my desk under all these things—I know it's there and I remember once I saw it. And who know, I may play with an idea for a new book.
VY: Good luck.
JB: Thank you
VY: I’ll take a couple of photos.
JB: Okay. I haven't shaved or anything. Is that all right?

Larry Beutler on Science and Psychotherapy

Posted on by rezendevknowfully.com

The Making of a Psychologist

Hui Qi Tong: Good morning, Larry.
Larry Beutler: Good morning.
HT: So I’ve known you in different capacities for a couple of years, and I have to confess that it’s always been on my mind over these years that one day I might have the opportunity to just sit across from you and interview you.
LB: Well, I'm glad to get a chance, myself. It's nice to have you here.
HT: I’m always kind of intrigued with people’s passions–their choice of profession. How did you come to choose to be a psychologist?
LB: That's a good question. Subjectively, I'm not sure I chose. I think the profession kind of chose me. My first year in college, I had probably four different majors. I started out in chemistry because my cousin was in chemistry. And then in the middle of the quarter I think I switched to physics. I went through math. By my second year I think I'd been in art, I'd been in social science, I'd been in sociology, I'd been in pre-law. But I transferred from a junior college to a university, and on a whim, I'd taken one psychology course and I'd really enjoyed it, and they asked for my intended major and I wrote down "psychology." And I've never looked back.

But I'm sure that it's more complex than that. I think there are other some other hidden issues. I had struggled for a long time, as most adolescents do, trying to find a place for myself, and….

HT: To establish your identity.
LB: And a lot of my identity was built in regard to my family's very conservative values. And part of their conservative religious values put them at odds with what I came to be learning in high school and college, in particular, around the role of service. My family's values emphasized the role of service, but only within the confines of a religious organization. And it really had a very hierarchical kind of structure. And I became very concerned with what it did to disenfranchise certain people–people who were outsiders, people who by virtue of their skin color, by virtue of their ethnic background, by virtue of their gender, were given a different role within my family's value structure. And I struggled with that for many years and ultimately made some very significant changes. quote[:I made specific decisions about wanting to build into my life a view of people that was infused with more equality than I had seen.] I don't mean to say that my family wasn't respectful and interested in people's assets, but they regarded people only based on their religious beliefs, and infused in those religious beliefs were a lot of attitudes about gender and race. Within their religious view, for example, people whose skin was darker colored than Caucasians came from a place prior to their birth that was less righteous than those of us with white skin. And that was a real troubling aspect for me as I came into my early twenties, and became an organizing theme for what essentially became a break with my family and a break with my traditions.
HT: Have you had any opportunity to voice your own opinions within your family?
LB: Oh yeah, I did What it meant was that nobody in my family would talk to me for a number of years!
HT: That’s hard.
LB: When I was going through this struggle, we had strong words. I was not slow to voice my objections. And I did so in a very clumsy, awkward and hostile way. And what it did was disenfranchise me from my family, my sister, my father, and all my relatives that I'd been raised with. And some of those relationships have survived, some have healed at least partially, and some never healed. So I would have to say it was in some ways costly, but it was also freeing. I did become very much my own person in that regard, in how I set my values. But by the same token, what I set as a value, to live what I considered to be a good life, was very different from what I'd been raised with, and there have been periods in my life where I've had to struggle with, and really make sure I was doing what I had vowed myself to do. And you know, I haven't always been successful in that. I find little pieces of bigotry and rigidity and other kinds of things hidden in my persona that I have to expunge from time to time. It has been an organizing theme for me.
HT: What was your family’s religion?
LB: Our religion was Mormon. And the reason I guess that this comes up right now is I've just been in a conversation with a childhood friend that I have resurrected a relationship with. We haven't talked to each other for 50 years. But over the past year, we've developed a friendship again. And he has had a lot of similar experiences that I had in regard to family struggle, and now I'm in contact with his brother, and I've just gone through a week of revisiting some of these old issues. And resurrecting some of the feelings that occurred to me back when I was going through this in my twenties and thirties. So it's very raw to me right now. But I think that it was very pointedly involved in my decision, happenstantial as it might have been, to get into the helping fields, and ultimately to become a clinical scientist and practitioner in psychotherapy.
HT: So that’s really profound, your experience during adolescence and young adulthood, how you moved away from the old frame of view and broke some bonds to free yourself to establish your own identity. You mentioned that before you entered psychology, you were exposed to math, chemistry, physics. I also believe that no experience is wasted.
LB: Oh, no, I enjoyed it.
HT: And you’re such a hardcore scientist in the field of psychology. I just wonder whether the experience of being immersed in basic science had an impact on your research in psychology.
LB: I think so. I think I gained some appreciation for science in that process, although my original aims in psychology were to be a private practitioner. I didn't make the decision to be a scientist until I was well into my doctoral studies. But it occurs that that is a theme in my life: I wind up making decisions that, it feels to me, are really not made decisively. But as I look at my life it's almost as if I had planned it from the beginning.
HT: That’s a wonderful feeling.
LB: It's a curious phenomenon to observe that one does make something of their life, and sometimes their brain is the last part of them to know.

The Challenge of Training Psychologists

HT: You mentioned you started out wanting to be a practitioner, then later on became a researcher, a scientist-practitioner. I wonder–at our school (Palo Alto University) our training model is more practitioner-scientist–if you were to design a training program, how would you design it?
LB: Well, that too is a good point, because I struggle with that still. I struggle with it now as I teach my Introduction to Psychotherapy class, because I designed that as I have thought for years would be the best way to teach people how to be good psychotherapists. But I'm finding now that I may be wrong, that I have to relook at how I develop the steps to becoming a good scientist-practitioner, practitioner-scientist.

I wound up moving from being a clinical researcher with, as most psychologists want, a practice on the side. I've always had a practice, and sometimes it's been a very big part of my life, but other times it has not been. But always there since receiving my PhD, has been the clinical scientist. My practitioner world has been taking what I find in the laboratory and then trying it out. And there have been people who have talked about their research–good scientists like Hans Strupp, for example. He's a remarkable man. But he's always said that his research findings, his science, really never had any influence on his practice. And see, I find just the opposite–what I found in my research had a very direct impact on it. And that being the case, I see that what has occurred as I have thought about the third role, which is education, that I have changed a lot in how I think the concepts need to be given or provided for students. And I'm still changing, and I'm not certain about that right now. Because I'd say what I have been doing the past three or four years isn't working as well as I'd hoped it would.
HT: What have you been doing the past three years?
LB: I've been trying to teach the students from the beginning what the core basic concepts are in psychotherapy, independent of the theoretical model they apply. The core basic principles, the most fundamental ways of looking at an individual and constructing the interaction that will have a beneficial effect. This is what I've derived from my research, looking at others and so forth. The fundamental core principles of psychotherapy.
HT: Do you mean the principles of change or…
LB: The principles of change, the principles of how one person can interact in a closed environment with another person to facilitate change. And I put a lot of stock in those principles. And the more I find out about them, the more I find that there are more principles, but there are some really good ones. I just wish I could articulate them better. But I have been operating on the assumption that if I taught them the basic principles first, and then taught them their theoretical models, that then they would be better practitioners. But this is just the opposite of what I did for years at the University of California: we would teach the theoretical models first and then teach them how to integrate concepts out of those models and principles.
HT: So now you’re adopting an approach that is broader to start with–just lay the foundation, then later on students will study the specific models.
LB: That's the idea. And it sounds good. But it's not working. It's really not working.
HT: How can you tell it’s not working?
LB: My students tell me. I mean, I am going through a period where students, I am finding, are very resistant to the methods that I am applying. And so it makes me want to return to some of the ones that worked before, and to redo the educational process. So in answer to your question, I don't have a handle on how to go about teaching people at this point. I have little glimpses of how to teach people. The real problem that you have in trying to teach people psychotherapy is you can't just teach them about it–you have to expose them to it. And in the beginning processes, that is a very tender, fragile kind of interaction, to teach people to interact with a client. Because the therapist is afraid, the client is afraid, and bad things might happen. Good things might happen, and most of the time they do. But bad things might happen. So one has to be careful in that initial interaction. I haven't found a way to do that in a way that students feel safe enough to try it.

I don't like the way that psychotherapy is conventionally taught. I don't think it works well. I think out of it we have produced one third of therapists who are ineffective at best and maybe harmful. That's not a good track record. We have an article that just came out, for example, in one of the APS [American Psychological Society] journals from some old colleagues of mine,1
that most psychologists simply don't practice anything based upon any scientific evidence whatsoever.
that most psychologists simply don't practice anything based upon any scientific evidence whatsoever. And we know that. We've known that for years. And what they propose is that we begin to make our training programs reflect specifically how well students are able to incorporate scientific findings into what they do. I think it's important. But then, just this morning I was interacting, I'm a member of APA Council and I was interacting with people on the Web about this very article. And one of the very strong themes in that is, "These people are all wrong. Science doesn't matter to clinical practice." And these are very senior people. Some of the former APA presidents and leaders are saying this, that science doesn't really matter to practice. These people are all wrong.

Making Science Matter

HT: You have a paper just published this year about making science matter and redefining psychotherapy. What I see that’s interesting is that bidirectional communication is disconnected. Some clinicians do whatever they want, and disregard what scientific evidence is there. And some researchers actually don’t pay attention to what’s really going on in the room.
LB: They don't. They don't.
HT: They come up with narrow, rigid focuses of the scientific inquiry, as well as the way they design their research.
LB: That's very true. We have, I think, in the course of our experience as a budding science, defined ourselves almost out of… not out of existence, but out of value. We try to adopt, in the psychotherapy field, a model of research that was being used very successfully in psychopharmacology, was being used somewhat less successfully in medicine, but was highly advocated and highly regarded. And it was a model that to many people looked really good. It's the medical analogy that you consider the treatment to be like aspirin: we need to know the ingredients of it, and the person who gives it shouldn't matter. So we give cognitive therapy disembodied from the therapist. And we studied in a disembodied fashion. Now people are giving lip service, finally, to the inappropriateness of that, but they haven't changed the method. They still rely upon that narrow method that says we will train people to follow a prescription, we will train them to do it so it doesn't matter who is delivering it. And then we will study the outcome.

And the one thing that these people are wrong about is they make a big case out of the fact that they have discovered that cognitive therapy worked well with all of these groups. Now, they're right. But what they don't say is that they've discovered that cognitive therapy is better than something else. Because we haven't discovered that. What we've discovered is cognitive therapy works. But people hear the implication that it works better, and therefore we should be doing it. But that's only because we have in our research model excluded characteristics of the therapists, nondiagnostic characteristics of the patient, qualities of the context, and certainly qualities of the relationship. And so the paper you're talking about is one in which I try to make the argument that
psychotherapy is not just what the therapist does. It is, in fact, who the therapist is, how the therapist interacts, who the client is, how they interact, and the nature of the relationship.
psychotherapy is not just what the therapist does. It is, in fact, who the therapist is, how the therapist interacts, who the client is, how they interact, and the nature of the relationship. And all of those components can be scientifically studied. But they can't be studied using the research designs that we're currently using. Interestingly, out of that, I've gotten an invitation to present a paper at the SPR conference in June at Asilomar.
HT: What’s the SPR?
LB: It's the Society for Psychotherapy Research, an international society. I've been president of it. But it was the place in which Gerald Klerman, who was head of the National Institute of Mental Health, made his first pronouncement that we were going to study psychotherapy as if it were aspirin, and initiate the randomized clinical trials model for psychotherapy research. And at that point we began forgetting about therapists and patients and relationships.
HT: That reminds me of evidence-based practice in psychology–it’s really parallel with evidence-based practice in medicine.
LB: Well, that's what they try to make it.
HT: Tell me about your opinion of the EBPP [evidence based practice in psychology] movement. There are so many different terms coming out of that, and now there’s also research-informed practice. I’m a bit confused about all these forms.
LB: I'm confused too. I strongly believe that practice should be research based, and should certainly be more than research informed. "Research informed" is where the American Psychological Association has now taken this with their task force a few years ago. This was discussed just the other day in the council exchange that I was talking about a moment ago, where James Bray, who is currently the president of APA, tried to make the case that psychotherapy is not research based, and should not be. According to him, it should be based upon research knowledge, plus patient values, plus the personal impressions, feelings and judgment of the therapist. And that to me is a scary thought, but that's where we are in psychology.

It's the one thing that makes this whole thing into a soup rather than a science, because it says there are three equivalent ways of knowing something is true: one is through patient values, one is through the observations and judgment of the clinician, and the third is through science, and they are to be equal as they go into this soup. Well, to me that makes a soup that has no character. Because if we don't keep the research base–not just research informed, but research grounded–we are back to the point in our history that anything goes as long as you're sincere. The patient values guide us. Those values may be quite disturbing and distorted. Certainly we know that therapists' judgment is often very poor. If one third of therapists produce more patients that get worse than get better, well, I'm not sure I want to trust my children to those therapists. And that means that we need to do something to improve their judgment, and I don't know any better way to do it than through scientific grounding.
HT: It seems to me that all of these three components–the patient’s values and preferences, the clinician’s wisdom or experience, as well as the scientific evidence– should be integrated and tested.
LB: They should be integrated. If we could adopt research, plans, programs and methods that incorporated the investigation of how patient values affect clinical judgment and treatment procedures that would be psychotherapy. But as long as we are conceptualizing it as separate, it will stay separate and it will stay ineffective. The common finding is still that all therapies are the same. It doesn't matter too much whether it's therapy as usual or whether it's a therapy constructed out of the theoretical research model or what. They're all pretty much the same as long as all you do is study them in a disembodied way, separate and independent of the patient's values and of the therapist's judgment, experience, background, etc.
HT: That reminds me of the Dodo bird verdict2, that everything works.
LB: It is a Dodo bird verdict. All have won and all must have prizes. Everybody wins. The problem is also that everybody loses.
HT: Yeah. So if in the near future there would be a new research design which is not as narrow, incorporates every factor that is important, relevant…
LB: I'm cautiously optimistic. I want to be alive when it happens.
HT: But you’re doing it now.
LB: Well, I have tried very hard to make it happen. If I have a mission in the world, this is the mission I would like to accomplish.
HT: Can you state your mission so we capture it here clearly?
LB: To redefine what we are studying in psychotherapy, to be more inclusive rather than exclusive, to be inclusive of the common factors, to be inclusive of the therapist factors, patient factors, etc., that are not bound within these narrow definitions of diagnosis and treatment model. Now, it seems periodically that we have made some headway in doing that. People are interested in this paper I published3, they're citing it and so forth. But it's not the one that's getting on the front page of the New York Times. This is the one that's getting on the front page of the New York Times: Psychotherapists are not practicing scientific methods and they won't. And again, there are two things wrong with that. One is that that is a sad shame if it's true, and second is that our definition of psychotherapy almost makes it impossible for psychotherapists to do otherwise.
HT: So in this particular paper, “Making Science Matter,” you said something really salient. You said, “Despite all the evidence or lack of evidence that science matters so far, I still believe that scientific methods offer the best way of finding optimal and effective ways to intervene with behavioral health problems.”
LB: That's right. That takes me back to my chemistry and physics. There are connections between things, and the best way to find them is to control variables and allow other variables to vary, and systematically evaluate the outcome.

Matching Therapists, Treatment and Patients

HT: What are the variables you think are important to study in a more broad kind of approach?
LB: There are so many of them. I think, increasingly, the evidence as I read it says
the maximal amount of change that we'll be able to account for is going to be embodied in the way therapist characteristics, treatment, and patient characteristics interact
the maximal amount of change that we'll be able to account for is going to be embodied in the way therapist characteristics, treatment, and patient characteristics interact–algorithms, essentially, that bring those three things together. Those will be the strongest contributors. It will not be therapy procedures, it will not be patient diagnosis, it will not be these other isolated variables. It will be the interaction among them.

And so I am very tied to looking at ways to match patients to therapists and match patients to treatment. And those are two different things, but they have to be incorporated within the same research model. There are certain things we find very difficult to randomly assign. The gender of the therapist, you know, that's difficult. We can assign male and female therapists, but we can't assign to a therapist a different gender and separate out of that connection what the therapist is from the gender the therapist assigns. So we've got to find more flexible research models that don't throw away the randomized clinical trial but add to it more correlational kinds of variables to put into that mix and evaluate the outcomes. And that, I think, is where science needs to go to become really relevant.
HT: I’ve taken your course twice, and in the class we read your book Systematic Treatment Selection4. And that model is what you’re talking about: to try to capture the patient’s characteristics, the therapist’s characteristics, and to match them, and also looking at what kind of treatment approach will work best for a certain patient depending on the stage of their condition. Can you tell more about therapist and patient matching? What do you match them on?
LB: Well, again, the potential is limitless. But what we look at are four basic kinds of variables. And sometimes it's difficult to assign the ownership of those. Are they characteristics of the patient, the therapist, or the treatment? They should call it intervention, not treatment, because it describes what the therapist does, and we can only roughly categorize those into groups. Of the variables that we look at, the first one is really the impairment level of the patient. Now, the impairment level of the patient isn't just something owned by the patient. It's also owned by the context in which they live, the social environment, the culture, the value system that exists in that culture to define what is adaptable and not adaptable. So we can't just study functional impairment disembodied from the culture in which it lives.
HT: So it’s really beyond the DSM-IV.
LB: Oh, way beyond the DSM-IV. But we can take functional impairment and say, once you have defined it within a cultural context, then there are a couple of things we can clearly say we know about that; one of them is that the more impaired the person is, the more treatment they require, the more varied kind of treatment they need to get, and the more it needs to extend into the environment in which they live. There's some real implications with this. This means family treatments need to be involved based on the impairment level. That means groups–social groups, not just therapy groups but social groups–need to be involved, and that the intervention needs to be more life consuming the more impaired the person is. But you need to start with how you define the impairment in the culture in which it's done.
HT: By life consuming, you mean more sessions, longer sessions?
LB: More sessions, longer sessions, and sessions out there, not in the office.
We need to help take the person out into the world in which they live, and therapists are still reluctant to do that.
We need to help take the person out into the world in which they live, and therapists are still reluctant to do that. The second variable we look at is the patient's coping style, but that too is a culturally defined variable. It reflects what works within the culture that one lives. It's clear to us now that at least people in many Asian cultures, certainly Japan and probably China, tend to cope with things in a much more internalized and self-reflective fashion. And the concept of collectivism becomes very important in the whole concept of coping. So we need to understand coping within the context of the culture it occurs in.

But within that there is variability, and it varies along this dimension of how one copes, how one deals with the self versus others, how one accommodates to others versus defends against others. Once we know that, then it can tell us a little bit about how we need to intervene, what kind of focus we need to take. And again, the effect sizes of this cut across cultures pretty well right now. Compare the effect size of cognitive therapy to interpersonal therapy: the mean effect size is zero. But if you can compare what we call a good match between the focus and the coping style of the patient, and a poor match between the focus and the coping style of the patient, we get effect sizes on average of 0.6 to 0.7. That's good–those are high effect sizes. That means that we're having a much more significant effect upon that patient by taking into account coping style than we are by identifying their diagnosis.

Then we take the next variable, which is a patient's resistance. And this is where we get some real problems. We've always thought that if a therapist can identify and deal with how the patient wards off efforts to persuade them or change them, then the therapist can adapt to that. And we find, in fact, that this only works in some contexts. For example, we just did an analysis of the effect size related to coping style and directiveness of the therapist. We've always thought that if the patient was very resistant, then if the therapist was less directive and confrontive they would be able to persuade them. But that seems like it may only work in North America. And it may only work with relatively serious problems. People with less serious problems and people that are outside of the North American value system may not always relate to that. In fact, very resistant patients in some cultures may respond well to a very directive, authoritative therapist. We don't know yet. And we don't know whether the therapist is able to change their level of directiveness. We don't know if it's a characteristic of the therapist or a characteristic of the therapy, or if you can even make those distinctions.
HT: Yes, I can see that–even with different therapists the resistance level would be different.
LB: Then the final thing we look at is the distress level. This is an aspect of patient adjustment, obviously. It becomes a problem of separating that concept from functional impairment, because your distress level changes functional impairment. People can't function well if they're highly distressed. On the other hand, they don't get motivated very well if they don't have some distress. So the real clinical struggle is to find that window in which they are motivated for change, because they are uncomfortable and they want to become comfortable. They're motivated for change but they're still functional.
HT: Distressed but not overwhelmed.
LB: And then if you're successful in therapy and help them lower their distress, what does that do? Does it take away their motivation to continue to work? There are some interesting answers with this that we don't know, but what we do know is that motivation, as embodied in concepts of arousal, are important in trying to facilitate and negotiate this road of psychotherapy. There is something here about the management of patient emotions. Helping them manage their emotions so they stay within a window, an optimal range that is very important. And many therapies talk about that, but it's real hard to define what the window is.

Lessons from Horse Training

HT: At the VA (Veterans Administration) we often say it’s not only the distress but also the functional impairment that will bring the veterans in. So they will avoid seeking service until their relationship doesn’t work.
LB: Things crumble.
HT: Yeah. They lost their job. And of course they’re subjectively distressed, but they avoid that due to different reasons. But it’s not until they’re really impaired in their social or interpersonal occupational functions that they come in.
LB: Some people have a lot of tolerance for distress, and other people have very little tolerance for it. The levels of impairment and disruption in their lives become an additional factor in helping them. In fact, there's a principle in horse training that has been articulated by several different people in what's called the natural horsemanship movement. It says: Distress motivates, release teaches. But to take that analogy further–and I do find the analogy an interesting one–I got back into working with horses when I moved to California in about 1990. For the twenty years prior to that, I'd been flying airplanes and interested and enjoying airplanes, and then it just got too expensive to do, so I thought I'd get back into a cheaper kind of thing.
HT: And you didn’t find a good analogy.
LB: I didn't find a good analogy in flying airplanes. It's very interesting because I used the airplane functionally. I used it to go from Point A to Point B, and it was fun to do. I traveled all over Texas trying to recruit students to our graduate programs and talking to them about psychotherapy and so forth. But the plane was a way to get there and have fun while I was doing it.

When I got back into horses I discovered that there are so many parallels with psychotherapy. And it has changed so much–it gave me some hope for the field. When I was a kid doing horses, we broke them. We really tried to bend their wills, and we forced them into positions. It took a long time, and it was hard to do, and they were always resistant. As I got back into it, I discovered a whole new movement had occurred, in which what was important in horse training was the relationship you had with the horse, not the technology you used to make the horse do something.
When I got back into horses I discovered that there are so many parallels with psychotherapy. And it has changed so much–it gave me some hope for the field. When I was a kid doing horses, we broke them. We really tried to bend their wills, and we forced them into positions. It took a long time, and it was hard to do, and they were always resistant. As I got back into it, I discovered a whole new movement had occurred, in which what was important in horse training was the relationship you had with the horse, not the technology you used to make the horse do something. So it was the development of a relationship that became important and that gave you the avenues to do all kinds of other things. And I saw people doing some marvelous things with horses that I'd never thought we could do when I was 15 years old and trying to do these things. And I started to apply some of that to psychotherapy.
HT: Like what?
LB: Like this concept of managing their arousal level. For horses, that becomes a central component of any training experience–to be able to raise it up and be able to release it, to stop it. With horses that's relatively easy to do once you get the concept and the additional one that says, well, if it doesn't work in big steps, take small steps. If we could apply just those two concepts to psychotherapy, I think we'd have greater levels of effectiveness than we do now. But we don't; we couch them in all kinds of other things, and the human condition makes it harder to observe when a person is optimally aroused, and it also makes it more difficult for a therapist to relieve that arousal, because they're responding to so many things out there.

I began to note that in a small, enclosed area anybody can train a horse to come to you when you ask it to. All you have to do is control those two basic principles. You control their arousal and you break it down into small steps. I could teach anybody to do that. But then when I said, "Okay, generalize that principle, take it out of that small, enclosed area, and teach a horse to do the same thing out there in a hundred acres," some people could analyze it and decide how to do it, but most people could not. I began to observe how psychotherapists learn to do something. To most psychotherapists, they see it as a technique, but to some psychotherapists, they see it as a principle. And that means that they can change it and still be true to the principle and apply it in a new situation to a new patient in a new environment. The difference between a technician and a therapist, an artist, is not that they don't follow the same principles. It's that they are able to translate them into new settings, new environments, and new ways of operating. And that's where the real art and science of psychotherapy come together: to identify what the scientific principles are, and then learn to use them creatively in new environments with new people under new circumstances. It's happened in horse training.
HT: But the challenge is how to apply these principles to human behavior.
LB: If it can happen in horse training, it may be able to happen in psychotherapy. We've got bright people working in psychotherapy. Can't they just move beyond that narrow view to be able to see the creative way of applying scientific principles?

Therapy Research Across Cultures

HT: So we’ve come back to evidence and science. And I know you’ve been working in Argentina, Japan, China. Any findings from the STS (Systematic Treatment Selection) approach? Any preliminary data that shows that it’s a better alternative to the traditional “gold standard” of manualized treatment? What does the data say so far?
LB: The data is pretty clear, so far, that we can do a better job of predicting outcome and even controlling outcome by controlling things that include the context and the environment. I point to the coping style focus of therapy, for example. This seems to be a construct that does nicely moving across cultures. We don't know about all cultures, but many–we've tried in Northern Europe, we've tried in North and South America, we're beginning to try it in Asian countries. It's a general principle that cuts across culture, that
if you can identify variation in the coping style and then begin to fit the focus of therapy as either insight-focused or symptom-focused based upon that coping style, then we can facilitate change.
if you can identify variation in the coping style and then begin to fit the focus of therapy as either insight-focused or symptom-focused based upon that coping style, then we can facilitate change. Therapists seem to be able to change what they do, at least a little bit, to become more insight-focused or more symptom-focused. It is not a characteristic that's so closely bound to the therapist that they can't alter it.

The relationship between resistance and directiveness with therapy, that seems to be more difficult to generalize. That seems to be a characteristic that's very tied to the therapist–can they be both directive and non-directive? No. It's hard for them to do. The way that people resist and the way they respond to directiveness also varies across cultures.
HT: So you’re identifying that some principles are universal but some are more culturally bound.
LB: That's the important aspect of all of this: being able to define what is generalizable from one place to another, and what is not. And what makes it generalizable and what inhibits it from being generalizable. People talk to some degree about this model of mine, this STS model, as being a common factors model, because it looks at the same variables across all of treatment. But it doesn't apply them the same. It asks specifically for variation in what one does as a function of the patient characteristic. It's not common across and it doesn't fit all therapeutic models, it doesn't fit all cultures. But we don't know all of the limits yet, so that's really where we're going.
HT: One thing that occurred to me is I’ve heard over the years that therapy is about what, when, who. But what you’re talking about is the how. You’re not talking about therapy itself, but rather what you’re using with whom and when to use it. STS sounds to me like you’re figuring out how to take all these factors into consideration.
LB: Yeah, that's what we're trying to do. We're really still addressing Donald Kiesler's concern of 1967, that there is still the myth of homogeneity of therapists and patients and so forth. And a real central question that Kiesler raised at that point was what treatment works with what patient under what conditions by whom. And we're still trying to do that. What psychotherapy as a field has done is move away from everything but the what. We want to incorporate the what, but we want to keep the who there, and for whom, by whom, under what conditions.
HT: That’s amazing.
LB: It will be amazing if it works. Well, it does work. It will be amazing if it catches on. People, psychotherapists in particular, continue to look for something more simplistic than that.
HT: I’m thinking about China, where we have a limited number of therapists. It’s really hard to do this matching, because many of them were trained in one approach, for example, a more dynamic approach, and they use this approach with everybody. And some of them were trained in CBT and they do CBT with everybody. And I think in the beginning of this kind of developing stage, it’s almost inevitable.
LB: Yes, but the nice thing about the STS model that defines all of these principles is that you don't have to use all of them at once. If I could just give you one principle that could make a significant impact on your treatment that you could follow, for example, the fit of the impairment level of the patient to the intensity of treatment. The more impaired they are, the more they need a wide variety of different treatments, the more they need treatments that involve other people, the more they need treatments that involve the society out there. If I could just give you that principle, you could do substantial things to your effectiveness rates.

The other principle I could give you has to do with the coping style of the patient and the focus of treatment. If you could just change that–and you could do it within any model. I mean, Freud talked about symptom-focused kinds of interventions versus more insight-oriented interventions. The range of what the therapist does within a particular model is not as great as what they might do if they had a wider range of therapeutic models at their disposal. But they have some variability, and thus they have some choices, and could improve their effectiveness if they were just to apply one or two principles. I have no hope that people will apply more than five, because I don't think people can keep more than five in their head at once. The best thing we know, the closest thing to truth we have out of this whole field, is that they could make a very substantial difference in how effective they were in working with a wide range of the people by just taking one or two of the principles. You don't have to take the whole thing.
HT: But from an STS approach, the therapist needs to have expertise in more than one approach, right?
LB: Well, to be optimal, it would be nice. But it's not more than one approach. They have to have a toolbox that's filled with more things than screwdrivers. If you're going to do a job, you need to have a toolbox that's full of tools. So you don't just have reflection. You don't just have interpretation. Or you don't just have behavior reinforcement or contracting. You try to have a toolbox full of many of those things. And ideally you need to have a toolbox that's filled with individual interventions plus group and multi-person interventions. You need to have a toolbox that has in it both tools to increase distress and lower distress, that both focuses upon indirect change through insight versus direct change through behavioral reinforcement, and that gives you variation in being reflective versus being directive. If you have a toolbox that has some of those tools, you don't need the whole model. You don't need to buy psychoanalysis and have the whole training in psychoanalysis to do an interpretation. You have some tools to do it, and then what STS tells you is when you might optimally use each of those tools.
Don't use a hammer for every job you have. I mean, around the ranch I like to say, I can fix anything with a hammer. But you know, it's really not true.
Don't use a hammer for every job you have. I mean, around the ranch I like to say, I can fix anything with a hammer. But you know, it's really not true.

The Future of Psychotherapy

HT: So if I may, I have two more questions. One is more practical, and one is more broad and general. Let’s go with the more practical one. If you’re speaking to a group of entry-level therapists who are just starting their career in this business, what would you say to them about what they can do to be more effective therapists?
LB: The central theme: first is relationship. That's what I would tell the horse trainer, and that's what I would tell the psychotherapist. If I have one thing to tell them: learn to listen. And you'd be surprised at how difficult this is. But it's the one thing that they need to start with, the ability to sit and listen to another person without an agenda, without inserting some salesmanship, trying to sell a point or a point of view or a perspective. Don't sell a perspective. First, learn to listen. Now, for more advanced ones, then they can learn one principle at a time. The next principle I would say…
HT: How many do we have? How many principles do we have?
LB: We can have a hundred principles.
HT: Eighteen?
LB: Well, we've got 18 in STS, but we know there are more principles than that. But the ones that are going to have the most powerful impact are the principles having to do with the quality of the relationship, because most of the patients that you see will benefit just from that. They don't need anything else. So learn to listen. If you just learn to listen–I'm talking to you as everyone. You're a collectivist, right?
HT: I’m integrative.
LB: Integrative. All right. This perspective, if people could just learn to listen and to do it without inserting. It's called motivational interviewing, it's called client-centered therapy, it's called humanistic therapy. If you could learn that concept of listening, most people that you see would benefit from it without adding anything else.

And then if you were to add the principle of intensifying therapy with the level of impairment that a person has. Just those two concepts. If I could get that across to new therapists out there, they would make a huge difference. But they don't believe me. They say, "research be damned." They don't believe me.
HT: How many years did it take you to come up with these ideas?
LB: What am I? I'm almost 69.
HT: It’s 50 years of wisdom.
LB: At least.
HT: At least. No, every year counts–69 years. Okay, one last question–it’s kind of a broad one. What do you think of the future of psychotherapy, or the best possible approach to psychotherapy?
LB: Well, those are two different questions. My greatest fear is that psychotherapy will continue to persist in this fragmented way, and that we will see an increasing schism between the science of psychotherapy and its practice. And people will continue, as practitioners, to try to sell a point of view that is needed and will be valued, but which society will not ultimately support because society has a price tag attached to everything. And what the price tag is going to say is that you have to be able to prove what you do, and you have to be able to replicate it. That means we're going to have to move increasingly towards a broad view of science. Though I don't know, frankly. Back in 1970, George Albee, then president of APA, was asked to write an article on the future of psychotherapy. And I believe completely what he wrote, which was four blank pages. It has yet to be written.

I believe there will always be a place for people who can listen and who can provide, through whatever means they can, the experience of help to other people. There will always be a place for that. I don't think that we will continue to support it through health care indefinitely, because we will have to accept the fact that it is not health care–it is life care. Society is forcing us into that in part by credentialing all these other quasi-therapists–you know, life coaches, etc.–that have taken away the things that we used to call psychotherapy, and now they use them under a different label. And it tells us something: that our view has been too narrow. Within the narrow view that we use–psychotherapy to treat psychopathology–we're going to have all kinds of medical, biological, chemical treatments to do away with symptoms. What we won't be able to do is change a lot, through this chemical interjection, some of the basic angst that people experience in not being connected to other people, not being heard, not feeling relevant. Having another person, someone who is be trained to do something that is helpful and optimal, who will listen and care for them, is going to continue to be very important.
HT: Thank you so much, Larry. Thank you for your time and wisdom.
LB: Well, I don't know how wise it is, but you got it.
HT: Thank you.

Insoo Kim Berg on Brief Solution-Focused Therapy

Posted on by rezendevknowfully.com

White Rats to Social Work

Victor Yalom: You were not born in this country?
Insoo Kim Berg: You think so? (laughter)
VY: Your vita says that you went to college in Korea.
IB: Yeah, yes I did.
VY: How did you end up coming to this country?
IB: To go to school, of course. To get better educated. I came in 1957. I was a pharmacy major in Korea. I came, supposedly, to continue my pharmacy studies. And my parents let me go.
VY: That was a way to get out of Korea, or get out of the family?
IB: To get out of the family, yes. But I thought seriously I wanted to study pharmacy, further my education. One thing led to the other. I did quite a bit of work as a tech because of my pharmacy and chemistry background. I was very comfortable working in an animal lab. I worked for a guy who did stomach cancer research at the medical school. I was very tempted to stay because I was getting good money. I was writing papers with him. I have to tell you, though, I did a lot of work with white rats—surgery on white rats! And I was very good at it because of my delicate hands. They have such a tiny, tiny veins. And you have to cannulate them.
VY: Which means?
IB: You cut a little slit in the throat and put a tube into the bleeding vein. I was pretty good at it! That kind of stuff is fun. One of the things I learned working with white rats is that the rats die on you sometimes. And if you stop at about 2 p.m. it’s too late to get started with a new rat because it takes so many hours for the real experiment to get going. Sometimes I worked there until 8, 9, 10 o’clock at night, because once you get going you really want to stay with it. Sometimes you just say, “I’m so tired….” So I found out that if you put a little air into your vein, it kills you. It does.
VY: Their veins right, not yours?
IB: You know if you shoot air into them it kills them.
VY: So I’ve heard.
IB: So, I would do that. At 1 o’clock or so, I’d say, “I’m done for the day. I’m going home.” That’s my confession. I hope I didn’t kill too many rats. I didn’t keep track. That’s one of my secrets that nobody knows about; but here I am telling you!
VY: So you had such a good scam going, what encouraged you to go into social work, which is much harder work?
IB: Yeah, and much less pay! I really did have a good scam going. I could make my own hours, work late if I wanted to.
VY: So how did you get interested in social work and therapy?
IB: I had never heard of social work before. I got into pharmacy studies because my family was in the pharmaceutical manufacturing business. That was one of the reasons I was selected to be the family pharmacist—that was the scheme of things. I was really shocked when I first came to this country and talked to people younger than I was. They would talk about how they decided they wanted to study something.I thought your parents decided for you and then you obeyed your parents’ wishes. Students in the US had a choice in their area of studies. I was absolutely shocked by that. The idea just blew me away. And so then I got this idea: my parents are 7-8,000 miles away. They have no idea what I’m doing here. So maybe I could do the same. It kind of slowly dawned on me. So I actually switched to social work.

VY: What attracted you to that?
IB: The idea of helping people.
VY: Rather than killing rats!
IB: Rather than killing rats. Make up for all the rats I’d killed! So I switched majors, and I didn’t tell my parents. I thought, “They won’t know.” I didn’t tell them for about two or three years. Eventually I did tell them, and they had no idea what social work was. They’re dead now, but I think even until they died, they had no idea. Pharmacy they understood. Medicine they understood. The rest of the stuff—all the soft stuff, they had no concept of that. So I got away very easy. They didn’t give me any grief. I didn’t tell them about anything. Why talk about something? Why create tension? So I just did my stuff. It was pretty nice. Coming to the United States was a good thing personally as well as professionally.

Phenomenal Failures

VY: What was your initial training in social work and therapy?
IB: I went in the direction of family therapy. That really attracted me. I commuted to Chicago for a couple of years after I got out of graduate school. Those were exciting days in family therapy—the late ’60s and early ’70s. Haley’s work, MRI work, and on the East Coast people like Lyman Wynne were doing some amazing stuff as well.
VY: So your initial training was in some of the briefer, strategic therapies?
IB: Not at all. During my initial family therapy training I had to keep a family in treatment for a year. That was a condition for graduation. It’s very hard to do with a family.
VY: That’s a different incentive. Your approach now is to solve the problem as quickly as possible.
IB: Absolutely.
VY: But your mandate at that point was to keep them in treatment as long as possible.
IB: Yes, and I did. I had one family in treatment—I have no idea how I did that. Of course, I didn’t meet with them every week. One year could have been maybe 10 times. But I did it.
VY: Today you make a point of not continually asking about clients’ problems. Instead, you focus on asking them how they’ve been solving their problems. But at that time you had to keep making sure they had enough problems to keep them in treatment.
IB: In those days, family therapy was still very much like Murray Bowen’s ideas. It’s a literal translation from psychoanalytic concepts to family concepts. So, he had stuff like, what was the word? “Undifferentiated ego mass —if that isn’t psychoanalytic? So that’s what was available in those days. That’s all there was. People who were pioneers in family therapy came from that kind of psychoanalytic background themselves. It was a natural transition. Of course, I was trained in that as well, so it was a very comfortable transition for me.
VY: When did you realize it did not fit for you?
IB: I realized that it was just not helping the families, not helping the clients. I pretty much worked with working class families. I don’t understand all of it, since I come from a fairly financially well off family background, but I felt so comfortable working with working class families. They’re not interested in “insights” or “growth,” or “development”—they’re interested in getting the problem out of the way. Here I was using a very psychoanalytically-oriented family therapy model with these clients.It was such a bad fit. It wasn’t working very well. So I had some phenomenal failures with families, which disturbed me terribly; I wasn’t used to failing. Academically all my life I had been successful, and here I was with all this education and I felt like I was such a failure. I couldn’t stand it.

VY: Where did your ideas go from there?
IB: So I searched and looked around and came across Jay Haley’s writings. It just blew me away. Because I was raised as a Presbyterian. I read the Bible many times, because that’s one of the things you do when you’re a Korean Presbyterian! Anyway, Jay Haley had this article called, “Power Tactics of Jesus Christ.” I said, “What the hell is this?” It’s such an upside-down way of seeing the old Bible stories about Jesus that I had grown up with. I thought, wow, what is this? I became fascinated with this. I just kept reading and reading. And then I came across the MRI approach. I lived in Wisconsin and commuted to Palo Alto, California, to train there. That’s where I met up with Steve; he was living in Palo Alto at the time. He came from Milwaukee, so somehow we got together.
VY: You’re referring to your husband, Steve De Shazer?
IB: Right. He says I put a spell on him. But somehow I convinced him to move to Milwaukee. Can you believe that? Palo Alto to Milwaukee! And he did. And we formed a little group, a team of us. That’s how we got started. Our initial goal was to create a Midwest MRI, in Milwaukee.

Solution Focused Model

VY: This is probably difficult, but can you say in a nutshell what are some of the basic principles of solution-focused therapy?
IB: Instead of problem solving, we focus on solution-building. Which sounds like a play on words, but it’s a profoundly different paradigm. We’re not worrying about the problems. We discovered, in fact, I don’t say that just for an audience today, but we discovered that there’s no connection between a problem and its solution. No connection whatsoever. Because when you ask a client about their problem, they will tell you a certain kind of description; but when you ask them about their solutions, they give you entirely different descriptions of what the solution would look like for them. So a horrible, alcoholic family will say, “We will have dinner together and talk to each other. We will go for a walk together.”
VY: These are the solutions.
IB: Yes. We kept hearing this and we asked, “What is this?” No matter what the problem is, the solution people describe is very similar. Whether it’s depressed people or people who fight like cats and dogs, they still describe the solution in a similar way. They will get along, talk to each other.
VY: The solution being the outcomes. But to get from A to B,that must vary a lot from person to person.

The Miracle Question

IB: That’s where we learned the miracle question, as the quickest way to get there.
VY: And the miracle question is?
IB: “Suppose a miracle happens overnight, tonight, when you go to bed. And all the problems that brought you here to talk to me today are gone. Disappeared. But because this happens while you were sleeping, you have no idea that there was a miracle during the night. The problem is all gone, all solved. So when you are slowly waking up, coming out of your sleep, what might be the first, small clue that will make you think, ‘Oh my gosh. There must have been a miracle during the night. The problem is all gone?'” And that’s the beginning of it. People start to tell you, and they add more and more descriptions.”How could your husband tell that there was a miracle for you during the night? What about your children? What would your colleagues do?” You keep expanding the social context wider and wider.

VY: So then they can start to visualize some concrete steps that could get them to a better place?
IB: Right. Then the followup is, “What do you have to do to get this started?”
VY: To play devil’s advocate, these people may have had other people in their life give them very sensible advice, or asking them, “Why don’t you try this?” or “Why don’t you stop drinking?” Evidently, they have not been able to make those changes, up to the point of seeing you.
IB: Right. That’s why they show up.
VY: So, it sounds so simple.
IB: It is.
VY: So, but why haven’t they made those changes already? How does asking these questions help?
IB: Because we are asking them about their own plan. Not my agenda for you, but your plan. You didn’t even know you have a plan. You actually don’t when you first walk in. You tell me you have no idea what to do. And then in the process of talking, you start to gradually, through this building process, to develop a blueprint.
VY: So you think people have some kind of blueprint to help them grow and change?
IB: No, I think they have all the necessary bricks and lumber, somewhere lying around, but they don’t know how to put it together. I think that talking to me helps them figure out how to put it together. Not only create the blueprint, but which lumber goes where, which piece goes where. That’s how I see it.
VY: Isn’t this somewhat similar in its underlying philosophy to, say, a humanistic approach to therapy? That people have these innate abilities inside them for growth that somehow are blocked.
IB: Yes, I suppose. I’m not familiar with the humanistic approaches. As I said, my background is very psychodynamic.
VY: Well, even from a psychodynamic point of view, people have various strengths and capabilities. But the psychodynamic approaches tend to focus on what the defenses are, or what the blocks are, to people growing and blossoming, and then attempt to help clients remove those blocks. And that’s very different than your approach. You don’t focus on the blocks.
IB: Right. We assume people want to have a better life. We trust that people want to have a better life.
VY: Some people would criticize your approach by saying that clients may not be ready to make those changes, or they may not feel understood. They’re feeling depressed and hopeless, and you’re talking about all the things they can do—or you’re helping them talk about it. But perhaps they need you to first understand how depressed and hopeless they feel. When I see you on videotapes, you’re very optimistic, you’re very enthusiastic. Some people would say you’re not meeting clients where they’re at. How would you respond to that?
IB: That’s not my experience of clients.Clients don’t complain to me, “You don’t understand. Why don’t you listen to me?” They feel very listened to. Because I think that when they decide to do something about their problem, they already recognize that whatever they’re currently doing is not working. So there is this hopeful side of them. If they didn’t have any hope that this could be solved, for example, they wouldn’t even bother. But they must have hope, otherwise why would they go to the trouble of calling up for an appointment, showing up, and paying for it. So I am addressing the hopeful side of them. Otherwise they would have given up a long time ago. Some of these people have been suffering from the same kind of problem for years and years.

VY: So you are allying with their strengths and their hopes.
IB: Absolutely! Right.
VY: I think you have an unusual ability, because you have a natural kind of energy, enthusiasm, and hopefulness that is contagious.
IB: I’m not aware of that. People tell me that, but I’m not aware of that.
VY: I guess another danger that could occur in Solution Approaches is that it is focused so much on techniques: the miracle question, scaling, and so on. Do you think there’s a risk that, like any technique, a therapist could grab onto the technique and apply it without a greater context?
IB: Sure, but that’s the first step. When you learn piano, you have to teach finger technique first. Then after they master that, then go to the next level, the artistic side of it. But without the technique, how can you get to the artistic side of it?
VY: You work with some very difficult clients. Do you think this approach is generally useful for all types of clients? Or do you think there are some types of clients it’s not as useful for, who would benefit more from longer-term approaches?
IB: Steve talks about this. I wasn’t there, but he was doing a workshop for two or three days, and at the end of the workshop somebody raised their hand and said to Steve, “Does this work with people with normal problems?” (laughter) So Steve said, “No,” with his usual humor, “It will never work with normal problems.”So that’s what makes me laugh. So, yes and no, it depends on what you mean by work. If work means, they are going to be living happily ever after, then no. We have a very narrow sense of the goal. We really insist on that from the beginning: very small, achievable, realistic goals. So our job is to carry the client to there. No happily ever after. Then, at least we got them on the right track. The rest of the journey is on their own.

VY: And what happens if someone wants to shoot for a larger change, say, someone who has never been in a successful relationship due to character difficulties. They want to make some more fundamental changes in how they relate to people so they can have a successful, intimate relationship. Would you work with someone like that? Or do you think other types of therapies may be better suited for that?
IB: I would work with that person. Let me give you an example of how I would do it with such a client. I would say something like: “You want to have a good relationship with someone of the opposite sex. So tell me what’s been good about the relationships you’ve had. How did you get that to happen? (Then I negotiate with that.) So you know how to get involved with a relationship?”The client might say: “I am able to get into relationships but they never work out. The beginning is fine, I know how to do that.”

I would respond with something like: “So it’s the middle part of the relationship and onwards that’s bad. Okay, I want you to go out and meet someone that you are serious about. Come back and talk. You do the first part, and we’ll do the second part together.”

That how I do it. So I don’t have to hold their hand every step of the way. Why would I hold her hand when she knows how to do the first part?

VY: Why not?
IB: Why? Why would you want to do that?
VY: It can be helpful. If someone never had a positive, trusting relationship in their life and they can spend 50 minutes a week with one person who can help them, what’s the harm?
IB: I suppose. So if a female client were coming to me with that kind of problem I would say, “How do you know this is a positive relationship? What will tell you that it’s a positive relationship?”And she responds, “Well, he would not steal money from me. He will not two-time me.”

Leading me to say, “That sounds pretty reasonable. So you know how to look for those?”

She says, “Yeah, I think I can tell how to look out for those.”

So I’m trying to be as minimalistic as possible, not so intrusive: “What you have going is wonderful. It just needs a little helping hand.” That’s what I do. I’m not interested in overhauling personality, because what’s wrong with her personality? Most people just have a little quirk here or there that doesn’t work.

Dr. Rubin Joins In

VY: Are there other areas of your work with solution focused therapy that I have not addressed that you think are relevant?
IB: I don’t know. I can’t think of any. (Dr. Berg then turns to speak to Bart Rubin, Ph.D., a psychologist and family therapist who has been observing the interview). Do you have any questions you’d like to ask?
Bart Rubin: Starting where Victor was at when he was playing devil’s advocate. The solutions model is so different than traditional models, and for you it makes so much sense. You throw out so much. You don’t bother with it. And other people are bothering with that stuff as if it’s really important. So I guess I wonder what do you know that they don’t know? What do you make of all these other people who are doing that other stuff?
Insoo Kim Berg: I don’t try to persuade them or try to compete with them. What they’re doing works, and that’s helpful for some people. What I do works and it’s helpful to some people. I’m not 100% successful. We’re still trying to figure out what is the other 20% that it’s not successful with. We have no idea.
BR: When you have self-doubts about the model, what are the doubts that you have? Can you critique it yourself?
IB: Well, self-doubt has to do with, let’s see…in the middle of December there was this brief therapy conference in Orlando. I felt that these people would be really similar to where I am, to how I’m thinking. I tried to attend as many of the other people’s presentations as possible. Those are the kind of times that make me doubtful, when it seems like the whole world thinks like this. And I’m way out here all by myself.
VY: Even among brief therapists?
IB: Yes, I’m way out on the left side. But at the same time there were some disturbing things about what I was seeing and hearing. They were just doing case presentations, going on about what’s wrong with these people.Especially the panel discussions I watched—it was like they were competing with each other about how much they each knew about what’s wrong with the client. I was very discouraged by that. That we’re still, in this day and age, we’re still talking about what’s wrong with people. So on the one hand I got very upset and discouraged by it, and on the other hand, I thought, “Do they know something I don’t know? Do they know something I should know?”

That used to be the way I thought about clients, but I have since I rejected all of that, turned my back on all of that. I have tried not to look back. Most of the time I don’t. But the big name therapists and presenters, they all seemed to be there. In a way, we have come a long way, but in another way we haven’t come very far. So that was pretty discouraging, and at the same time it made me wonder, “Oh, my God. Am I so way out there?” (laughter)

BR: Am I a radical pioneer, or am I missing the boat?
IB: Right. I was thinking about that. I still come back to, “No, I don’t want to join that pack.” It’s so distasteful. They were just going on and on and on and on about what was wrong with this client and that client. How is that going to be helpful? If the client were sitting there in the audience, listening to them talk about him, I wonder what he would say? I think he would get very upset. That’s not how they see themselves.
BR: In your work the therapeutic relationship seems to be important to the extent that you need to do the work.
IB: What’s the relationship for? It’s to do your work better. To do your job better. That’s what it’s for. You’re not paid to bond with someone. You and I are never going to be bonding for life, why would I want to do that? You should go out and have some real life out there.
VY: But when you’re doing longer-term work where you’re doing character or personality change, for lack of a better term, you can examine the relationship. It can give you a lot of data that can help you understand more what’s going on in that person’s relationships.
BR: One model assumes understanding is terribly useful; and another model would see understanding as not necessarily useful.
IB: You’re right. But you get a lot of feedback from the people around you, right? Your neighbors, your co-workers, your friends tell you about how you come across to them.
VY: People don’t usually tell you as directly as in therapy.
IB: But people let you know you’re an ass, right? You get the clue that you’re an ass, that they think that. They don’t invite you to go out to lunch together, that kind of stuff. So you don’t think that you get that?
VY: Well, yes, I do think people in life can give you feedback if you’re an ass. People usually don’t know why they don’t have friends. They may know something very basic. But say in a relationship you find that that person is very dependent, they’re always looking to you for the answers, or they put themselves above other people. Experiencing and understanding that relationship in the room with the client can really bring those issues alive to really help them in their life outside therapy.
BR: I think that in a long-term model, one would spend a lot of time talking about why you don’t have friends, whereas in your model you’d be focusing to get them to started on making friendships work.
IB: Yes, for the most part, we want to get them moving.

Cultural Similarities Matter More than Differences

VY: Let’s switch gears. You travel around the world a lot and teach in many different cultures. And you’re from a different culture originally than most of your clients, I assume.
IB: Yes.
VY: So what have you learned about applying these techniques in different cultures? How do you have to modify them?
IB: I think there are some modifications. Small ones. Again, I have a lot of gripes about the way that cultural differences are talked about in this country.My main gripe has to do with emphasizing the differences between cultures—what is different between you and me, instead of talking about what is similar between you and me. That we are all human beings with the same aspirations, same needs, same goals. When I look at those things, it’s very easy to translate. It’s the same everywhere you go. Everyone wants to be accepted, validated, supported, loved, and to belong to a community. That’s not different at all, no matter where you go.

It’s a different way of belonging to the group, but that’s a small difference. But even among the same culture, like among the white middle class, there’s so many variations. Just because you went to college and I went to college doesn’t mean we came from the same kind of families. Even some Jewish families, some Korean families are so different.

So I think too many people talk about culture/ethnicity as being a bigger difference than is necessary. I feel very comfortable no matter what culture I go. I just look at you as another human being rather than I am this group and you are that group. I think it’s very divisive. So that’s my main gripe.

VY: So you don’t pay a lot of attention to it.
IB: I don’t pay attention to that. People ask me, “Aren’t you feeling discriminated against because you’re Asian, and a woman?” I think “so what?” Some people get discriminated against for being too short, too tall, too blond. So what? It’s not that different from any of those things. I don’t really pay attention to that.
VY: So you focus on the solutions.
IB: Yes, on what works. Because that works. If you didn’t like me, if you really hated where I come from and couldn’t stand it, we probably wouldn’t be good friends very long anyway. I know there are some friends I like, I’m thinking of a couple I know; I love the wife but I can’t stand the husband. So I don’t see the two of them together very often. So we solved that problem that way! There are different ways for getting around that.

Living and Dying with Meaning

VY: I heard that you’re 68 years old, although, I would never have…
IB: Don’t say that! (laughs)
VY: One would never know it by your energy and enthusiasm!
IB: Yes, I am.
VY: So what do you think you know about life and about therapy that you didn’t know 20 years ago? Or 30 years ago?
IB: Oh, a lot. There are good things about getting old. You are much more comfortable with yourself.Take me or leave me, I’m an old hag. What do you expect? I’m old. Take it or leave it. I feel more comfortable with myself than when I was younger. That’s very nice. I figure if you don’t like me, well, that’s too bad, I’ll somehow go on, and you will go on. That’s kind of a comfortable feeling. I think you get a different perspective about life, too. You become much more aware of your body; it’s not what it used to be. I get tired easier. I used to be a very energetic person. I still am, but used to be even more so. I’m one of these very high-energy people; I’m just made that way. But I can tell I need to slow down a little bit more than I used to. You think about end of life more.

VY: What kind of thoughts do you have about that?
IB: How do I want to die? As if I have any control over that. I don’t have any control over that, unless I decide to commit suicide. That’s the only control I could possibly have. But I don’t think I would do that. I don’t have any control.So I’m still trying to accept that, that I don’t have control over how I die.

VY: You learned the trick with the white rats!
IB: I suppose I could use that! I may do that, because it worked! But you think about what is the meaning of life in a very different way when you get older.
VY: For example?
IB: What am I living for? What is the purpose of living on? What do I want to do with the time I have left? That kind of stuff. I’d like to be able to… I don’t know whether I’ll have the opportunity or not… to say on my deathbed (this picture of one dying, surrounded by friends and family…who knows? It may never happen that way). I’d like to be able to say I had a good life. And what’s the definition of a good life? I made some difference. That’s it. If I could just say that. I’ve made some difference because I’ve been here in this world. Life is a little bit better and I contributed to that. I think that would be a good life.
VY: You look a little bit emotional right now as you say that.
IB: Yeah,I’m getting tearful about that because I think it’s really important. I’d like to be able to say that to myself, and believe it, that I lived a good life. I don’t know if I’m going to do that or not. We’ll see.

VY: If you had to answer that using the scaling question that you ask so many people, on a 1 to 10 scale, where would you place it right now?
IB: I don’t know about people like you… you learn something and then you quickly turn it! (laughter)
VY: I didn’t think I was turning it against you!
IB: I don’t know about that.
VY: You can take a pass. You can email me your response.
IB: I am going to take a pass on that, for now at least.
VY: To step back to your life’s work, what do you see as the qualities that therapists need to become really seasoned, skilled therapists, and what are the ways to develop these qualities?
IB: Just keep doing it, doing it, doing it. Like a pianist, for hours and hours and hours. We did that. We used to work from 9 am to 10 pm at night; we’d have cases, cases, cases. We’d be exhausted, go home and collapse, and start over again the next day. Again and again. I tell you, we did that for years. I think that’s what it takes.
VY: How have you used whatever life learnings or wisdom that you’ve acquired to become a better therapist?
IB: Oh, God. You assume that I’ve acquired some wisdom.
VY: Well, some, I would certainly imagine. How do you think you’re a better therapist than you were 20 years ago?
IB: When I was younger I used to think that I was very accepting of people, because of my training. I’m realizing that I still have to learn a lot, and to let people be themselves and let go of that idea. If anything, I think I’m still learning to be more accepting of other people as they are. I’m just learning all the time.
VY: So maybe being less confident that you know so much makes you a better therapist.
IB: Maybe. I think that’s one of the marks of our profession is being very accepting of the other person, where they’re at right now. That’s been something that we try to instill in our students in our trainings. Golly, it’s really hard.
VY: You can’t learn that in a weekend workshop.
IB: I don’t think so. It’s a lifelong learning.

“I am Korean… You Dumb Ass”

BR: In terms of you learning over the course of your career, are there ways in which your earlier experiences with psychodynamic work affects your work now, or lead to your being more solutions-focused?
IB: Yes. Having been there, it’s easy for me to turn my back on that. Having had that experience, and those failures with cases.One experience was especially important. It was in the mid 1970s when soldiers started coming back from Vietnam. I went to Menninger for training in group therapy to work with a Vietnam vets group. We had a horrible case. One young man thought that the Viet Cong was coming after him. So he always slept with a shotgun under his pillow. And in the middle of the night, he shot his wife who was sleeping next to him. I thought, my God. I was a teenager when the Korean War started and was in the middle of it. So I had some experience of being in the middle of a war. I volunteered to work with these returning Vietnam vets because they would not go to VA hospitals. I organized this group. I sit with them week after week after week, and they tell horrible stories. About how they themselves killed women and children, how their buddies next to them had their heads torn off, and that kind of stuff.

VY: What did you do with these groups?
IB: I didn’t know what to do with them. So I made a videotape of a session and took it to Menninger, to a supervision group. This very famous psychoanalytic supervisor was there. I showed him the tape and said, “I need help. I don’t know what to do for these people.”He turns to me and says, “What is your countertransference issue?” I said, “What? What are you talking about?”

I was sort of shocked by this because I was asking for help. He said, “These are veterans, these are people who shot and killed your kind of people.” I was just absolutely floored. Never expected something like that. To turn my plea for help, to turn it around and suddenly it became my problem, that it was my countertransference issue. I thought, “You ass. My kind of people — I’m Korean! These are Vietnamese! You dumb ass.”

I thought, that’s it. That was the beginning of my end with psychoanalysis.

VY: Well perhaps it’s good that you walked away from that, because it allowed you to create a model of therapy that obviously has helped many people, and resonates with your personality. It’s been a pleasure talking with you today.
IB: It’s been a lot of fun.