Category: Approach

David Nylund on Narrative Therapy, Curiosity and Queertopia

Posted on by rezendevknowfully.com

Narrative Therapy 101

Lawrence Rubin: Thanks for sharing your time with our readers, David, some of whom may not be familiar with Narrative Therapy. Can you give us an overview that would do it justice? Narrative Therapy 101, so to speak.
David Nylund: Well, that’s a challenge, but I’m going to give it a go. I imagine if you asked me at a different time, I might have a different take on it. Narrative Therapy is based on a narrative metaphor and the idea that people are multi-storied. And people get locked into a singular story which tends to be deficit-based and internalized. The job of the narrative therapist is to create a conversational context, usually through questions, to trace these thin, deficit-based stories that contradict the dominant stories that are always apparent. The job of the narrative therapist is not to coach them or help them build skills, but to trace those alternative stories that are always present but, as Michael White would say, “thinly known.” And through different narrative practices like questions and letters, to help thicken that story so it begins to gain some momentum and density. And when people can step into that story, they come to maybe a different version of who they are.
LR:

Narrative Therapy is based on a narrative metaphor and the idea that people are multi-storied.

You make it sound as if it’s a process of rewriting a life script in which the therapist is a co- editor or the editor. How do they work together to rewrite this story?

DN: I like the idea of a co-editor, where it’s a collaborative inquiry. The therapist is decentered, but is definitely influential, attending to certain things and not others. It’s based on a critique of individualism. It’s a very anti-individualist approach, and it’s very much informed by post-structuralism and thinking relationally. People are always in relationship to others, to a larger cultural narrative. I think narrative pays a lot of attention to how people’s stories are shaped by larger cultural narratives, or what Foucault would call discourses. I think one of the aspects of narrative that really drew me to it was its focus on how peoples’ problems and struggles are not their own, they’re shaped by the larger culture. So, it leads narrative into a certain kind of arena of social justice, which is what I was drawn to as a social worker.
LR: So, the job of the narrative therapist is to disabuse people of those deficit-based stories they’ve been told or have come to believe are true about themselves? How directive is the narrative therapist in moving the person off center in their cherished story?
DN: The intention of the narrative therapist is to not be impositional or directive. I would refer to it as invitational.
LR: Invitational?
DN: And yet, the narrative therapist is informed by a couple of basic premises: that people are multi-storied and many of these stories contradict each other; that people always have skills and abilities and values that run in contradiction to their dominant story that is often very deficit-based or problem-focused; and that problems are separate from people. For Michael White,

the problem is the problem, the person is not the problem

the problem is the problem, the person is not the problem. Peoples’ lives and problems are always relational and informed and shaped by the larger culture, especially around issues like normative ways of being related to race, class, gender and sexuality. And some of those dominant norms help shape peoples’ lived experiences and can contribute to their problems. So, the narrative therapist enters through an invitational conversation from a stance of curiosity about these alternative stories and what they might mean. I think the job of the narrative therapist is not to determine whether these alternative stories are good or bad, but to invite their client to become curious about them. And that might be an entry point into some new stories, and that entry point is often referred to as a unique outcome.

LR: It doesn’t sound like you’re trying to be a car salesman, but you’re visiting a car lot with a person and considering new colors and new models, psychologically. So, from a traditional and individualistic perspective, a client diagnosed with depression might be referred for medication and cognitive behavior therapy. How would a narrative therapist approach that same depressed person?
DN: The first step would be to be curious about depression. Perhaps you would externalize the depression, and then you’d be curious about what the depression means to the person, to the client. I don’t want to assume some clinical DSM version of what depression is. I want to understand it from the client’s perspective and their meaning around it. Now that it’s externalized, we might explore the effects of the depression on their life. I might ask questions like, “How is the depression affecting your thoughts about yourself?” “How it is affecting your relationships?” “Who’s in league with the depression?” “What supports depression?” “If you look back on your life, were there some people or experiences that contributed to depression’s hold over your life?” Through these questions, which are referred to as deconstructive questions or relative influence questions, we always find some contradiction or gap, because no story is seamless. There’s always some event or disruption; one day, one moment where the depression wasn’t as strong. It might be the client reached out to a friend. It could even be the act of coming to therapy is a unique outcome.I might start out by asking, “Did depression want you to come to the session today?” “I’ve worked with many clients with depression, it tries to convince them that therapy won’t be helpful. So, do you think it tried to do some of that?” “How did you defy depression’s dictates to come to the session, and what does that reflect about your hopes, your values, your ethics?”

I don’t want to assume some clinical DSM version of what depression is. I want to understand it from the client’s perspective and their meaning around it

One of the things that is important in Narrative Therapy, but also one of its challenges, is that it requires clinicians to rethink some taken-for-granted ideas in our field, especially around identity. From a modernist perspective, therapists like Jill Friedman and Gene Combs refer to internal states of identity. It’s based on this idea that identity is fixed, it’s static, it’s inside the person. It’s often linked to biology, and it’s outside of language and history and context. From a narrative perspective, it’s more of what I like to call intentional states of identity.

LR: This reminds me of Kenneth Gergen saying, “We come bearing multitudes” when referring to the difference between an individualistic and relational definition of identity.
DN: I like to think of identity as fluid, performed and in context. It’s relational, and about people coming to know themselves in relationship to others and in relationship to what’s important to them, their values, their ethics, their hopes. And so, a narrative therapist is really curious about their clients: their hopes, their intentions and their values that run in contradiction to, in this case, depression. And that leads to a very creative use of language and questions to help that alternative story, maybe anti-depression, to become thicker through reauthoring questions. And these re-authoring questions might be circulated to other folks in their life such as, “I imagine some of your folks in your life have an outdated version of you. What do you think is the best way to bring them up to date in terms of your journey away from depression?”The two challenges to the narrative therapist are to rethink and to challenge some core assumptions that we’re trained in our field and in the larger culture to believe. But your main tool is the use of creative questions that come from a stance of curiosity. This is very different from, for example, CBT or some of the more traditional models where the therapist is more of the expert helping coach people to develop skills. They might make more direct statements. They might interpret the client’s experience for them. In narrative, you’re influential but you’re decentered; maybe you lead from behind and you keep up that stance of curiosity. I think therapists are curious, but

narrative therapists practice a kind of curiosity about how things might be other than what they have been – a curiosity about hope and possibility

narrative therapists practice a kind of curiosity about how things might be other than what they have been – a curiosity about hope and possibility.

LR: It’s a very optimistic type of therapy, a liberating practice in a sense.
DN: Yeah! At the same time, I think narrative gets associated with positive psychology or solution-focused; or in my field of social work, a strength-based perspective. To me, it’s much more than that. It’s like these alternative stories that speak to a whole possibility. Values are always present. There’s evidence of it, and it’s inviting people to speculate about their significance. So, it isn’t like you’re having to find them or search for them, and it’s not about applause and cheerleading. It’s like coming from that place of honoring peoples’ experience, and there’s always things that stand outside the problem.
LR: Helping the person to widen their gaze to see instances in their life when they did stand up to the story that has previously defined them. So, you’re not a cheerleader on the sideline, you’re out on the field, playing with them.
DN: That’s a great metaphor. Definitely.

The Narrative Therapist

LR: What are some of the core qualities of a clinician that would make them a more effective narrative therapist? Not all therapists favor the use of metaphor or consider themselves to be particularly creative.
DN: I think one quality would be a real ethical stance of curiosity and respect for the client. I think there must be the ability to entertain multiple perspectives and not get captured by one singular truth. It might mean having to give up some of our training of being an expert. It also might be a commitment to social justice. And I think what often what attracts folks to Narrative Therapy is its demand to be intentional. If you look at most models, like CBT, for example, you won’t see much attention placed on how, let’s say, thought distortions are shaped by racism or the larger culture or dominant norms. It’s just very highly focused on the individual. I think there’s this commitment to seeing things within the larger social context, which then opens up this ethic of justice. Narrative uses language that can be social justice-oriented. The person is not oppressed, the problem is oppressive. The narrative therapist might ask, “Is it fair that the problem of oppression is cutting you off from your hopes?

a lot of narrative therapists also have this experience of standing outside the norm in their own lived experience, in a good way, like a rebel or an outlaw

As a social worker, I have a commitment to social justice. A lot of narrative therapists also have this experience of standing outside the norm in their own lived experience, in a good way, like a rebel or an outlaw. You know, like a commitment to a broad notion of queer. It’s not necessarily tied to gender and sexuality, just this broader definition of queer as a critique of norms and of normativity. I know that a lot of narrative therapists are committed to critiquing taken-for- granted assumptions or norms. I think that a narrative therapist is also drawn to new ideas and staying curious. It requires not just learning, but kind of more of an unlearning. It can be really challenging for people, especially if you’ve invested time in a model like CBT. It can be hard to give that up a bit.

LR: Do you think it’s more important that graduate social work and other clinical students learn first before they unlearn, or can we teach them first to unlearn before they can learn?
DN: It’s a great question. My preference is to start with unlearning. I don’t think I’m the majority there. I think my classes are as much about unlearning as learning, and I tell my students that. For example, last night in my class, I was presenting an overview of different family therapy models, and most of the students are also in a class to learn the DSM.But then I said, “Here’s another way of doing assessment.” And I introduced them to Karl Tomm’s ideas of assessing relational patterns, not people. So, a lot of my teaching is offering alternatives to the ways one can do the work. It’s a kind of tension between learning and unlearning. I think everywhere in the States, you have to learn some of these dominant ways of working in terms of charting and having to do diagnoses for billing purposes. You might have to use the more traditional language as shorthand to connect with other colleagues. So, I think narrative therapists have to find a way to entertain multiple perspectives simultaneously, even if they contradict each other.

What Counts as Evidence?

LR: Narrative therapists must be subversive!You once said, “I believe in evidence, but I’m more interested in what constitutes evidence and who gets to decide what counts as evidence.” You and I well know that these days, if you’re not doing randomized controlled trial studies, if you’re not doing meta-analyses, if you don’t have outcome studies based on psychological tests, then your work is not considered valuable. How do therapists operate from this anti-evidence base that you talk about?

DN: It was a conference in Osaka, Japan, and on the panel was the top voice of CBT therapy in Japan, and he challenged me about, like, “Hey, this is all great, but what do you think of evidence-based treatment?” And that was in 2001. Evidence-based therapy is much stronger than it was even then. I don’t have an easy answer for that one. I think that you’re right, unless the way you work has evidence from that more traditional notion, quantitative meta-analysis, randomized clinical trials, it doesn’t get the same respect. And that’s been an ongoing journey and struggle for me and my work. I’m in a privileged position now because I’m a professor and I’m the clinical director of the Gender Health Center, which is an agency working with trans and queer communities, but when I was earlier in my career, I had to work in hospitals and other settings. County mental health, community mental health, hospitals at Kaiser, and I just had to learn to be subversive, kind of covert, and let the work speak for itself.And you know, I think one thing that we’ve done at the Gender Health Center is use some of Scott Miller’s ideas around feedback-informed treatment, which is considered evidence-based now and has been sanctioned by SAMHSA, Substance Abuse Mental Health Services Administration. They’ve done a lot of random clinical trials and meta-analyses proving or having evidence that it’s not the model, it’s more about the alliance.

And alliance starts with how the client is doing. You create a culture of feedback. So, it’s interesting that some of the core ideas of feedback-informed treatment line up with narrative, right? Creating a culture of feedback, checking in, privileging the client’s voice. So, that’s one of the ways, strategically, we’ve been able to give narrative a voice. We use those measurements and the online program that gives all this data.

To me, unfortunately, it’s a reality that you need to have numbers. So, that’s one way we do it, and then there is a growing body of research on the effectiveness of narrative. It tends to be mostly qualitative. So, there is some evidence, but again, qualitative doesn’t earn the same merit as quantitative.

LR: Of course.
DN: It’s an ongoing journey.

I think a lot of narrative therapists are just subversive

I think a lot of narrative therapists are just subversive, and they might also be able to work more independently in their private practices. It always helps if somebody in the agency who is a leader or director is supportive of narrative. That can help.

Narrative Thoughts on Gender

LR: I want to move into questions around gender and working with queer folk. I never thought of, and I love being challenged by new thoughts, that queer is a critique of normativity, whether it’s queer racism or queer gender or queer religiosity.
DN: Right.
LR: Queer is an adjective, it’s not a noun.
DN: Right.
LR: Interesting. So, my question, David, is in what way does narrative therapy lend itself to working with gender queer folks?
DN: Okay. And when you say gender queer, are you referring to folks who identify as non-binary or are you talking more just—
LR: Yes, around the work that you’ve done.
DN: Often, what you just referred to is a term that’s used and that comes out of queer theory and queer scholarship, is heteronormativity. The norm that heterosexuality is the only sexual orientation and that the gender binary male/female is the only healthy way of being. So, I think what you’re referring to is everybody who stands outside that heteronormative way of being in their identities or practices. I think narrative therapy lends itself well to that because narrative therapy comes from this deconstructive lens, so it really is curious about these taken-for-granted assumptions, in this case, about gender and sexuality.

Narrative Therapy is informed by post-structuralism, and one of post-structuralism’s theoretical allies is queer theory

Narrative Therapy is informed by post-structuralism, and one of post-structuralism’s theoretical allies is queer theory, so there’s this connection between queer theory and narrative, because both are informed by social constructionism and post-structuralism, which pay close attention to dominant norms and language that can oppress folks.

So, it opens up that kind of dialogue about who gets to decide what’s normal. A lot of the conversations will be around these deeply entrenched gender norms, like masculinity, femininity, and around sexual identity. And I think it gives you some vocabulary; narrative offers a vocabulary to have those conversations.

LR: Can you give an example, David, of a recent client you’ve worked with whom you helped to challenge the heteronormative discourse that’s plagued them and maybe stood between them and becoming who they are from a sexual/gender perspective?
DN: At the Gender Health Center, we often do what has traditionally been called reflecting teams or outsider witnessing. Some folks refer to them as response teams. So, I’ll be interviewing a client in the presence of my colleagues, and my colleagues will then have a conversation amongst themselves while the client and I observe or listen in on that, and they’ll reflect on what stood out in the conversation, where did it take them? The comments are situated in trying to attend to the alternative story. So, I was doing that just yesterday with a 32-year-old person who was assigned male at birth who identifies as a trans female. However, she is in a family that comes from a very conservative faith tradition, and that’s held her back because she’s afraid of losing support from her parents.So, she’s really holding back on moving forward with her transition, meaning like hormones or surgery, because of her fears of how her family and her support network will handle it. So, instead of focusing on those issues, I was really curious about how, in spite of the religion that she was raised with, she was able to challenge that. What gender norms did she have to defy in order to even come to see me? And what did that say about her hopes for her life? I asked, “When you think about a person who comes from that background like yourself, and they’re beginning to consider that they’re trans, would you have respect for that person? Do you think it would take some bravery or courage?” And then, I started to ask questions like, “Who in your life might support this idea that you’re brave?”

And from there, she discussed a friend who supports her gender identity. And that led into some of the restraints and limitations of masculinity and toxic masculinity. I just kind of hovered around that, and then I said, “If you were to get a further appreciation of your bravery in living the counter story, what difference will that make towards your next step?” And that led to a conversation of coming to one of our programs at the Gender Health Center. It’s a respite program. It’s often more of a social context for trans folks who are feeling really isolated and disconnected to meet. You know, three days a week, they have this respite program. It’s for six hours and just kind of a place to hang out, relax, be yourself. They do some narrative work there, but it’s more just a meeting place.

So, by the end, she was open to going to that place. And then we talked about her ability to be more overt in her gender expression, and I noticed that she was wearing painted fingernails and earrings. We then talked about what those acts meant about her and ability to navigate her world, given that her parents wouldn’t be supportive because of their faith. I asked her to consider, “If I move forward, does that mean I’m no longer sinning?” And these kinds of discourses. That was the conversation, and then we had a reflecting team. And of course, in the team, there was various therapists who were queer or trans, so now this client is seeing community and support. One even shared that they also came from a deeply conservative religious tradition, and they talked about their journey and how they were able to move forward in their own life. So, that kind of gave the client some hope and inspiration.

Even Well-Meaning Therapists…

LR: In a sense, you’re helped this client connect with an external reflecting team, but also helped her to consider the internalized reflecting team that has been oppressive and could now be challenged.You’ve worked with and written about transgender oppression and suggested that even well-meaning therapists can further contribute to transgender marginalization through internalized transphobia and cisgender privilege. I find that fascinating. What do you mean that otherwise well-meaning therapists can contribute to the marginalization through those two things?

DN: Most therapists, most social workers I know, including my students, come from a place of ethics and wanting to help and might see themselves as open minded and progressive. When it comes to issues around LGBTQ, however, that acronym doesn’t account for the different hierarchies of worthiness, like gay white men have more power and privilege than, let’s say, lesbians, and then bisexuals are kind of held in somewhat of a suspicious or more marginalized status, and then T is at the end. Often, the T is rendered invisible or not really discussed. So, people will say, “I’m an ally for the LGBT community,” but not really know what T means, never having worked with folks who identify as trans. And so, they might go into a session with somebody who identifies as trans with these predetermined, taken-for-granted ideas of gender.

when it comes to issues around LGBTQ, however, that acronym doesn’t account for the different hierarchies of worthiness

The client might identify as a trans woman but be expressing their gender in a way that’s read as masculine in our culture. And so, what the well-meaning clinician might do is mis-gender the person by not using the pronouns that the client identifies with. The therapist might not share their own pronouns, it’s sort of taken for granted that there’s a normal gender. They might focus more on voyeuristic curiosity about genitalia and might have normative ideas of what it means to be trans. And for trans folks, there’s no one monolithic trans experience.

And then, I think the therapist who’s cisgender–this being a term for somebody whose gender identity is congruent with the sex they’re assigned at birth–may have a lot of unearned privilege in many areas. I am cisgender and don’t get misgendered. If I go to a doctor, the forms are very clear for me. My gender is right there, I click the box male. I don’t have to worry about spaces like restrooms and public bathrooms. I don’t have to worry about questions about my genitalia or dating or all that sort of stuff. Cisgender people don’t necessarily have to worry about being harassed in public because of their gender presentation. So, I think therapists who have cisgender privilege often don’t really take that into account in their work with transgender people.

Another thing that I’ve been really thinking about a lot more lately is the Black Lives Matter movement and some articles I’ve read around transgender allies. I see myself as an ally, but I’ve been reading some material asserting that simply being an ally is not enough. It becomes an identity, a noun, not a practice, and you know the ally almost gets centered, and people build their whole career on being an ally and profit from it, but not necessarily helping the community. That was really hard for me to look at because I do good work. I try to use my voice to support marginalized communities like trans folks. I’m writing a book on it, I do speaking engagements, and so it got me to rethink about what is my role? Am I putting myself out there? Is there any sacrifice? And so, there’s these new ways of rethinking allyship and referring to being an ally as more of a co-conspirator or an accomplice. And that’s happening in Black Lives Matter movements. We don’t want white allies, we want white co-conspirators, where you hold your white colleagues and friends accountable. So, it would be like me, as a cisgender person, really holding other cisgender people accountable for when they make transphobic comments. So, I think those are some of the things that might contribute to well-meaning therapists who are cisgender inadvertently imposing certain ideas that are cisnormative or transphobic.

LR: Elegant answer, David. Elegant. My mind is spinning with possibilities. What is queertopia, and if, in some wonderful future, we can live in that queertopia, would there be a need for therapists?
DN: That’s a great question. I don’t think so. I’m going to take that position of a queertopian, through a queertopian lens. A colleague of mine, Julie Tilson and I, wrote some about queertopia, and I’ve given some speeches on it. One was at an event called the Transgender Day of Remembrance, which is an international event – it’s a very somber, moving event about honoring and recognizing all the folks who were trans or gender nonconforming who were murdered over the past year. So, one of the years, I was asked to do a talk about what it’s like to be cisgender and then about what a queertopian world would look like.

In a queertopia, we would dismantle the gender binary. There would just be multiple genders.

In a queertopia, we would dismantle the gender binary. There would just be multiple genders. There wouldn’t be a need to police sexuality, you know, these hierarchies of gay and straight. There would be a loosening up of these strict identity categories, because I think identity categories can be useful, but they also impose restraints and limitations.

If somebody comes out as gay, there’s all these normative ideas of what it means to be gay. So, it can become another opportunity for policing and surveillance. There would be more of a loosening up of these identity categories. There wouldn’t be a DSM. There would be more work in the communities and community work rather than just individual clinical work. I think it would also be intersectional, so there would probably be a lot of focus on anti-racism and looking at some of the ideas about what it means to be male. There would be a loosening up of those ideas. And there would be a lot of just understanding of people’s identities and lived experiences, not necessarily related to their biology, their genitalia. Those are some of my thoughts about what a queertopia would look like.

LR: In queertopia, therapists might not be cloistered away in private practices behind closed shades. They’d all be social workers, they’d be co-conspirators, they’d be advocates, they’d be out in the community. There’d be more conversation about all the different ways of expressing oneself.
DN: It would be more like a deprivatization of the culture.

Hierarchies of Worthiness

LR: It’s ironic, almost paradoxical, that you have this forward-thinking vision of a queertopia, deprivatization and removal of gatekeepers of normativity. But one of the things that you do in your practice is psychological assessments for trans folks who want to pass through the portal of acceptance. Do you find yourself on the wrong side of the gate when you’re doing these assessments?
DN:

the standards of care when working with trans folks have moved a bit more towards depathologizing trans identities

We have this queertopian vision where mental health would get out of the way of people’s journey or transition, but that’s not the reality. Things are better. The standards of care when working with trans folks have moved a bit more towards depathologizing trans identities. In the DSM-IV, there was Gender Identity Disorder, now it’s Gender Dysphoria. The WHO (World Health Organization), in their next ICD – version XI, will no longer include gender dysphoria in the mental health section. It will be in the sexual health section. So, there is this movement forward. There are more trans voices, including trans folks who are providers, therapists. So, that’s the ideal, where it’s moving. But there still is this requirement by insurance companies and by physicians to diagnose a person with gender dysphoria. It needs to be medicalized in some way or psychiatricized, and since that’s the reality, I’m going to try to use my privilege, my credentials, to help make that gatekeeping as painless as possible, to not go through too many hoops.

What that might mean for me is that instead of a trans person having to see a mental health professional for a three to six session evaluation–which is a big cost and presents a barrier for so many folks, because this population is underemployed or unemployed–I don’t charge them if they need a letter. And I do it as fast as possible. I don’t really question them around whether they have a legitimate trans identity. I’m just using the letter to be an advocate, using letters as another form of co-conspiracy. It’s me saying, “You need this, I’m going to do it as fast as possible. One day, I hope we don’t have to do this, but in the meantime, you know, this is a way I’m trying to help support you.”

LR: A subversive gatekeeper.
DN: And then what I do for trans youth is to write a second letter. So, there’s the traditional clearance letter/assessment in which I diagnose them and say why they need hormones or surgery out of medical necessity, but then I’ll also write a counter letter, a narrative letter that is more about their own standards of care, their own appreciation of their gender journey, so they get two letters.
LR: That’s neat. So, you’re representing both sides of the fence, so people pass through it more easily.
DN: I think over time, I’ve figured that out. So, in my assessments, I’ve focused less on “Do you meet the standard, the criteria?” I’ll even say, “You know, I’m supposed to ask these questions. Why do you think I’m not going to ask them?” And they’ll say, “Because I already know that stuff. I know what hormones do. I know what the side effects are.” So, I focus more on their journey, on their narrative. I was working with this trans youth, where I asked him, “In your journey, have you thought about the kind of masculinities that you want to take up?” A lot of the conversations are more along those lines: their hopes, their visions of their own life, their gender identity.

Final Thought

LR: If we were to finish this interview up by trying to touch on kids, can you say a few words about what a therapist should know about working with trans kids?
DN: So, in working with trans children and teens, one thing that is really important is that young people are pretty clear about their gender identity. There are these discourses that they’re not capable of making decisions, I’m talking more teenagers where they might want to start taking hormones or hormone blockers. There’s this idea that they’re not capable and mature enough to make those decisions. As a narrative therapist, I look at how there’s a lot of discrimination like youth oppression, not honoring their voices. One thing is just to really honor their version of their gender identity and not to begin from the notion that they’re confused about their identity. That would be one thing, in terms of working with trans youth.I think another thing is to have conversations about how is it that they’re able to navigate this in spaces like schools that can be pretty tough and where there can be a lot of bullying. It is about helping them develop strategies to advocate for themselves and protect themselves. I use them a lot as consultants to other trans youth.

I’m working with one young trans man who then consulted another one of my clients and their parents because they’re earlier in their journey and had some questions. The dad is really concerned about hormones and their effects. So, I’ll use my other families’ experiences to help each other. I find that in my work with queer and trans youth, I’m always amazed and honored about how they’ve had to live their life and that they have these amazing ideas we can learn from as adults.

LR: Empowering them.
DN: Around how to look at gender and sexuality differently.
LR: Because of their honesty.
DN: Exactly.
LR: David, I’m going to draw us to a close. Thank you for a couple of things. You’ve been inspirational to me through your writings, truly. And as I did the reading and preparation for this interview, it further deepened my affection for narrative and strengthened my reserve. It’ll make me a better teacher and clinician, and I trust that our readers will also benefit, so I thank you for all you do on both sides of the fence.
DN: Thank you. I appreciate that.

What’s the Limit? Maintaining and Understanding Boundaries in Psychotherapy

Posted on by Psychotherapy.net Team

Anita* was an experienced therapist who consulted with me about a client who consistently arrived late for sessions and refused to leave when his time was up. “I don’t usually have difficulties setting limits with clients,” she told me. “But I’ve tried everything with him, and nothing is working. In our last session, I told him that I was going to have to start charging him for the extra time. He just said, ‘okay.’ And he still didn’t leave.”

We all know that boundaries are extremely important in any psychotherapy relationship, but they are not always easy to define or to maintain. They’re also not always easy to identify.

Defining Boundaries in Psychotherapy

What is a boundary, in fact? I like what a group of physicians has said: “A boundary may be defined as the ‘edge of appropriate professional behavior, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role.” I also like what Gary and Joy Lundberg write in their book I Don’t Have to Make Everything All Better: In daily interactions with others, boundaries “are statements of what you will or won’t do, what you like and don’t like, how far you will or won’t go, how close someone can get to you or how close you will get to another person…they are your value system in action.”

These definitions apply to both therapists and clients, yet other factors also play important roles. For instance, how we set and maintain boundaries reflects not only our personal and professional values, but also respect for our clients and their boundary needs. Furthermore, boundaries reflect something important about our respect for ourselves.

In fact, this was one of the problems that Anita was struggling with. She wanted her client to respect her, and his behavior around the scheduling of sessions felt to her as though he was disrespecting her. She was having difficulties finding a way to maintain her boundaries, her self-respect, and his respect for her

Boundaries also reflect important information about a relationship between two people, whether the relationship is a personal one or a professional one. Boundaries can be ephemeral and often confusing, in part because they embody the often-unclear lines of connection and separation in a relationship. In psychotherapy, a significant amount of work is done within the relationship between therapist and client. Individuals have an opportunity to work on their relational difficulties. Boundaries, whether they have to do with office rules, payment, scheduling, electronic communication or a therapist’s personal life can become the medium for exploring, understanding and working on issues that emerge in a client’s life with others.

“Freud sometimes made house calls to do therapy with patients and often interacted with them socially”; such behavior is seen as boundary-crossing today. Yet the Internet has created dramatic changes in traditional boundaries. While some therapists refuse to communicate anything other than appointment times in electronic communication, many others conduct psychotherapy online and by telephone, even exploring the benefits of doing online psychotherapy with clients in their beds.

Boundaries Have Meaning

While both a therapist’s and a client’s boundaries need to be clarified and respected, a therapist’s curiosity about any boundary question that comes up for a client can be an important tool in the therapeutic process. In their Psychotherapy.net essay on doing therapy with clients in bed, Giré and Burgo tell us, “Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of any boundary transgressions.”

For instance, over the years many clients have asked to hug me. Physical contact between therapist and client has long been an area of controversy, and, of course, a question of boundaries. Not only is it significant in terms of potential sexual coercion and assault, but it also raises important questions about both the therapist’s and the client’s comfort with non-sexual physical touch.

I am not a particularly physically demonstrative person and do not always find that kind of contact comfortable. Because I know that to cross my own boundary in those cases would be harmful to the therapeutic work, I have found ways to tactfully and gently refuse the request, often explaining that it is one of my own boundaries that I am careful not to override. Such an explanation often leads to a client’s apologies, and sometimes to a painful discussion of their fear that they are not only unlovable, but also so repulsive that no one would ever want to touch them.

In one instance, with a client who seemed to go out of his way to make himself as unattractive as possible, I asked if it was possible that he actually did not want to be touched. He seemed taken aback by my question, but then he began to wonder out loud. “I think I want to be touched,” he said. “It’s not that. But I think I’m afraid that I’m going to be rejected; so, I sort of set it up that I’m so disgusting that I know that it’s going to happen.” I replied that that made sense to me. I said that I thought he was trying to take control of something that he feared. “It’s better if it doesn’t come as a surprise,” he agreed. “Somehow it doesn’t hurt so much that way.” That client and I spent many years working together, and the process of trying to understand what might be going on with each of us, and within our relationship, helped us to understand some extremely important, complex and subtle aspects of many of his other relationships.

I have learned to share this information about myself with clients in a way that often leads to our finding other ways that they can feel soothed and comforted by me and close to me without touching. In many instances, the process of talking about our different needs has also opened areas in which they struggle with similar issues in their personal lives.

Role Modeling and Boundaries

How we look at and work with boundaries can also serve as a role model for clients, whether it is in the service of protecting their own or respecting the boundaries of others.

For example, there are times when I am comfortable hugging a client. I am not always sure exactly what makes me feel comfortable with the contact, but I have learned to respect my internal communications – the same way that I encourage clients to pay attention to their own wishes not to always do what someone else wants them to do.

Not too long ago, two separate clients who were struggling with painful realities in their lives brought up the issue of hugs. Both had been in therapy with me for some time. One shyly asked if it would be okay if she hugged me. The other told me that I was not to hug her and was not even to look at her sympathetically. In both cases, I agreed to the request. I also asked if we could talk about what their requests were about – what they were hoping for and what they were hoping to avoid. And finally, I asked if they could talk to me about their responses to my response.

I was willing to accept and respond to what they needed, but I also maintained my curiosity about what was going on beneath the surface – what either the hug or the restrictions meant in terms of the larger picture of their lives. In part I was able to provide this kind of approach because of my awareness and respect for my clients’ boundaries and for my own.

Exploring, Understanding and Maintaining Boundaries

To return to Anita: as we attempted to understand her client’s refusal to accept her boundaries, we began to see that the dynamic between them was complicated not only by each of their personal dynamics, but also by social and cultural factors. “I feel like he’s being sadistic,” she said. “By refusing to accept limits that I set, he’s setting up a ‘MeToo’ situation. He’s being an aggressive male and putting me in the position of being a compliant victim. And I refuse to be in that position.”

In his book Attachment in Psychotherapy, David Wallin explores some of the links between a client’s behavior, a clinician’s reactions, and unarticulated, often unknown attachment issues. Because I thought that her client’s behavior might be related to some unspoken, maybe inaccessible relational dynamics, I asked Anita if she could imagine talking about her dilemma with her client. At first she doubted that it would be useful. “Why would I make myself vulnerable in that way?” she asked.

I told her that I thought by sharing some of her dilemma, she might also be putting into words some feelings and relational issues that her client was enacting with her. I said that I thought he might even be relieved that she was able to articulate something that he felt but could not talk or even think about. I said that I also was hoping that by putting her dilemma into words, she would be altering the power struggle between them. She decided that there was really nothing to lose. “I’ve tried everything else I can come up with,” she said.

When he arrived late for his next appointment, Anita brought up the combination of his late arrival and refusal to leave on time. She said, “I’ve been thinking about what’s going on here, and, although I’m not sure you’re going to like them, I’d like to share my thoughts with you. Would that be okay with you?” He nodded, but she said he looked uncomfortable. She then told him what she had told me.

The client seemed deeply moved by her comments. After sitting quietly for a few minutes, he said, “”Wow. I’ve been feeling resentful that you have all the power in this relationship. And you’ve been feeling assaulted by me”. I think you might have just solved a puzzle I’ve been unable to solve for a long time. I haven’t even had a way to think about until now.”

He went on to explain that he often seemed to get into similar kinds of power struggles at work and in his personal relationships with women. “I’ve always felt like I was the one who was being forced to do things against my will,” he said slowly. “But maybe other people feel like you do—like I’m the one who’s pushing them around. That’s really weird. But it kind of explains why people get so mad at me when I’m feeling like I’m just trying to protect myself.”

This insight did not change the power struggle completely, nor did it magically shift the client’s difficulties with other people. In fact, they had to repeatedly revisit the same dynamics both in their relationship and as they discussed his interactions with other people in his life. The client began arriving closer to the proper time for his appointment, but he continued to have difficulty leaving. But now they were able to look at some of the reasons for both behaviors, not as a power struggle, but as an attempt to control both the connection to and the separation from his therapist. Exploration revealed that he found separation extremely painful, but that he was embarrassed to admit how much it hurt him to have to leave—or to be left by—someone he felt close to.

Theirs was a long and productive therapeutic relationship, and the early struggle over the end of sessions became an experience that the two of them referred to over and over again as a template for understanding what was going on when the client began testing boundaries and acting (and feeling) like a rebellious teenager.

Conclusion

Boundaries are crucial to any relationship, including a relationship between a therapist and a client. Yet these often unclear, ephemeral lines between connection and separation and self and other can become the means by which we can understand a client’s self and relational struggles. A clear and consistent frame protects the work of therapy. But that work can be greatly enhanced through the process of exploring, understanding and reflecting on those boundaries.

*names and identifying information changed to protect privacy  

Daryl Chow on Reigniting Clinical Supervision

Posted on by rezendevknowfully.com

Supervision at the Crossroads

Lawrence Rubin: Good morning Daryl. Thanks for sharing your time with our readers. Your research and writing suggest that supervision as it has traditionally been practiced is in crisis. What is the crisis in the field of supervision that you are responding to in your work?
Daryl Chow: I think there are weaknesses in the status quo practice of supervision, and that is something that we should pay attention to and do something about. I think change needs to start to grow from what we know from the research, as well as from clinical practice in supervision. We need to do something that's closer towards two domains: helping therapists improve their performance and, while they're doing that, also emphasize what they are learning. So,
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time
it's not just helping supervisors with what they're doing on a case-by-case basis, but also helping them to develop and evolve through time.
LR: What does it mean to help supervisees or therapists grow and develop, as opposed to just performing in supervision?
DC: In my online course, Reigniting Clinical Supervision, we make an important distinction from the get-go between coaching for performance and coaching for development and learning. Coaching for performance is one way of doing clinical supervision where we help each therapist improve in the stuck cases they are presenting in supervision. This is indeed important in helping them work through the clinical issues that may be blocking progress or preventing them from making inroads in their work with clients.

But I also think what supervisors need to support is an undulating process of helping clinicians with their stuck cases, while also trying to glean general principles with which they can help clinicians then create or identify patterns that are showing up through these stuck cases. It is a matter of looking closely at the cases in which the clinician is not making progress in order to help them in their own personal and professional development. This transcends a case-by-case supervisory discussion in order to focus on the therapist’s growth edge; those skills and characteristics that are generalizable, or what Wendell Berry talks about in terms of agriculture, which is solving for patterns. So, these two worlds of coaching, or supervising for performance and development, need to come together in the supervisory relationship.

If you look at the literature right now from Edward Watkins and others who have done great work in the study of clinical supervision, we have not made any progress. If the outcome of effective supervision is reflected or measured in client improvement, we have not actually moved the needle.

Tony Rousmaniere and his colleagues wrote a paper in which they concluded that
the variance in client outcome accounted for by clinical supervision is less than 1%
the variance in client outcome accounted for by clinical supervision is less than 1%, which means not much, right? That's concerning, because we put so much time, effort, and money into supervision. So, while I don't think I would use such a strong word as crisis to describe the field of clinical supervision, there is definitely a need for change. I really think that we are seeing things slowly changing on the ground level and there are people who are trying to change what we have come to accept as standard practice in supervision. 

Supervising for Development

LR: Okay, so what is the supervisor actually working on when she is focused on the supervisee's development?
DC: Well, the short answer is specific stuff such as the supervisee’s learning objectives. And their learning objectives are based on their performance. I will give you an example. If a clinician was to seek help from a clinical supervisor, that clinician (the supervisee) would first need to have a baseline of their performance, not just at the client-by-client level, but based on a composite of cases that they're seeing that provides them with enough reliable client outcome data.

And then, from those results, they would try to figure out where they're at before deciding where they need to go and what issues they need to address in supervision. I think that's a critical first step, because better results in in clinical supervision as measured by client outcome are obtained sequentially, not simultaneously. By that I mean we need to figure out where the supervisee is at. If their clinical outcomes are average, that really doesn’t say much about what they need to do in order to improve their performance. It is a matter of taking the second step, which is zooming in or focusing on those areas of clinical practice and therapeutic relationship where that clinician needs to improve. Simply focusing on the fact that the clinician is “average regarding their clinical outcomes,” doesn’t tell the supervisor where she needs to focus her lens regarding the supervisee’s skills and development.

So, as an example, if a clinician’s performance was average compared to international benchmarks, the supervisor would then focus in on those cases in which the clinician was stuck. They might listen to some recordings of the clinician’s work to discover that the clinician and the client did not develop therapeutic goal consensus. And it is often the case that
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions
goal consensus is one areas that's not often fleshed out or verified in the process of the first or even in subsequent sessions. You and I both know that the goalpost changes as we go, right?

Sometimes the goal is to figure out the goal, to figure out what is or should be the focus of the session. Then the therapist and supervisor work on that one specific area. And then—and this is the critical piece—if the clinician and client are indeed working on goal consensus, it's important for both the therapist and the client, as well as the therapist and the supervisor, to follow through with the work towards that goal and then determine if doing so actually had an impact on therapeutic outcome.  
LR: And just to define the outcomes variables you're talking about—are you talking about outcomes in the client progress, or in the supervisee’s behavior?
DC: I think you hit on an important note, because the feeling of benefit for the therapist does not mean actual benefit for the client that they work with. Remember, we're dealing with two steps removed from the office, so we need to make sure that the work we are doing with the supervisee translates into positive outcome for the client. It's almost like a paradox if you see two overlapping circles. Yes, it's about the supervisee’s performance, but if you focus purely on their performance, you're not going to go anywhere with the client. You're going to be riddled with anxiety. "Am I doing well? Am I doing badly?" And there's so much judgment involved.

We need to see the impact on our clients and see if our learning leads to impacting the people that we're working with. If the learning was focused on goal consensus, we want to see that it actually translates to an actual impact on the clients that you're working with on that level, on one client at a time. But we also want to see if that helps you to move up your effectiveness above your baseline. 
LR: It seems you're saying that, if a supervisor is good at his or her job and guiding the supervisee effectively in the deliberate practice of therapy, then the client will by definition improve.
DC: Wouldn't you expect that?
LR: I would, but isn't it possible that—and I'm not trying to be provocative—but that a supervisor may be very effective in guiding the supervisee or the clinician in deliberately practicing their craft, but the client doesn't improve? Does that mean that the supervision failed? Or might it just be that something was missed? In other words, can you have good supervision and still poor therapeutic outcomes? Or do poor outcomes in therapy mean that the supervision was not effective?
DC: That's a really good point that world-champion poker player, Annie Duke, talks about in her book, Thinking in Bets. She makes a very important distinction which I think we need to think about slowly and carefully. And the point that she was making is:
we tend to conflate outcomes with process
we tend to conflate outcomes with process.

She says that when we get a poor outcome, let's say in the game of poker, we think that our process is responsible for that outcome. She says we tend to conflate the two. If you take some time to think carefully about how you're making decisions, how you're building the process and making a good plan, then if the outcome is bad, don't make that conflation too quickly.

Because in the game of poker, just like in the game of life, there's a lot of random noise, a lot of things that are beyond your and my control. But if you understand with the help of a supervisor that you are working on something critical—in our case, goal consensus because we know the effect size for goal consensus is huge, then it becomes a matter of focusing more directly on building that particular skill in supervision, not other skills unrelated to goal consensus.

And if goal consensus is indeed important—even if one client doesn't work out well, you don't want to go and throw the baby out with the bathwater. You want to just go back and refine goal consensus building skills again. Close the loop. And this is one thing supervisors and therapists can do, is to make sure that, after a discussion, they close the loop.

It sounds so plain and simple, but I think it's really something that's lacking in supervision as well as clinical practice, that people don't really close the loop by figuring out ways to refine the important skills in supervision that actually impact client outcome. If you continue doing this with other clients, will this have an impact as well? 

Deliberate Practice

LR: Along these lines, you have an upcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, with Scott Miller and Mark Hubble. How can supervisors use deliberate practice to improve not only their supervisee's performance but their own performance as supervisors?
DC:
When we are working in supervision… we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client.
It's a brilliant question, and I know, Lawrence, we've talked about this. My belief at this point is I think that it is critical. We are really in the early days of this type of investigation, but I think it's an important area to work on, and here's why.

My belief is that knowledge is multilevel. When we are working in supervision, we are doing just that because we are really working within a multi-tiered structure that includes the supervisor, supervisee and the client. And let me just use an analogy from the world of music. I'm always impressed by not just what the musician does in a music studio or how they work. I'm always interested in who else is in the room. And one of the things that comes up very often for me is the role of the producer. Sometimes it's the group of artists itself, and sometimes it's someone else.

And a couple of people that stick out to me are Brian Eno, who has worked with Talking Heads, Madonna, U2, and Rick Rubin who has worked with death-metal bands like Slayer. He's worked with many Hip Hop artists. He's also worked with the late Johnny Cash. There’s something about being in the presence of these types of producers that brings out the best in the musicians.

My question is twofold. One, what the hell are these producers doing that brings out the best in the musician? But I also am interested in how I can help others and myself be able to become more like a coach or mentor the likes of college basketball’s John Wooden. And the one thing that I think is becoming a little bit clearer as I go is that we really need a system of practice, a way to systematically organize ourselves around how we think about supervision. So, when I say system, it just means as simple as: how do we track outcomes?

My mentor and collaborator, Scott Miller, talks a lot about feedback-informed treatment. To me, measuring what we value is key, because measurement precedes professional development, so it is critical to help people, supervisees in this case, to systematically track their outcomes and to have a system of coaching already in place by the time they come into supervision.

And then we develop a taxonomy of deliberate practice activities so we know where they're at in the baseline, how to help them figure out a way to deconstruct the therapy hour and then pick up little things that they can work on. So, I guess my short answer, or rather my long answer is really, to figure out a system that can function as a platform from which we can begin to work on the more nuanced stuff in the role of supervisor. Am I making sense about this? 

A Portfolio of Mentors

LR: You are indeed, Daryl, and related to this notion of the producer and artist working in collaboration, you recommended that clinicians build a portfolio of mentors. Does that mean that, even though supervision is, as you call it, a signature pedagogy, that clinicians should build a production studio of sorts with other professionals? 
DC: As much as supervision is a signature pedagogy for our field, what's interesting for me of late is how people reaching out for consults or coaching often follows having given up on working with a supervisor for various reasons, unless they are in an agency setting where that is provided. But, yes, I think the idea of a portfolio of mentors is to say that
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you
if you can figure out what's your leading edge or the gap that you're trying to work on, your default supervisor may or may not have the knowledge to help you.

And what you want to do is to create a community of people that you can turn to, that you can talk with, and then maybe a certain person you turn to more routinely. For instance, I've known a supervisor for more than a decade, and I always return to her. But if there was something else that was missing, or I wanted to stretch out and pick another mind to think of it from a different perspective, I would reach out to other people, even people who are so-called experts, and send them an email. I would ask them, "What's the fee? Can I come talk with you?" And most people are friendly. 
LR: In a way, isn’t that what you are trying to provide through your online supervision training, Reigniting Clinical Supervision?
DC: My focus for Reigniting Clinical Supervision is to help clinical supervisors design better learning environments that sustain real development for therapists, so as to achieve better client outcomes. The choice of an online learning platform is not a mere substitute for live teaching. Instead, gleaning from the best of what we know of optimizing learning, adopting a “one idea at a time” drip-based method of delivery of content and maintaining learner engagement, helps the busy practitioner weave what they learn into practice, and return to renew and reconsolidate new knowledge as a result of being in the course with me and other clinicians/supervisors.

Here’s how I think about the difference between a live training and how Reigniting Clinical Supervision is designed: A real-time training/workshop is like a river. It is a constantly flowing torrent of ideas. If the learner steps out of the river for a few minutes, or needs some time to think, he is now behind. The learner may be able to ask questions but needs to constantly try and catch up and not fall behind. A chance for a revisit of the content after some time of reflection is not possible, with only the notes or slides that you've captured.
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time
Online learning, on the other hand, is like a lake. The learner can step in and out of the water at her own time, and pace herself as she moves along; the water remains the same. This stillness allows for pausing, revisiting the material, reflecting, and connecting with past knowledge. Online learning at its best allows for the learner to ask questions, revisit the materials, and for the person to master a difficult segment before moving on.
LR: Within this community of mentors model, there are different factors that predict therapeutic outcome. They include goal consensus, alliance and repairing therapeutic ruptures. Can the same principles be applied to improve supervisor performance and development?
DC: Hopefully, that's paralleled or modeled within the supervisory work. I would encourage supervisors to also elicit feedback within the supervision. And most of us do that, but it is also important to do it in a way that's a little bit more about a ritual. This would mean using some quick check-ins that give the supervisee some space to think about it, and then to explore the nuances of the supervisor/supervisee relationship. It's much harder when you really know somebody well, like the supervisor knowing the supervisee, to give feedback.
LR: Have you experienced working with expert clinicians who are lousy supervisors?
DC: I'm thinking of the converse. So, let me look back in my mind. I don't mean this in any disrespectful way because I really respect this person's work. Jay Haley of the strategic school of family therapy talked about this and said that he was really good as a supervisor, but not as good as a therapist [laughs].
LR: I think of myself as being a better supervisor and teacher than therapist. In your language, perhaps that’s because I have not deliberately practiced therapy.
DC: Yes, right.
LR: I've performed therapy, but in the words of Scott Miller, I've not deliberately practiced it. So, it's interesting that just because someone may be a very competent clinician, it doesn't mean that they have the patience or skill to guide a fellow clinician as a supervisee, and vice versa.
DC: This harkens back to your question about the role of training supervisors in how they do deliberate practice, because, to me, there are overlaps, of course, but there are also distinct skills required in their roles as supervisors and therapists.
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction
The role of a supervisor requires some skill to be able to articulate the concepts without getting lost in the weeds of abstraction.

Cardinal Supervision Mistakes

LR: Talking about getting lost in the weeds, you wrote an article for us about seven mistakes in clinical supervision. If you were to pick the top two cardinal mistakes from that list of seven that supervisors make, which ones flash red to you, and what can supervisors to do about them? 
DC: This is tough because the language around mistakes is all negative. I think, for me, the one that I've seen in my own experience and through my own mistakes is that of too much theory talk.
I think we talk too much. On the ladder of abstraction, talk is quite high up there
I think we talk too much. On the ladder of abstraction, talk is quite high up there. Bear in mind, when we're in supervision and in the absence of the actual client, we spend all our time talking in abstractions, at the level of theories about the client rather than about the therapeutic relationship.

When we're doing that, we've got to bear that in mind, that we don't have that person there, and we're talking at the level of theoretical abstraction, so many steps removed from what is occurring between the supervisee and the client. It's very easy to speak of it from whatever orientation or whatever philosophy you hold, without joining the dots of what's going to ripple down into the actual therapeutic relationship where the real work is happening.

Another big mistake in supervision is that when the clinical work is stuck and the supervisee and client are not making progress, the supervisor may say something in an attempt at being supportive to the supervisee like, "Well, at least they keep coming back, right?" In this instance, the supervisor is doing little more than what I call, patting them on the back–encouraging the supervisee without giving her any clear direction out of the stuck situation.

I'm really conflicted about that statement that I hear very often. Is that good enough for you, that they still come back? Or what else? What else can we be thinking of? How do we escape this domain of just talking on their level and to be able to make some real impact?  
LR:
Another big mistake in supervision is…encouraging the supervisee without giving her any clear direction out of the stuck situation
I know that being able to effectively conceptualize a clinical case, to think about it from different theoretical perspectives, is important. But you're saying, Daryl, that sometimes we err on the side of overthinking the theory at the expense of guiding the supervisee in building the relationship with their client, and then we congratulate the therapist for minimal progress? Seems like damning by faint praise.
DC: Yes and no. I think all prudent supervisors know that therapeutic relationship really matters. And by therapeutic relationship, let's be clear, it's not just about the emotional bond, even though that is one critical part. But the other part is the focus, which is about the goals, the directionality, where it's going. The next is also about whether there is a cogent method for both the therapist and the client. Are we in agreement? Is there a fit in where we're going? All those things relate to the therapeutic alliance.

I think most people are focused about that. But as you will see in the upcoming blog that I am writing for Psychotherapy.net, I will be talking about the three types of supervisory knowledge. One type of knowledge is about the content knowledge, about the clinical case, about the psychopathology. Those things are necessary but not sufficient. The second type of knowledge is the process knowledge about how you engage with somebody who's, say, depressed? How do you engage with somebody who's anxious? That's a process or type of relating kind of knowledge. How do you have that kind of conversation? As David Whyte, the poet and philosopher, would say, "the conversational nature of reality." How do you engage in that? How do you come into being with another person into that field? But the third one is conditional knowledge, which is; if you're working with somebody who's depressed due to bereavement, it's going to be very different than when you're working with somebody who is depressed as well but due to, say, domestic violence. The context is very different, and you need to figure out a way of relating with them given the different situation. So, by considering all three of these in supervision; playing into the content knowledge, process knowledge and conditional knowledge, I think the supervisor can synergize them for the benefit of both the therapeutic work and the development of the supervisee. The supervisor and supervisee having this multi-level conversation will benefit both the client and the supervisee. 

The Humble Teacher

LR: What do you see as some of the important personal qualities of an effective supervisor or a clinician who might become an effective supervisor?
DC: For me, of course,
a good teacher is somebody who is willing to be a good student
a good teacher is somebody who is willing to be a good student. If I'm picking a supervisor for myself, I'm always looking for somebody who implicitly—and it's not something that people would say explicitly, is willing to be wrong, willing to seek the counterfactuals, and then to have by default a stance of humility not just because they're trying to act humbly or bragging about their humility.

This humble teacher will say, “Hmm. Oh, hang on a second. I've really never thought of that.” And they're rethinking. That, to me, is interesting. And it's not because they don't have a wealth of knowledge. It's because this is dis-confirming what they know. And that's so exciting. That's like fresh air, you know, when you're working with somebody that way.

Additionally, somebody who has mental models or mental representations and concepts in their head about different ways to think about clinical situations and suggestions for the supervisee. They know that when they're facing this kind of situation, they have what Gerd Gigerenzer calls fast and frugal heuristics. They have little maps of how they will approach stuff. You know, they've thought it through before. They have ideas in their memory bank that they will pull into their working memory.

And you know that because when they're just giving off-the-fly statements, you know that it's off the fly. But if you know that they've thought about it, you realize their mental networks are vast. They know that it's an “if-then” situation, and they're thinking about it and all kinds of communications. That excites me because that shows to you this person has done some thinking before meeting with you. 
LR: Is this what you refer to when you say that true experts think like novices, or beginning therapists, while true novices think they're experts? Is it related?
DC: I think so. [chuckles] I think so.
LR: I like that idea that the expert supervisor, who may or may not be an expert clinician, has these—what did you call them—fast and frugal heuristics? Was that the term that you used?
DC: That's right, and I mean that's the term from Gerd Gigerenzer, who studies cognitive science. He talks of the importance of having these sorts of heuristics. You know, the way we've been terming it is mental representation. Things that happen might not just be easily explained using therapeutic models but by different ways of thinking. Like, what do you do if you meet somebody who is angry or depressed in the session? These heuristics or maps are not like stock answers but are based on clear principles that flow from these mental representations. What do you do with somebody who doesn't have a goal? How do you work with them? They have a rough and ready guide.

At the Cutting Edge

LR: So, the supervisor should aspire to flexible thinking, drawing on different belief systems, different ways of looking at the human condition, different interpretations of the same clinical presentation? It sounds like the advanced supervisor is out at this cutting edge of creativity, untethered to any one way of thinking.
DC: Yes.

This domain of creativity is something I'm really interested in. I think one thing we need to remember about creativity is that it's about something novel and something useful coming together? Wouldn't it be great if supervisors were not restricted to thinking solely in terms of the field of psychotherapy in the course of doing their supervision, and could bring in greater creativity?

Just thinking about architecture, music, art—thinking about other aesthetic forms and how all of these can inform ways of thinking. Coming back again to the example about goal consensus, why do we need to only think about this within the domain of psychotherapy? Why don't we learn about how other fields and business organizations think about creating focus? 
LR: So, we should consider using a flexible system of metaphors that transcend psychology and psychotherapy. When we first contacted each other, I mentioned that there seemed to be almost a spiritual undertone to the way that you described your personal philosophy of living and helping. Am I seeing it correctly, that there's a certain spirituality or spiritual dimension to your work as a clinician and a supervisor, and perhaps we should embrace that as well?
DC: Well, I'm grateful that you picked that up. To me, the answer is yes. And I think that's personally a deep embedment in my life. I was raised a freethinker from my Singaporean days. You know, this means I'm free to think or whatever that means. But I converted to become a Catholic when I was 21. When everybody else was running out of the Church, I was going back in. So, to me, that was my start.

But I think, fundamentally beyond religion, what's really driving me on a first principle level is human dignity. And the way I think about this is that
if a person comes to seek help and opens up to another person, that's a sacred moment
if a person comes to seek help and opens up to another person, that's a sacred moment. We need to honor that. We need to figure out a way that we can help each other come alive, because it's not just about creating purpose and meaning, but it's really to help each other come alive. And the therapist needs to come alive. The therapist needs to be alive and kicking and playful and to be able to ignite that. And the therapist also needs help and guidance from a supervisor. And for the supervisor to do that, the supervisor also needs to come alive. 
LR: I remember Bill Moyer’s interview with Joseph Campbell at George Lucas’ Skywalker Ranch. He said to Joseph Campbell, “So, you're saying that people are searching for the meaning of life?” And Campbell said, “No. People are searching for the experience of being alive.” How does that find its way into the world of supervision, that tripartite relationship between supervisor, supervisee, and client? Where does that element of being alive get infused in that three-level process? And whose responsibility is it?
DC: Sounds like a family.
LR: Yeah, doesn't it?
DC: Yeah. I think everybody is going to come into play. I think it is the interaction. It's this ecology of a systemic perspective that's going to be important. How does it come alive? You know, I think we need some kind of platform for this to work, which we have talked about. But I think it critical is to keep this conversation going. Once we see that therapists are working hard to improve in what they are doing—once they figure out the baseline, once they figure out what to work on based on the baseline, then they develop a system to help them do their practice on an ongoing basis. And that they see the payoff of what they're doing.

It's like your child who's worked hard for the math test and starts seeing see the result. There's the real payoff. I mean the whole temperature of the room changes. Their focus becomes more intrinsic. And at that point, the role of the guidance is going to evolve as well. There's always going to be state of change. You’re right when you pointed out that quote from Joseph Campbell as well. That's something I'm very familiar with, and I think it's important that we continue to keep the conversation alive within clinical supervision as well as at the level of the therapist and client. 

Fanning the Flames

LR: So, just as we encourage clinicians to take care of themselves and to grow and to rest and to seek meaning and a reason for being alive, so too must supervisors continually replenish and rest and grow and seek internal expansion, because if they wither, then the supervisee withers and the client withers. Who are the roots, and who are the leaves in this tree? It's a quite interconnected system.
DC: [chuckles] It is. It's just like our world now, isn't it? I mean I'm suddenly reminded about this teenager from Sweden that's really been striking me about what she's doing. I don't know if you follow the news about Greta Thunberg and how she's doing this protest about climate change and rallying a million teens around the world to protest about how the adults in this world had better take this seriously. And she's been going on global forums just speaking about this.

And I heard one of her speeches which she starts by saying, “Our house is on fire. What would you do if your house was on fire?” And she expands on that. And I think that's so important, that somebody her age is speaking about this. 
LR: So, supervisees must find ways to, in your words, reignite supervision. I have one last question. You were born in Singapore, you live and practice in Australia, and you've traveled the world doing training in therapy and supervision. What have you noticed about teaching and supervising cross-culturally?
DC:
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people
I think the first thing that comes to my mind is how similar across culture we are in terms of helping people, trainings and our roles as therapists and supervisors. But, of course, each culture has its own subcultures that you're dealing with. But to me, really what's striking is how much similarity there is. We're all in the same boat.
LR: What do you mean, the same boat, Daryl?
DC: We're all struggling to get better. We all want to. I mean all therapists and all supervisors want to do a better job. And that propels us. That makes us stay hopeful. It makes us invest time, money and effort to go and do CPE [continuing professional development] activities. You know, we're all trying to get better. But what's implicitly underneath that wish to get better is worry. We do worry about, “Am I getting any better? Is what I'm doing really helping to translate?”

And people are asking this question as they are looking deep, long, and hard. And I think the onus is on us as a collective, as a field, to start to come together, to start to build this brick-by-brick, to help out from the therapist's level and the supervisor's level, and to help us build this house, build it up again, and to help us to get just that 1-2% better each step of the way. Because the payoff and the morale that comes with that is going to move us even further. 
LR: So, if everyone in that multilevel relationship strives to be a little bit better, then the whole system becomes better.
DC: That's right.
LR: If client outcome improves, then that goodwill is shared beyond the therapeutic space. If the supervisor is dedicated to practicing their craft, then they are in a better position to teach clinicians. And if clinicians practice deliberately, they are in a better position to help their client. And that is consistent across cultures.
DC: That's right. And, you know, I'm not the only one who is doing this, but I think I've started doing this whole thing about clinical supervision because I think we are a critical piece to the puzzle. And I think this one little story might help to illuminate this. You know, this gentleman, he knocks on his son's door, and he says, “Jamie, wake up, please. Wake up. You've got to get to school.”

Jamie then says, “I'm not going.” And the father says, “Why not?” He says, “Well, Dad, there are three reasons. First, school is so dull. And second, the kids tease me. And third, I hate school anyway.” And the father says, “Well, I'm going to give you three reasons why you must go to school. First, because it's your duty. And second, because you're 41 years old. And third, because you are the headmaster.”
LR: [laughs]
DC: I think we play that critical role. We do need to show up. And when we show up, we then need to think about what's our status quo and what's the one thing we need to start in order to refine our work to bring us alive again.
LR: To play that instrument a little better, to hit that tennis ball a little straighter, to run a little bit more efficiently. The supervisor must have a commitment to continued growth and development if the supervisee and the client are to improve.
DC: Yes, and I will say one last thing, if I may, Lawrence.
LR: Of course.
DC: If we use the musician analogy, I don't think it's to play the instrument a bit better.
LR: No?
DC: I think it's to play the instrument well enough but to be able to become better songwriters. I think that's a tougher job, because you can get technically better as a musician, but to write the next Hard Day's Night or Yesterday or Bohemian Rhapsody, I think that's a different skill. And I think we need to find a way to become better songwriters in our field.
LR: So, we can make better music together and because the audience is indeed listening.
DC: That's it.
LR: I think on that note, Daryl, I'm going to say goodbye, and on behalf of our readers, thank you so very much.
DC: Thank you.

Internal Emigration & Online Therapy

Posted on by Psychotherapy.net Team

“I was born in the wrong place,” one of my online clients told me. She is someone with fidgety feet and a knotty relationship with her homeland. Growing up she had felt out of place in her native town, tucked in the middle of Pennsylvania. I keep hearing different versions of this harsh statement, from clients from various cultures and social backgrounds.

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The feeling of not fitting in, not belonging to their original environment, is shared by many emigrant writers. Edward Said’s account of this experience is probably the most quintessential: “There was always something wrong with how I was invented and meant to fit in with the world of my parents and four sisters. Whether this was because I constantly misread my part or because of some deep flaw in my being I could not tell for most of my early life. Sometimes I was intransigent and proud of it. At other times I seemed to myself to be neatly devoid of any character at all, timid, uncertain, without will. Yet the overriding sensation I had was of always being out of place¹.

Said’s experience of being deeply flawed, his constant uncertainty and confusion about his own worth, are all indicators of various degrees of feeling shame related at least in part to his sense of not fitting in.

Joe Burgo, a psychotherapist and the author of a recent book Shame, insists that: “Unreciprocated affection or interest will always stir emotions from the shame family. As part of our genetic inheritance, we want to connect with a loved one who will love us in return; when our longing is disappointed, when we fail to connect, we inevitably experience shame, however we name the feeling². The motherland, which does not love us back, is similar to a parent that fails to meet our expectations of love. Both unfortunate situations naturally result in feeling that something is deeply wrong with us.

One of the ways we can cope with such circumstances is by leaving our original place altogether. For some, the decision to emigrate, often a difficult one, is unconsciously driven by the need to avoid shame provoked by the discordance between who we are and who we are expected to be in order to fit in. In many cases, the choice to leave home is the best survival strategy. The most obvious examples are queer individuals from countries that pathologize and punish homosexuality: they flee their homes in order to be able to freely live their lives in the way that feels right to them.

But such physical escape is not always possible. Individuals who grow up feeling that they do not fit in countries that they cannot leave for various reasons (e.g., an iron curtain of any kind, family situation, physical handicap, economic dependence) feel trapped and disempowered in the face of such an unresolvable conflict. Not being able to escape the place that is rejecting them only reinforces the feeling of shame triggered by a constant experience being different and not fitting in, and of being excluded.

When emigrating outwards is impossible, the only way of fleeing such reality is inwards. My own Russian culture offers abundant examples of such a psychological strategy for subsisting in an unfriendly reality. Soviet history gave us not only the concept of internal immigration, as mentioned by Angus Roxburgh in a recent Guardian article on life in the 70’s, but also a rich cultural heritage, which thrived “underground” despite the intermittently tyrannical regime. Many artists—Shostakovich being probably the most striking example—lived a paradoxical experience of inner freedom in the middle of an oppressive outer reality.

Russian emigrant writers give us a powerful lesson of resilience in dealing with hostile but inescapable realities. Through their art, they created inner bubbles of freedom, and often had to evolve in parallel realities like Joseph Brodsky who, decades before emigrating, introduced the notion of an “indifferent homeland” in his early work inspired by the quintessential poet in exile, Ovid.

Emigrant writers such as Brodsky or Nabokov’s use of a foreign language for writing is emblematic and has deeper meaning: they claim a new freedom from constraints imposed by their culture. Committing to a chosen second language, despite the difficulties and losses that this choice implies, is a powerful affirmation of individual freedom. This second language, according to Kellman, becomes the tongue of the parallel inner world and a language of freedom.

The same is true for some of my clients living in the state of internal exile. They often reach out to a therapist who speaks English even though it is not their mother tongue. This choice certainly complicates their therapeutic journey, but also allows it some unexpected depth and richness.

When I meet with clients who evolved under an authoritarian regime (e.g., Saudi Arabia, Putin’s Russia, China), I recognize the strength of this coping strategy. Our sessions happen online through videoconferencing systems, as the clients are often unable to find a suitable support in their home countries. The regimes they live under have no love lost for therapy, which aims at empowering the individual; they usually opt for a kind of punitive psychiatry, which was so well developed in the Soviet Russia. Its aim was, in Brodsky’s words, “to slow you down, to stop you, so that you can do absolutely nothing…”

Evolving in self-created bubbles of parallel realities drives us even further away from those who share this harsh external reality with us. This further isolation can only deepen the shame that we already feel about being deeply flawed and not fitting-in. Those who are restricted to these self-created inner worlds often display some recurrent symptoms: depression, anxiety, low self-esteem, and constant self-doubt.

Online therapy can offer these inward emigrants a third space, located outside of their unfriendly environment, on the outskirts of their inner reality. In these two conflicting worlds, they are alone, but in the virtual space of therapy, they find a friendly person in front of them, open and curious to learn about their worlds. The online reality shared with their therapist eventually becomes a safe space to reflect on the painful discordance of their inner and outer worlds.

Communication media that online therapy actively uses for its own scope often play an important role in dealing with life in unfriendly inescapable surroundings. Many of my clients living in the state of internal emigration turn to social media on the internet to find like-minded peers and feel less alienated and less ashamed.

There is an intriguing parallel between the voices of the free radio that had offered an opening towards the other side of the curtain during the Soviet times, and the social media of today. The latter is more interactive by nature. During the Soviet times, one was only able to listen and feel connected by a stranger’s voice talking in one’s own language from the other side of the divisive wall, whilst modern technologies offer the possibility for a dialogue, often in English used as the lingua franca.

I have witnessed many situations in which such an outlet kept individuals sane: Saudi women who connect with each other in the ethereal space of freedom; a gay man from Siberia finding connection with those like him and acquiring some form of validation of his own experience; a queer young woman in Putin’s Russia working for a liberal news online platform and through her work connecting with those whose thinking she can share.

Online therapy with a transcultural therapist, who evolved on the other side of the wall, in a different and often freer reality, becomes an ultimate opening for individuals who experience their external realities as oppressive. In some lucky cases it can shake up the juxtaposition of the two incompatible realities the individual is locked in and offer something else—a less lonely space in which they can experiment with fitting in, belonging and imagining other, less lonely and shame-filled, and freer possibilities.

References

(1) Said, E.W. (1999). Out of place: A memoir. New York: Knopf.

(2) Burgo, J. (2018). Shame: Free Yourself, Find Joy, and Build True Self-Esteem New York: St Martins Pres. 

Dual Aspect Monism: Centering Psychotherapy on Mind

Posted on by Psychotherapy.net Team

“My brain needs to be fixed.” My prospective client looked down, then up, to search my eyes.

The statement is deceptive in its simplicity. I feel an involuntary retreat from almost all the multiple layers of meaning I can fathom for the utterance. I don’t think my client’s neuro-chemical functioning is the cause of his pain. I think I can help him more effectively if we explore his mind.

Back in the day, there was body, and there was mind. Medical practitioners treated bodies. Therapists and analysts treated minds. Every binary hides a hierarchy: the people who treated bodies were highly respected. Those who treated minds were considered, well, a little off.

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Then people started realizing how much mental and physical functioning affected each other. They can’t be completely separate. The obvious solution (that preserved the hierarchy) was that mind must be an epiphenomenon of brain. Somehow, matter (brain) behaves in a way that creates a non-material phenomenon (mind). The battle cry became “mental illness is disease of the brain.” If you believe that mental illness is a disease of the brain, the way to fix it is to alter the brain. Chemically, surgically, magnetically, whatever. Talk therapy in this scenario is a poor substitute for direct neuro-chemical intervention, and one glorious day we will remember psychotherapy as a treatment analogous to applying leeches.

Except…logic dictates that the effect cannot impact the cause. The effect cannot precede the cause. So, if mind is caused by body, then mind cannot, logically, affect the body; a change in mind cannot precede a change in the body. And yet we know that it does. So maybe mind exists separately from the body after all? But if they’re separate, we’re still left with the problem of how two completely separate things can interact with and affect each other, as we know mind and body do.

As an ontological position (a statement concerning the nature of reality) offered by some philosophers of mind, Dual Aspect Monism offers a simple solution. The position is that there is a single reality that has two equal and irreducible aspects: mind and matter. Prior to the development of Dual Aspect Monism, there were basically three competing views concerning what is real. The dominant view today is Material Monism. From this perspective, reality is believed to be that which has physical properties. If you can’t measure it, it isn’t real. From this perspective, mind is the product of physical (neuro-chemical) activity. Idealistic Monism is the view that what is real is mind, and that matter is an illusion generated by mind. The third ontology is Dualism, which posits that mind and matter are both real, but they are completely separate realities. If they are completely separate realities, it’s hard to imagine why changes in one covaries with changes in the other.

According to Dual Aspect Monists, there is a single reality that is both physical and mental. Neither of these aspects is derived from or reducible to the other. These aspects are like two sides of a coin: you can’t make the head side of the coin square without altering the structure of the tail of the coin. But this does not mean that the change in the head caused the change in the tail. It is the change in the coin that changes both the head and the tail. When we use this analogy to understand humans, we see that some changes are more easily accomplished if we focus on body (I would not suggest that we focus primarily on mind to treat cancer), others may be more malleable by focusing on mind (I would not want to give a client a drug to help them develop a more fulfilling sense of self).

The implications are profound for psychotherapy: if mind is real and irreducible, we can legitimately aim our interventions directly at mind. We can use our minds to help clients change their minds. That means that our minds are the mutative factor in therapy. More precisely, the connection between our mind and the client’s is the mutative factor in therapy.

This means that some of the most profound changes our clients experience are changes in qualia (purely subjective experiences), and hence difficult to put into words, let alone observe from some outside objective position. It means that we know when our clients are improving because our minds are working together, and when their minds change, ours does too, a little bit. It means that what I do/say next is completely dependent on what my client and I are experiencing in the connection, not on some pre-determined protocol. That, in turn, means that my mind must remain attuned to the connection between our minds, not busy trying to problem solve, predict, or control the direction of the process.

We are psychotherapists. Many of us entered this field because the human mind is fascinating to us. Some of us have felt that the understanding of what we do has been slowly eroded as mind has become more and more devalued as an epiphenomenon of body. We always knew the two were connected (Freud was, after all, a neurologist). But many of us also know that what we do is not best captured by purely physical descriptions, or best understood using methods designed to understand the physical world. For us, dual aspect monism offers a way of understanding the world that explains what we do.

“Can you tell me what it feels like for your brain to be the way it is?” I try to join my client’s quale. By seeking to do so my mind reaches out, searching for, inviting a connection that can lead to change.  

It’s Time for Supervisors to Help Clinicians Marry Data with Intuition

Posted on by Psychotherapy.net Team

“It’s easy to lie with statistics, but it’s hard to tell the truth without them.”
—Andrejs Dunkels

Nearly every therapist I ask says that they regularly monitor the progress of their clients. Besides, why wouldn’t therapists check in and ask for verbal feedback?

Yet, given our clinical expertise, how is it that the assessment of our client’s progress is often inaccurate? In addition, why is it that therapists’ view of the process of clinical engagement is less predictive of outcome than that of their clients?

I believe this is because of our over-reliance on clinical intuition. We are trained to listen and take heed of our gut sense. Don’t get me wrong; intuition is critical, as scores of studies on this topic will attest (see Gary Klein’s body of work). Yet, relying solely upon clinical intuition is like asking a physician to treat a patient without the use of a stethoscope, a thermometer and the results from a bloodwork.

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From Assessment Thinking to Conversational Thinking

It’s time that practitioners learn to use outcome measures and engagement tools as part of regular clinical practice. And not merely as assessment tools, but as conversational ones. And to make this happen, clinical supervisors need to be on-board, trying it for themselves (especially if they are also practitioners), learning as much as they can about how to integrate measures as part of treatment and then teaching them to supervisees.

I once had a supervisee who wanted help getting “unstuck” with a client. We talked at length about the presenting concern, clinical background and what she had previously tried. The supervisee and client had just completed their 4th session when the therapist described that “things aren’t moving.” In other words, there was no discernable clinical progress.

Therapist View of Progress in the First Four Sessions.

I asked if she used any form of measures in her work. I learned that this therapist had been using outcome and alliance measures in her practice, but had not reviewed the graphic description of those measures. She was using the measures only because the management team insisted that she do so. I suggested that she bring the graphs to our next supervision meeting.

Here’s what the graph looked like:

Therapist View of Progress Alongside Client’s View of Session-by-Session Progress and Engagement

Even though there was a dip in the alliance at the 2nd session— a rupture from which the clinician was able to bounce back—contrary to her perception, this client’s experience suggested that outcomes were gradually improving. Not only was the therapist’s appraisal off the mark, but the plans we had devised with which to repair the perceived rupture were not right for the context. It was like wearing winter clothes in anticipation of being in the frigid Alaskan north, but instead finding ourselves baking on a beach in Bali.

We went back to the drawing board. We spent time working through the supervisee’s uncertainty and anxiety about her perceived lack of progress, while keeping in mind that the client was clearly perceiving and experiencing benefit from the engagement. As it turned out, the therapist was torn between addressing the psychiatrist’s referral concern of OCD, versus the client’s implicit desire to improve his relationship with his father. Thankfully, the therapist maintained fidelity to the client’s rather than the psychiatrist’s concerns.

In supervision, we re-focused our attention around attending not only to this particular client rather than the referral source, but how to do so with future clients so we could also address the perceived need of their referring sources. More importantly, the therapist needed to unpack and clarify some inferences about what she was doing and thinking that might have contributed to this gradual improvement, despite thinking that none was being made, so that she could continue doing so.

In this instance, thankfully, the client was improving. However, the opposite can just as easily happen, i.e., when we think that improvement is being made, but the client reports that “things aren’t moving.” When intuition and real-time data are either out of synch with each other or not taken together into consideration, clinicians (supervisees in this case) are prone to self-assessment bias. While we are re-playing mantras in our heads that say, “The clients will get worse before they get better,” we quickly realize that our client has dropped out of treatment.

Quick tip: In clinical supervision, make sure that supervisees bring in graphs of the client’s outcome and engagement. This is one critical way to privilege the client’s view of progress and engagement across time, while incorporating it into supervision. In turn, we can also monitor the impact of the “backstage” conversation of supervision on client outcomes.

But Why?

Here are two primary purposes for weaving ongoing measures into therapy and using them in clinical supervision:

1. At the Client Level

a. Guide the treatment process: “Are we on-track, or are we off-track?”

b. Use the feedback to feed-forward: Real-time feedback allows you to tweak the service delivery to fit each client, each step of the way.

2. At the Therapist-Level

a. Effectiveness: If used systematically, session-by-session with every client, the
therapist can figure out the nagging question at the back of all our minds: “How
effective am I?”

b. Individualized Development: Once you figure out where you are with the help of a
supervisor who is attuned to this type of process, you can start the journey of figuring out
“where you need to go” in your individualized professional development. (More on this in an upcoming blog post).


There may be many reasons not to use routine outcome measures in therapy, and only a few good reasons to do so. Personally, I am not a fan of numbers. The irony is not lost on me being Chinese and failing math (and Mandarin) in my early years. Besides, it is not as if therapists around the world need another thing to pile onto their existing and ever-growing paperwork! Yet, the benefits far outweigh the costs of not integrating some form of measures—tracking what is of value to the client.* A groundswell of studies now show that the use of measures such as a real-time feedback tool not only reduce deterioration in client well-being by a third, but doing so cuts drop-out rates by half, and as much as doubles the overall effectiveness of therapy.

The use of intuition without high-value data** is like trying to drive in a foreign country without a GPS or an old-school map. It’s possible to still get to your pinpointed destination—especially if your sense of North is better than mine—but the journey is likely to be mired in and derailed by unwanted detours. On the other hand, the use of data in the absence of intuition is like blindly following your GPS into a ditch, when the new road, which is just to your left, has simply not yet been updated into the system.

The knowledge gained from the marriage of data and clinical intuition contributes to a type of dialogue that is richer and aids clinical decision-making. Sometimes, client-reported data confirms what we intuit. Other times, the data contradicts our gut sense. The point of monitoring progress and weaving it into clinical supervision is not to defer all judgement to cold and unintelligent data. The point is to wrestle with this tension in order to see and think more clearly.

To learn more about becoming a better supervisor, check out the in-depth online course, Reigniting Clinical Supervision.

Notes:

*It is highly possible to be measuring something systematically that is not relevant to your client. For instance, capturing data without integrating the measures to inform the treatment process. Second, dogmatically using a symptom-specific measure that may not make sense for all your clients. This is why it makes more sense to be capturing information about a person’s global wellbeing.

** Data is only valuable when you are not valuing whatever you measure but measuring what is of value. 

The Performing Art of Therapy: Acting Insights and Techniques for Clinicians

Posted on by Psychotherapy.net Team

“Where does the actor acquire the understanding that for the doctor takes years of study?"
-Theater Director, Peter Brook

Act I: Therapists as Performers

Therapist, you are a performing artist, whether you realize it or not!

The moment a client enters your office, you are on stage, face-to-face with an audience, a scene partner, and a variety of characters you do not yet know how to play (after all, our clients both become and cast us in all of these roles faster than we can say, “How can I help you?”). And every move you make—or don’t make—influences the treatment, the play, the story you tell together.

“Like actors, as therapists our appearance, aura, voice, and relational responsiveness often leave stronger impressions on clients than the words we say or the techniques we use”. This is not to say that our clinical training is of no use; of course it is. But effective technique is less about what we do—less about reading a script by rote—and more about how we do it, how we use ourselves, how we perform our interventions.

When you watch actors performing in movies or plays, do you think about their techniques?—whether they used Strasberg, Adler, or Meisner? Probably not. You are more likely moved by the performers themselves—their ineffable presence, their use of self. Likewise, our clients are more affected by us than by our schools of thought—whether we studied psychoanalysis, CBT, or family systems.

No matter what kind of therapist you are, if you approach your work like an actor—or better yet, like a performing artist in your own right—I promise you will become more awake, alive, and engaged with your clients, while also having a greater capacity to care for yourself. I offer this promise as a psychotherapist who has used my experience as a trained, professional actor every day.

The skeptical reader may think that the words “perform” and “act” don’t belong in the therapy office. When I tell people that I use my training and experience as an actor more than any other resource as a therapist, they often take me to mean either that I’m “fake” with my clients, or that I deploy literal dramatic exercises in session. I’m not (or at least I try not to be) fake with my clients, and I rarely, if ever, use theatrical interventions in session, unless I believe they might be useful for a specific client in a specific moment. However, when I simply think about my clients the way actors think about their characters and scene partners, I enhance my capacity to dive into the deep end of their stories, beyond the words they speak—their “scripts”—even when I do nothing more than listen to them compassionately.

I may not end up doing anything radically different in session from what any other clinician might do instinctively. But by thinking of myself as a performing artist, as opposed to just a clinician, I find creative ways to join my clients in their emotional subjectivity, relate to them like a character who can help them grow, and allow myself to expand personally in the process.

Again, to be clear: “Acting” does not mean being fake, it means finding truth within a given set of circumstances. So, in that sense, “as therapists we are all actors: we use our selves (our primary instrument) to help bring other people’s authentic selves to life”.

Below is a pair of vignettes, each including a significant learning moment for me as an actor, and a corresponding revelation as a therapist. These dramatic/therapeutic narratives, illustrate how my use of self helped me to pursue the three main objectives that apply to the creative process of both artforms:

  1. To create a treatment frame in which our scene partners feel safe, oriented to the nature and purpose of our work, and free to participate in it.
  2. To join our clients in their emotional subjectivity, like actors embody their characters.
  3. To relate to our scene partners as a character who can help them to heal and to grow.

Act II: Using My Self as an Actor

I was 20 when I was cast as the gun-obsessed Quigley in Hyperactive, an edgy play about teen angst by Olga Humphrey. Quigley was described as a “masculine, hard-edged” adolescent, whose favorite magazine was Soldier of Fortune. I was an effeminate, soft-natured man, whose favorite magazine was Entertainment Weekly—in other words, nothing like Quigley. But I was also an actor, and as an actor’s my job is to find diverse characters within myself, even if they seem very different from me on the surface.

Other than having a teenager’s build, the only quality I seemed to share with Quigley was the determination to prove my worth. In my case, proving myself not only meant getting hired, which I did, but also finding some genuine version of this unlikely role within me. My greatest challenge was to make an empathic connection with Quigley’s bullish personality, his gratuitous language, and (most difficult of all) his obsessive, violent fantasies. All these qualities—or symptoms, if you will—made me extremely uncomfortable and seemed to alienate me from him, rather than to invite me into his emotional world.

My first task was to create a framework for my rehearsal process, within which I would have room to discover and explore who this person was, through trial and error—ideally without judging him. Rather than begin with preconceived acting choices for Quigley—much like therapists are often tempted to impose treatment interventions onto new clients—I needed to find a way to let him speak to me on his own terms. And since my head could not make sense of this boy, I had to find a way to access him viscerally—using my body, voice, and imagination.

As I began reading his crude and aggressive lines aloud at our first rehearsal, I imagined I was one of the bullies from my own high school past. I widened my legs, puffed out my chest, and spoke with an affected tough-guy bellow, straining to produce the intimidating, nasty persona adopted by so many males from my youth.

The result was what the kids call a “fail!” “My performance was cartoonish and over the top”; I’d created a caricature, not a human being. “Um, that’s a bit much,” my director said, with a penetrating squint of disdain in her eyes. Humiliation flooded my body and shut down my spirit. My effortful impersonation seemed to expose my limitations as both an actor and a man. I wouldn’t need to try so hard if I was actually talented or masculine enough, I thought to myself, further shamed by my inner critic.

But in the same moment, a window opened for me into Quigley’s inner, subjective life. I had unwittingly, but effectively, joined him in his debilitating self-consciousness, vulnerability, fear, loneliness—and self-hatred. His core intention wasn’t to intimidate and destroy other people, I realized. Those behaviors were secondary to his primary objective: to protect himself, validate himself, survive.

With those visceral motivations living in my body and mind, I could commit to Quigley’s macho expressions while maintaining an underlying sense of vulnerable truth. And as I played with this duality—grounded in my own fear of failure, and my instinct to overcompensate for it—I increasingly understood how he/I was motivated by a desperate need to be validated by other people. I could now bring a genuine version of him (and me) into the rehearsal studio with my scene partners, supported by the technical breathing and vocal exercises, as well as mind/body practices I had developed in drama school. (Again: the creative use of oneself is not a replacement for technique, but rather it informs the performer of what specific moves we need to make at any given moment in our scene work.)

By the time the production was on its feet, I was able to embody Quigley without extraneous effort: from his brusque introduction to his cathartic end, in which his mother and best friend hold him in their arms and thwart him from carrying out a violent attack on his classmates. Actors often try to force emotion and tears in high-stakes moments like this—not unlike therapists when we impose heavy-handed clinical interventions onto challenging clients we want to “fix.” As my actor friends say, we often try to “play the end of the scene” too hastily, rather than allow ourselves to be present in every step of the journey.

But I didn’t have to strain myself to find Quigley’s deep-rooted pain for this scene. All I had to do was surrender my feelings to my scene partners, with whom I’d cultivated a great deal of safety and trust throughout our creative collaboration. As we performed the climax of the play, Quigley’s taut energy thawed from my jaw, neck, and shoulders—where it had been deployed as a shield—and it dispersed throughout my body, accessing a range of other emotions. In fact, at one point I awakened to the insight that all along Quigley had been defending against, and overcompensating for, the absence of his father. It’s an abstract clinical exercise to analyze a data point like this about a person’s life, either in a script or a psychological evaluation. “But when we make efforts to join that person in all their subjective bodily, emotional, and intrapsychic complexity, we expand our capacities for empathy”, mutual recognition and creative transformative action, both on and offstage, in and out of therapy. Best of all, we learn to relate to that other person (character or client), no longer through the trailing edge of their transference, as the recipient of their resentment, frustration and fear, but through the leading edge of their transference—as the embodiment of their generative desire, longing, and hope.

Act III: Using My Self as a Therapist

Harry burst into my office each week like he was in a race against time; he wanted answers, and he wanted them fast. A straight, white, corporate millennial, he was used to instant gratification, and he expected no less from his therapy. He emphasized that he already understood himself “extremely well,” and that all he needed from me were “professional tips” to reduce stress in his highly successful life.

I was flattered; I’d been cast in the role of commercial guru, the kind who might dominate the American market with bestselling, confidence-inspiring catchphrases. Except I felt too slow, discursive, and insecure to play this part for Harry, more the man behind the curtain than the great and powerful Wizard of Oz. Each week, I expected him to look at me incredulously—much as I’d feared audiences would respond to me portraying a butch, gun-wielding teen—and see that my training and degrees were all a sham. I anticipated the day he’d tear back the curtain and expose me as the talentless hack I felt myself to be in his presence.

On the plus side, Harry showed up for our weekly “rehearsals” consistently, which spoke to the frame I had provided, which apparently made him feel safe enough to “play” with me. But each scene between us had a palpable yet indiscernible tension. First, he’d summarize his week, speedily and with the energetic poise of a cocky movie star—shoulders back, chest protruding forward, eyes sparkly with intense self-assurance. Then he’d present a dilemma—“I need to make more time for relaxation and balance,” for example. At this point, he’d look to me as if to indicate it was my turn to perform, and to prove I was a worthy scene partner.

I would then try to seize the spotlight, so to speak, masking my self-conscious insecurity with a commanding delivery of a line like, “I recommend yoga, three times a week. Put it in your calendar.” I was desperately trying to personify the omnipotent coach I imagined he wanted me to be. And though my “acting choice” arguably answered Harry by his own method, it felt as though I was trying way too hard to impress him—much as I had overcompensated in my bullish portrayal of Quigley, as I stumbled through my first few rehearsals of Hyperactive.

Eventually, I’d look back on these moments and realize how all these unnerving sensations could help tune me in to Harry’s complex internal world, and to join him there. But in the meantime, I felt blocked, like a superficial actor who failed to connect with his character on a deep personal level.

Over time, it became abundantly clear that Harry couldn’t be bothered with my attempted interventions. He’d wince disapprovingly at my suggestions and say things like, “Yoga never works for me. I just end up obsessing about the more productive things I could be doing with my time.” At the end of our sessions, “he’d stride out of my office with a proud posture, leaving me behind to reel in a slouch of inadequacy”. I couldn’t seem to reach him, no matter how hard I tried. I felt like the FBI agent Tom Hanks played in the movie Catch Me If You Can, endlessly chasing Leonardo DiCaprio’s slick and wily character, a master of escape.

This frustrating dynamic manifested in a number of ways between us, including our weekly schedule. Harry would frequently ask to alter our meeting times due to his ever-changing obligations, and I’d accommodate him more than I wanted. I did this because I was afraid to disappoint him. Not only did I sense he’d fire me if I didn’t manage to keep up with his demands, but more significantly, I had an inexplicable sense of dread that he’d erase me from his mind entirely if I let him down. Unwittingly, I was tuning in to Harry’s inner life. I could feel his deep ambivalence about trusting and depending on people vibrating within my own body. And as it turned out, my fears were not unfounded.

One day, after two years of working together, Harry raised the emotional stakes of our scene work. I was running behind (by about a minute), between notes and phone calls, and he had no intention of waiting; it was his time, and he’d enter my office if he wanted to. I was completely shaken off-center as he blasted through my door. Within the flicker of a second, my face flushed with a combination of shock and shame, but also disapproval and a smidge of anger.

As we made eye contact, Harry stopped in his tracks—and his reaction to me was startlingly evocative. While his body asserted its typical conviction, his eyes betrayed a doubt, fear, and deference that I’d never consciously sensed from him before. Since I was too caught off-guard to address this novel improvisation between us in the moment, Harry made a beeline for the couch and shared his latest dilemma as if nothing had happened.

The latest dilemma, it turned out, was that his long-term girlfriend, of whom he’d always spoken glowingly, had proposed to him. “It came out of nowhere!” he exclaimed wide-eyed. “I was totally thrown off my game. Shaken.” Hmm, like what just happened to me now? I thought to myself. “We’ve talked about getting engaged for a while,” he continued, “but I just thought when it happened, it’d be…different.”

“You mean you thought you would be the one who proposed?” I asked.

“Well, yeah,” he replied. “I mean, not because of gender roles and tradition and all that. It’s just…I would’ve made sure it was perfect.”

“What would you have done differently?” I asked.

His eyes squinted as he struggled for an answer. “I guess I just wish she…” he paused for a while, “seemed surer of herself?” As we talked, he realized that this proposal had surfaced an implicit contract in their relationship: that he was in charge of their major decisions as a couple. His girlfriend had gone out on a limb and broken that contract—and now Harry was struggling to understand why he didn’t feel safe following her lead.

Uncharacteristically, his body sank back into the couch as he stared blankly in silence for a while. Finally, he spoke again: “Maybe she’s not the right partner for me.” There it was, the confirmation of my underlying fear; if his long-term girlfriend was expendable, so was I.

“It’s normal to feel a range of emotions at a pivotal time like this,” I said in an effort to validate him. “I appreciate your confusion and doubt, and since your girlfriend seems willing to give you some time to reflect, I suggest we continue talking before you make any big decisions.” He seemed momentarily held by this, but as I watched him take a minute to shield himself with his typical smug poise before leaving the office, I understood deep inside that this sense of security was tenuous, for both of us.

“Harry colonized my mind for the rest of that day, much like a challenging character might consume me as an actor”. At home, I looked in the mirror and tried to emulate his self-possessed posture. As my shoulders dropped back and down, my chest expanded, and my eyes and mouth affected Harry’s cool-guy charm, I began to recall the unpleasant sensations I’d get when trying to play the part of his expert guru. The external posturing I would affect at those times didn’t feel grounded in confidence, but instead seemed to serve as a shield to my internal self-doubt and fear of rejection.

Suddenly, I understood that the same was true for him. The look on his face when he’d barged into my office earlier that day, and the months and months of tension between us, began to make more sense. And as I joined his mind/body experience of self, I realized that what he really wanted was not for me to catch up to him or project the same overcompensating confidence that he did, but to get ahead of him. He longed for me to become someone who could set boundaries with him, disagree with him, and ultimately, care for him—without getting caught up in the same debilitating self-criticism that plagued him. But how could I successfully embody these qualities in the therapy room, and become the character with whom Harry longed to relate?

I thought about the end of Catch Me If You Can, when Tom Hanks learns to approach Leonardo DiCaprio no longer as an elusive fugitive, but as a boy abandoned by his father. I thought also of Harry’s father, who’d died suddenly of a heart attack when Harry was a child. Gazing in the mirror and focusing on the sensations within, I rediscovered what I had first learned with Quigley: biographical details about clients and characters alike resonate within us much more richly when we embody them, rather than simply study or analyze them. I then shifted roles and explored ways that I could present myself to Harry that might make him feel safely held.

I drew inspiration from men, in my life and onscreen, who were both palpably strong and nurturing, including Tom Hanks, Robin Williams, and Barack Obama. I considered their physical groundedness, the clarity of their thoughts, as evidenced by the easy poise of their heads, but also, most significantly, their emotional openness, illustrated by the lack of tension and flow of energy in their chest region.

As I played with where I felt these qualities in my own body, I didn’t try to impersonate the men superficially, but to connect with the experiences in my life—like caring for my younger brothers when I was growing up and being a camp counsellor—that brought out the warmth and confidence Harry needed from me now.

“When Harry next raced into my office, I was prepared to get ahead of him, and relate to him with focus, calm, and an embodied sense of security”. As we revisited the previous session, I validated his anxieties about depending on his girlfriend (or any intimate “scene partner” in his life) and invited him to talk about the pressure he puts on himself to “be ahead” of other people, including me.

Throughout this session, there was more ease, vulnerability, and play between us than ever before. But it wasn’t what I said, so much as how I’d learned to be in the room with him, that made the difference. I was even able to recommend self-care activities like yoga, which he’d rejected in the past, in a way that he now responded to with complete openness—in theater terms, same script, better performance.

As Harry exited that day, he turned around in the doorway, took a moment, and then said through the shimmer of a tear, “Thank you.” I simply smiled in return, maintaining the combination of groundedness, strength, warmth, and vulnerability that we’d discovered together in our session.

Finale

While I waited for my next client, alone in my office, I reflected on the connection Harry and I had found, and I recalled an interview with Meryl Streep, in which she explained that in her view, her success as a performer was only as good as it was “the last time.” Thinking of our sessions ahead, I knew we could expect more tension, insecurity, fear, and doubt to manifest between us. But at the same time, I knew my acting training could help me perform on this different kind of stage, where we’d continue to explore various versions of ourselves together.

I initially felt I needed to be someone else in order to access both Quigley and Harry. Like so many actors and therapists, I am driven by the desire to please my collaborators, to be the “expert,” and to “get it right” on the first line reading. But at the same time, in order to connect with our clients, characters, and scene partners as performing artists, we must practice our craft with humility, patience, and the belief that we are enough. We must trust that if we show up to each “rehearsal” with the willingness to be fully present—along with our vulnerabilities, naivete, and deep self-reflection—we will give our creative partners what they need to be present with us as well. Especially if we engage each other in a process of imaginative, empathic play.

Through our respective play sessions, Quigley and Harry both showed me that their apparent toughness, butchness, and self-containment were part of me as well—keys existing somewhere within my instrument, even if I don’t embody them every day. But an even greater revelation for me in both cases, was that the idiosyncratic “soft” qualities that makeup my everyday self—and that I originally believed were obstacles to bringing both young men into the spotlight—turned out to be exactly what they needed to find hidden keys within their own instruments. By playing these untapped versions of ourselves—even, and perhaps especially, when we felt inadequate—each of us found a way to breathe, to integrate, and to become more fully alive.

Note: This article has been adapted from Mark O’Connell’s new book, The Performing Art of Therapy: Acting Insights and Techniques for Clinicians, and his article “Character Work: What Therapists Can Learn from Actors,” in the Psychotherapy Networker, March/April 2019 issue. 

Think Act Be: A Whole Person Approach to Healing

Posted on by Psychotherapy.net Team

When John came to me for treatment, he’d lost his job a year earlier; at 58 years old he was not optimistic about finding a new one. Since then, he’d stopped exercising, his diet had deteriorated and he’d had a recent health scare. His relationships were also suffering, as he often argued with his wife, felt alienated from his adult children and rarely got together with his friends. He felt broken, and sometimes wondered if life was worth living.

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John’s situation is not at all uncommon. As one part of our life suffers, others often go down with it. What might start as a physical illness soon affects our minds, just as a psychological stressor like losing one’s job can lead to physical exhaustion and poor health. The cascade can continue and affect us at our core, leaving us feeling lost and dispirited.

I’m well acquainted with this downward spiral not only from my clinical work but from my own extended physical illness that resulted in social isolation and a major depressive episode. Eventually I felt like a burden to everyone and wondered if my family would be better off without me.

Just as our struggles often spread into many areas of our lives, our healing requires a multi-faceted response. My own approach as a therapist integrates cognitive behavioral therapy (CBT) with mindfulness, which I call “Think Act Be.” It’s a simple reminder of three interconnected paths to healing—Mind, Body, and Spirit (see figure).

When I’m working with clients I often ask myself which of these paths might be most helpful to them at this point in their treatment.

  • Are their thoughts serving them well?
     
  • Are their actions consistently rewarding them with enjoyment and a feeling of accomplishment?
     
  • Do they find meaning and connection to nourish their spirits?

Other clinicians before me have recognized the power of combining these three schools of thought (e.g., Mindfulness-Based Cognitive Therapy). Indeed, integrative approaches in general are commonly used by clinicians, whether or not they follow a CBT approach. Therapists of all stripes see the value in treating the whole person.

Bringing the Principles to Life

The principles of mindfulness-based CBT are very straightforward and easy to explain:

Foster healthy thinking.
Do life-giving activities.
Practice present awareness.


The challenge lies in bringing these principles to life, otherwise they’re no more effective than easy truisms like “be in the moment.” How do we retrain our minds? Which activities are the right ones for me? What are ways to practice mindful awareness?

In my experience, three ingredients are necessary to develop new and more effective habits that promote healing:

  1. A clear and focused plan
  2. Daily practice
  3. A wide range of practices
Without these three factors, we’re likely to slip back toward unhelpful thoughts and behaviors. Thus, each CBT session generally ends with planning for things to work on between sessions. This emphasis on consistent practice of new skills and techniques is part of what makes CBT effective.

In general, it’s best if the plan is written, which makes it much easier to remember and provides greater accountability. Some therapists write the plan on an index card so it’s easy for the client to carry it with them. That idea inspired me to develop The CBT Deck, a deck of cards printed with daily CBT and mindfulness-based practices. It includes many of the same techniques that John and I worked on during his treatment; example exercises from the deck are included in bold in the following discussion of his treatment and recovery.

John’s Recovery

In my work with John, we focused first on adding valued activities back into his life because this seemed like an area of “low hanging fruit,” and behavioral activation tends to pay off quickly. His activities included going on weekend adventures with his wife and doing fun things that also provided physical movement.

We also worked toward taking care of tasks around the house that he’d been putting off and on building positive interactions with others since his relationships had suffered. Given his health challenges, we worked on ways to improve his sleep and eat more healthfully.

Soon we began addressing his thoughts, starting with recognizing thoughts as thoughts. He identified an overly negative self-critical voice that told him he was “unwanted” and “useless,” which we worked to correct in various situations (see sample card).

Mindfulness became the third pillar of John’s treatment and recovery. Through different meditation practices he learned to quiet his mind and recognize its chatter, and could prevent himself from getting caught up in negative trains of thought. He also found relief from putting up less resistance to reality, instead opening to the unpredictability of life.

We worked together to bring these practices into his daily life and his interactions with others. Gratitude was also an important part of John’s recovery, as he started to notice how much was right in his life.

It was only a few weeks before John was feeling markedly better. That said, the improvements were somewhat delayed; he didn’t feel immediately better after the first weekend outing with his wife, and his mindset didn’t change miraculously after one week of working on his thoughts. Just as giving up life activities took a while to affect John’s well-being, so the effects of resuming them were somewhat delayed. This delay is part of why consistent practice is important; if a person stops the practice after a day or two, they probably won’t have gotten a sufficient “dose” to see real improvement—and may conclude prematurely that “it didn’t work for me.”

John and I met weekly for more than a year as the improvements continued. Eventually we tapered down to meeting about once a month, which John finds helpful to maintain the practices that keep him well.

Healing for All

After many rounds of inconclusive medical tests, I began to accept that a mind-body-spirit approach to healing was just as relevant for me as for those I was treating:

Think: I’ve found it extremely helpful to make simple adjustments to my mindset—for example, seeing myself as “still healing” rather than “still sick.”

Act: I threw myself into life-giving activities like gardening, where I can see the fruits (and vegetables) of my labor.

Be: I’ve given myself space to connect with deeper parts of myself that I’d forgotten about, including a renewed connection to sacred scriptures.

It might sound funny, but I plan to use The CBT Deck myself as a regular reminder of the kinds of practices that enrich our lives.

As you assist others in healing—or work toward your own—what framework do you find most helpful? In what way does your approach tend to the mind, body, and spirit?
 

How to Master the Art of Developing Your Therapeutic Voice

Posted on by Psychotherapy.net Team

Becoming an Artist

Surrounded by a sea of attendees at Psychotherapy Networker’s annual conference, I waited to ask my hero the question that had been burning inside. One man, with an uncanny resemblance to Sigmund Freud, entranced us yet again with a story of the work we’d all been celebrating and emulating in our own offices for so many years. Our master clinician and storyteller, group therapy guru, and most importantly, the single most generous and open discloser of his clinical process, Irvin Yalom was reflecting on his lifetime contributions.

It was now our turn to ask him questions. “Dr. Yalom, you’ve shown us how to embrace the process, and as the poet Rilke advised, to: ‘be patient toward all that is unsolved in your heart and try to love the questions themselves.’” Was I even talking into the microphone? The notes on my phone bounced out of focus, but I pressed on.

“Like jazz musicians, you’ve reminded us to enjoy the dissonances and savor the surprises we find within them. Can you talk about that, the role and importance of being an artist in our field?” I was grateful when he acknowledged that yes, he had thought of calling his book Letters to a Young Therapist after Rilke’s famous missives. “Even though I idolized so many, no, no, I never thought of myself as an artist. Even though I had wanted to be one, it wasn’t me!” It was like I had framed the wrong man. With him ready to quickly move on, I was stunned, stung, crestfallen. If Yalom couldn’t recognize being an artist, how could any of us?

Luckily for me — and us — Sue Johnson, the puckish British couples therapist and our evening’s interviewer, held him up a minute to take stock of his knee-jerk demurral. Wasn’t his work — its graceful storytelling and open embrace of the therapeutic process a testament to the power of our art to heal and enlarge? Was this any less artistic than the poet, musician, or actor’s craft?

Yalom’s initial objection ripened into delight on stage, and after the conference, in a private email, he thanked me, stating simply, “I’ll remember your comment for a very, very long time.” That’s what this essay is about: the artistry of our work and how we develop a therapeutic voice to help us get there. This is vital not only for ourselves and our supervisees, but even more so for our clients, who cultivate their own voice in the interplay with ours. Happily, there is ample scientific and empirical support for this artistic venture and cultivation of the voice, and I will use it to contextualize and illuminate our journey along the way.

Finding Our Voice

All artists — whether writers, musicians, or actors — must develop a voice, that hard-to-define yet distinctive style which runs like an invisible thread through their work, opening a space of creative possibility between their art and audience. As a supervisor of beginning therapists, I view this as essential, and liken it to the process we see on television each week on the show “The Voice.”

Just as Kelly Clarkson, Blake Shelton, and Adam Levine compassionately and thoughtfully mold, mentor, and inspire young talent, so too must we as supervisors help our beginning clinicians. Each has their own music and style they come in playing, and supervisors help them draw out their raw talent, experiment with new genres, and ultimately learn about how to make music that is, as Duke Ellington said, “beyond category.” This is therapy that transcends theoretical orientations, becoming a unique blend of the clinician’s theoretical and empirical knowledge, their personality, and emerging therapeutic repertoire.

There is a yin and yang here that, when in proper balance and harmony, lead to a fully developed artistic voice. This voice not only serves the therapist but promotes the opening and expansion of the patient’s own voice, becoming the driving force of creative therapeutic work. This also forms the basis for a lifetime of creating art. Yes, all of us therapists (veterans too!) do this daily, in the poetic and musical lines we shape in what others easily pass over as ordinary prose. Freud had it right from the beginning when he suggested, “When we can share that is poetry in the prose of life.”

Wouldn’t it be inspiring if all of us — beginning and veteran clinicians alike, supervisors and supervisees — could embrace the artistry of our everyday work? Wouldn’t it be illuminating if we had a working model of how to cultivate and deepen this?

Building a Voice

The model that I’ve arrived at is both simple yet expansive. A therapeutic voice is the combination and interplay of therapeutic presence and therapeutic authority, the complementary and seemingly contradictory elements that like yin and yang, enable us to create a three-dimensional picture of our patients and ourselves. Think of it like how our two eyes, each with their independent perspectives, magically create depth perception.

An ambitious supervisee recently confessed to me, “I have to anticipate everything before our session, and know exactly where I am taking my clients. I feel like a white-water rafting guide who’s one turn away from taking the whole crew down with me!”

This supervisee, like so many others, is proficient at being directive, setting goals, and moving quickly towards intervention. Unfortunately, they don’t offer enough room for the patient to openly explore and steep in their feelings or draw on the relational process to entertain new possibilities, which is why they so often feel up a creek without a paddle.

Therapeutic Presence

What they need more of is the yin of therapeutic voice, therapeutic presence — the capacity to be receptive, mindfully attentive, emotionally available, nonjudgmental and resonant with the client’s unfolding experience (1). Freud originated this concept in his earliest recommendation for practicing therapists in 1912, underscoring the vital importance of “evenly hovering attention.” Like a koan, the therapist should “simply listen and not bother about whether he is keeping anything in mind.”

Considered the foundation for tuning in to the patient’s unconscious, it provided a potent tool for opening one’s mind and heart to new possibilities for understanding and engaging the patient’s psyche. Like the Zen Buddhist notion of “beginner’s mind,” or mindfulness itself, therapeutic presence comes from the framework of “not knowing” in the service of creativity. To paraphrase the Nobel prize-winning poet Wislawa Szymborska, the point — like the poet’s main task — is to say I don’t know and keep on going. It’s to wonder aloud!

Therapeutically present therapists are understanding, open-minded, and comfortable with a range of different feelings and perspectives.These therapists have internalized Robert Frost’s prescient quip, “No surprise for the writer. No surprise for the reader!” Patients feel a sense of safety, trust, and warmth in their company. The space seems to open with them. This disarming quality makes it easy for patients to explore new subplots and turns in their stories. They find themselves surprised at how much they are saying and learning in just the telling itself.

Therapists who practice this kind of presence don’t have to know immediately and aren’t bothered by the ambiguity or complexity of what they are hearing; they “dwell in possibility,” as Emily Dickinson said, a “fairer house than prose.” They allow patients to be in the driver’s seat so that they can show them the territory first, and in so doing, instruct their therapist how to best be of service. This openness allows patients to take more risks in therapy, to deepen the exploration of their thoughts and feelings, and to get to genuinely enjoy the deeper waters of the psyche, even providing modeling for them to be more open to the various and contradictory sides of themselves! In short, to paraphrase Whitman, they are reminded that, “We are large. We contain multitudes!”

Owning A Voice

Plopping down in my office chair, and letting out a formidable sigh, another supervisee recently lamented: “Sometimes I feel like I’m taking it all in but then can’t get a word in edgewise, and I’m not even sure if what I’m thinking even makes sense. Am I really helping them at all, or are my own mixed-up feelings just getting in the way of making any headway?”

I know many fantastic supervisees who excel at being empathic, reflective, and thoughtful with their patients, but lack the confidence to make discriminating interpretations that take into account their valuable instincts and intuition regarding new creative possibilities.

These supervisees, understandably, worry that if they use too much of their authority, they will overwhelm or possibly hurt their clients.

They need more of the yang of the voice of therapeutic authority — which I define as the command of theory and technique and a discriminating awareness of how to put these into practice. It is the confidence to properly select, apply, time, and adjust one’s interventions in a multicultural and relationally sensitive manner (by relying on the yin of therapeutic presence, of course!).

The clinician with therapeutic authority is happy to show patients how to blaze a new trail and empower them to sort through the various aspects of their experience to find bigger patterns and new possibilities. Like an artist mentoring a new student, they can see the bigger and smaller picture and can help with the difficult passages encountered in putting new skills and pieces together. Most importantly, the therapist with a balanced dose of therapeutic authority knows how to do this with proper timing, tact and empathy. They are not going to break patients down like a military drill sergeant, but instead are going to be thoughtfully discriminating and penetrate deeper into problems and their implied solutions.

Supervisory Support

It is vital for supervisors to support beginning clinicians in developing their clinical intuition and instincts, the confident application of their theoretical and empirical knowledge, and a sense for having the “authority” to make therapeutic moves. Just as a singer needs to take risks with trying out new ways to expand their interpretation of a song, so too does the beginning clinician, and as supervisors, we are right behind them to encourage it!

Supervisors also need to model how to both be comfortable with and to chase the kind of not-knowing that makes creative therapeutic work possible. Like Yoda to Luke Skywalker, we help emerging clinicians to learn how to use “The Force,” showing them that, paradoxically, it is only by surrendering and letting go that we truly open the space for something new to emerge.

Just like our young poet needed Rilke to learn how to become an artist (and Rilke in turn was mentored by the great sculptor Auguste Rodin), so too do our beginning clinicians need us to illustrate how they can be balanced and integrated in their own unique therapeutic voice by uniting these two crucial faculties. And it turns out that all of us, no matter what level we are at, need to remember that we are always cultivating and expressing this artistry!

Empirically Supported Artistry

Art never needs more than its own justification, but as a scientist practitioner, you might need to be reminded of the scientific support for viewing therapy as an artistic enterprise. Look no further than Neuroscientist Antonio Damasio’s recent book, The Strange Order of Things, which eloquently showcases the way in which our “right-brained” feeling comes first, inspiring and motivating our greatest cultural innovations and products, and that joined together with the logic and language of our left-brains, becomes something truly extraordinary. Daniel Pink in In a Whole New Mind illustrates the 21st century’s cultural sea change from a left-brained leaning computer age, to a right-brained leaning conceptual age that integrates right and left to make the best of both worlds.

In my model, therapeutic presence is the right-brain dominant aspect of our therapeutic artistry, and therapeutic authority is the left-brain pilot, so to speak. Therapeutic presence is at once dreamlike and free-associative, holistic and big-picture, image and metaphor centered, and largely implicit and nonverbal. It undergirds the profound empathic connection between us and our patients, especially to those sides of our clients that have experienced trauma and yet still long for—even in secret — a more redemptive narrative.

Therapeutic authority flows from the language and logic-based sides of our brain with its highly developed executive functioning. More largely conscious and deliberate, this side enables us to zero in and edit the many clinical possibilities before us so that we can work with true specificity and discernment, tailoring our treatment for the unique person sitting across from us, and getting to the heart of the matter.

A 19th century poem by Frances Cornford sums up this lovely process best. Entitled “The Guitarist Tunes Up”, we learn that this musician leans into their instrument with ‘attentive courtesy’:

Not as a lordly conqueror who could

Command both wire and wood,

But as a man with a loved woman might,

Inquiring with delight

What slight essential things she had to say

Before they started, he and she, to play.

For a visual of this interplay, we can look to none other than that famous Renaissance man — Da Vinci and his iconic drawing of his Vitruvian Man. It is only by integrating the square of our logic with the circle of our feeling do we become something truly divine — artists in our own right.

Learning & Teaching from Art

If we are to find and develop a therapeutic voice, we must first look at how therapy itself connects to the arts and how, as supervisors and supervisees, we can attend to these important dimensions. We’ll look specifically to poetry and music as starting points.

Poetry Lessons

A poem, such as a sonnet, compresses a question or problem, its exploration, and a final statement of some revelation or new understanding into 14 lines. In Shakespeare’s famous sonnet, “Shall I compare thee to a summer’s day?” the speaker wrestles back and forth with how his love is and is not like summer. Initially, it seems very fitting to compare her to the beauty and splendor of the season, but upon further inspection, new ideas emerge. Among other things, she is much more constant, evenly tempered, reliable, and more lovely than the summer months.

Much like Shakespeare’s speaker, we wrestle with our initial diagnostic impressions of our patients: Shall I compare thee to a borderline personality, a depressive, or an adjustment disorder? It is not immediately clear, and so many of our first sessions entail testing out various hypotheses to determine who the patient is and is not.

As Shakespeare’s poem continues, surprises and new discoveries emerge and toward the final turn of the poem, the poet concludes that his love will be eternal as a result of the poetic act itself: “So long as men can breathe or eyes can see/so long lives this, and this gives life to thee.” This is the aim of a transformative therapeutic process. Much like a sonnet, by the end of the therapeutic experience, a patient will be able to make a few “turns” and come to a way of internalizing the therapeutic process so that it too will become eternal.

Music Lessons

Beethoven’s fifth symphony provides an immediately recognizable compressed musical idea. In only four notes, a focal theme is established that is explored, varied, and reharmonized much in the same way that occurs in therapy. The capacity of the therapist to articulate that melody — the dominant trend or relational pattern that pulls the various strands of a patient’s story together —goes very far in clarifying what has been troubling patients while it points them in the direction of how they can move forward. Much of the time, patients are playing the notes of their issues but are not aware of the melody and cannot synthesize it into a focal theme. They bring us their own invisible scores and hope we will give them feedback to recognize their own music.

About seven and a half minutes into the third movement of Rachmaninov’s Symphony in E minor, we hear the main theme played by the French horn, in the manner that a patient initially expresses when it is recognized by the counselor: “You hear me! This is the song I didn’t know I was singing.” Shortly after, the theme gets played by the violin with a melancholy poignancy: “I have been waiting a long time suffering with this alone.” This is the sense of sadness and mourning that the patient feels for having had to sequester this aspect of self in the service of protection and adaptation.

As the theme gets worked upon and elaborated, new instruments, such as the oboe and flute, come in to take on the line, with hope gathering. Calmer and with greater poise, a certain pride and expressiveness opens now that this very significant idea can be incorporated into the larger musical narrative of the patient’s story.

Let’s see how this artistry translates to a representative case and get a preview of putting all the pieces together.

A Case of You

I’ve named this “A Case of You” as a nod to Joni Mitchell’s heartbreakingly beautiful song because this patient seemed at first blush like she was too much to handle. Pretty quickly into our first session, I realized that, like for so many of our cases, the following lyrics truly applied:

“You’re in my blood, you’re my holy wine, you’re so bitter and so sweet, oh I could drink a case of you, and I’d still be on my feet!”

A student came to her intake appointment complaining that her friends did not understand her, that she couldn’t fathom why they were so turned off by the razor blade that she kept on her desk as a reminder that she could cut herself, and that she had been told to come to counseling many times, but it had never been helpful in the past. She asked, why should she bother now?

Previous counselors told her that she needed a higher level of care than they could provide, and those appointments left the student feeling misunderstood and blamed for troubles she could not fathom. She also felt a sense of hopelessness at not being able to make true contact, just as she had not with family and friends. Aiming right for the jugular, she also scoffed at me: “Counselors are incompetent and don’t really understand me. You probably won’t either!”

In addition to feeling interpersonally rejected on several fronts, as a first-generation college student, she experienced the pressure of well-meaning parents who hoped to see the family’s metaphorical stock rise with her success. At the same time, her family expected her to be at the ready when they called her to take care of her younger siblings. She was a painter who loved the darkest colors of her palette, with her works centering on Hopperesque misfits wandering in the night.

Initially, her cutting was a regular strategy to express and modulate her emotions, combined with a preoccupation with death, and the ways in which friends and other therapists had been repelled by her behavior made me wonder whether this student had borderline personality disorder. Like in Shakespeare’s poem, though, I was not sure whether this comparison truly fit.

Here we see the internal wrestling of therapeutic authority and presence. The first stab at therapeutic authority can have us all too quickly categorize or even pathologize what we are seeing before we get the full story. At the same time, this discriminating faculty provides crucial information that we really need to follow. Like a samurai warrior, psychologically speaking we need to forge the sword and learn how to use it appropriately. Toggling back and forth between this function and therapeutic presence — the open and receptive Buddha nature — allows us to see the big picture clearly while also focusing keenly on the supporting details that we need to assess and intervene incisively.

As I got to know more about the patient’s relational backdrop and leaned into my therapeutic presence, things looked a bit different. I learned about her parents’ difficulty tolerating fear, anger, and sadness, and their own struggles with managing chronically high levels of stress. I also learned about my client’s repeated experiences of the family being unable to acknowledge or stay with her emotional experience.

Just as the subject of the Shakespearian poem was no longer so much like the summer, it seemed more and more that she was no longer like a patient with a borderline organization and instead more like one with a neurotic organization or a possible adjustment disorder. She appeared to be in a conflict that could not be acknowledged squarely as she was in the midst of an important developmental transition, both issues coloring each other and placing her in an ever-tightening Gordian knot.

By trusting my therapeutic authority, a focal theme emerged. When this patient expressed negative emotions, people could not tolerate them and emotionally and physically abandoned her. This pattern was consistent with her emerging friendships — others were not interested in hanging out with her despite her charm and intelligence — and extended to her early family experience, in which her parents subjected her to the silent treatment for days whenever her emotions ran too hot. Taken together, the patient internalized a message that her emotions were problematic and disruptive and that they must be put aside and suppressed. In other words, they became “not-me” and funneled into the dissociative symptom of cutting.

Until I was able to home in on a focal theme, I, like the therapists before me, was part of the problem, imagining in my countertransference that it was the patient who had the major issue. Internally, I underestimated how much my feelings were part of an enactment, containing only a small piece of the story. Initially, I was bracing myself for difficult work, assuming that the student had a great deal of pathology and would make little movement. In a way, I was reenacting the dynamic of the student’s relational backdrop, finding her issues disruptive to my sense of authority just like her parents and her prior therapists had — “it is not me, it is her.” By maintaining a therapeutically present stance, I was able to observe this crucial dynamic and incorporate it into a new understanding and relationship with the client.

Therapeutic authority led me to a focal theme that helped me see that it was totally understandable for her to shy away from sharing her intense feelings and need to hide and express them in her not-so-secret ritual of cutting. She was protecting both myself and herself from “not-me” and letting the world know, with what seemed to be twisted pride, that cutting was her right and a very valuable part of her emotional life. Looking back on that detail now, it was very prescient in the way it encapsulated her attempt to express and independently resolve her bind.

Reading and Tracking Changes

Guided by a mindful application of therapeutic presence and a discriminating use of therapeutic authority, the student went through the kind of musical sequence referenced above. Initially, having a therapist who was able to respect and receive the fullness of her experience without mistreating or abandoning her by becoming critical or explosive or falling apart was a tremendous step toward a new relational experience. The recognition that her focal theme was understandable and heard enabled her to begin to speak of it without the kind of shame and dissociation that often accompanies a “not-me” experience. It also enabled her to begin to trust and hope again.

She became inwardly and outwardly relaxed so that she could begin to examine the many facets of her current and past experience and thus begin the riffing that is essential to the jazz improvisation that is therapy. In short, she began to find and develop her own voice as a patient!

The patient could view her behaviors as more comprehensible and expressive of the hidden conflicts she had been harboring and that had been left unformulated and disconnected. This expanding sense of self-compassion became an important antidote to her cutting behavior and provided an alternative avenue for exploring and containing her emotional experience. Interpersonally, she became less defensive and fearful of others abandoning her, having had a transformative set of experiences in which she felt the consistent presence of a reliable other. She began to show her pain not only in her words but in the artwork, she did as a painter.

When a poetic turn or musical theme has been established, shifts can immediately be seen in the patient and felt in the relationship. These can occur simply in the change of posture (often, a straightening of the back and sitting up in one’s chair), a richer tone of voice, a feeling of newfound connection and space in the therapeutic relationship, or in the spontaneity and flow of narrative or images that emerge in the therapeutic interplay

In the first session, trust was developed as the student began to see me as a figure who could understand and appreciate the depth of her pain and recognize the myriad ways in which she had been misjudged and pigeonholed by her family, friends and, most notably, other therapists. We also developed a focal theme centering on how this rejection led her to suppress and negate her important and precious feelings. Taken together, I believe that these turns led to decreased scores in hostility and emotional distress, each indicative of the fact that she was feeling more trusting, less defensive, and relieved at being able to begin to experience her emotions more directly.

These scores continued to remain significantly lower than baseline for the next few sessions, whereupon we worked on developing ways of shifting patterns in her relationships with friends and family. At around session five, the student’s depression scores started to decrease as she began to feel greater self-efficacy and agency in being able to affect change in her life inside and outside of the therapy space. Simultaneously, her levels of anxiety followed suit as they made a statistically significant drop from baseline in our final session of the semester. Our work together concretized the notion of making a more poetic and musical line in our therapeutic work, and the importance of drawing on artistic metaphors to inform treatment and expand both the therapist’s and the patient’s voice in that process.

A New Slant on Working Dynamically

We are very accustomed as clinicians to thinking vertically, troubling ourselves over quick diagnoses and assessments, especially given the limited time we often have. At some points, this may take away from focusing horizontally on the musical line and the movement of the intervention. In music, in order to play or sing a melody successfully, one needs to be as attentive to the horizontal motion of the notes carrying a melodic line forward as to the vertical axis of hitting the note itself.

In clinical practice, one can analogize the horizontal forward motion to the momentum of an intervention, the movement toward a new relational experience. The vertical playing of the note is the clinical equivalent of ensuring you understand the patient’s experience correctly and getting a proper diagnostic read. This horizontal motion is informed by therapeutic presence just as, conversely, the vertical movement is guided by therapeutic authority. Both are essential, and they need to be worked in concert to turn notes into music.

This musical way of approaching relational work helps us to be more efficient, fluid, and creative, focusing simultaneously on how to skillfully assess and intervene in our fast-paced culture. Moreover, it enables us to carry the themes of the patient’s past into new orchestrations and harmonizations in the present, providing a model for continued transformative possibilities in the future. Through this process, patients internalize working creatively with their own themes and then take us into new melodic and harmonic territory, stimulating further treatment progress and development. Taken together, this fosters a positive feedback loop in the creative matrix between patient and therapist, and from this synergy, transformative changes quickly follow. This is precisely what a well-tuned therapeutic voice does for the clinician and their client.

References

Cornfeld, F. D. (1965). Collected poems. Cresset Press.

Questions for Thought and Discussion

Who inspired you to find your voice?

What are some of the unique attributes of your therapeutic voice?

Which of your clients helped you to find your therapeutic voice?

In what ways do you compare psychotherapy to an art?

Unlearning to Learn

Posted on by Psychotherapy.net Team

Eternally inspired by and forever indebted to the philosophy of Wabi Sabi – Nothing lasts, nothing is finished, nothing is perfect

Being young in the field of psychotherapy, does not really permit us to share lofty professional insights or postulate what this monumental field entails. If psychotherapy were a person, then we would recognise ourselves in the early phase of courtship. Nonetheless, we believe that our shared inspirations are worth documenting, and it is certainly worth acknowledging what this field has given us and how it has shaped our being.

Wabi-Sabi

Psychotherapy as a school is a development of the Western world. Alongside being introduced to the nuances of counselling and psychotherapy as a part of our academic adventure, we have also been influenced by Eastern philosophies from our birthplaces and neighboring lands. One such ideology that has had a deep impact on our personalities and perspectives is the Japanese philosophy of Wabi-Sabi. In its essence, Wabi-Sabi emphasizes impermanence, incompleteness and imperfection.

In many ways, “Wabi-Sabi embodies authenticity, beauty in fallibility and transience”. It also entails appreciating the ordinary, that which we may easily overlook in our pursuit of the extraordinary, or in the case of psychotherapy, the abnormal. We are still absorbing the learnings that Wabi-Sabi has bequeathed us. However, there has been a beautiful and serendipitous confluence in our learnings from this philosophy and our pursuit of psychotherapy as a profession. Though this article is not so much about Wabi-Sabi, we cannot deny those occasions in our therapy sessions where we have had delightful Wabi-Sabi encounters. We hope that through this article, even though discretely, this trail of our psychotherapeutic unlearnings and the Wabi-Sabi learnings will converge for you as well.

Awe and Authenticity

Psychologists and therapists often describe their profession as a holistic enmeshment of the personal and professional, an experience in unadulterated authenticity and a dynamic narrative of its own. The more hours we spend working with clients, the more we are amazed at human strength, potential, resilience, growth and adaptability. Also, the more hours we spend working with clients, the more we are amazed at how much we can change. It is precisely this sense of awe, and several reflective conversations, that compelled us to give clarity to and expression of our thoughts.

By the very nature of the profession, therapy involves, if not demands, almost continuous self-reflection—a positive yet strenuous occupational hazard. Just like the surgeon finesses her skills through experience, the therapist becomes more present through practice. Psychotherapy is a unique space that provides the therapist with daily, challenging life-altering perspectives. At the same time, it also allows for a renewed appreciation of the mundane, the ordinary, and that which we take for granted.

“Clients may underestimate the profound impact they have on their therapists”. Therapists are neither blank slates nor are they “experts.” Do therapists know the human mind, theories of normality and abnormality, and modes of treatment? Of course, we spend years studying them. Do we know to “fix” every problem for every client? No, we do not. The point of therapy has never been to “fix” anything, at least from our subjective standpoint and theoretical orientation. Even though “doing” therapy is often easier than “being” a therapist, “doing” does very little for the natural process of healing. Therapy after all is a healing relationship that facilitates reduction of overt symptoms and enables psychological well-being. It took us both considerable time to understand and acknowledge that it is the therapeutic relationship between the client and the therapist which is one of the many pivotal healing points. The therapeutic relationship may catalyse significant shifts in the way a client may perceive interpersonal relationship outside of the therapeutic space. This relationship in some ways is the vehicle that helps the client carry their changes from within therapy to outside of therapy.

Power and Fallibility

Media, unfortunately, has done little to promote the profession and benefits of psychotherapy. Instead, it has mystified the process of therapy (you must be crazy to go to a therapist!) and sensationalised the role of therapists—therapists can read minds and pick up impossible micro expressions. We do painfully regret the lack of these superpowers. What happens in reality is that very fallible human beings called therapists stumble, and doubt, and learn, and then learn even harder in order to best help their clients. It is this very ambiguity in the nature of the profession that makes the therapeutic journey both rich and adventurous for the therapist to embark upon. We have grown to recognize the ambiguity of life in general—not just for our clients but for ourselves. Ambiguity is defined as a situation that is complex, novel and insolvable. It makes drawing concrete interpretations difficult and may imbue a person with uncertainty. It’s not pleasant for most people, but tolerating ambiguity might just be the ticket to being a more grounded therapist. If therapists were to have a superpower, it probably would be tolerance of ambiguity.

We believe that at the very essence therapists are people, with beliefs, values, opinions and personalities. They are also people who have biases, needs, faulty assumptions, and introjected patterns of thinking. Therapists, just like their clients, are fallible beings. Irvin Yalom, our personal hero, in his book The Gift of Therapy¹ notes that the therapist and the client often trade places in the therapy room, each learning from one another. Yalom’s view of therapy, as a journey that two fellow travellers take together, is supremely reassuring to us novices. Therapists always place the client’s needs before their own. However, this does not mean that the therapist is unaffected by the therapy process. Rather, we believe it is impossible to not be affected by the suffering and pain that is contained in the room and subsequently not rejoice in the victories and potentials of our clients. Therapy entails a very real human connection.

Curiosity and Trust

The client–therapist alliance is that of trust, fidelity, and curiosity; a fascinating blend. The client entrusts the therapist with painful or ambivalent information from the “real” world. The therapist attempts to soak in this information, remaining curious at all times about the client’s life without projecting anything from their own. Thus, the attempt is to maintain objectivity by seeing the information in itself. This provides the therapist with a formative playground to test and retest their own existing belief systems as the objective lens aids them to see the previously recorded data in a newer light. It is this genuine curiosity that helps a therapist look beyond their own preconceived notions, beliefs, and knowledge.

Therapists are cognizant of the notion or at least attempt to be conscious of the idea that people see the same situation differently and from their own frame of reference. The therapist must be reverent of that. This is comparable to an octagonal prism. When white light passes through, the prism separates it into spectrum of different colours. These colors are similar to the varied human perspectives that we hold at different points in time. This prism metaphor gives us the solace that in the therapeutic set up, one reality can be perceived in many ways.

All human beings are subjective in their interpretations and analyses of issues, therapists included. The world looks pink when we wear pink glasses. Thus, our core values as humans remain phenomenologically ours. We recognize that everyone has their own subjective world. Therapists specialize in recognizing these intricate subjectivities. It’s what helps them remain non-judgemental. Therapists are cautious in assuming and careful in hypothesizing, and amidst all that, authentic.

Unlearning to Learn

It is our fundamental premise that both clients and therapists learn and unlearn in therapy. For the client, learning can be anything from forming a trusting relationship to altering destructive actions. For the therapist, the process of learning might in fact be a process of unlearning. It is our personal belief that has its roots in early psychodynamic theories that during the early stages of our development we learn or rather introject without careful evaluation, a number of beliefs and values. Some of these beliefs are adaptive and others are not. These beliefs help us operate in society and we cling to them like an infant to their primary caregiver. When we attempt to change our maladaptive beliefs, we face resistance from within. This is because of our inability to tolerate cognitive dissonance (holding two or more clashing thoughts at the same time). We often stick to our more maladaptive beliefs even in the face of contrary evidence to maintain equilibrium. This is where the tiresome, yet fruitful, process of self-reflection comes in. Self-reflection helps us unlearn our introjected beliefs that hamper our own growth and progress. Because the “personal” interacts with the “professional,” for therapists, unlearning in personal life affects professional development and vice versa.

Self-reflection is an active, arduous vehicle in this grand process of unlearning. Many other aspects of the art of psychotherapy facilitate this unlearning automatically. One of these is learning the power of narratives. “When we try to view the client as a storyteller, we appreciate the complexity of their characters and the power of those complexities”. As we help them weave their otherwise fragmented life episodes into a meaningful journey, we learn from their stories. This process of stitching the disjointed pieces into a meaningful narrative often mechanically diffuses some of the previously held pre-conceived notions. For example, imagine working with a real world “bully.” Now imagine that this “bully” presents as unruly, aggressive and oppositional. What would our natural reaction be? How understanding would we be of that behavior? How difficult would it be to propel our empathy wagons? Now imagine that this “bully” tells you why they have chosen this role. They explain to you their story, their family, their parents, their life. How would you feel after learning about their phenomenal world? Would your feelings change? Would it be a little easier to empathize?

Knowing and understanding that the “bully” had a story to tell, that they were influenced by the negative experiences in their life, and that those negative experiences invariably propelled them to assert dominance and a grip over self might have mitigated the negative feelings that some of us held towards them in the beginning. Interestingly, as much as we attempt to maintain an objective lens to avoid biases, narratives help us unlearn objectivity in order to appreciate the client’s phenomenological realities. And this dual process functions simultaneously and rather beautifully. The key unlearning here is that no absolutist response really exists.

The Power of Witnessing

As therapists, we also use the technique of paraphrasing and summarizing to the client about their own narratives. Oliver Sacks³ has eloquently postulated that “We speak not only to tell other people what we think, but to tell ourselves what we think. Speech is a part of thought.” Hence, paraphrasing has double edged benefits. On the one hand, it gives a newer perspective to the client about his/her own problems and at the same time it gives both the client and therapist the opportunity to stay on the same page and to postulate that the story is being understood from the lens of the client. This helps the client to unlearn his or her cognitive fallacies associated with the story, and at the same time aids the therapist in creating a renewed understanding of why the client behaved in a certain way. The technique of paraphrasing/summarizing by the therapist, gives clarity and opportunity to reframe our thoughts, check our biases, and better understand narratives.

“The process of witnessing change and resolution in another human being is powerful and overwhelming”. Also, as therapists we are constantly utilizing ourselves as a resource to bring about progress. The therapist by default experiences shifts and alterations in their own worldview further reiterating the notion that nothing lasts. On rare calculated and sometimes spontaneous occasions, depending on therapist preference, we use the technique of self-disclosure with our clients or admit our fallibility to them and share the human connection. This is our attempt at normalizing vulnerability, treating the client as an equal. This vulnerability is also utilized as an instrument of moral support for the client. This self-investment on the part of the therapist is another step to assure the client that they are being viewed as both unique and normal. Often, once a human invests a little in a joint process, it is hard to operate independently from one’s own prejudices. We unlearn the shame in vulnerability and instead embrace it. Or like Brene Brown suggested, we learn to believe in the power of vulnerability.

One of our most treasured learnings in this process so far has been that an “average” life is worth living. To come to this realization, that what has been termed “average” by the larger society is in fact normal and fulfilling, is a big one for us. We have unlearned that purposeful life exists only in the extraordinary life path. We are trying to normalize average, both for ourselves and our clients. Better yet, our vision is to glorify average. Reciprocating to the client that their so-called average lives filled with failures and anxieties are not just normal but also acceptable, gives us average beings the courage to bask in the glory of our own average narratives.

We have taken it upon ourselves to unlearn as much as we can and to stay true to our authenticity and curiosity during this process. As we attempt to disentangle the web of the distorted learnings we have accumulated in life so far, we are learning to engage in compassion toward ourselves. As Noam Chomsky said, “I was never aware of any other option but to question everything”². This is perhaps what this profession is doing to us—inciting us to question the most scrupulous nuances of our present being.

References

(1) Yalom, I. (2002). The Gift of Therapy: An open letter to a new generation of therapists and their patients. New York, NY: Harper Collins Publishers

(2) Chomsky, N. (2004, November 30). Question Time [Interview by T. Adams]. Retrieved April 27, 2019, from https://www.theguardian.com/books/2003/nov/30/highereducation.internationaleducationnews

(3) Sacks, O. (1989). Seeing Voices. New York, NY: Vintage Books.