Author: Psychotherapy.net Team

Eysenck, Rogers and Psychotherapy Effectiveness

Posted on by Psychotherapy.net Team

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

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

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

Psychotherapy outcomes: The best therapy or the best therapist?

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

Preventing Psychotherapy Dropouts with Client Feedback

Posted on by Psychotherapy.net Team

“You understand me thirty percent of the time.”

“I need to you to slow down.”

“I was sad and you cut me off.”

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

Anne: A Case Study

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

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

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

Existential Threat

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

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

The Ubiquitous Scourge

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

What Counts as a Dropout?

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

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

Insisting on Feedback

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

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

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

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

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

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

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

“What else?”

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

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

Four Rules for Receiving Feedback

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

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

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

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

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

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

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

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

Incorporating Feedback

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

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

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

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

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

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

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

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

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

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

2011 Update

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

Footnotes

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

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

Further Reading

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

Psychotherapy Training on Steroids: Remote Live Supervision

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

Rules for a Good Relationship

Posted on by Psychotherapy.net Team

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

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

Trusting the Client as the Agent of Change

Posted on by Psychotherapy.net Team

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

Clients as Agents of Change

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

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

A Casual Conversation

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

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

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

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

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

Florence: A Single-Session Case

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Doors of Possibility

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

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

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

They need doors of possibility, and they need company.

Suicide During the Holidays . . . Not So Much!

Posted on by Psychotherapy.net Team

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

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

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

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

What if Its All Been a Big Fat Psychotherapeutic Lie?

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

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

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

Bids for Emotional Connection in Couples Therapy

Posted on by Psychotherapy.net Team

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

Methinks Jay Haley Hit the Bulls Eye

Posted on by Psychotherapy.net Team

My client began her session with an interesting saga. In an attempt to improve her health she began each day by ingesting a nutritional drink that was loaded with nearly 100 superfoods. Since I personally take enough vitamin and mineral supplements a day to capsize a small battleship, I was all ears. Unfortunately, my client lamented that the supplement seemed counter-productive. That is to say, instead of having unlimited energy, she was nearly falling asleep at the wheel on the way to work. The client was quite savvy when it came to nutrition and therefore hypothesized that the product was excellent, but it needed more protein.  In other words, the high carbohydrate formula was the problem.

Truth is always stranger than fiction and the very next week — as if the supplement company had a bug or a webcam in my office — they released the identical drink in a high protein low carb version. Problem solved? Well to use the oft-quoted phraseology of our times: not so much. The client reported that she was dragging through the morning just as bad as ever. Her dilemma was solved quite by accident when one day she discovered she was out of her superfood protein drink and thus she began the day with a banana and a slice of white devitalized bread and a low-tech multiple vitamin. (Sheer blasphemy, incidentally, for nutritional zealots like myself or my poor client.) The verdict: She had boundless energy and felt terrific. After that day she continued with the banana/bread regiment with excellent results.

Along these same lines another client was telling me about how he became very serious about his golf game.  The golf pro felt his swing was sound but he almost fell over laughing when he saw my client's antiquated clubs. The pro promised to set him up with some serious equipment. The irony, however, was that his his golf game suffered markedly when he began using the new high-tech, super high price tag, custom fit clubs. My client became somewhat obsessive and in the years that followed and he secured club recommendations from golf pro after golf pro and purchased set after set to no avail. Finally, one day, just as a joke, he pulled out his early 1970s aluminum shafted clubs and shot the best round he had in years.  He decided to stick with the zero tech clubs of yesteryears and his game continued to improve.

Like most therapists, I have literally heard hundreds of stories like this including:
• Men who gave their wives flowers or compliments based on the recommendation of some self-improvement expert, an Oprah approved bibliotherapeutic work, or a well-credentialed psychotherapist, and the relationship deteriorated.
• Parents who followed the behavior modification instructions to reinforce their child's behavior and saw the behavior stay the same or perhaps get worse.
• Clients who were told to wear orthotics in their shoes to take their comfort to a whole new level and now had pain in their feet or legs that never existed prior to wearing the devices and
• People who jogged extremely long distances every day to "do something good for themselves and to ward off old age" and now look considerably older than their peers (yes, there is even some scientific research that seems to be backing up this one) . . .  to name a few.

So what in the world is going on here? At least for me, the riddle was solved in an instant when I attended a lecture of Jay Haley's several years before he passed away. An audience participant asked Haley to spell out what caused most people's discord and Haley remarked, "The solution to the problem is the problem." I'll leave it up to historians of psychotherapy to discern whether Haley really came up with this on his own or whether he lifted the idea from the great Milton H. Erickson or perhaps Gregory Bateson.

In any event, the key point is that often, the very strategies that the client is using to make his or her life better are at the root of the problem. But I ask you: How often as therapists do we investigate this dynamic? In all probability, it is not nearly enough. We like it and get excited when clients seemingly do good things. Nevertheless, the message to take back to the therapy room is that something that appears positive is not always positive. The protein shake, the orthotics, and giving a spouse flowers could be the culprit. Most of us would never suggest that the client give up the protein shake, or perhaps stop complimenting a spouse. Instead, many therapists will gloss right over these behaviors and look elsewhere for the root of the problem. In essence, The solution to the problem — even when it appears to be a good one — can the problem. Jay Haley hit the bull's eye. Now it's your turn.