Author: rezendevknowfully.com

Philip Kendall on Cognitive-Behavioral Therapy

Posted on by rezendevknowfully.com

Working with the Masters

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

“These Kids Think“

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

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

CBT Then and Now

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

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

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

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

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

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

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

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

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

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

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

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

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

CBT with Kids

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

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

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

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

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

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

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

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

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

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

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

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

“I Must Be Doing Something Right”

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

Grief and Gratitude: Working with Stroke Survivors

Posted on by rezendevknowfully.com

Together

May we sit with wisdom and compassion

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

 

An Interruption

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

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

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

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

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

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

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

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

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

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

The Group

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

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

The Beginning

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

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

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

“You Don't Get It”

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

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

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

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

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

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

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

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

Be Curious

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

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

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

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

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

Finding a Community

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

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

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

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

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

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

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

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

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

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

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

A Different Kind of Challenge

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

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

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

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

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

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

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

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

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

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

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

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

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

Look for Wholeness

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

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

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

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

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

A Good Boy and a Bad Girl

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

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

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

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

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

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

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

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

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

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

Warrior Heart

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

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

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

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

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

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

Paul Wachtel on Therapeutic Communication

Posted on by rezendevknowfully.com

The Third Wave in Psychotherapy

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

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

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

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

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

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

“What Should I Say?”

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

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

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

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

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

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

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

On Modeling

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

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

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

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

But

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

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

The Old Guard

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

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

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

Shaming

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

The Gold Standard?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Integration of Neuroscience

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

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

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

Cathy Cole on Motivational Interviewing

Posted on by rezendevknowfully.com

Talking About Change

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

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

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

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

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

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

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

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

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

Stages of Change: Importance, Ambivalence, Confidence

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

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

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

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

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

Offering Advice and Information

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

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

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

What’s New About MI?

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

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

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

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

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

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

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

MI with PTSD

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

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

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

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

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

Teaching MI Skills

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

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

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

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

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

Motivational Interviewing in End-of-Life Care

Posted on by rezendevknowfully.com

Betty: A Case Study

When Betty answered the door and welcomed me into her living room, I couldn’t help thinking she looked almost like a different person from the Betty I’d seen just the day before: a neatly dressed, very composed 80-year-old woman. Today, her clothes were messy, her hair was disheveled, and she had bags under her eyes. Her husband, Frank, was resting in their room after his morning nursing visit. He had been diagnosed with prostate cancer a year earlier, and the treatment had been unsuccessful. The hospice team of which I was a member had been called in to assist with the final few days of his life, which is why we had met Betty and Frank the day before.

The nurse, spiritual counselor, and I had visited the couple in their home, as this was where Betty and Frank preferred for him to pass away. During the initial visit, Betty had engaged appropriately, was very pleasant and cooperative, and asked common questions about what to expect in this process. She had hired a caregiver for further support. She seemed to be coping well and had a strong supportive network with her children and neighbors. Frank had been a bit lethargic, but was able to engage with us as we discussed his care over the next few days. The visit had gone smoothly; we hadn’t expected any unusual problems.

But the morning after the initial visit, the nurse called me explaining that she had completed her daily visit and Frank had declined significantly overnight. He had been very lethargic and difficult to arouse during her assessment. Betty had asked the nurse if she could feed her husband, since he had only a few bites of food at dinner the night before and had not had breakfast. The nurse had informed her of the risk of feeding when a patient is closer to death, but felt that Betty was very resistant to this information. The nurse was calling me to ask if I could meet with Betty to address this resistance.

As a social work intern, this would be my first meeting alone with a client. As I was simultaneously enrolled in a graduate course on Motivational Interviewing, I decided to put my beginning skills to use.

Engaging the Client

I began by checking in with how Betty had been feeling since our visit the previous day.

“I feel good,” she said, “but I had a hard night last night with Frank waking up several times. He was moaning and confused, and even tried to climb out of bed. It really scared me, but I was able to call hospice and they walked me through giving him some medication to calm him down. It worked quickly and I was able to get some rest for a few hours.” She paused and touched her forehead absently. “I’m glad to have our caregiver here this afternoon so I can lie down and get more sleep. She was so helpful yesterday.”

I remembered from my MI course that open-ended questions, affirmations, reflections, and summaries (OARS) are key to building rapport and conveying empathy and understanding. When clients feel heard, they are not only more inclined to engage with the practitioner, but they are also more comfortable processing their ambivalence, and eventually reaching a resolution. I knew that Betty had had a fraught conversation with the nurse that morning, and that she must be feeling overwhelmed, so even though we had limited time, both in the session and in terms of Frank’s life, I began slowly.

“Wow,” I said. “It sounds like you had a difficult night caring for him. Caregiving for someone in the dying process is challenging. I’m really impressed that you’ve been doing this, while also recognizing you need some help and have hired a caregiver. I’m glad you called our main line for support, too. We’re always available to help.” The simple reflection and affirmation I used helped us start the visit well. Betty knew I was present and listening to her. I was also able to validate and affirm the challenges of providing caregiving at end-of-life and how well she was doing.

“I understand you met with the nurse this morning,” I continued, now that I saw Betty relaxing a bit in my presence. “How did that go?”

Betty paused and her voiced dropped. “Fine. She told me I should stop feeding my husband, but that’s hard because he could be hungry.” She paused again and then raised her voice. “She said that feeding him could hurt him, though. I’m not going to be the one to kill him!”

I reflected that Betty felt confused about what the nurse had told her about feeding.

Betty raised her voice again and spoke more quickly. “It’s really confusing. And it’s like she doesn’t really understand where I’m coming from.”

“She doesn’t see how much you value feeding Frank,” I nodded.

This exchange confirmed for me that Betty was struggling with understanding and accepting that her husband no longer needed to eat or drink as he was declining quickly. As the nurse had explained to her, feeding him would have likely caused more harm because as his body declined, it would not metabolize food and fluid as well, which could cause increased toxicity, pain, and discomfort.

Given the medical nature of this information, and especially because of the urgency of the situation, with Frank having only a few more days to live, it would have been tempting to believe that Betty’s inability to understand could be solved by intellectual persistence: maybe if someone explained the details to her again, she’d “get it.” But using an MI framework, I saw clearly that Betty needed to be met emotionally in her struggle before she could comprehend the medical problems that continuing to feed her husband would create.

In situations where there is a clear preferred outcome, it is often challenging for counselors and other helping professionals to steer away from what in MI is called the “righting reflex,” the temptation to tell the client what is best for her and what she ought to do. But this technique does not support client autonomy or self-determination, and defies the MI belief that the client is the expert. It also tends to pit the client against the therapist as an adversary or an authority against which to rebel. Telling Betty to stop feeding her husband could have caused her to shut down and damaged any trust she had in me that I understood her situation. Furthermore, the righting reflex may have robbed Betty of the opportunity to process her loss.

Change Talk

 It is important to note that Betty acknowledged that she heard that feeding could be harmful and even said, “I don’t want to be the one to kill him.”

MI emphasizes two concepts called “sustain talk” and “change talk.” Clients engage in sustain talk when they discuss the status quo, or give reasons why they cannot make a change. Betty had been engaging in sustain talk thus far in our conversation, going through her reasons for believing she should continue to feed Frank. Change talk, which is any mention of change as a possibility, marks a client’s willingness and preparedness, however slight or tenuous, for change. A clinician using MI should emphasize and explore a client’s change talk through reflections and open-ended questions. This allows the client to focus on change rather than maintaining the status quo.

Betty’s statement that she didn’t want to be the one to kill her husband identified her ambivalence and was an example of change talk. It let me know that Betty was open to exploring the possibility of refraining from feeding her husband in this final stage of his life, though clearly she had not yet reconciled herself to this option.

Before we examined the change talk, I wanted to reflect Betty’s ambivalence and confusion while stressing how much Betty loved her husband and wanted nothing more than to give him the best care possible. “You’ve really taken on the role of being his caregiver and part of that role is feeding,” I began gently. “The way you see it, just because he’s at the end of his life doesn’t mean you should stop that role now. And as you said, he could be hungry.”

Betty sat forward in her chair. “Exactly!” she exclaimed.

Sensing I had struck a chord with her, I continued. “You also said that you heard the nurse explain that feeding could be harmful.” Here I was able to focus on both sides of the issue: one the one hand, feeding was part of her role as caregiver, and on the other, she was aware that it was risky and could likely cause more harm, which she didn’t want.

“Yes, but I don’t really understand why,” Betty said, her voice heavy now, and she slumped back in her chair a little. “I know if people don’t eat, they die, so I don’t want to have that guilt that I’m not feeding him and he dies. He’s my husband, and I want to do the best job I can.”

Noting that Betty was moving back into sustain talk, I continued with affirmations and reflections to build a sense of alliance. “You have taken excellent care of your husband, and your family, for the sixty-four years you’ve been married. Feeding is not only part of caregiving, but also a way you show your love for him, which is something I definitely understand. It sounds like if you stop feeding him you’re scared that it could hasten his death, which would make you feel guilty, like you’re responsible for him dying.” I was able to use this complex reflection—drawing on Betty’s implied statements and feelings as well as the words she spoke—to assign meaning to the feeding, explore the sadness of her changing role as a wife, and allow her to process the fear of hastening her husband’s death.

“Yes,” said Betty. “I’ve taken care of everything all these years. The cooking, cleaning, laundry, shopping. And he likes that I do those things. I want to take the best care of him all the way until his last breath.”

I affirmed her role by saying, “Something I’ve seen from you in the times we have met is that you are a very dedicated, loving wife, who wants nothing more than to care for your husband, especially at the end of his life.” I began to understand that Betty’s roles as wife and mother were not only central to her relationship with her family, but also to her personal identity. Although cooking and her other activities seem like minute household chores, these activities were how Betty showed her love for her husband and children. If she was no longer feeding, how could she express her love, especially at this most intimate time in life?

As I reflected Betty’s deep desire to provide the best care to her husband in his dying process, she became tearful. “I’ve cared for him for so long,” she said, “and I’m feeling very overwhelmed about this. I just can’t believe he’s dying. We’re high school sweethearts. I can’t remember life without him.”

I could really empathize with Betty in that moment. Although she had been able to understand intellectually that her husband was terminal, the emotional impact of the dying process weighed heavily on her. Thinking about what her life would be without her husband was devastating. “This experience has been really difficult and emotional for you,” I said. “It’s hard to even imagine life without him.”

With tears filling her eyes, all she could say was, “Yes.”

Ambivalence, Not Resistance

 I was sensitive to not push her too far. We still needed to address the feeding, and if she became overwhelmed with grief, it would have been inappropriate to have that conversation. So I continued to affirm her. “I see just from listening to you that you and Frank are so incredibly in love and have been for a long time. You’ve created an incredible life together, have two wonderful children, three beautiful grandchildren, all are an extension of you two and represent your life and your love for each other.”

Reflecting on the lives patients and families have shared is a vital component in helping them experience a peaceful death with dignity. Processing their lives affirms they were special and facilitates closure. Here, affirming Betty’s desire to continue providing loving care helped her to feel understood and acknowledged. My acknowledgment of the specialness of her bond with Frank seemed to calm her down a bit.

I decided this moment was the opportunity to provide some education about Frank’s state, but first I needed to ask permission. Asking permission is essential in MI because it gives the client control of the session. In a careful tone I said, “Maybe if we could clear up some confusion about the feeding, then that could help you feel a little better and assured that you are taking the best care of Frank. Would it be okay if I shared some information with you about feeding at end-of-life?”

“Yes, I’d be okay with that,” said Betty. “The nurse just didn’t explain it to me well.”

“I can understand,” I said. “Sometimes we think it’s clear because we have this discussion often, but the family needs a little more education and I’m happy to provide that.”

“Yes. I just cannot understand how eating could be harmful.” She had become quite agitated again, her shoulders tense and limbs tense.

Maintaining a gentle tone, I explained, “It seems very unclear because when the body is healthy, it needs nutrients from food. As a person gets closer to death, the body doesn’t need the same amount of nourishment as it did when it was healthy. The body slows down and its metabolism slows down, so the food cannot be broken down at the same speed as when the body was healthy. Now that Frank’s body is slowing down, he can’t digest food in the same way, so the food and liquid gets kind of stuck in the body, causing more harm than good. I know that sounds strange, but does that make sense?”

She seemed puzzled. “So he can’t break down the food?”

“Exactly,” I told her.

I was becoming hopeful that Betty was beginning to understand the risks of feeding and we were about to make a break in resolving her ambivalence. But then she responded, “Well, what if I just give him less food?”

I suppressed a twinge of impatience. That question made me see that she was still unsure and possibly resistant to stopping the feeding. But although resistance can sometimes be frustrating for practitioners, an MI practitioner always rolls with the resistance and should avoid the righting reflex in times of client ambivalence. Betty’s question was simply her way of expressing that she was still unsure what was right.

Resisting the urge to use the righting reflex, I calmly said, “Well, sometimes that can be okay, but if the food is not soft and thick, there is a risk that it could go into his lungs and he would aspirate. That could cause an infection and actually hasten his death.”

My hopes that this education would help move discussion along were quickly halted when Betty said, “Oh. Well I’m glad to know this, but even if I gave him just a little, it couldn’t hurt him that badly, right?”

A Circuitous Route to Change

I was unsure how to move Betty out of her now entrenched sustain talk. Betty was trying to argue for feeding, even just a small amount of food. Sustain talk can be difficult to address, so I decided to offer some compromise and then affirm and reflect. With empathy, I said, “Well that is something that we can discuss with the nurse. I would just like to affirm what the food represents in your relationship. This is the way you’ve shown your love for your whole marriage, so that’s hard to stop that now. I know you don’t want to hasten his death by not feeding, but the scientific knowledge we have indicates that feeding could be more harmful.”

Betty immediately interjected with more sustain talk. “But he may be hungry,” she protested.

“I think that’s a great point,” I replied. “Unfortunately, we don’t know for sure if he is hungry or not.”

Betty interrupted and asked, “Do you think it’s better to not feed him because it’s more dangerous?”

I realized that Betty was looking to me as an expert, and as the hospice social worker, I was more of an expert on the issue. This is another temptation to resort to the righting reflex and simply use my authority to tell her she couldn’t feed him. But I reminded myself that this was Betty’s life and I did not know what was best for her. Any decision I made for her, she could still reject. She had to come to it herself. Furthermore, I needed to support her self-determination and autonomy. “Well, I think it’s better that you do what you feel most comfortable with,” I told her.

Betty appeared to appreciate this point as she sat back in her chair and relaxed her shoulders. My statement affirmed her autonomy and validated that I supported her self-determination. I realized I may not have acknowledged before that the choice had to be hers.

Although Betty had relaxed, she was somewhat hesitant. “I just don’t know,” she said. “This is so hard.”

I knew then that I needed to help Betty navigate the pros and cons of this decision. For this, I used an MI technique referred to as a decisional balance. Betty already had the information about the advantages and disadvantages of feeding and not feeding, but I needed to help her sort through them.

I asked Betty, “Well, what are some of the dangers of continuing to feed Frank?”

Betty reflected for a moment. “Well, he could choke. And you said the food could get stuck and he could aspirate.”

“Yes,” I replied, adding, “The body also cannot digest the food well, so it could store in his body and cause an infection. And what are some of the good things about continuing to feed him?”

Betty looked puzzled, but said, “Well, he wouldn’t be hungry.”

I gently replied, “Yes. If he is hungry, which we don’t know for sure and likely never will, the food could satisfy his hunger. But if the food doesn’t break down correctly or pass through his stool, then it could be more painful for him.”

Using the term “pain” seemed to resonate with Betty. Her eyes widened and she sat up in her chair. “Oh! I hadn’t thought of that. It could cause him pain?”

“Yes, think of it like this: if you eat more food than your body can handle, you get a stomachache. Now imagine not being able to get that built-up food out through your stool. That’s likely what it feels like.”

Betty smacked her arms down on the armrest and said, “Well, I definitely don’t want him to be in pain. Do you think that his pain and agitation last night was because I gave him some mashed potatoes?”

Betty seemed ashamed by this prospect. She moved in her chair and did not make eye contact with me.

Sensing her uneasiness, I softly said, “You know, we will probably never know. I’m glad that you knew to call for help when he was having new symptoms. That was very intuitive and shows that you knew what to do in a crisis.” I did not want Betty to feel guilty, because a number of factors could have played a role in her husband’s symptoms.

I wanted to return to the decisional balance to speed up our arrival at Betty’s decision about feeding her husband. “What are some of the bad things that could happen if you stop feeding him?” I asked.

“Well he could be hungry and that would make him more uncomfortable. But after talking to you, I'm not sure if he would be hungry because maybe he’s just too sick to be hungry,” Betty said sadly.

“So you’re thinking maybe he’s hungry, but we don’t know for sure. You also see that he could be far enough along in the disease process that his body isn’t feeling hungry anymore.” She nodded. To continue with the decisional balance, I asked, “And what would be the benefits of not feeding him?”

“Well you said that feeding could cause infection, so if I don’t feed him hopefully he won’t get sicker. Maybe he would live longer?”

A Breakthrough

I was so relieved to hear change talk: an acknowledgment of the possibility that Betty might stop feeding her husband. I felt that we were finally getting somewhere with her ambivalence. “He could live longer, and maybe even be more comfortable,” I told Betty.

“Yes, I want him to be comfortable,” Betty nodded.

“I want you to know that we really do understand how confusing it is to not feed your loved one at the end-of-life,” I affirmed. “It seems so unnatural because feeding is typically associated with us feeling better. And also with your relationship, feeding is not only part of your role as his caregiver for the past sixty-four years, but also the way you show him how much you love him.”

I wanted to ensure I normalized Betty’s ambivalence regarding feeding at end-of-life, as this is something that hospice clinicians discuss with families every day. Like many therapeutic interventions, normalizing is useful in MI because it makes clients feel comforted that they are not alone. This is especially critical in hospice because family members often feel isolated as their loved ones transition through the dying process. Affirming and normalizing Betty’s confusion regarding feeding, while also providing a complex reflection of Betty’s role as caregiver and how she expressed her love, helped us transition from the issue of feeding to ideas for how Betty could continue to express affection towards her husband in his final days.

“If we can brainstorm together other ways you could express your love,” I continued, “then maybe we can implement those into your caregiver role. Maybe things that are less risky, like reading to him, holding his hand, playing music for him. How does that sound?”

“That sounds nice. He loves reading.” A note of relief emerged in Betty’s voice. “We used to go to the library together and get books. Sometimes he’d read to me at night.”

“Wow,” I replied, “that is really special. So now you could maybe do that for him.”

She paused briefly. “Yes, I think he would like that. But can he hear me?”

Again, I wanted to avoid jumping into an expert role here, especially with what must have been an emotionally loaded question for Betty. “Well, what do you think?”

“I’m not sure,” she said. “He doesn’t respond like he can.”

“Would it be okay if I gave you some information about senses that some other families like to know?” I asked.

“Of course,” Betty said, “You’ve been so helpful, I want to know.”

“Well, we always ascribe to the belief that if there is breath, then there is hearing. Some studies have shown that hearing is the last sense to go before someone dies, so I always tell families to behave like their loved ones can hear them.”

“Yes, you’re right. I think he can hear me,” she said hopefully.

Peaceful Passing

Betty’s husband lived just two more days after this visit. I learned from the nurse that Betty’s husband declined even more the day after our visitand was actively dying, so I followed up with Betty and her children with telephone calls to assess the status of feeding and how they were coping. Betty and her children all confirmed that Betty had not tried to feed her husband again after our visit.

I learned from my bereavement telephone call that Betty spent the last two days she had with her husband reading his favorite books to him, writing him a long letter that reflected their life together and the impact it had on Betty, playing their favorite music on an old record player, and holding his hand and providing a supportive presence.

My visit with Betty not only provided her with important education about her husband’s dying, but also helped her process some of that anxiety so she could help Frank’s dying process be more dignified and peaceful. Like so many of the families I see, Betty needed someone to validate what she was feeling and also hear, understand, and affirm what feeding represented to her relationship with her husband.

Motivational interviewing skills, such as reflections and the decisional balance that I used with Betty, have been effective in my clinical practice with hospice patients and families who experience ambivalence with administering morphine for pain, hiring caregivers, or asking family members for help to protect the primary caregiver from burnout, and processing denial related to rapid decline.

Often families I work with are extremely concerned with doing everything “right,” so affirming that they are doing an excellent job caring for their loved one is very important for them because the feel empowered and validated. Although they may not be ambivalent about providing care, they are still at risk for becoming so overwhelmed that effective coping and a healthy life balance are damaged. Emphasizing individual strengths through genuine affirmations empowers the caregiver and results in better care and support for the patient. The patient having a peaceful death with dignity is not only valuable for the patient, but also for caregivers and family members as it decreases their risk for complicated bereavement.

The spirit of MI is rooted in the notion that the practitioner and client have a collaborative relationship. Once that relationship is established, the practitioner is responsible for evoking the client’s motivations, perspectives, and autonomy. Starting the visit with exploring and reflecting Betty’s motivations, understandings, and feelings regarding feeding allowed us to make progress on this issue. If I had come into her home telling her why she should not feed her dying husband, she likely would not have listened. Furthermore, she would not have had the opportunity to process their life and the emotional impact of her husband’s death.

MI techniques emphasize and foster a collaborative therapeutic relationship, which is critical in hospice work, and more generally in working with individuals and families coping with terminal illness. We clinicians are not the experts in our patients and families’ lives or their dying process. Using MI techniques not only helps hospice patients and families process their ambivalence, but are also extremely valuable in conveying empathy in a way that moves towards change.

My work with Betty was the first experience I had in applying MI to my clinical work in hospice. I was initially unsure how the MI skills, specifically reflections and affirmations, would help Betty resolve her ambivalence, but this experience showed me their value. I believe that my ability to avoid the righting reflex and simply repeat back to Betty her confusion and fear helped her feel heard and validated. The reflections also allowed her to process her thoughts that supported the ambivalence. These skills helped us establish a collaborative relationship as I was sure to never make her feel I was the “expert.” Although Betty saw me as more knowledgeable of the issue of feeding, I was not more knowledgeable in what was best for her. These skills allowed me to use the decisional balance, which ultimately led to her resolving her ambivalence and not feeding her husband again.

I feel tremendously honored to have the opportunity to work with hospice patients and families. Being present with patients in their dying process, and supporting their families as they navigate the demands of caregiving and effects of anticipatory grief, is an incredible privilege. I believe strongly that everyone deserves a peaceful death with dignity and am passionate about being part of providing that experience to all of my patients and families.  

Maria Gonzalez-Blue on Person-Centered Expressive Arts Therapy

Posted on by rezendevknowfully.com

Formula for Compassion

Victor Yalom: Maria, as I understand it you’re a person-centered expressive arts therapist. A good place to begin would be to ask you, what is person-centered expressive arts therapy?
Maria Gonzalez-Blue: I'll start with what the person-centered approach is, because that's the foundation. Expressive arts then becomes a tool that's been integrated into the person-centered approach, which was, of course, defined by Carl Rogers. The person-centered approach is based on the humanistic principle that, within every organism, there is an innate movement that will always move that organism towards it greatest potential, if it's given a nurturing environment where that potential can grow. The nurturing environment was defined by Carl Rogers as one that includes the elements of empathy, congruence, and unconditional positive regard.
VY: Carl Rogers is certainly well known by our readers and he's had an enduring influence in our field and in many fields to this day. We’ve just been doing some work with Sue Johnson in emotionally focused therapy, and she gives a lot of credit to Carl Rogers. We’ve also just been filming some videos on motivational interviewing, which also has strong Rogerian roots. What, for you, are the essential components of Rogers’s person-centered approach that you hold near and dear to your heart as you teach and as you work with clients?
MG: I see his emphasis on empathy and unconditional positive regard as a formula for compassion. It requires therapists to consider those things any time they sit before clients, students, or other individuals. If I enter a session knowing that I want to bring these elements in, it forces me to bring them home to myself, as well. I have found that it becomes a way of life and makes you a better person, because you're always conscious of when you're not being empathic or when you're being judgmental.

In my work, what I've seen is that when you listen to someone truly carefully, instead of listening to your own ideas and expectations—when you set all judgments aside, incredible things happen. People contact information that's long been repressed. It seems a simple thing, but I find it has a profound effect on an individual to be listened to with such caring. 

The Intention of Tolerance

VY: Coinciding with the publication of this interview, we’re releasing on video an interview that Carl Rogers did in the ’80s. When discussing these concepts, he clarified his conception of unconditional positive regard. He said something along the lines of, “It’s not that we can always achieve unconditional positive regard, but it’s fortunate when we can have that with our clients.”
MG: Right. And that's what I tell my students all the time: what's important is to hold that intention. Certainly we're human beings—we're judgmental. If we can simply go into an environment with that intention, that is far reaching.
VY: I think that’s an important clarification, because otherwise, people can hear that and think it’s Pollyannaish. It’s an impossible ideal to attain. As you say, we’re human. We have our judgments. We have different feelings for our clients and for different people in our lives.
MG: We have to start with tolerance. I think this is why I am so dedicated to this process, because I feel we need this so much in the world. You can at least start with tolerance.
I don't think it's necessary to accept or condone everything and everyone you meet in a session. But you can keep in mind that somewhere in that organism, there is a desire towards growth.
I don't think it's necessary to accept or condone everything and everyone you meet in a session. But if you can keep in mind that somewhere in that organism, there is a desire towards growth, then that's the part that we as person-centered therapists hold: that seed in there that wants to move towards wholeness. Accepting that that is there requires trust and faith on the part of the therapist. And if the therapist can hold trust and faith, then that can affect how clients feel about themselves. If you as a therapist aren't judging them, then maybe their own self-judgments can start falling away.

Not Just Parroting Back: Reflecting as Witnessing

VY: Another one of the core techniques of this person-centered approach that I think has had a vast influence but also been misunderstood is this idea of reflection—repeating back what the client says. Some people have made fun of this as parroting or being too mechanical. What are your thoughts on that?
MG: That mirroring back of language, for people who haven’t really experienced it or been part of it, is often seen as mocking the individual. But that’s really not the case. Reflecting back the language that a client is using can also be useful, but we don’t always use the same exact words. Often, as clients are rattling off issues, problems, and feelings, they’ll say something that they’ve never said before; in their sharing, they’re coming to insights, they’re making connections without knowing they’re making connections. If you, as a therapist, can reflect back what you’re hearing, then those connections that are being made come to consciousness. Clients are speaking from a kind of flow of consciousness, and
I like to see myself as a mirror that’s reflecting back the wholeness that I see in them.
I like to see myself as a mirror that’s reflecting back the wholeness that I see in them. So that reflection is really important.

What’s also important is that you want to understand. Part of being empathic in Carl Rogers’s process is to see clients’ experience from their own worldviews. If you can really hold that idea that you want to understand, it’s also a way of saying, “Is this what I’m hearing you say?” And that gives them a chance to say, “No, that’s not it.” But, if they realize that that’s not it, then that gives them a frame of reference of what might it be. It’s a stepping stone.
VY: Right; as clients talk, they'll say things they didn't even know existed inside them. And of course, that's always the goal in any kind of therapy—that people will discover new things about themselves. If they're repeating things that they already know, then not much new is happening.
MG: Exactly. It’s like the therapist is walking through the woods side by side with the client, discovering things together. There’s something about that witnessing that can ground those new discoveries in a way that people can’t really do on their own.
VY: That’s a nice image. I’ve seen videos of Carl work and, of course, many other master therapists from different orientations. And what comes through is not his technique or the words he utters. Instead, you get a such strong sense of him really being with clients, listening deeply, committed to hearing and understanding them. I think it’s the intention. It’s the spirit of it, rather than the words that come out, that really is profound.
MG: And for many people, this has never happened. Even your best friends, and particularly family members, have all kinds of biases. They know you as this certain person. Sometimes your best friends want to help you, so they give you advice that may have worked for them, but may not work for you. But when you want to hear your clients, when you want to really see their worldviews and understand them, something shifts.

The Blank Page: Exploring the Unknown with Art

VY: Tell me about the expressive art component and how that is integrated into the person-centered approach.
MG: We just talked about a client discovering buried material, stepping into unknown material that strikes a surface, which is a good segue. Often, clients who enter therapy are approaching unknown territory. Either they’ve left a job or a relationship, or their life doesn’t feel right anymore, so they know what’s not working, but they don’t know what’s ahead.

The blank page, whether it’s in visual art or movement, is a great way to enter this unknown material. Art is really the language of the unconscious; it allows symbols to come forth. People make discoveries of potential and understanding, which become new resources to enter this unknown material. I believe that there’s a time and place for everything, so I’m not critical of any therapies. But talk therapy has its limits; art does not. It can be limitless. It can also be contained.
VY: I should add at this point that person-centered expressive arts therapy was developed by Natalie Rogers, Carl's daughter, who's a psychologist and psychotherapist in her own right, as well as an artist. And I know you've worked and trained with her professionally over many decades.
MG: Yes, we've worked substantially together, we've taught together, and we've played together. And what Natalie really brought in to weave those two things together was what she came to call the "Creative Connection." It's actually an intermodal process where we work with different modalities in sequence. A person might be exploring an issue through a visual arts piece. We don't diagnose or interpret art; instead, we ask the artist to explain what came through as a feeling, what is in the art that he or she wants to discuss.
The art doesn't have to be analyzed or intepreted. It's an image that has its own language.
The art doesn't have to be analyzed or intepreted. It's an image that has its own language. So the work is processed through listening, really respecting what the artist has to say about it. If the client wants reflections that a therapist might have, I might add something that I sense in the art without trying to analyze it—maybe noting the energy or the color, the person's body language in the making of it. I like to observe body language; sometimes you can tell energy is moving through.
VY: When you say artist, of course, you’re just referring to a client who’s engaged in the expressive arts process.
MG: The person who made the art.
VY: Yes. I don’t want to our readers to think that only artists can be involved in expressive art therapy.
MG:
We are all artists of our own lives.
We are all artists of our own lives. Expressive arts therapy is not looking for an end product, necessarily. It's really about the process and what comes through in doing the art.

Introducing Expressive Arts into Sessions

VY: Can you say how you use art? As you said, people are often going through changes. They're talking about concerns in their lives, some situational issue or an emotional reaction to that, feeling depressed or anxious. How do you go about introducing the expressive arts into a session?
MG: Pretty early on, I observe the client. I bring my intuition into my sessions. I watch body language. Let's say I have a client who is really kinesthetic, moving a lot while she's talking, making certain gestures—for example, she's talking about an issue, and she keeps putting her hand on her heart or keeps holding a part of her body. I might ask her if she'd be open to movement work. And whenever I introduce anything, I do it with a lot of asking permission, asking how it feels, so she doesn't feel like they're being directed. But she's given the opportunity, the invitation, to explore something.
VY: One of the other names of the Rogerian approach is non-directive therapy.
MG: Exactly. And what's important about that is that it makes clients ultimately responsible for their own processes. So I might ask if she would feel comfortable just holding that posture for a bit. Often what happens is the client may hold that gesture, perhaps holding her heart. And then I see more come into it—maybe her shoulders lift up, her facial expression might change. So I say, "If it feels right, why don't you go with that movement and see if there's more there?" And that's a subtle invitation to enter a movement process.
VY: And how might that evolve? A client might get up and move around or dance?
MG: She might get up and move around. She might move where she’s sitting. And if a client feels shy, sometimes I say, “Would you feel more comfortable if I move with you?” Because the body has its own wisdom. What’s happening here is that we’re tapping the body’s wisdom to help inform the person, maybe of something that’s repressed, or something that really wants to come alive. Then I just might check in and say, “What’s going on? What do you want to share about that movement?” At that point, people can easily start describing what they’re feeling, what they’re understanding. Sometimes they have their whole stories come forth. It’s like opening a door into the body.
VY: So, in this case, movement might in turn elicit some emotional reaction or some image or ideas that then they’ll go back and process verbally?
MG: That gives them better understanding. They might process it verbally. If there's time, they could do some freewriting. And I might suggest making some quick "I am" statements to see what comes. It also could go into some art—whatever the client is feeling. I'll usually have chalk pastels and oil pastels. I'll ask, "Would you like to take a color and see if you can draw that shape, or just see what comes through?"

There's so much happening when you tap this deeper language. Using pastels has been a really successful way to draw shapes, draw feelings. Sometimes I start my workshops by having people draw their breath going in and out, and it's such a abstract concept that no one has to feel that there's a right or wrong way to do it.
VY: I’ve seen Natalie say, “Would you like to work with color?” And my sense is that that’s a way of de-emphasizing that this has to be some artistic creation. It’s more just an experience of taking some colors and playing with them.
MG: Yes, it’s very much a meditation. In fact, I use the word “scribble” a lot. I tell people, “When we’re done, you can just throw this away. It doesn’t have to be put up in an art gallery somewhere.” It’s really about what’s happening when clients go into the stillness to just be with themselves in the process, but with me as a witness.
VY: Just so our readers can get a better idea, can you give an example of how this is used in individual therapy?
MG: I have a new client, and this client is an artist. It's funny; I work with all people that are creative, and people come from all different walks of life. But I typically don't work with artists. We talked for a while; she's had some major changes in her life, and she was feeling a block from her artwork.

I talk with clients, too. It's not like it's all expressive arts. In fact, in some cases I may not bring the arts into it if it doesn't feel relevant at the moment, or if it doesn't feel in the flow. But in this case, I asked her if she would like to do some artwork before she went further to her issues. I had her work with pastels. I had her, first of all, just look at the colors and see if there was a color that she was attracted to start with. I let her know, "This does not have to be an art piece. This is a process." I always try to make that clear.

And what unfolded was that she drew aspects of her life in very basic, rudimentary forms. And there were some surprises already, in what she saw there. This was after she came with the issue of block in her artwork. Then we turned to process a little bit more, her sharing her story, which I won't go into. I listened to her carefully. As she talked, she was able to make some discoveries of elements of her life connecting to ongoing issues that she was aware of.

I had her do a second piece towards the end, and the interesting thing was that she was drawn to all the same colors, but this time in her drawing, everything seemed connected, whereas before they had seemed to be these small, disconnected pieces on the paper. Now there seemed to be flow—all the same colors, but everything seemed integrated. You could see movement. A change had happened, and it's not something that's easy to articulate. But using the arts, she could see it. And she could feel it in her body.
It's not something you can read in a book. You can explain details, but until you feel the changes firsthand, you don't get it fully.


Like you say, it's hard to articulate a lot of this because so much is happening at the cellular level, the emotional level. I think all of us who facilitate the person-centered approach have felt like it's not something you can read in a book. You can explain details, but until you actually live it, experience it, and feel the changes firsthand, you don't get it fully.
VY: Coinciding with this interview, we’re publishing a video (LINK) of Natalie working with a client for two sessions. Having a chance to watch that, I certainly got a clear sense of the power of this approach, and how shifts can happen in a short amount of time.
MG: And what I have noticed is that the shifts tend to stick. I'm still in touch with students I had long ago from our training program, or past clients. Person-centered therapy can help to build that self-trust and the trust in the natural movement towards growth. I really try to encourage my clients to know this, and I think that it helps life changes to be healthy ones.

Using Art in Groups

VY: Natalie's first book on this topic was The Creative Connection, and I know she just recently published a follow-up to that, The Creative Connection For Groups. I know you also work with groups. Do any examples of work you've done recently pop to mind?
MG: There's a group process that really stays in my mind, where I saw the profound effect of person-centered and expressive arts therapy. I was doing a seven-day training program. What we like to do is invite feedback every day. It always feels like a bit of a risk to open yourself to feedback, but I find that it's really important because people need to feel that they're safe and that whatever they're feeling or going through is okay and a process.

So I was doing a training, and during a morning feedback session on our second or third day, something arose between two women. It was something about a transportation conflict; one of them was very upset that the other hadn't waited for her at the airport. I said, "Let's go ahead and take some time," and asked people to say how they felt, without blaming, if they could. That's not always possible.

But the people in the training were versed enough in the person-centered approach that they were open to hearing whatever needed to be said. Both these people spoke, and then a couple other people started speaking. The conversation got quite heated. I let it go for a little bit, and then I intervened and said, "I'd like to make a group agreement, because many people are not involved in this conversation. It's important for you to express how you're feeling. But I know there are people who also want to do some work. So can we put a time limit on it?"

So we compromised, and the conversation continued about transportation and what one person said and the other person said. At some point I said, "Okay. The time is up. Do you want to keep going, or shall we do some art?" And, of course, all the other people said, "Let's just do art." So I laid out a huge mural sheet and put on some music that was kind of driven, because I could tell there was a lot of heat in the conversation. We got out paint, and people started just drawing on this mural.

And as a witness of this process, I could see the energy shifting. At first, the drawing people were doing was kind of intense and stark, big. But by the end, people were starting to write poems, affirmations about themselves and their desires. Some spontaneous singing started happening. By the end of that process, I could feel that everything had shifted.

Ultimately, what I know is that in a process like that, those surface feelings that come up are not about the people themselves, but about inner issues that people are grappling with. And to give it space to be there is really, really important.

Collectively, we like to hide that negativity, hide our anger, come to the table with a smile. But something really beautiful happens in the community when people are allowed to be "negative" in a group and have that held—when you see that that's okay and no one's judging you for having those feelings.

The next morning when we had our check-in, it was totally different. People were sharing personal feelings about their woundings and discoveries, but it had nothing to do with the group anymore. So it's really very amazing to see.
VY: Are you suggesting that people may have an easier time expressing some negative feelings through expressive arts than they might be able to put into words?
MG: Yes, because a lot of times the words can be hurtful, or the words aren't even there. It's just this strong energy moving through the body. If you can put that into some artwork, it becomes a creative fire. You can move that strong energy through and see what's underneath it. And that's exactly what happened with that group process.

Building Bridges: Art in International Group Work

VY: You've trained a lot internationally and you've cofounded an expressive center. Is it in Argentina?
MG: That’s right, in Buenos Aires. We have person-centered programs now in many countries.
VY: Any thoughts or comments about doing this work internationally?
MG: The beauty of the person-centered approach is that it lends itself to meet any group, any culture, exactly where it is. You design any program you do towards who you're working with. I don't go in with a structured program. I have a sense of where we might go, but it's always fluid. So with every culture, first I get to know the culture. I hear from them. I hear what they might need.

In Argentina, I knew a little bit about the background of a violent dictatorship in the '70s. So I went into that culture with a lot of humility. What I found was that the culture needed a very tight structure in the beginning. Everything needed to be on time. I needed to be perhaps more directive than I usually am. That just meant that if we were working with a certain modality, I would try to keep everybody with a certain modality, whereas working in an environment where there's already a lot of trust, I might just say, "Whatever modality you want to work with, you can."

But, what I found in Argentina was I needed to hold a tighter structure at first to develop trust. It's a culture that hasn't been able to trust their government in the past, so self-trust then comes into question. The beauty was that their hearts were so tender and beautiful that by the end of the ten-day program, everyone wanted to come back. Everyone wanted to go deeper into the work.

The person-centered approach really has a potential to bring great things into our planet, to bridge cultures.
The biggest thing that I want to underline in working with other cultures is that I think the person-centered approach really has a potential to bring great things into our planet, to bridge cultures. I think it's really important as a way of being with cultures that's accepting, that can bridge us into healthier places.
VY: It seems the arts are an international language. Have you had a chance much to work with groups of people from different cultures in the same group?
MG: Yes. In fact, CIIS (California Institute of Integral Studies) is very multicultural. The art becomes the universal language then. A closeness happens with these groups. What happens in group process is it’s almost like they start dreaming together when the art images start to appear. After the group has been together for a while, these same symbols end up appearing within the group as if they’ve just had the same dream. It’s a wonderful bridge.

Psychotherapy with Older Adults: Unjustified Fears, Unrecognized Rewards

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I am a geriatric clinical psychologist. I love working with older adults. I have often wondered, though, why there are so few of us around. Ten thousand people in America turn 65 every single day now. There is an accelerating rate of this already underserved segment of our society, and there is a huge and growing but untapped market of potential revenue for psychotherapists wanting to expand their practices. Why, then, are there so few psychotherapists actively working with older adults? While it is estimated that 70% of psychotherapists see adults on their caseload, only 3% of them have had formal training in working with older adults. What has stopped clinicians from getting training that could be so valuable in their professional development? Despite the general finding that the motivation and attitude of the older adult toward psychotherapy is as positive as it is in other age groups, many clinicians doubt this nevertheless. As I began working with older adults, I confronted these issues, and as I did, I found new joy in my work. What I discovered was this: I have as much to learn from my older clients as they may have to learn from me.

Many clinicians prefer not to work with older adults, and I have a great deal of respect for those preferences. In my own practice, I'm not inclined to work with children or adolescents. Oftentimes, though, the therapist’s preference is based on a view of older adulthood that is grounded less in fact and more in myth. When I first started seeing people in nursing homes, I felt like a fish out of water. I was trained in two of the best graduate psychology programs around, but when I was in a nursing home, I was consumed with doubt and fear.

It was 1999. I had just become licensed as a psychologist, and I was offered a job with a firm that brokered psychological services to nursing home residents. I was excited about making a living as a psychologist, energized about venturing into this new application of my skills, and eager to ply my trade—that is, up until the first week I actually saw clients! It was then that the reality of working with older adults eclipsed my fantasies of doing so. It was then that I confronted my awareness that this was incredibly challenging work for which I felt ill prepared.

My main fear: could my cognitively compromised clients even benefit from psychotherapy? I asked myself, How much of my work with them could they actually comprehend? How capable were they of working through their emotional struggles and inner conflicts? To what end would our psychotherapy serve if their lives would soon come to a close? I was overwhelmed with confusion, uncertain of my effectiveness, and scared I might be practicing outside my area of competence. Out of an amalgam of fear, guilt, and good sense came a series of consultations with a wise geropsychologist, and it was there that I began my schooling about the cognitive, emotional, and functional eccentricities of the older adult.

I am here to tell you, though, that 13 years later, I have come full circle. My acquired knowledge and experience in geriatrics have been invaluable, but I see now that, with respect to the essence of effective psychotherapy, it turned out that I had been sufficiently trained to do the work all along. Becoming technically proficient as a gerontologist has taken me on an invaluable path, but I see now that my former fears about conducting psychotherapy with older adults were driven almost entirely by my own introjects from the social stigma of aging. That’s what this article is about—to describe my own journey as a clinician framed within the cultural mythology around aging.

Myth #1: Psychotherapy with the elderly is time wasted, because the elderly client has so little time to enjoy any gains that might be made.

There is a film released in 2011 entitled Beginners, for which Christopher Plummer won the Oscar for Best Supporting Actor. The story involves a widower who, at age 75, joyously begins living a sexually authentic life as a gay man. To justify such a change, how many years should this man have left to live? Is the length of time he would have to enjoy his newfound emotional freedom really the issue? I am reminded of the elderly client who responded to her therapist’s query why she wanted psychotherapy by saying, “It’s simple; all I have left is my future.” At age 49, Freud is well known for having contended that anyone over 50 was uneducable, and I wonder if some of our biases working with older adults might stem from this overstated assertion.

Due to a very severe stroke, Estelle had for some four years been living in a nursing home. At 75, this was her home now. She was referred to me because she could not stop getting into heated arguments with other residents, and she was sad a lot. She had a history of drinking moonshine; she had been an ironworker and a barmaid, drove a semi, and had graduated high school with honors.

As with most nursing home residents, she was on a ton of meds, including an antidepressant, two anxiolytics, and an antipsychotic. When I first met her, she told me she had multiple personality disorder (which wasn’t the case), but due to her stroke, she did have memory problems and severe aphasia (difficulty expressing herself with language). In fact, her aphasia was so pronounced that it took her as long as a minute to express a complete sentence. She grinded out each word—one by one—with persistent determination. Her desire to communicate was relentless, and this was what allowed her to stay connected to others.

My psychotherapy with Estelle lasted two years, and I learned a great deal from her. I learned about the incredible courage and fortitude it takes to cope with an abusive upbringing, the loneliness and isolation that can accompany nursing home life, and the debilitating physical ravages of vascular dementia. I also learned about the connection that occurs between two souls—where words are often not needed.

More than her aggravated depression, though, Estelle wanted to work on emotional abuse issues from her childhood and the disparaging way her mother and father had treated her. She was open to the idea that those images—and the ways she coped with them—were influencing how she related to others and to herself. And this was how we approached her psychotherapy.

I am tempted to say that Estelle was a wonderful psychotherapy client, but the temptation to do so implies that it was Estelle’s characteristics that made the therapy meaningful. It was not. What made the psychotherapy beautiful—even reverent—evolved from the exceptionally meaningful way the two of us found to communicate with each other. And not unlike Victor Frankl’s odyssey through Auschwitz, what was most meaningful to me was to witness Estelle’s search for meaning in the limitations of her own life.

In the beginning, our therapy focused on relieving her depressive and angry feelings, and Estelle made comments like,

I have been fighting lately—it’s enjoyable … and it’s not enjoyable. It relieves tension, but I am crying all the time. If I told you all that is going on inside of me now we would have to meet all day!

Take a minute and think about her, though—grinding out each sentence—me wondering where in the world it was going to go—waiting almost interminably for each idea to unveil itself—and to eventually experience just how wondrous it was to witness such life-revealing self-reflection. How could a therapist not marvel at the human capability that was co-existing with such daunting a physical disability!

As our therapy progressed, the emotional work Estelle and I did together chronicled her evolution in becoming a more whole person. She created a process where she found her inner self in a way she had never done—developing her own autonomy and independence by resolving longstanding introjects that, for the first time in her life, she was now ready to expel. Toward the end of our work together, she proclaimed,

I’ve overlooked myself … but I can discover me … I can see the good inside me now. That surprises me to hear myself say that, but I see I will make it … and I know now who I’ve been angry at, and I see that I don’t need to be angry at everybody anymore. I’m not quite proud yet, but I do like being alone with me now … I really do enjoy my company. I’m on my way.

When I began doing psychotherapy with older adults, I didn’t realize that the kind of emotional and spiritual trek that Estelle would make was more similar than different from the journey I made with clients in other age groups. This is my joy of working with older adults—to see them unveil to themselves and to me their indomitable wisdom. For me, this is a revelation perhaps most profound in those who have lived with their darkness for so long.

Myth #2: The grief, loss, and somatic and socioeconomic burdens of the elderly are too excessive to warrant believing they could get better.

There is a great deal of pessimism about doing effective psychotherapy with older adults. Many of these clients have limited resources to face unimaginable social, medical, and economic struggles, and many clinicians tacitly believe that the elderly’s frustration, deprivation, fear, and dependence are so emotionally injurious that no amount of psychotherapy could really help them. When I began my psychotherapy career with the elderly, I wondered about these things too. With experience, though, what I learned was that it was not my clients’ deprivation and burden that was too excessive—it was my own. It was my inability to cope with my fears and frustrations working with excessively burdened people, and I was projecting these issues into my elder clients.

Marge was a ten-year resident of her nursing home. Legally blind, she had a longstanding diagnosis of mild mental retardation and had been institutionalized with paranoid schizophrenia for much of her life. When her mobility began to fail and her dementia and other medical conditions became too much for her family caretakers to manage, she was admitted to a skilled nursing facility. In order to address issues of depression and to help her manage her psychotic symptoms, for almost three years I saw Marge weekly for psychotherapy. I wondered if the odds of Marge overcoming her burdens were too great. I wondered if she could fight the good fight. What I came to learn, though, was that I was actually asking that of myself.

Like many people with schizophrenia, Marge was an isolationist, and this often exacerbated her psychotic symptoms. The structure and consistency of our weekly visits, though, allowed her to quell many of her paranoid thoughts, and she made remarkable progress. For the first time in many years, she was successfully managing most of her troubling and longstanding paranoid symptoms. Her solitary lifestyle, however, unintentionally reinforced her chronic feelings of loneliness.

As does happen sometimes, changes in my own life forced me to turn her psychological care over to another clinician, and we spent two months planning for the transfer. As you might imagine, my concern was that my departure would lead her to regress into further isolation. As it turned out, though, my underestimation of her strengths and concerns about her succumbing to her fears were a projection of my own issues.

In the waning weeks before my departure, Marge began to voice her sadness with our impending termination, and this was clinically therapeutic for her. She also began to tell me about the new and pleasant experience she was having on "the boat," so asked her about it.

Marge: "I will miss you."
Dr. Kraus: "Yes. It's sad that our therapy together is going to end. You have made great progress, and I am proud of you. I know you will continue your good work with Dr. Hamilton. … You had mentioned to me about a boat. Can you tell me more about it?”
Marge: "Oh, yes! We travel around."
Dr. Kraus: "Do you, now! Where have you been?"
Marge: "Well, we're going to France."
Dr. Kraus: "Really! How nice! It sounds like a cruise ship."
Marge: "Not really.{whispering} It's a submarine, but you can't tell anyone."
Dr. Kraus: {with curiosity} "How come?"
Marge: "Because they might throw me off!"
Dr. Kraus: "I see. What's it like for you traveling to all these places?"
Marge: "There's a group of us … my roommate … and a few more … and Nancy {one of her nursing assistants} … I like it."
Dr. Kraus: "That's terrific. It sounds like you're seeing that while you are sad our therapy is ending, you also see that you will have some good friends here with you after I am gone."
Marge: {Smiling and in a very calm and self-assured voice} "Yes, I will." 1

And so it was with Marge that I learned two very important lessons: 1) even with a mentally retarded, schizophrenic, aging nursing home patient with dementia, extraordinary things can be accomplished, and 2) the fears and discounting of her strengths that I imagined within her were really projections of my own.

Myth #3: Old people are staid in their ways; they are too stubborn to change.

In some of my geriatric workshops, I ask the audience what the four essential signs of aging are. Invariably, they will say things like grey hair, illness, and memory loss. Then I tell them my four: wisdom, confidence, character, and strength! I tell them that I threw them a little curve-ball, but they get the point that we often ignore or minimize the tremendous assets and capacities possessed by older adults. We overfocus on their liabilities and underrecognize their strengths. We miss how many competencies increase with age: appreciation, authenticity, desire to help, maturity, patience. Being stubborn can imply having mettle to take a stand and stick to it, and it is often quite effective for a psychotherapist to run with a resistance than to try to overcome it. It also occurs to me that to say that the elderly are staid may again say more about the patience, optimism, and confidence of those who serve them than anything else.

In Psychotherapy with the Elderly, psychologist George Bouklas offers an extraordinary account of a conversation with Errol, an 82-year-old patient of his with mild dementia, who entered a nursing facility for rehab following a colostomy. Errol never accepted his surgery, was constantly angry and agitated, and would routinely resist medical care. He was referred to Bouklas for ripping off his colostomy bag and spreading its contents across the room. He then would ask the staff what the fuss was all about! Here’s a powerful and provocative excerpt from their therapy:

Errol: (in an angry tone) "I stopped spreading shit on the floor.”
Bouklas: (silence)
Errol: "I told you, I stopped spreading shit on the floor! You act like that doesn’t matter! Well, does it matter to you?”
Bouklas: "Should it matter to me?”
Errol: "I thought you might be proud. The room doesn’t smell like shit anymore.”
Bouklas: "What’s wrong with the smell of shit?”
Errol: "You mean you liked it?”
Bouklas: “I like everything about you, no matter what it looks like, what it sounds like, or what it smells like.”
Errol: (now weeping) “You son of a bitch, if you’re lying to me I’ll kill you.”
Bouklas: “If I was lying to you I would deserve it.”2

Errol is typical of most elderly clients in that their stubbornness is a defense, albeit maladaptive—an indication that something more loathsome, more unacceptable, more humiliating may lie beneath. From my point of view, the word “staid” is an exemplar to some extent characterizing every psychotherapy client.

All clients resist—they all hold on to old patterns of thought and action. Resistance is the sin qua non of all psychotherapy, and it is no less true of the elderly. But when clients are unblocked, when resistance evaporates, psychotherapy with the elderly is an amazing thing. When we can help our clients abandon their defenses—even for just a moment—we create in the therapy a transcendent experience that elevates and inspires. It takes something special to really dare to live, and I feel privileged to witness them doing it. If we are open to our undeniable emotional connection to our clients, we can truly witness their transcendence—and it then emphatically becomes our own. With the elderly client, the metamorphosis is no less exalting, no less divine.

Growing old changes the way people relate to themselves and to others. The aged are often dealing with three principal issues: (1) how to adapt to the biggest transition of their lives—their changing health, the idea of getting older, and their changing family and work roles, (2) how to cope with the grief and loss that accompany their advancing age and decreasing abilities, and (3) how to manage their interpersonal relationships with others. As people advance in age, they go through an immense life transition—their role in their family changes, their view of themselves as a healthy person changes, and their sense of their own longevity and mortality changes. If kept silent or hidden, the feelings underlying these transitions often get acted out in disguised forms. Listening to and being there for the elderly client is invaluable to them not only because it makes available a problem-solving process that may ameliorate their distress, but also because it brings a heightened sense of connectedness and bonding with you. When this happens, they are not alone, and in that moment, neither are you.

Grief over family that's passed on, sadness over their sense of lost usefulness, loss of their former and more active pursuits that once gave them so much pleasure all make it more difficult for aging people to emotionally cope with their circumstances. Simply listening with supportive understanding and making meaningful emotional contact can bring them a sense of calm and solace. More than that, though, most of my older clients have the capacity for and can benefit from deeper emotional work. Not always are they aware they are engaged in such work, but my experience has been that it doesn’t really matter whether they are aware of it or not. It can go on, and they can reap the benefits of it nevertheless. Although the person's memory for recent events may be lacking, long-term memory, especially for well-learned actions, events, and knowledge, is one of the last cognitive abilities to decline. By helping them share something important and meaningful about their own lives, you bring into your here-and-now relationship with them the feelings of closeness they have experienced or longed to experience with others. In my view, this is so important in facilitating the growth process.

Geraldine was one of my depressed nursing home patients. Her Alzheimer's was at a moderate stage, and she could not remember my name to save her life. I met with her every week for months, and at every session she had trouble recognizing me. "Its Dr. Sparky," I would say. The social worker at the nursing home who introduced me to each of the residents there liked telling them my nickname, and that's how everybody soon started knowing me. When she would hear this, Geraldine's brow and eyelids would rise ever so slightly. "I'm your psychologist," I would say. I would prompt her recall with a verbal sketch of my role and why we were meeting. With this, you could begin to see her recognition building and she began feeling more at ease with me. I never really knew for sure that she actually was recognizing me, but it really didn’t matter, because she felt more comfortable with me.

As a rule, Geraldine's mood was irritable, she had a cynical view of the world, and she isolated herself excessively. Keeping to herself was a real problem for her, because she had begun to develop sores on her backside from lying in bed so much. When she wasn't in her bed, she was lying in her recliner. Her sores were becoming so severe that the medical staff felt they would soon threaten her life. Despite forgetting who I was and what we had talked about the week before, after a number of sessions together she began to learn that she could trust me. This is not learning that is taking place in the cerebral cortex but learning that new neuroscience research explains is occurring at a subcortical level. One thing was true—I enjoyed her sarcasm, and she could see that. I encouraged her to socialize more with others, to give others a second chance, but it was not my expertise or even my words that made a difference—it was her trust in me that eventually allowed her to risk taking my suggestions to heart.

You see, underneath her rough exterior, Geraldine really was a sweetheart. As she allowed herself to trust me, she learned that she just might be able to trust others as well. As she allowed others to know her, they began to see her sweetness, too, and as she socialized more, her depression began to lift, she spent less time in her bed and chair, and her sores began to heal.

Along with her physical healing, Geraldine experienced a significant emotional healing. Just how emotional healing occurs in therapy is still quite a mystery, but for Geraldine, it seemed to occur at a level that went well beyond what she could articulate in words or what she could remember. In this sense, her Alzheimer's did not prevent her emotional recovery. Her learning seemed to take place not within her cognitive self but as a consequence of how she felt about her relationship with me and, later, with others. Communication with her took place beyond words, beyond logic, beyond conscious thought.

“What I learned from Geraldine was that in psychotherapy, words are overrated—I learned that it is the relationship that can heal.” I have often mused about how insightful my interpretations were in a session and believed how it may have been my pithy comment that was a turning point in the therapy. That seems almost never to have been the case. When my clients recall their own turning points in therapy, it almost never has to do with anything I have said but almost always relates to something I have done or been for them. Being with them in their “staidness” may be the most effective thing I do with my older clients.

This type of healing occurs because an emotional reconciliation is reached within the aging client that has more to do with restored faith, with renewed hope, and with enhanced trust in the world, in themselves, and in their relationships with others than it has to do with cognitive functioning per se. Granted, cognitive decline generates fear, anger, suspiciousness, loss, and any number of other difficult and challenging emotional experiences—but the aging process impairs emotional functioning on a biological level only in its final stages. And that's why many people with Alzheimer's can be comforted and counseled, can feel support from others, and can reach a greater sense of peace with their experience. It's your empathy that eases their suffering. It's your empathy that cultivates their sense of joy in the life they might see they are blessed to be living and can give thanks to have lived.

How Clinicians Get Stuck: Some Emotional Risks in Working with the Aged

For several years, I led a biweekly consultation group with psychologists and master’s-level clinicians interested in learning from their own experience with their elderly clients. Some of what we discussed had to do with gerontology, cognition, testing, contracting, and the like, but much of what we discussed related to the emotional lives of the clinicians when they were with their clients.

Despite the growing evidence on the effectiveness of psychotherapy with the elderly—even with those who have dementia—psychotherapists underserve this population of clients. One of the reasons for this stems from how clinicians defend against the knowledge of their own physical and emotional mortality and the terror of their own vulnerability and dependency. I believe that this is especially true in psychotherapy with the dementia patient, where, in some form, the death of the cognitive self is confronted.

Another reason psychotherapists shy from involvement with older adults arises from the necessity for therapists to manage their own unresolved internal representations of parental and grandparental figures. Much has been written about how the older client sees a younger therapist as a younger (adult) child. When this occurs, the client needs to work through issues within the therapeutic relationship that mirror unresolved issues in the client’s relationship with his or her own children. Younger therapists, especially, can have a difficult time addressing an older client’s provocative comments like “You’re just a kid. What do you think you know about what I am going through?” In the reality of older adulthood—where the older client is increasingly dependent on younger caretakers—the unjustified but prejudicial attitude that older clients can develop toward their younger therapists can be exceptionally challenging.

It is generally understood that psychotherapy occurs within an intersubjective field—where the therapist and the client affects and is affected by the other. At some level, the therapist is always experiencing what is emanating from the client, and the client is always projecting into the therapist his or her needs, fantasies, and stereotypes. And the therapist cannot help but do the same. When skillfully observed, this can lay the groundwork for significant therapeutic gains. The therapy progresses when the therapist is aware of these processes and can use them to move the therapy forward. The less therapists are trained to do so, or the more they are hampered by their own complete internal resolution, the more likely that these processes will be acted out within the therapeutic relationship, and the less likely these processes will be therapeutically worked through. The less therapists are aware of their own projections, the more their idealized and devalued stereotypes of “old age” will unknowingly creep into the therapy, and the meaning they unknowingly assign to “old age” will color their relationships with their clients. Signifiers that should alert therapists that they may be developing distorted attitudes toward their clients are:

  • the assumption that an elderly client would not benefit from therapy,
  • the assumption that medication would be preferable to psychotherapy,
  • the attitude that a client may be too old, too stubborn, or too burdened to benefit from psychotherapy, and
  • prominent feelings of boredom, anxiety, or frustration when with a client.

In America, we honor the young for their beauty, strength, and vitality. However, in other places on the globe, old men and women are objects of veneration. This leads to a curious consequence: the less we acknowledge what can be respected, admired, or even venerated in the parents and grandparents of the world, the more we make ourselves orphans who lose a piece of our faith, security, and connection to a past that we risk repeating. This has been part of my joy in working with older adults: I am able to honor them, to sit at their feet, marvel, and learn. As their therapist, I have become their faithful student, their privileged witness, and my life is ever richer because of it.

Footnotes

1 Kraus, G. (2006). At wit's end: plain talk on Alzheimer's for families and clinicians. West Lafayette, IN: Purdue University Press.

2 Bouklas, G. (1997). Psychotherapy with the elderly: Becoming Methuselah’s echo.Lanham, MD: Rowman and Littlefield.

Esther Perel on Mating in Captivity

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Lori Schwanbeck: You are widely known around the world for your unique and thought-provoking stance on what makes marriage work. Can you tell us a little bit about your perspective and what makes it unique?
Esther Perel: I was originally trained in psychodynamic psychotherapy, but my real home for many years has been in family systems theory—I trained with Salvador Minuchin, and then in psychodrama, expressive arts therapies, and bioenergetics. And for many years, I worked extensively as a cross-cultural psychologist with couples and families in cultural transition, primarily refugees, internationals, and mixed marriages—interracial, interreligious, and intercultural couples.
LS: So you saw a lot of different people’s lives.
EP: Yes, I'm interested in difference. I'm interested in the relationship between the individual and the larger context, looking specifically at gender relations and childbearing practices. I then added my interest in sexuality, so that I'm now working at the intersection between culture, couples, and sexuality.

I also like to work with clinicians, be they physicians or mental health professionals, to promote the integration of sexuality within the couples therapy world, and to integrate relational thinking within the sexuality world.
LS: What do you think is missing in most clinicians’ approaches to working with sexuality and intimacy in the Western world?
EP: I just read a whole review article by Eli Coleman about sexuality training in medical schools, and it has undergone yet another major decline since 2010. We would have thought we were finally creating comprehensive training in sexuality for physicians, but we are not. So what is missing? First and foremost, for mental health professionals as well as for all health professionals, is training: the acknowledgment of sexual health as an integrated part of general mental and physical health. The vast majority of couples therapists have had no training in sexuality whatsoever—maybe an hour here and there. Couples therapy has become, over the years, a desexualized practice. Sex is the elephant in the room.
Couples therapy has become a desexualized practice. Sex is the elephant in the room.
Most therapists do not talk about it, don't know how to talk about it, and often wait for a couple to bring it up. And the couple themselves are often uncomfortable talking about it, so it remains the unaddressed subject, though it's often hardly insignificant.

A Better Sexual Relation

LS: You see our sexuality, our erotic life, as vital in the health of a couple.
EP: I see a couple's erotic life as an important dimension of their relationship because it is an integral part of the romantic ideal that is the dominant model of modern love. We took love and brought it to marriage or committed relationships. We then sexualized love. Then with the democratization of contraception, we liberated women from the mortal dangers that were associated with sex, and sex got separated from its sole reproduction function—as Anthony Giddens says, it became a reflexive project of the self, an ongoing process of self-definition. We have, for the first time in history, a sexuality within long-term relationships that isn't about having ten kids or a woman's marital duty, but that is rooted in desire, i.e., in the sovereign free will of individuals to engage sexually with their partners. And in the process, we have linked sexual satisfaction with marital happiness; that is what has made sexuality an important element of modern marriages.

I realized in writing Mating in Captivity that I was not interested only in sexuality, per se. And I certainly was not so interested in, "Are people having sex? How often? How hard? How many? How long? Are you a sexless couple because you have less than 11 sexual interactions a year?" and so forth. My interests lie not in the statistics of sex or the perfect performance industry that pervade our society.

Instead, I found I was really interested in what makes a couple feel a sense of aliveness, vibrancy, vitality—of Eros as a life force. When couples complain about the listlessness of their sex lives, they sometimes may want to have more sex, but they will always want a better sexual relation. And they will invoke the experience of renewal, of connectedness, of playfulness, of mystery, of regeneration, of power.

My distinction between sex and eroticism actually came out of my work in trauma. My husband directs the International Trauma Studies Program at Columbia, and he works a lot with torture survivors. I would wonder, "When do you know that you have reconnected with life after a traumatic experience?" It's when people are once again able to be creative and playful, to go back into the world and into the parts of them that invite discovery, exploration, and expansiveness—when they're once again able to claim the free elements of themselves and not only the security-oriented parts of themselves.

In the community of Holocaust concentration camp survivors in Antwerp, Belgium where I grew up, there were two groups: those who didn't die, and those who came back to life. And those who didn't die were people who lived tethered to the ground, afraid, untrusting. The world was dangerous, and pleasure was not an option. You cannot play, take risks, or be creative when you don't have a minimum of safety, because you need a level of unself-consciousness to be able to experience excitement and pleasure. Those who came back to life were those who understood eroticism as an antidote to death.
LS: That’s a very powerful statement. Do you find many couples that come to you dead in their relationships?
EP: Yes, but it's not always in their relationships. Sometimes they feel deadened inside of themselves as individuals.
I think that one of the prime motives for transgression is trying to beat back a feeling of deadness.
I think that one of the prime motives for transgression is trying to beat back a feeling of deadness. And the deadness isn't the fault of the other person at all. It may be a slow progression of an atrophy that has taken place inside themselves. I think that when people miss a sexual connection, there's often one partner who misses it more than the other. That longing, that yearning for that feeling of aliveness, of connection, of transcendence, of vitality, of energy, of rush is what people talk about. And on the other side of that, they will talk about feeling flat, feeling numb, feeling shut down, feeling dead.
LS: It sounds like you’re really talking about eroticism as an expression of libido, of life energy. How do you support couples in reinvigorating the passion in their lives?
EP: There’s a little exercise that I like to do, which I borrowed from the work of Gina Ogden. I ask the each partner in the couple to complete the statement, “I shut myself down when… I turn myself off when…”

We tend to talk about “what shuts me off” and “what turns me off”; we say, “You turn me off,” but we don’t often ask the question, “When do I turn myself off?” “I turn myself off when I look at an email just before going to bed. I turn myself off when I am disinterested in what you’re talking about. I turn myself off when I worry about the kids. I turn myself off when I remember my childhood.” What do I do to shut myself down? “I turn myself off when I don’t take time for myself.”
LS: It’s really about personal responsibility.
EP: That's exactly it. So the partners go back and forth, and they can come up with a list of 10 or 15 each. And then we come to, "I turn myself on when…I become alive when…"—not just sexually. Because if you're feeling dead, the other person can wear the nicest Victoria's Secret lingerie (and there is no Victor's Secret, you know), and it's not going to do anything because there's nobody at the reception desk.

Most of the time, in response to the "I turn myself on" question, people will say things like, "When I am with friends. When I go out dancing. When I take time in nature. When I take time for myself. When I've accomplished something that I'm proud of"—things that have to do with our sense of self-worth, our connection to meaning, and our sense of pleasure—things that make us feel alive.

Then you ask a person, "You tell me you like to dance. When's the last time you went to dance?" And if they tell you, "It's been months," or, "It's been years," then, before you start to work on anything connected to sexuality, you say to them, "I think it's high time you went dancing, since it seems to be something you really love to do."
LS: When you say that modern couples therapy has become a desexualized profession, it really sounds like you’re talking about more than just sex, but really about tracking and supporting aliveness in people.
EP: I think that there are a few forces that desexualize couples therapy today. One is the notion that sexual problems are the consequence of relational problems. Then it follows that, if you fix the relationship, the sex will follow. Therefore, if all sexual problems are relational problems of complicity, of intimacy, of communication, of trust, and all of that, then there are no sexual problems. So we don’t talk about sex because sex is just a consequence of something else.
LS: And you’re saying it stands alone as a phenomenon in a relationship.
EP: I don't think that sexuality is only a metaphor: "Tell me about the state of the union and I know by extension what happens in the bedroom." I think that sexuality is a parallel narrative. I think, in fact, that when you change a couple's sexual relationship, it has an effect on every other part of their lives.
When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core.
When you change people's relationships to their own sexual selves and their ability to connect with others, you have touched them at the core, because it's everything: mind, body, spirit, breath.

Love and desire both relate and conflict. Looking at the way people connect and their emotional history is very important, but it gets translated into the physicality of self, and then it inhabits its own narrative. They are parallel stories and they need to be looked at as such. So that's one.

Another element of the desexualization, which is, I would say, stronger here in the United States, is related to the fact that the focus over the last decades has been on security, attachment theory, the need for safety, and much less on the need for freedom, sovereignty, and self-determination. This is because we are working within a context that is among the more egalitarian contexts of the West, and one where people are often so individual and so alone that all the theories that have proliferated have been theories of connection. In the few decades before, they were all theories of individuation. It's like in art: you have one wave succeeding another. This is not a time when, in this country, people are very interested in investigating the need for freedom. That happens in environments where people are a lot more oppressed, and where they are overly connected in layers of extended family. That is not the dominant concern here, existentially or socially. And sexuality plays itself in both realms. You need a certain security for sex, for some people—not for everybody. But you certainly need a lot of freedom for sex.

Balancing Security and Freedom

LS: Tell us more about how that need for security and need for freedom can coexist.
EP: For me, the reference person is Stephen Mitchell, who in his work in Can Love Last? looked at how modern love and romanticism have brought us to try to reconcile within one relationship, within one person, fundamentally sets of opposing human needs.

In every epic story—in The Odyssey, for example—there is the home and the journey, the travel and the base. Today we want our needs for security, predictability, stability, reliability, dependability—all the anchoring, grounding elements of our lives—to be met in the same relationship with the person from whom we also expect adventure, novelty, mystery, and all of that. We still want what marriage always gave us, which was about economic support, companionship, family life, and social respectability, and on top of it, we want our partner to want us, to cherish us, to be our trusted confidant and our best friend. In effect, we are asking one person to give us what once an entire community used to provide.
LS: It’s a lot to ask for.
EP: We've never tried to experience both like that at that level in the history of human relationships. We also live twice as long—a hundred years ago, we died seven years after we were done raising children. So the longevity of what we expect from a monogamous, committed relationship is also unprecedented.

There is something about the enshrinement of the modern couple that has basically made it this hermetic unit where we have get all our needs met, rather than understand that there are certain things you're going to get from your sister, your aunt, your grandmother, your best friend, your colleague. I think that we can have multiple intimacies that are friendships and deep relationships with other people.

The model for me is really seeing the movement between freedom and security, which are the two pillars of development—connection and autonomy, independence and dependence. I think they are the two main pillars of growing up. And it is the same as any system. Every system needs to balance homeostasis and growth. It isn't just on an individual level. And every system regulates change and stability. So do individuals regulate connection and separateness.

The image that I often use in my work with couples is little kids: if everything is nice and going accordingly, you will have your child sit on your lap very cozy, nested, at ease, comfortable. And at some point, the child needs to jump out and go into the world to meet what are called the exploratory needs: freedom, independence, separateness, autonomy, all of that. If the little kid turns around, which kids always do, and looks to see what's going on with the adult, and the adult says, "Kiddo, the world's a beautiful place. Go for it. Enjoy it. I'm here," often the child will turn around and go further, and experience at the same time connection and independence, freedom and security. At some point, she has enough, and comes back to base and plops herself into your lap again, happily returning as an act of freedom to a place where she feels welcome because it offers security as well as the respect for freedom.

But if, on the other hand, the little child turns around and the adult says, "I need you. I'm alone. I miss you. I'm depressed. I'm anxious. I'm worried. What is so great out there? Why don't you want to be with me? My partner hasn't paid any attention to me"—any of the messages that basically say to the child, without ever saying it in words, "Come back"—then there are a number of dominant responses. One common one is that the child comes back, because we'll do anything not to lose the connection, since that's the primary need.

But we will sometimes lose a part of ourselves in order not to lose the other. We will forgo our need for freedom and space and separateness in order not to lose the other and the connection. And we will learn a way of loving that will have a certain excess emotional burden, responsibility, worry, that is beyond the normal elements of love that have to do with mutuality, reciprocity, care, and responsibility—so much so that once I love you, I can no longer leave you enough to be able to experience the freedom and the unself-consciousness that are necessary for sexual excitement and sexual pleasure. The adult makes that motion into sex: the ability to be inside myself while I am with another. If, when I am with another, I have to leave myself, stay outside of myself, basically, I can't even culminate. Physiologically, we cannot come if we don't have a moment where we can be completely with ourselves and inside ourselves in the presence of another.
LS: So it’s really holding that dialectic of being both within yourself while also connected.
EP: Yes. But when you talk about intimacy, you need attachment as a precondition for connection. In the realm of desire, separateness is a precondition for connection.
Love needs closeness. Desire needs space.
Love needs closeness. Desire needs space.
LS: Could you give us a practical example from a couple that you’ve worked with of how someone can have both connection and separateness? And what does separateness mean within a relationship?
EP: Imagine the person says, "I turn myself on when I go to the movies alone." Not sexually, right? "I come to life. I connect to my desires in the realm of pleasure"—that broad sense of the word "sex."
Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter.
Sex isn't something you do. It's a place you go, inside yourself and with another or others. It's a space you enter. I work in the erotic space, if you want. It's not an act. People have had sex for generations and felt nothing. I am not into promoting people having sex, but having a certain relationship with a certain dimension of your life.

So, if they say, "I like to go to the movies," then the next question will be, "Do you go?" And you will listen to the degree to which they tell you, "It's hard for me to leave," or, "It's hard for my partner when I leave," or, "No, it's just a matter of circumstances. Lately, I haven't had a chance to go, but it's never been an issue for me," or, "When I come back, I'm always worried." The third child I didn't describe is the one who does go, but is constantly looking over his shoulder, making sure that the adult here isn't going to punish him, reject him, become depressed, or collapse on him when he returns.

So the person says, "I don't go often to the movies alone, or listen to music, or play my music for that matter"—or whatever it is—"because when I come home, I experience that anxiety, that knot in my stomach that I'm not going to be told, 'How was it? How wonderful,' or I'm not going to be told, 'Stay out as long as you want. Everything's fine. Enjoy yourself.' I'm going to be told when I leave, 'Again you have to go? When are you coming back? Why are you staying out so late? Why do you not want to go with me?' I'm going to hear comments that basically say, 'Give up your freedom so that I can feel secure.'"

That is a classic transaction in the couple, versus, "I'm happy for whatever it is that you are experiencing elsewhere, even when it has nothing to do with me, because you bring this back, and that makes you a more interesting and alive person that maintains a certain vitality between us."
LS: If we use attachment language, it sounds like you’re trying to cultivate secure attachment.
EP: Yes, and a secure attachment for me isn't a singular experience: there is not always just one person to whom we turn. And I think it's a difference in culture. There are loads of places in the world that are more likely to think that your partner is the person with whom you experience parts of your life, while friends and family provide the existence of multiple safe harbors.
LS: So secure attachment for you is about feeling securely attached in the world, in your life, but not exclusively attached to one person. That’s a big difference.
EP: Right. The enshrinement of the modern couple is connected to the exclusiveness. I don't think we are more insecure today than we were before, but I think
We bring all our security needs to one person, and then we blame them for whatever is missing in our lives.
we bring all our security needs to one person, and then we blame them for whatever is missing in our lives. God forbid you have conversations with others that you should be having with your partner, because that becomes an emotional infidelity. The system is rigged with injunctions against leaving the relationship in any way possible—not just in sexual terms.

A Vibrant Field Has Multiple Voices

LS: How are you finding your ideas are holding up in our Western culture? Are other therapists embracing them, or is there a push back that you’re finding when you teach?
EP: I think that a vibrant field is a field that has multiple voices. When I wrote my book, it wasn't written for professionals. I did not think that it was going to become one of those voices—that it would be embraced in the couples and sexuality fields, as it has by some. I'm happy that it is one of the many voices. One of the things that you get when you work cross-culturally, as I do, is that every time you hear a truth in one place, you know that another place is thinking of it completely differently. The pacifier, the baby's bed, the baby's crying don't mean the same thing in every culture. And it's very refreshing to be located in a much more multicultural, nuanced, nonjudgmental, relative way of thinking. It works for me.

I think that there are people who have difficulty with what I talk about, and there are people who find a tremendous sense of affirmation in what I talk about—this is how they have been thinking, and they've been looking for that approach. I'm glad to be part of the conversation, and I'm glad to be a stimulant in the conversation.
LS: You're certainly that, and it is very refreshing. It's almost like you're bringing that multicultural perspective of relationships into a multicultural perspective of how to do therapy, as well—how to hold and look at a relationship and embrace different perspectives
EP: I think that romanticism has appeared in every part of the world, even in very traditional cultures. And wherever romanticism has appeared, people are investing more in love than ever before, and divorcing more in the name of love—or the disillusions of love—than ever before. And
I think that wherever romanticism has appeared, there's a crisis of desire.
I think that wherever romanticism has appeared, there's a crisis of desire.

Originally, I wrote my book from the perspective of a European therapist observing American sexuality. I started the original article during the Clinton and Lewinsky scandal because I was very intrigued as to why this society was so tolerant towards divorce—you can divorce three, four times without much stigma these days—but it was very intransigent towards any transgression or infidelity, whereas the more traditional family-oriented world had always compromised towards infidelity (a burden carried primarily by women, I should add), in the name of preserving the family, and separated the well-being of the couple from the well-being of the family.

I had no idea that I would be going to 20 countries on book tour. In the process, I began to realize that a crisis of desire was nothing unique to this country. It is really part of the romantic model and the changing meanings of sexuality in modern committed relationship.

But there are some unique features to this culture that have to do certainly with its relationship to sexuality. First, it's a society that often relates to sexuality as smut or sanctimony, titillation on the one side, and condemnation on the other side. It vacillates between extremes.

Second, it's a society that has certain views about transparency, and about transparency as essential to intimacy: wholesale sharing, telling it all, being explicit, not beating around the bush. I think that this is a society that looks at honesty from the point of view of a confession. Minimal tolerance for ambiguity and the imponderables is what makes American business great, but it's not necessarily what other cultures bring into the private sphere.

Keeping Secrets

LS: You’re saying that the emphasis on complete transparency and honesty actually gets in the way of creating a vital relationship?
EP: I think that one should know that, while it is obvious in some cultures, like here, that if I can tell you everything then we are closer, there are other cultures—sometimes your own neighbors—who actually think that the ability to maintain privacy is what enhances intimacy, and not necessarily transparency.
LS: It’s a big difference.
EP: It’s a difference. And I think each one evolves in its own context. But it’s very refreshing to know that there is a whole other way of looking and thinking out there that totally throws off what you take for granted. Working in New York City, I get people from 15 countries coming into my office. I practice in many languages. I cannot assume that that a couple who came at nine o’clock and wants to tell each other everything is the same as the couple who comes at ten o’clock with a completely different notion of boundaries, individual space, the mandate for sharing, the hegemony of the word as a form of intimacy, gender structures, power dynamics, and so forth.
LS: The policy of not keeping secrets within the couple is also widely held among therapists here. I’m wondering if you have a different perspective. As a therapist, do you have the same policy that many therapists have of not holding secrets?
EP: There is a clear hierarchy of secrets. There is only one particular secret that therapists really grapple with in terms of credibility, ethics, and mode of working. If you tell your therapist that you have had a miserable sexual relationship with your partner for years, that you’ve been faking it forever, that you can’t stand his smell, or her looks, or whatever it is, you rarely will hear a therapist say, “Either you need to tell your spouse, or you have to go to individual therapy.” That’s also a big sexual secret. I cannot imagine a partner one day after 27 years finding out that their wife or their husband has been lying and faking to them all these years. They’d be no less crushed. But somehow that one doesn’t do it. It is really any one of the secrets in the range of the infidelity spectrum. And even if you raided your bank account, a therapist would not usually say, “If you don’t tell, I can’t start working with you.”
LS: So you have more of a subjective stance to the issue of whether or not full transparency between your clients is ultimately serving them.
EP: I think it needs to be examined. Sometimes it's dangerous. In the field of infidelity, I would align myself very much with the work of Janis Spring, Michele Scheinkman, Tammy Nelson, or Stephen Levine, who are examining the concept of keeping a secret. Today, in the first session with any couple, I will say, "I will see you as sometimes together and sometimes apart—I don't know how much of each. When I will meet you apart, it's because I think that there's certain conversations that may be better held alone, because you will be less defensive. You will take more responsibility. You will be more able to examine yourself quietly. You won't be in the reactive stance. And those will be confidential conversations, which means that each of you will probably tell me things that your partner may not know. And you will decide at what point you want to share that."

I'm often asked, "What do I do with the secret of infidelity?" I sit with it, because sometimes the secret is the therapy. Or, as Janis Spring says, "Giving up on the secret is the therapy." Then the question is, is revelation mandatory? It is often seen as mandatory here. The concept that intimacy needs to be rebuilt through transparency and revelation doesn't take into account that for some people, revelation may be more traumatic, which then is answered by other people who say, "But, somehow experiencing the trauma is part of rebuilding the relationship." But that's one view.

So I work with secrets. If I agree to work with the couple, I take the couple as it comes to me. It's not for me to decide what risks people need to take in terms of revealing their secrets. There are major power imbalances in society—major risks involved for women to reveal certain secrets, for instance. I very carefully assess with them what is safe. I've learned that when I go to Cuba, Mexico, and other places, I can't just take transparency as a norm without looking at the political and social implications of gender politics. In that sense, the dominant theories and trends du jour are not as contextual as systemic thinking used to be.
LS: What advice would you give to therapists in looking at their own erotic lives, in terms of how that’s going to affect the way they show up with clients?
EP: There are two levels: the professional and the personal. On the professional level, I think you want to continue to learn, renew yourself, grow. I think it's particularly important for experienced therapists to not stop growing, to not stop listening to other people.

Every time I go to a workshop or a conference, I know that I work differently the week that follows. I am filled up. I am renewed. I'm trying out new things, stepping outside of my own comfort zone. Every time I go and I lecture some place, I ask people, "Has my work grown? Has it changed? Have the ideas matured? I hope I'm not repeating the same thing." At this moment in my work, I have made new choices, different choices than the ones I certainly was trained with—or indoctrinated with, we could say, because they were never questioned.

I also think that it's very important for me, anyway, as a therapist, to read anthropology, history, poetry. The arts are a lot more able to deal with the complexities of love, sex, desire, and transgression than psychotherapy is. The greatest novels, movies, and poems capture the complexities and the contradictions of our life. I strive towards the embrace of the contradictions, or the dialectic, and not necessarily towards the dogma. I tend to work more on the side of art than on the side of science. And to work in the realm of art is to work with the unknown, rather than to want to simplify the known and to make it predictable and organized. I don't have a set model in that sense.

Maybe what people have appreciated about my work is the fact that I am questioning our assumptions. I really don't think I have the truth on things, even though I sometimes sound very confident. But I am willing to ask myself, "Is this the only way? And who says? And must it be this way? And for whom?" The people who come to study with me do so because I'm out of the box, not because they're going to get a nicely structured framework. There are a lot of other important elements to couples' lives, but it happens to be that this existential dimension is the one I have become very interested in. So I write about that.

And personally, make sure you stay alive. Make sure you stay in touch with your own experience of pleasure, of receiving, of giving, of sexuality, of your body. Don't disconnect, or you will bring that into your work, and it doesn't benefit anybody.

Assessing Partner Abuse in Couples Therapy

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Mark and Julie were in their late thirties, and had been married for seven years after living together for three. During their initial session with me, they expressed concern that they had been drifting apart over the past year. They were both under considerable stress. Julie’s planned six-month leave of absence from her job following the birth of their son Brandon had now lasted four years. Brandon required lots of Julie’s time: he was highly impulsive, displayed frequent temper tantrums, and recently bit another child at daycare. Mark supported the family as a salesman for a medical equipment firm, but getting along without Julie’s income meant longer hours and more frequent travel.

“We hardly ever have time for each other anymore,” said Mark. “And I’m out of town so often these days that it’s hard for us to readjust when I get home. Julie is always preoccupied, either with Brandon or something else, and our relationship isn’t a priority for her the way it used to be.”

“We don’t communicate well,” added Julie. “We argue about parenting Brandon, about my housekeeping, about Mark’s being gone so much of the time . . .”

“There’s an example of one of our problems,” Mark interrupted. “ I don’t feel like she appreciates how hard I work to support us. Traveling on business is no picnic, I can tell you. I miss being home with my wife and kid.”

To most outward appearances, this was a couple caught in the typical dilemmas of our age: how to balance work and home life, how to be both parents and intimate partners, how to get one’s own needs met while meeting the needs of the other.

Mark and Julie had been in conjoint therapy twice before; each stint had lasted about one and a half years. Their first therapist, they told me, helped them understand how their relationship replicated themes from childhood. A couple of years later, when their arguments grew more frequent, they decided to try a new therapist. Mark liked their new therapist’s pragmatic approach and appreciated learning how to make “I statements” and practicing reflective listening. Mark felt that he had finally gotten through to Julie about his concerns. Julie agreed that the therapy had been helpful, but wasn’t willing to continue because there was too much focus on Mark’s concerns and not enough on hers.

When I asked Mark and Julie how they argued, they reported that Mark frequently raised issues in an angry way. Julie would withdraw, and Mark would press for resolution. She sometimes burst into tears during these encounters, and he saw this as her way to avoid addressing his concerns. Yet they both reported that their arguments “never get physical.”

Over the next few sessions, I gave Mark and Julie typical homework assignments. We discussed taking time-outs when their interactions grew too heated. We reviewed and practiced reflective listening skills. They voiced an appreciation about each other every day. And despite difficulty finding a babysitter who could handle Brandon, they managed to schedule two “date nights” over the next two weeks.

I did not yet realize it yet, but I was making the same error as their two previous therapists: I was attempting to do couples therapy with an abusive relationship.

Obligation to Assess

Many therapists, including those of us with extensive clinical experience, frequently plunge into doing therapy before we have adequately assessed whom and what we are treating. It is in the nature of the therapist-client relationship that we cannot know the whole story from the outset. Our clients may be lost, confused, withholding, or in denial. They aren’t ready to divulge everything at a first session (and if they were, we would probably wonder why). In the cause of establishing a working alliance, we leave avenues of assessment unexplored until a more opportune moment. Assessment and treatment necessarily walk hand in hand as the ongoing process of discovery and healing unfolds.

However, none of this relieves us of the ethical and professional obligation to carefully assess factors that may undermine treatment. “Sometimes we collude with our clients’ denial systems, deliver services that are misdirected or even harmful, and allow problems to get worse, under the guise of providing treatment.” Meanwhile, our clients continue to believe they are getting help, and we continue to collect our fees. Whether the undiagnosed problem is addiction, bipolar illness, domestic violence, or some other weighty issue, part of our job is to make educated guesses and follow up on them.

One error I encounter with troubling frequency is the failure of couples therapists to assess adequately for partner abuse. By partner abuse, I mean the use of force, intimidation, or manipulation—or the threat to use any of those methods—to control, hurt, or frighten an intimate partner. Note that the definition can be met even if no physical violence is involved. Verbal and psychological tactics are more common; frequently, they are also more effective at controlling, hurting, or frightening another, and they can be more emotionally damaging in the long run.

I have met with couples whose seasoned therapists, over the course of several years’ treatment, missed the extent and severity of the physical and emotional abuse taking place at home. We might be tempted to believe that clients bear some responsibility for staying silent on the issue (whether out of fear or outright denial), but the obligation to assess rests firmly on our shoulders. For example, an abused partner may feel unsafe bringing up abuse in the presence of the other because of likely retaliation, yet many therapists have a policy of never meeting separately with one member of a couple they are treating jointly.

Regardless of the reason for the assessment failure, the tragic result can be months or years of continued abuse. “Suffering” is a pallid word to describe the soul-damaging, spirit-deadening impact of ongoing abuse on the abused partner and the children who live with it. The corrosive nature of some abuse leads to an erosion of the self that can be extremely difficult to reverse. The effects are cumulative and must stop before healing can begin. Additionally, abuse generally grows worse without intervention. Meanwhile, clients incur a sizable expenditure of time and money, and the therapist (and, by extension, our profession) loses credibility.

Common Misconceptions

Several common misconceptions hamper or prevent an adequate assessment of partner abuse.

“The couple report that they yell at each other, so they both contribute to the problem.”
Loud arguments should always suggest the possibility of partner abuse. Most abusive relationships involve some angry behavior by both parties; some involve mutually abusive behavior as well, although the degree of fear is generally much greater for one partner than the other. While both partners are responsible for their own behavior, one of them probably contributes disproportionately to the abuse.

“I spoke to them about partner abuse and they deny it is going on.”
As therapists, we know better than to accept clients’ analyses of their difficulties and to probe more deeply. “If an angry client reports that he believes in firm discipline but would never abuse his children, do we simply take his word for it?”

“It is my policy never to meet individually with clients I see in couples therapy.”
Adequate assessment for abuse cannot be accomplished with both partners in the room. Asking directly about abuse in a conjoint session puts the abused partner in a no-win position: to disclose and risk reprisal, or to deny and thereby avoid getting needed assistance.

“I have a ‘no secrets’ policy, so clients know that anything they share with me individually will be brought into the couples session.”
In my view, such a policy is designed to relieve the therapist’s anxiety and hinders rather than helps the client. As therapists, we often learn things we cannot or choose not to divulge. Holding some information in confidence is a small price to pay if it allows us to leverage our clients into the right form of treatment.

“Even if there is undiagnosed partner abuse, I’m helping them resolve the underlying relationship dynamic.”
By its very nature, abusive behavior prevents the resolution of other issues. Abuse skews the relationship dynamic and leaves most of the power and control in one partner’s hands.

“I can teach them better communication skills until they trust me enough to disclose the issues they are withholding.”
Abusive partners easily subvert communication skills at home. “I” statements are meaningless if the intent is to hurt, control, or manipulate.

“I’m not taking a stand on the issue because I’m afraid the abusive partner will bolt from treatment.”
Again, the delusion here is that some treatment is better than none. What is needed is a referral to appropriate treatment, rather than maintaining the fiction that the couple is getting help while the abuse continues.

An Abusive Dynamic

At their next session, Mark and Julie reported that their second planned date night had started out well. They ate dinner at a quiet restaurant, reminisced affectionately about the first time they met, and held hands as they shared a frozen yogurt. Brandon was asleep when they got home, even though it was still relatively early. When they went to bed, Mark anticipated they would make love; Julie was tired and just wanted to curl up and go to sleep. Mark persisted, saying that this was the only chance they’d had for sex in a while so they’d better take advantage of it. Julie said she was tired of his “guilt trips.” He said she was frigid and accused her of withholding sex to punish him.

They had carried on late into the night as the argument broadened to include many other areas of disagreement. The conflict continued in my office the next evening.

” . . . And I appreciate how hard he works to support us,” Julie was saying. “But when he gets back from a business trip, he’s constantly finding fault with the way I keep the house, the things I wasn’t able to get to. He thinks I’m too soft with Brandon and that’s why he’s been acting up at daycare. It’s true that I could do a lot better job of housecleaning, and I paid the credit card late last month. My hands are so full with Brandon that everything else seems to take second place. I know I need to get better at setting priorities, like Mark says, but I feel like I’m doing the best I can and I wish he appreciated how hard my job is.”

Mark was restless but listened quietly while Julie spoke. When it was his turn, he spoke quickly, with increasing agitation and volume.

“She talks about not being appreciated. Well, she doesn’t do a very good job of appreciating me. I work really hard to support us at this level, and you’d think I could at least come home to a house that didn’t look like a bomb hit it. And Brandon is out of control because she doesn’t know how to set limits with him. He never acts up with me the way he does with her. Plus, she has the entire day to spend at home and take care of the things I can’t get to because I’m out of town. Brandon’s in daycare now, and she has so much free time to get together with her girlfriends for coffee . . .”

“Now, wait just a minute!” said Julie angrily. “That only started a couple of weeks ago!”

“No, you wait a minute!” replied Mark in a louder voice. “I don’t appreciate your angry tone, and I didn’t interrupt you when you were talking. I’d appreciate it if you could show me the same respect!”

“It’s hard to sit still while you misrepresent things,” she said petulantly, slumping in her chair.

“There you go again. When I give my point of view, I’m misrepresenting things. “ He turned to me. “You see how this goes. She never seems to respect my opinion. Everything I say, she counters it.” He raised his voice. “She treats me like she doesn’t even like me anymore! Ever since Brandon came along, our sex life has gone out the window. She always has something else on her mind, or she’s too tired, or I don’t know what.”

“Maybe if you treated me with more respect, I’d feel more like getting close to you,” Julie replied softly.

“See, there you go again. It’s always my fault!” said Mark. “We disagree on so many things, I’m really not sure what’s keeping us together anymore!”

There was a pause. Mark’s face grew darker and his brow furrowed as he spoke. The skin around Julie’s temples grew taut and her shoulders sagged.

“Tell me, is this kind of how things go at home?” I asked. “You start to talk about an issue, and things escalate? Mark, you seem angry and frustrated, and Julie, you seem angry and resigned. I can see that there are a number of issues on the table. But I’m wondering if I’m getting to see how your efforts at communication get off track. Is this how things go when they don’t go well?”

They answered simultaneously. “Pretty much,” said Mark. “This is mild by comparison,” said Julie.

“So what would typically happen at this point?” I asked.

“Mark usually kicks something, then leaves the room,” said Julie, hands crossed over her chest.

“Oh, really? What about you turning on the water works, then giving me the cold shoulder and playing the Ice Queen for three days?” said Mark, pointing his finger at her. “You left that part out. As usual!”

“OK, hold on a moment, both of you,” I said. With ten minutes left in the session, I felt the need to intervene, based on the growing escalation, the content and tone of the communication, and Mark’s increasing impulsiveness. I also feared that their disagreements were severe enough that continuing to talk about them would result in yet another argument as they left my office.

“There’s been a lot of heat expressed in this office today, and I’d like you both to cool off before you leave. I want you both to take a few nice deep breaths, s-l-o-w-l-y. Good. I want you to drop this argument, and I want you to agree not to talk anymore about these issues today.” We spent a few minutes addressing the difficulties they might experience in keeping to this agreement.

It was now clear to me that this couple was caught in an abusive dynamic. Mark had initially given the impression that he was listening to Julie, but he shifted restlessly as she spoke; when she finished, he responded quickly with an increasingly angry and critical tone. He blamed her for their problems and employed various strategies—such as exaggeration, distortion, and counterattack—to deflect any suggestion that he might also bear some responsibility for their difficulties. When Julie attempted to correct his misrepresentation of her coffee dates, he turned the tables by attacking her for the interruption and accused her of having less respect for him than he had for her. Mark felt free to express his anger but could not tolerate Julie expressing hers. He accused her of employing the very tactics he used (for example, “Everything I say, she counters it”). Mark demeaned Julie for the upset feelings she experienced following his angry outbursts and her subsequent need to pull away.

By contrast, Julie recognized some of her contributions and validated many of Mark’s concerns. Her brief efforts to defend herself were quickly overwhelmed by Mark’s responses. Her petulant tone and slumped posture were signs of defeat.

Indicators of Partner Abuse

Like Mark and Julie, clients in abusive relationships present with typical complaints: “We don’t know how to communicate with each other.” “We’ve been arguing a lot.” “We’re both under a lot of stress.” “We’ve needed counseling for a long time and he/she finally agreed.” “We disagree about disciplining the children.” Usually, their level of intimacy has declined.

More telling indicators are embedded in the relational dynamic that emerges in the consulting room. There may be unexplained tension in the room; certain topics appear to be off limits. “There may be a marked difference in the way and the degree to which each partner participates in the session.” The abusive partner may always start the session or, alternatively, always make the abused partner begin. One partner may be highly critical and judgmental, or exercise control through silence, intimidation, and manipulation. The other may speak hesitantly and haltingly—or, alternatively, may be hostile, resentful, and angry, seemingly out of proportion to the subject under discussion.

They may disagree on basic facts and have widely divergent views of the same events. Frequently, both partners are highly defensive and misconstrue what the other says, as though looking for an opportunity to act angry or hurt. They report or exhibit destructive communication patterns, such as escalation, invalidation, or a demanding/withdrawing dynamic. Impulse control may be poor. Problem-solving and conflict resolution skills are lacking.

Any of these symptoms are sufficient to raise suspicions of partner abuse. Alternatively, many abusive relationships present as typical relationships with occasional heated arguments that both parties have come to see as the necessary though undesirable price of an intimate partnership.

Assessment Protocol

When a couple comes to see me specifically because of my expertise in treating partner abuse, I typically employ a four-session protocol. I meet once with the couple, once separately with each partner, and then once more with the couple (or twice, if I need to gather further information or test hypotheses) to deliver my recommendations.

Alternatively, a couple like Mark and Julie may come to see me because they’re having difficulties and have decided to try therapy, and I might not begin to suspect partner abuse until they have seen me a few times. When I recognized the abusive dynamic in Mark and Julie’s relationship, I said to them:

“I think it would be helpful for me to set up an individual appointment with each of you so that you can share your concerns without having to worry about the other person’s reactions. I frequently do this in couples therapy, and given the volatility of today’s session, now seems like a good time.”

With an even more highly volatile couple, I might say something as innocuous as:

“During the last several sessions, I’ve had a chance to see how you interact with each other. As part of our work together, and in order to get to know you better, I’d like to schedule an individual appointment with each of you. I want to find out more about you, your childhood, family history—that sort of thing.”

I wait until the individual sessions to address the issue of confidentiality and “secrets.” With Mark and Julie, I began their separate sessions this way:

“This is a rare opportunity to get together with you, and I’m wondering if there’s anything you’d like me to know that you’re not comfortable saying with your partner in the room? If it’s something you want to tell me in confidence, I can keep it to myself. If it’s something I think would be helpful to discuss in a joint session, I’ll let you know that today, but I won’t disclose anything you don’t want me to.”

I also tell each partner that I would like to ask a series of questions about the kinds of behaviors that have occurred in their relationship. With the abusive partner, I am especially interested to learn whether similar behavior has occurred in any previous relationships, because it counters the common belief that the current partner is in some way responsible for the abuse. For this purpose, I use my own Abusive Behavior Inventory, an abridged version of which is included at the end of this article. I frequently supplement the specific questions on the inventory by inquiring about the first, last, and worst conflicts the couple has had.

Choice of Assessment Tools

To develop the Abusive Behavior Inventory, I spent one dreary weekend reflecting on all the variations of spousal abuse I had encountered during several years’ clinical experience and incorporated them with similar questionnaires employed at two agencies where I worked. I also referred to Patricia Evans’s The Verbally Abusive Relationship: How to Recognize It and How to Respond (Bob Adams, Inc., 1992) and Ann Jones and Susan Schechter’s When Love Goes Wrong: What to Do When You Can’t Do Anything Right (Harper Collins, 1992). An instrument similar to mine is R. M. Tolman’s Psychological Maltreatment Inventory (see “The development of a measure of psychological maltreatment of women by their male partners,” Violence and Victims 4 (3): 159B177, 1989).

I do not employ the self-administered Conflict Tactics Scale, developed and revised by noted researchers Murray Straus, Richard Gelles, and Susan Steinmetz. Despite broad acceptance as a research tool, it has numerous shortcomings in a clinical setting. For example, it measures violence only during the preceding 12 months, even though just one violent incident from many years ago may still be casting a shadow over the relationship. It does not ask whether the violence occurred in self-defense. And it equates acts that are inherently unequal due to men’s generally greater physical size and strength and women’s generally greater level of fear that men’s anger will erupt into abuse.

Using the Abusive Behavior Inventory in the individual interview allows me to uncover whether a pattern of abusive or controlling behaviors exists. This is accomplished best in the context of a clinical interview, for two principal reasons. First, clients provide much more information—factual, psychological, and emotional—than they would with a self-administered questionnaire. Second, clients may be so disturbed by their answers that they need an opportunity to process their reactions.

Comparing their answers side by side is an exceptionally useful diagnostic tool. Couples who corroborate each other’s answers generally exhibit greater awareness of problems in their relationships and are more often motivated to do something about them.

Suspicions Confirmed

As I suspected, my individual meetings with Mark and Julie revealed a long-standing pattern of moderate partner abuse. Despite their earlier contention that their arguments “never get physical,” on several occasions Mark had prevented Julie from leaving the room during an argument by standing in the doorway. Once or twice, he had slapped her shoulder as she walked away. He had grabbed her wrist a few times, in one instance hard enough to leave a bruise. He had also thrown several television remote controls and a cell phone when angry, and he frequently punched walls and slammed doors.

Mark sometimes used what he had learned in couples therapy against Julie: for example, by couching frequent critical and demeaning comments using a distorted version of an “I” statement, or by asserting that she was projecting her father onto him. When Julie raised a sensitive subject, Mark frequently got angry, yelled in her face, declared a time-out, stomped out of the room, and never returned to the issue.

Julie reported that her self-confidence had plummeted over the past few years, and she was feeling helpless and hopeless about her marriage. She said Mark had little sympathy for the chilling effect his behavior had on her libido and often criticized her for her infrequent interest in making love.

Recommendations for Treatment

When Mark, Julie, and I came together following my individual sessions with each of them, my recommendations went something like this:

“I have some thoughts about your therapy and where we go from here. We’ve discussed the issues and difficulties you experience together. For example, neither of you feels adequately appreciated, and you both report difficulty getting the other person to recognize and meet your needs. You’re both pretty good about identifying each other’s shortcomings but not so good about identifying your own. And it’s hard for you, even with me in the room, to discuss sensitive issues without getting into a heated argument.

“I think it’s clear to all of us that the two of you need couples therapy. But I think it’s premature at this point. It’s really just a matter of timing. You’re going to be spinning your wheels until you both have a chance to address your own issues. Then you’ll be able to take advantage of what couples therapy has to offer.”

In recommending separate treatment, there is a risk that the abusive partner will accuse the abused partner of having disclosed sensitive or confidential information that led to the recommendation. To minimize that risk, I cite only the behavior I observed or heard about in meeting with the two of them together when explaining my recommendation. If the abusive partner has acknowledged any abusive behavior—and it is extremely rare for the Abusive Behavior Inventory to bring no abusive behavior to light—I will refer to that as well.

In his individual session, Mark confessed that he had grabbed Julie’s arm once and frequently got so angry that he hit things. He also expressed remorse about it and a desire to change. So I added:

“And I appreciate your forthrightness, Mark, in acknowledging that you grabbed Julie’s arm and you don’t like the way you act when you get angry. That’s definitely something I can help you with.”

In the typical abusive heterosexual relationship, I generally refer the man to a men’s group with a focus on partner abuse (one of my own groups, or a colleague’s). I refer his partner to a group for women in abusive relationships. Other options include individual therapy with a therapist who has experience treating partner abuse, and group therapy for abusive women. I generally refer men who are being abused to individual therapy, since groups for this population are rare.

It is important to be resolute about my recommendations prior to the final assessment session so that I keep to them, whether or not the couple finds them acceptable. One or both partners will sometimes attempt to mount a persuasive argument for being seen together, and occasionally one of them will insist on having therapy together or not at all. My express purpose is to send a clear and unwavering message at this stage of treatment that couples therapy is premature—just as I would regarding family therapy with a parent who currently abused the children or who was an active alcoholic.

Arguments for and against conjoint treatment in cases of partner abuse are often heated and polarized among treatment professionals, in a process that runs parallel to the typical dynamics in an abusive relationship. By training and experience, I believe in the paramount importance of holding the abusive partner (or partners) accountable for his or her actions, regardless of what the other partner says or does. In abusive relationships, couples therapy undermines this goal by communicating, either overtly or by implication, that both partners bear some responsibility for the abuse.

There are practical considerations as well. Abusive couples who leave a session with unresolved issues are more likely to erupt afterwards. (I know, because many years ago I heard them yelling outside my office or pealing out in separate cars!) Additionally, conjoint therapy is generally not productive when control issues distort the therapeutic process or when either party fears serious repercussions for speaking the truth.

When is Couples Therapy Indicated?

Before I would consider treating an abusive couple together, they would have to meet several conditions.

  1. Their answers to the Abusive Behavior Inventory match closely.
  2. Past abuse was moderate to mild; currently, abuse is extremely mild or entirely absent.
  3. The couple can adhere to a contract of no further abuse.
  4. The abused partner is safe, unafraid, and able to mobilize resources if needed.
  5. Both partners are motivated for treatment out of a sincere desire to grow and change.
  6. Both partners are willing to be accountable for their behavior, without blaming the other.
  7. The couple can use basic communication skills in a non-manipulative manner.

In short, couples therapy is appropriate when the dynamics of the relationship, not the abuse, is the proper focus of treatment.

I presented Mark and Julie with two choices. They could each seek treatment with other professionals and keep me in reserve as their couples therapist at some future date. Or I could take Mark into one of my men’s groups, refer Julie to another therapist, and help them find a new couples therapist when Julie’s therapist and I thought they were ready. Mark’s reluctance to join a group, much less one led by a different therapist, led us to conclude that the second option was preferable.

Over the next three years, Mark and Julie both participated in group therapy supplemented by short bouts of individual work. I consulted regularly with Julie’s therapist to coordinate our treatment efforts, and we met together with the two of them from time to time to coach the couple through especially difficult logjams. Once Mark had achieved more than six months of abuse-free behavior, he and Julie began working with a seasoned marriage therapist who understood the dynamics of abuse. Julie ended her group work, but Mark remained for another six months because he had discovered that being accountable to other men helped ensure his continued recovery.

Conclusion

Treating partner abuse is a specialized field. Trainings in recognizing and treating the problem are helpful, but the only way to develop real expertise is through direct experience. To that end, I recommend that you become familiar with an assessment tool like the Abusive Behavior Inventory and practice administering it to a few colleagues. As with any new tool you add to your clinical repertoire, the greater your comfort in using it, the more at ease your clients will be.

Then, the next time you suspect partner abuse, you’ll be ready to assess for it. When you do, share your findings with colleagues, a supervisor, or an expert. If you discover your suspicions are groundless, you can breathe a sigh of relief. If your suspicions are confirmed, refer the couple immediately for further assessment, if necessary, and appropriate treatment. The hazard of proving your suspicions incorrect is small compared to the danger of leaving partner abuse undiagnosed and untreated.

In many ways, Mark and Julie experienced an ideal outcome. Their commitment to each other and to the process of change allowed them to leave their abusive dynamic behind. Mark was able to give up his sense of entitlement and develop greater empathy for Julie. Although some emotional scars remained, the damage was not so severe that Julie was unable to reclaim the genuine affection she had once felt for Mark.

But they were lucky: without any of these factors, a divorce was likely. And without appropriate intervention, the probable outcome would have been an uninterrupted, escalating pattern of abusive behavior, accompanied by additional years of unnecessary pain and suffering and the possible transmission of abuse to the next generation.

John Arden on Brain-Based Therapy

Posted on by rezendevknowfully.com

Why Brain-Based?

Rebecca Aponte: Why did you call your book Brain-Based Therapy? What does “brain-based therapy" mean?
John B. Arden: I've got to say that the actual title of the book was chosen by Wiley, the publisher. The earlier title had something to do with neuroscience—I forget, actually, what it was. But when this one was chosen, my initial reaction was, "Geez, that sounds so reductionist."
RA: That’s what I thought, too.
JA: And there's so much out there about neuroscience. A good friend of mine, Lou Cozolino, wrote a book called The Neuroscience of Psychotherapy, so maybe it was too close to his title. But from my point of view, it doesn't have anything to do with reductionism. I still regard Jung's analysis of culture and fairy tales and religion to be fascinating. In fact, I spent a lot of time sitting in yoga ashrams in different parts of the world meditating, and those parts of my development are still with me. I'm still interested in all of that, but I want to integrate it all. And it has to be integrated from a nondualistic perspective. It seems to me that for many years we were in what I call the Cartesian era.

RA: The separation of the body and the mind.
JA: Right. Between 1890 and about 1980, we were in the Cartesian era with no scientific grounding for this view whatsoever because, despite the fact that Freud was a neurologist and wrote a hundred articles in neurophysiology, on such things as the neurophysiology of the crayfish, we didn't really know much about the brain at the time. So the schools of psychotherapy just splintered all over the place—everything from primal scream all the way to radical behaviorism—because there was no common language, no common integrative core.

The picture changed around 1979 to 1981 due to the convergence of a number of different factors. For one thing, the DSM-III—the third Book of Bad Names—developed. And it was a whole lot better than DSM-II and DSM-I, because you didn't have a lot of terms like "neurosis." Even homosexuality, believe it or not, was in the DSM-I. Finally, in 1974, when the DSM-II came out, millions of Americans and Europeans became cured of their disorder. That's why people get really caught up with the diagnostic terms. So DSM-III came about, and there was a whole lot more science to it. People were saying, "Wow, geez, this is so much better. This makes a little bit more sense."

Also, up until about 1980, the efficacy studies for psychotherapy were pathetic. Way back to Hans Eysenck, the mere passage of time was as effective as psychotherapy. Before Timothy Leary went to Harvard, he actually worked for us as a chief psychologist at Kaiser Oakland. He was a pretty bright guy before he started taking acid and flipping out. And he did a study there where he found that people on the waitlist did as well as people in psychotherapy. So imagine all that.
RA: A huge crisis for the field to go through.
JA:

The Age of Pax Medica

Exactly, until the Smith and Glass studies, which came out in 1979 or 1980. I was at University of New Mexico at the time, and we were pretty excited because this big meta-analysis found that, actually, psychotherapy worked. "Oh, my god. What we're studying and what we're doing really makes sense. We're helping people. Thank God!" Then, too, the development of these SSRIs in the '80s was a major factor in the development of what we call Pax Medica.
RA: Can you elaborate on that term?
JA: Pax Romana was a term used to describe the Roman world roughly 2,000 years ago. You could travel anywhere in the Roman world, and as long as you didn't insult Roman gods and Roman law, everything was cool. Similarly, since 1980, as long as you recognize that that psychiatry is in charge and that the number one factor is psychotropic medication, everything's going to be cool. That's why we call it Pax Medica. We've been operating in Pax Medica roughly since 1980. I think we're ready to leave it.
RA: Yet you recently said in a lecture that, in some ways, Pax Medica benefitted mental health.
JA: Because it got us all on the same page. We were all over the place. We were talking about interjected self-objects on one side and behavioral reinforcement paradigms on the other. We didn’t have a common language.

But Pax Medica’s page is extremely one-dimensional. In fact, the common language that we began to use is rather clunky and presumptuous. So we became a medicalized group, and the psychotherapy world became medicalized psychotherapy. And instead of being called “psychotherapists,” we became “clinicians.” “Now, you’re talking.”
RA: “Now you sound medical.”
JA: Now you’re clinically speaking, but what were you speaking before? Is this a new language or something? I’ve sat around in these big meetings where people say, “So what’s the diagnostic picture here?” In other words, they want a name quick, from the Book of Bad Names. And then they say, “What’s medically necessary?” Medically necessary, what? The guy just had a divorce. He’s really bummed out. “Medically necessary” sounds kind of silly.
RA: It sounds you're saying there's a fundamental disagreement about what the role of the therapist is.
JA: Yeah, and I think that the disagreement resulted in a compromised agreement. And the compromised agreement became the clinical role. And the clinical role is, I think, very antiseptic and one-dimensional, and in some ways very subservient to the so-called "principal treatment," which was medication.

Now we know the efficacy studies for antidepressants are rather suspect. The negative studies outnumber the positive studies by 12 times. So the pillars of Pax Medica are actually falling apart in major studies in JAMA and New England Journal of Medicine and other places.
RA: Within the Pax Medica frame, what do you think has been the cumulative effect of the outcome studies that focus on a specific treatment for a specific problem?
JA: Another part of Pax Medica was evidence-based practice. From roughly the early '80s on, various CBT-oriented therapists were the ones doing a lot of the studies on specific methods. David Barlow and others were showing that specific approaches to panic or OCD were more efficacious, and that dovetailed really nicely with the Pax Medica model, whereby you had a diagnosis and you had a prescribed treatment for the diagnosis. There was a positive part of that, because, come on, now—a person with a panic disorder, you want to sit around and analyze their feelings about their mother endlessly? No, you want to get them doing interoceptive exposure and other approaches that have been found for the last 35 years to be much more efficacious than sitting around analyzing archetypes and other things that, even though I find them intellectually stimulating, are a waste of time with somebody with a panic disorder.

So there's a lot more science in Pax Medica, and that's a good thing. But I think we're ready to integrate many strata of science now, to emerge out of the one-dimensionality. Evidence-based practice is still going to be part of the picture, despite the knowledge that the outcome management people have provided us, which is that there are diffuse boundaries between these psychotherapeutic schools.

I'm arguing that we don't need any more gurus.
I'm arguing that we don't need any more gurus. I certainly don't want to be anybody's guru. We don't need another school. I'm not suggesting brain-based therapy is a school and now everybody's got to be an Ardenian. Oh, what a terrible burden it would be to be one of these gurus—and a hollow experience, at that.

Rather, I think we have the opportunity to integrate evidence-based practice—which still is part of the picture for anxiety disorders and depression—with a better look, for instance, at the building of the alliance. The Adult Attachment Inventory and things like that give us insight into the various types of relationships we have been taught to develop, that are going to be replicated in the therapeutic encounter anyway. So why not include that as part of the overall picture? And we know that certain types of brain dynamics and temperament are associated with relationships—neuroscience is a big part of this new equation, as well.
RA: The brain is a popular topic right now, but do you feel that we’re really there yet with the science backing biological theories about how the brain works?
JA: More than we ever have been. I’m also convinced that in five years, I’ll be looking back at what I’m saying to you right now and thinking, “God, John, you had such a limited understanding of what’s going on.” And I think that’s a good thing. So, yes, I think that we can begin to have a dialogue about neuroscience, but are we there yet? No. I don’t think we’re ever going to be totally there. There is no “there.” But we’re going to be far more enlightened about what’s going on. And certainly, not everybody’s brain is exactly the same, but we know that there are psychological syndromes, like anxiety and depression, that have some commonality across people. We ought to be talking about that among ourselves as therapists, and also in therapy with our clients. I’m always talking about the brain with my clients.
RA: A lot of people feel that there’s been an overemphasis on the brain and that therapy has really moved away from focusing on emotions and the human experience. Related to what we were talking about with Pax Medica, there’s a concern that overfocusing on biology closely ties in with overfocusing on pharmaceutical therapy.
JA: I think otherwise. In fact, I think it's an opportunity to focus less on psychopharmacology. Out of the 2,000 of us in the Kaiser system, I'm among the people who refer my clients less for medication evaluations, because I want to work with emotion. That's our province. So how do you work with emotion? Well, if you have people narcotized, you're not going to have access. And certainly with people who have anxiety disorders, anybody on a benzo I'm trying to get off of benzos as quickly as possible.

SSRIs I'm less concerned about, but I only go there when I exhaust all other avenues, including diet, which I'm always talking about at length. Exercise is the most effective biochemical boost that there is—as effective as psychotherapy. Exercise is as good as psychotherapy in alleviating depression. We ought to be doing that and psychotherapy together.

Including all these biophysiological dimensions that don't include the drug cartels is a good thing. Now, the reductionism to a specific neuron—no, I don't go there. Remember, I'm a guy steeped in psychodynamic theory, and I still love all the allure associated with it and all these characters that are battling with one another. It's fun, and it's enlightening in many ways. I think the new psychodynamic perspectives are quite a bit more advanced than the original psychoanalysis.
RA: So you see the new role of the therapist incorporating biology, traditional psychology, but also sleep hygiene, exercise, and nutrition.
JA: Absolutely. I'm not suggesting that we don't pay attention to the alliance. In fact, that's one of the principal effective agents. And we know that from psychotherapy research; the outcome management people have shown that to be pretty powerful. But why not pay attention to those parts of the brain that make that possible mirror neurons, the anterior cingulate, the orbital frontal cortex, the insula, the spindle cells? It's interesting for us to know that some people, if they've had a poor attachment history, have underdeveloped areas like the ones I just mentioned.
RA: You mentioned that you can see this information as a opportunity to teach clients about what may be happening in their brains. How does that help?
JA: Let me give a fairly common example. Say you have a client who says to you, "I just don't know why in the first part of the day, when I lie there in bed, I get so overwhelmed and I get paralyzed with this totality of anxiety. I don't know what's going on there. I get anxious and depressed. What am I going to do?"

Well, we know now from all these affective symmetry studies that people who get hyperactive right prefrontal cortex plus underactive left prefrontal cortex get more anxious and more depressed. And what kindles the right prefrontal side are withdrawal and avoidant behaviors. So when she gets into the withdraw-avoidant behavioral response, she's kindling up the right prefrontal cortex.

Now, how to get out of that? You've got to do what are called approach behaviors. The CBT people have known this a long time—it's called behavior activation. What do you do with depressed clients? Do you sit around and analyze things to death? No, you get them doing stuff. And you get them doing it quick. As soon as you start to feel overwhelmed, it's time to do something, because that kindles the left prefrontal cortex, which is about approach behaviors. But you do it incrementally, because it's always very overwhelming to do big, big projects.

We're not talking about the left hemisphere as being the new cool one now and the right hemisphere as passé, where it was the right hemisphere that was the cool one before. No, we're going to be talking about a relative activation of the two hemispheres. In fact, we know, too, that if you get the right prefrontal cortex knocked out, you lose your sense of humor. What's that about? Well, you want to have a sense of humor, right? A sense of humor is about plays on words, metaphors, juxtapositions, and all of that. You want to have that larger picture.
RA: So all of that also really speaks to how behavior changes the brain.
JA: Absolutely.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other.
Behavior changes the brain and the brain changes behavior. It’s a bidirectional flow of information. It’s not one way or the other. Pax Medica had it one way: “Brain changes behavior. All you’ve got to do is tweak up some neurotransmitter system like serotonin, and everything’s going to be fine.”
RA: “Because you have a chemical imbalance.”
JA: "Chemical imbalance" is so American, isn't it? "Okay, let's just go in there and change that chemical imbalance. I want to fix it quick, will you, Doc?"

Come Together

RA: Where do you think we are in the grand scheme of integration?
JA: I think it's slowly developing. There will always be tidal pools that pull back. For example, you mentioned earlier that some people are saying, "Oh, neuroscience. What's the big deal? Neuroscience isn't going to be part of the picture. Get over it." It's going to be, but how is the bigger picture? I think that there are a lot of people jumping in the bandwagon who aren't paying attention to the science in neuroscience. I'm not going to get into names, but some people make it rather New-Agey, and that kind of turns my stomach.

Science is a good thing. We ought to be paying attention to how the research actually shows this or that instead of, "Well, that's kind of a cool thing. Why don't you just talk about the so-called limbic system?"
How we incorporate neuroscience, I think, is going to be a big part of how we advance toward the future. And it's not going to be reductionistic. It's going to be a part of the picture. We're still going to talk about the relationship and pay very close attention to the alliance. And as I said earlier, it works both ways, because there are parts of the brain and parts of our nervous system that respond to close relationships, and that's something we ought to be paying attention to.

The psychological theories and all the alphabet-soup therapists—EMDR, EFT, CBT—the advances in some of those areas, I think, are going to be part of the picture. But I think the allegiance to the schools is going to be increasingly less of an issue.

Reshaping Memories

RA: I think a lot of people in the field really hope that your view is right. What evidence do you see that indicates the field is moving in this direction?
JA: It seems to me that the studies that show actual change in the brain resulting from psychotherapy are what will convince everybody that we’re moving in the right direction. And there’s a wealth of information out there that’s developing and will become stronger and stronger, and it’ll be undeniable that there’s an intersection here. Again, it’s all not reductionism: it’s integration. And memory is a major part of the picture here.
RA: Say more about that.
JA: Understanding memory and the complexities of our various memory systems, including the various types of implicit and explicit memory and how those systems work together to make us who we are, and how we, as therapists, interact with these memory systems—that, to me, is the foundation of therapy. Our job is to help people reconsolidate memory in a much more adaptive and effective way, because there is no such thing as a memory encapsulated in some sealed-off portion of time, where you go back in and you pull it up. That's where the early psychodynamic theorists had it all wrong. Every time we bring up a memory, we change the memory.

That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way.
That's what we do for a living: we bring up memories in the new context and help people re-adapt in a much more effective way. I regard memory as one of the major foundational aspects to psychotherapy in this unfolding sea change—not a paradigm shift, but actually a sea change—that's occurring in mental health.
RA: You’ve said that it really seems like we’re moving beyond brand-name therapies, but do you think we’ve just substituted techniques? You mentioned CBT. I’m not completely clear on what the theory behind CBT is, other than that it seems very removed from things like memory and emotional experience.
JA: Actually, it does incorporate them. If you think in terms of anxiety, for example, it's quite clear that avoidant behaviors make anxiety worse even though, over the short term, they make it feel less severe.

Let's say I'm a socialphobe and I walk into a room. I feel better for the first minute, and then I feel terrible, and my amygdala gets hyperactive as a result. In other words, I'm painting myself into a corner. Exposure is the antidote—the therapeutic direction that we ought to be working in. And that goes back to Joseph Wolpe, who doesn't get enough credit now, even in the CBT community. The whole idea of incremental exposure is critically important in psychotherapy for people with anxiety disorders. So the CBT people are talking about the brain even though they're not using the brain in their dialogue. They're not mentioning the brain because they haven't been really incorporating it into their understanding. But they are changing the brain, because exposure actually changes the brain. It could make the anxiety worse by flooding too quickly, but incremental change could make it much more resilient and adaptive.
RA: Let me see if I’ve got this right. It sounds like you’re expecting that there would be a much more integrated theory about how psychotherapy works, because it’s going to include neuroscience. And because we have more technology now, we’re going to be able to actually see these changes and understand it, and we’ll continue to see even more levels of complexity.
JA: We are seeing these changes. And in fact, with psychodynamic theory, the whole concept of working through is the same thing as incremental exposure. A book that I like to recommend that's now 20 years old is Psychodynamics in Cognition, by Mardi Horowitz. I really like that book. It was Horowitz's attempt by to talk about the overlap between psychodynamic theorists and cognitive theorists-maybe they aren't talking about something so different. Let's talk about how defense mechanisms and schemata have an overlap. That's what I'm talking about: finding the overlap between these therapy types. Just because they use different language doesn't necessarily mean that they're not talking about the same thing. Where there is an overlap, I get excited about it.
RA: So neuroscience is going to be what shows us that we’re all talking about the same thing.
JA: Neuroscience, and a look at these therapeutic styles. Defensive maneuvers are still relevant, and we can look at them from a cognitive perspective, and from this whole affective symmetry dynamic, as well. In other words, we could look at them from a number of different vantage points, and if all those vantage points have a cohesive quality to them, then I feel much more confident about it.

So we’re not just talking neuroscience or just talking psychodynamic or just talking CBT or memory, but rather how these all can overlap and say the same thing to give us a much more robust understanding of what goes on in psychotherapy and what goes on in our own heads.
RA: Do you believe this integrationist’s frame of reference changes the way that you work with clients?
JA: Absolutely. I've been in the mental health world for 35 years, and when I first started, I was part of this whole the institutionalization movement—we were creating alternatives to hospitals in San Francisco, and then wrote a bill for the New Mexico state legislature in 1980 to do the same thing. What I thought was going on back then is quite a bit different from what I think about what's going on now.

Even in 1976, when I was working with autistic kids—God, we had a stupid understanding of what was going on with those kids back then, because we didn't understand what was happening in their brains. We thought it had to do with these really cold mothers. Bettelheim was our popular hero. My God, what a dumb, dumb way of understanding.

It didn't mean, though, that what we were trying to do, in terms of developing a good relationship with the kids, wasn't a good thing to do. We called it reparenting, but nowadays we'd think about it as being helpful to the kids so they could acquire better social skills and develop a better ability to have human relationships.
RA: This makes me think about some of the preliminary studies in the news now about sudden-onset OCD in children after they have strep infections.
JA: And that has helped us to understand the role of the striatum very well, because that’s the area of the brain that gets attacked viciously in these kids during the infection. And we know that the front part of the striatum is kind of like a spam filter. In people with OCD, unfortunately, that striatum doesn’t work like a spam filter, and the orbital frontal cortex gets flooded with all this nuisance information: “This is wrong, this is wrong, we’ve got to do something, wash your hands, wash your hands,” or whatever it is. Baxter’s group down at UCLA showed very clearly the orbital frontal cortex being flooded with all this nuisance information, and that what can help alleviate the OCD is to “rescue” the orbital frontal cortex with the dorsal lateral prefrontal cortex (which has a lot to do with working memory) via CBT with a mindfulness approach. In these imaging studies, you could see OCD patients before and after the treatment. And the strep infection material was supports the idea that OCD involves this “gate” that is left open in the striatum.

But How Does It Work?

RA: Let's walk through a hypothetical. I come to see you because I feel depressed and generally anxious, and this has been going on for some months now. Where would you start to look for the cause of my feelings and some relief?
JA: It's interesting that you say depressed and anxious, because under Pax Medica, if you were depressed and anxious together we would have two diagnoses on Axis I—a comorbid problem. Well, you're one person. Are these two genetic disorders you have? What a silly idea. And the prescribed pharmacological agents actually work against one another. These stupid benzos, which are really a nuisance in the mental health world, would actually contribute not only to addiction, tolerance, and withdrawal problems, but also to depression. And then you'd toss in an SSRI or something like that, so you'd have this weird cocktail.

There is an interesting neurochemistry that occurs with anxiety and depression. For example, for 90 minutes after you experience a severe stressful incident, your levels of dopamine, norepinephrine, and serotonin will be down. Let's say that you've just found out that you can't get into school. All the PhD programs have turned you down. That's a pretty big blow, right?

So you're going to get a downregulation of all those neurotransmitter systems, and you're going to withdraw a little bit. But it's what you do with that neurochemistry and those neurodynamics that can tumble you into more anxiety and more depression, or get you out of it. If you do things that kindle up the same systems that would get you more anxious and depressed, you'll get more anxious and depressed.

Now, we're going to have bumps in the road. It's what you do in response—it's that resiliency. Some of the positive psychology spinoffs are paying attention to that, and of course the counseling psychologists have long done that.
RA: So, if I were your client, would you want me to tell you about something stressful that happened and what I did afterwards?
JA: I often do that, just to get an idea of how people react to certain events in their lives—to get a characteristic description. I'm also paying attention to the way they describe them to me, because that interaction between us is so important. It replicates other relationships they're having that might have great continuity with the earlier attachment-based relationships. It tells me a lot about how I can intervene, because I don't want to create more resistance. I do like Milton Erickson a lot—that indirect approach. I'm not going to want to shut you down and have you screen me off, but rather do some motivational interviewing to some degree—which is very Rogerian, in fact. Bill Miller was a Rogerian from the school that I came from.
RA: Out of curiosity, did you study with him at UNM?
JA: No, I didn't. In fact, I didn't know about him until after I left. I don't know if he was there then—that was 30 years ago. But had he been there and I missed him, I would have been disappointed, because I really like his contribution to the substance abuse community.

Addiction: A Sliding Scale?

RA: And substance abuse is one thing that we haven't really touched much on in terms of what neuroscience is really teaching us. There's big debate about whether addiction is a genetic disorder.
JA: There is some literature to suggest that if you have two alcoholic parents, your vulnerability to become an alcoholic is heightened. But let's say the concordance rate is 50 percent. Well, what about the other 50 percent? It isn't a one-and-one factor.

In a discussion I had with Fred Blume, one of the pushers of the alcohol gene concept, I asked, "How about an acquired disease? You guys are really into this disease concept." AA's really into it. AA and NA are the most powerful self-help groups in the world, in my opinion. My sister-in-law's life was saved as a result. Fantastic groups. I love their little jingles and all that. But they're too into this disease concept. It's useful in early recovery, but you could create a disease. It's bidirectional. The more I drink alcohol, the more I feel like I need alcohol, because my biology changes. I downregulate various neurotransmitter systems, so now I feel like I need to mellow out because now I'm downregulating the synthesis of GABA. That means I need more GABA-like effect because I'm always dampening down glutamate.

What I think therapists ought to be paying attention to is how these various substance abuse habits, if you want to call it that, create psychological symptomatology. “I see all sorts of people here in the North Bay who are suffering from anxiety and/or depression, and I find out they're just drinking a glass or two of wine at night.”
RA: That’s a lot of wine, though.
JA: I think it’s a lot of wine. I drink a glass every week or two. It would be nice if you could have two glasses of wine a night, but my sleep gets all messed up. You get the mid-sleep-cycle awakening and all that. And that’s a small snapshot. What about the next week? These are subtle effects, but when I used to do neuropsychological testing and psychological testing, and then later teach it, we used to say, “Don’t test a wet brain for up to three months after your last drink.” There are all sorts of artifacts to subtle alcohol consumption.

And red wine isn’t that cool, you know. It’s the resveratrol in the skin of the red grape. You can drink Welch’s grape juice and still get the same effect. You don’t need the alcohol.
RA: And what about other drugs? I haven’t heard too many therapists saying that they necessarily ask their clients, “Do you smoke pot?”
JA: Everybody here does. And pot is one that I really pay close attention to in the North Bay, because of all these people on medical marijuana cards. They have a sore back. Well, give me a break. So do I, but I don’t smoke marijuana now. I did 40 some years ago as a young hipster, but I’m glad I stopped 40 years ago, because otherwise I’d be muddled and kind of down. THC is chemically structured like a neuromodulator called anandamide, which is Sanskrit for “bliss.” It orchestrates the activity of a number of neurotransmitters, so when you’re stoned you get what we call virtual novelty. “Look at this cup! God, that is so incredible. Look at the way it’s shaped, and the colors! This is amazing.” Then the next day you get what we would call in the ’60s “jelly brain,” because everything’s downregulated now. And you never get the same high.

So now what we see are all these people smoking medical marijuana who have low-grade depression. They can’t remember much, because they downregulate the acetylcholine release in their hippocampus and have symptoms very much like ADD. God, I get people with ADD evals all the time who are smoking marijuana.

So with regard to substance abuse, psychotherapists should perform a full analysis of everything the clients are doing, instead of saying such things as, “Do you abuse alcohol?” I want to know what they’re consuming rather than ask blanket questions.
RA: Well, what’s abuse? “Yeah, I have five beers a night, but I’m fine.”
JA: Exactly. But if somebody’s drinking two, I’m concerned about that, especially if she’s anxious or depressed. Or if somebody’s taking a toke of marijuana a night, and he’s coming in with this low-grade depression, muddled thinking, and attentional problems, I’m concerned about that.

Defining Therapeutic Success

RA: In the way that you’re visualizing therapy, how do you define therapeutic success?
JA: We're always a little too symptom focused. I still think we ought to be paying attention to symptoms—that's an important part of the picture—but we also ought to pay attention to what clients are telling us about their overall improvement and their perspective in life: "I'm feeling so much more hopeful and so much more resilient and I'm not as easily stressed." And we're getting more of that from the outcome management process, instead of, "You originally came in with these panic symptoms. How's the panic doing?" "Oh, I don't have those panic symptoms anymore." Well, that's good. That's only part of the picture, though. There's got to be a larger look at things: is the relationship improved, for instance?

Therapists: The Next Generation

RA: As a mental health training director for Northern California for Kaiser, you work constantly with the next generation of therapists. What do you see in their training that concerns you?
JA: What got me intensely concerned and preceded the development of Brain-Based Therapy was typified by an answer to the question, "What do you want to do in the next year?" In the Kaiser Northern California, we have 60 postdocs in 20 medical centers, and another 50 interns. When I interview a postdoc and ask, "What do you want to do over the next year?" they say, "I really want to find my theoretical home." You want to what? We're certainly not going to be helping you find your theoretical home. In fact, I want to dissolve those theoretical homes into a grand unified area. So that's a concern.

And a lot of young therapists come out of these schools too young and inexperienced—they haven't had to go out in the world and learn business and all this, to augment their academic understanding. Between undergraduate and graduate, I spent a year in Asia and the Middle East, and I just kept circling the globe. I was gone for a year, and I don't know how many countries I visited. What an incredible education. I matured so much during that period.

Life experience is critically important. Having to deal with some stressful events can really help a therapist. Just being pumped out of all these professional schools with all these fancy degrees and all that, boy, that's such a limited area. I get a little concerned about too-young therapists being plopped out and wanting to be Dr. Somebody-or-other.
RA: That seems to address my next question: do your intern therapists seem to come with a broad base of knowledge about other aspects of the human condition—literature and art and history?
JA: That's a pretty interesting question. I remember when I was being interviewed for my PhD program, that was a question in the interview. I was in the Counseling Psych department, even though I later got involved in both departments. I was really into talking about Dostoevsky and D. H. Lawrence, and that perked up the interest of the interviewers. Contrast this with the clinical program applicants—I call them the GREs. All they got was a high GRE score and a good GPA. Big deal!
RA: In the next generation, are you seeing much of that?
JA: If you immediately go from a bachelor's to a master's and, usually, especially the professional schools, straight to a PhD program, I see a lot of that. And physicians, unfortunately, hardly read at all. It's just shocking that the educational system kills the quest for reading in diverse areas. It's amazing.

Therapists don't read enough. And when they do read, unfortunately, they read in their own little clubhouse. Where you get more cognitive reserve, if you will, is where you step out of your own zone of comfort. I particularly like to step out of all these mental health areas completely and pay attention to what other scientists are doing.

Particularly, I love complexity theory. When I'm back in Santa Fe, I like to go to the Santa Fe Institute. This place is incredible—founded by three Nobel laureates, two physicists, and an economist. And then there are biologists and computer scientists and archaeologists, all talking about the change in complex systems. Well, aren't we a complex system?

So I think we don't read enough, and not only of another psychotherapeutic school, but, also another area of science. It would be really good for us to do that on a regular basis. I'm perpetually advocating for that.
RA: There are some people who are advocating for academia to do something similar to what you’re saying psychotherapy should do, arguing that there really shouldn’t be such big walls in between each department.
JA: Yeah. In fact, in the Sonoma State University, there’s the Hutchins School, which is very much like St. John’s College in Santa Fe, whereby you have more of an interdisciplinary approach. At St. John’s it’s more of a classics approach, but at Hutchins, you have a department with anthropologists and biologists and other people all there. It’s that interdisciplinary approach that I think is so valuable.

Inside Kaiser

RA: Do you think, working at a large health maintenance organization, that this move toward integration will also eventually break down some of the barriers for clinicians to be able to determine what kind of treatment they want to give to a particular client? Right now, HMOs rely very heavily on CBT because there are so many studies of a specific symptom with a specific treatment.
JA: I don’t necessarily see Kaiser as being a CBT mental-health dispensary. I’d look around at all my colleagues, and one person might be into EMDR, another person CBT, another person steeped in psychodynamic or narrative. But we do pay attention to evidence-based practice. In fact, we have a whole administrative structure just for that. But we also have an administrative structure just for outcome management. The convergence of the two is pretty important.
RA: I’m sure that you’ve heard some of the recent complaints about Kaiser that people have a difficult time getting timely access to mental health care.
JA: That's kind of old news—20 years old. All departments are graded for access right now. I was hired during the Model of Care, which was 20 years ago, where we tripled or quadrupled the size of many departments because it was all about access. Every department now is graded on how quickly a client can come to see someone. If you call in right now, we've got to give you an appointment within two weeks. That's called initial access for the new, and there's a seen-to-seen that we're being graded in, too. We've improved dramatically in the last 20 years.
RA: There is a recent report that union leaders and employees were asking for an investigation to make sure that it was happening in a timely manner. Do you feel like the treatment model that you’re describing can fit well into an organization like Kaiser?
JA: Kaiser's in a difficult position because it's swimming in this vast sea of other medical providers, and it's trying to survive at the same time as thrive—to use that term. So I know what those folks are saying, and we're not immune from any criticism. There are always these concerns about improving, and that's a good thing.
RA: And people having access.
JA: Absolutely. Access is critically important. I know that we're trying to do whatever we can. I'm in meeting after meeting about improving access. We're always talking about improving access, while at the same time we're talking about hiring new people. But where are you going to get the money to hire the new people unless the membership rates go up? It's a complex situation.
RA: You obviously have a very expansive knowledge base that you're integrating. What wisdom do you hope the clinicians that you're training will take away from it?
JA: That there is this exciting sea change occurring in mental health, if you pay close attention to it and if you read voraciously. Just because you’re out of graduate school, we don’t want you to stop reading. We don’t want you to get rigor mortis. In fact, we want you to now read more than you read before, and go to more workshops in areas that you don’t even have any interest in initially. That’s where you get the best change, really, is if you go, “I have no idea what that person is going to be presenting over there.” Those are the ones you want to go to, rather than, “Yeah, I’m really into that kind of therapy.” How many more times are you going to hear that particular frame with a little bit of a twist to it here and there? In fact, you get more neuroplasticity if you get into an area you have no knowledge about at all. What we want to do for this next generation of therapists is to be integrators and to be active consumers of diverse areas of science.
RA: What are your hopes and concerns about the future?
JA: I'm concerned about the economy affecting mental healthcare and, again, as somebody who in the '70s and '80s was helping people who were chronically mentally ill and homeless, I'm really concerned about mental healthcare for the poor. Here I'm in Kaiser right now, and who are the Kaiser members? Well, they're people with jobs. So I'm really concerned about the disadvantaged groups, and that has a political component, too, because if we go Tea Party zone, you're talking about massive cuts in the safety net, and it's pretty primitive.

Into the more advantaged stratum, I'm concerned that, even though I think there's a sea change going on, it could go the other way—the continued focus on these clubhouses. But I'm heartened that things are going to change eventually. I'm totally convinced that they will, because of these converging fields. When it will happen is another thing. It might be more in your generation and in my son's generation who, like you, is applying for graduate schools right now, than my generation. I think for quite a while, we're still going to have the gurus out there. But hopefully they will be talking in more integrative ways and less about themselves, so to speak.