Category: Approach

The Gossamer Thread: My Life as a Psychotherapist

Posted on by rezendevknowfully.com

Below are three extracts from my book, The Gossamer Thread: My Life as a Psychotherapist (Karnac, 2010). The book describes my personal journey as a psychotherapist, how I started as a bumptious behaviour therapist, young, inexperienced and highly confident, and ended as a psychodynamic psychotherapist with a more reflective and intuitive way of working. Along the way I trained in Beck’s cognitive therapy although I found myself almost immediately doubting the rational simplicities of this approach.
The first extract describes my attempt to demonstrate the wonders of behaviour therapy to one of my students by treating an elderly lady, a chronic agoraphobic stuck in her flat on a run-down estate in south London.
In the second extract, Frances, a model cognitive therapy patient up to that point, becomes suddenly depressed and I behave in a not very therapeutic way.
In the third extract I take on my first psychodynamic psychotherapy patient, a charming, narcissistic young man, and discover how tricky it is to get through well-established defences.
 

Working as a behaviour therapist, London, 1970s

I park my car on the road that borders the estate, thinking that the safer option. Graham and I walk down the hill seeking to locate Arlington House where Mrs Hewittson lives. I’m aware that we stand out, dressed in our smart, professional clothes, each carrying a leather briefcase. But no one bothers us and we find No. 7, a ground floor flat fortunately, so we don’t have to negotiate what I imagine to be urine-smelling lifts or flights of bare concrete stairs. I ring the bell and wait.

I had briefed Graham beforehand. This is to be an assessment. Given that this is behaviour therapy, it would of course be a behavioural assessment. My plan was that flanked by the two of us, Mrs Hewittson would come out of her flat. Then we would send her off on her own as far as she could go until she couldn’t go any further. And I was going to be really scientific about this, for we would note down exactly how far she went, how long she took and how much anxiety she experienced on a scale of 0 to 100. This would be the baseline against which her recovery would be measured. In my mind, I fantasised Mrs Hewittson going further and further each week until we had her travelling all over London.

The door is opened cautiously by a young girl, no more than nine. I explain that we are psychologists and that we have come from the Maudsley hospital to see Mrs Hewittson.
“‘Nan,’ she yells back into the flat, ‘there’s two psychos from the hospital to see ya. Waddya want to do?’”
We hear the sound of talking from inside the flat, two voices, one female sounding very tremulous. Graham and I exchange looks. The door opens wider. ‘Nan says you can come in.’ The girl disappears into the gloom of the flat. When we get used to the darkness, for the curtains are drawn and the main lighting comes from a TV blaring away in the background, we see that the room is full of people. There are three girls, including the little girl who opened the door, playing around a Wendy house in one corner. A woman, barely in her teens, is seated at a table holding a baby who is guzzling milk from a bottle. A tiny, wizened man in an old grey suit sits on a huge settee, a cigarette dangling from his hand. And, in a rocking-chair in the centre of the room, there is a woman in her fifties, strands of mousy brown hair straggling down either side of a pale, thin face in which watery blue eyes stand out like on those odd goggle-eyed fish one sees in aquariums. She is staring at us unblinking. Mrs Hewittson I presume.

It is an unnerving situation, not what I’d expected. I’d imagined Mrs Hewittson stuck on her own, lonely perhaps, even pleased to have a bit of company. Not in the midst of a melee of people. But I’m the professional. So I take charge. ‘Mrs Hewittson?’ I say, addressing the lady in the rocking chair. ‘We’re psychologists from the Maudsley. We’ve come to help you get better.’
The woman says nothing. ” She rocks forward and back in the chair. I am uncomfortably reminded of the Bates motel in Psycho and the skeletal mother in the basement.”
‘Your daughter,’ I press on, ‘arranged for us to come and help you.’
‘Did she now?’ Mrs Hewittson says. It’s a rasping, throaty voice, the product no doubt of thousands of cigarettes smoked in the gloomy flat. ‘That was nifty of Jean.’
Somehow I feel that being ‘nifty’ is not something Mrs Hewittson approves of. The tiny man on the settee leans forward. ‘My Madge is not well, you know,’ he says confidentially as though she cannot hear him. ‘Trouble with her nerves. Had it a long time.’
‘That’s why we’re here,’ I say triumphantly. ‘To get her better.’
‘How are you going to do that then?’ puts in the woman with the baby.
‘First, we’ll go out for a short walk, say, to the post box.’ We’d passed the post box just twenty metres along the road. I turn to Mrs Hewittson. ‘You might have a letter you want to post and we could do it together.’
‘Sammy takes all my letters. He delivers them and takes whatever I’ve got. Don’t need to post anything, thanks all the same.’
‘Anyway, it’s an assessment, a sort of test, to see how far you can go. You don’t have to go far,’ I add hastily. ‘Just as far as you feel you can go.’
‘I can’t do that, doctor. Sorry, I can’t do that at all.’
‘Oh.’ This blanket refusal takes me back. ‘Well,’ I press on gamely, ‘what about going out of the front door and down the path to the gate? It’s only a couple of yards. I’m sure you could do that with our help.’
‘I would do it, sir. But it’s the fits, you see. Can’t risk it. I have these terrible fits.’
‘She does,’ interjects the man in the grey suit who I take to be her husband. ‘She has these fits. She’s a martyr to them.’

I sense I am losing the battle. What are these ‘fits’? Could they be epileptic fits? If they are, what do Graham and I do if she has one? I have never seen an epileptic fit. All I know is what everyone else knows from the films, how you have to grab the tongue, but then what? I curse myself. I should have read Mrs Hewittson’s case file before we came. Before I have time to say anything, the front door opens and in breezes another youngish woman with a two-year old in tow.
‘Madge, darlin’,’ she starts, then stops having spotted us. ‘Sorry, love, didn’t know you had visitors.’
‘They’re from the hospital. Psychiatrists,’ says Madge.
‘Psychologists.’
‘Sorry, didn’t mean to offend and all that.’
‘No offence.’
‘Thing is,’ says the new arrival, ‘I was hoping you’d look after Darren while I go to the Social.’
‘No problem, love. You leave him here with me.’ Mrs Hewittson turns to me. ‘Very sorry about the walk. But you see I’ve got my hands full. Another time, doctor.’
‘Yes. Right,’ I say decisively. ‘What about Friday morning? At 11?’
‘That would be ticky-tack. I’ll be more meself then, I expect.’
Unfortunately, that’s exactly what worries me.
 
Friday morning comes and Graham and I make our way back to the Dog Kennel Hill estate, to Arlington House, No. 7. I have found Mrs Hewittson’s case file. A bulging, tattered, beige-coloured, wallet with letters, documents, case notes, and other bits of paper loosely packed into it. I have waded through it all. There is no mention of epileptic fits. Just panic attacks, which I suspect is what Mrs Hewittson meant. As we approach the door, we see pinned on it a scrap of white paper, fluttering in the wind. I fold it down so we can read what is on it.
Too the Doctors. Very sorry, had too go to the dentists for me tootheyk really bad it is. Mrs Hewittson
We try to peer in through the windows but the curtains are closed. There is not a sound from inside. But I knock a couple of times anyway.
““It seems,” Graham says, “that a visit to the dentist is preferable to a visit from us.””
“Maybe it was an emergency.”
“Yes, of course that might be it.” He gives a half smile.
I take the paper off the door and, beneath Mrs Hewittson’s scribbled message, I write:
Sorry about your toothache. Hope you get it fixed. We’ll come again on Monday at 11.
I am not about to give in so easily.
 
On a bright, sunny Monday morning Graham and I are again standing outside No. 7 Arlington House. This time there is no scribbled note on the door. We knock but there is no response. The curtains are not completely drawn on one of the windows. Peering in, I see that the front room is empty and the TV is off. There is no sign of occupation. I step back and look at Graham. He shrugs. Just then a young girl, a similar age to the ones we had seen playing around the Wendy house, comes skipping down the street towards us. She skips right up to us and proceeds to skip round us as though we are part of some game she is playing.
“Are you,” she says as she skips, “the doctors?”
“I suppose so. Yes, I mean.”
“To see Mrs H?” Skip, skip.
“Mrs Hewittson, that’s right.”
Skip. “She left a message.” Skip, skip.
“And?”
Skip, skip. “She’s gone to the Isle of Wight.” Skip. “To visit her brother-in-law.” Skip, skip.  “For the whole week.” At that she skips off the way she came.
As we trudge back to the car, Graham says: “You could say we had a great success. After all, we got her out of the house.”
“Drove her out,” I say with a grin.
“And in one session.”
“We should write a paper. ‘One session treatment for agoraphobia: a breakthrough in behaviour therapy.’”
We did not write a paper, of course. Nor did we return to bother Mrs Hewittson again. It had taken me a while to get the message but I did get it in the end.
 

Training as a cognitive therapist, Oxford, 1980s

One week Frances fails to attend a session, something she has never done before. We are well into the therapy. We have moved on from changing negative thoughts to identifying the underlying beliefs, what Beck calls schemas. These are the major drivers of depression, ideas that are often formed in childhood and become reactivated in current crises. They can be encapsulated in key phrases or prescriptions like: To be happy I have to be accepted by everyone all the time, I must succeed in whatever I do, I have a fatal flaw in my personality, I am fundamentally a bad person. According to Beck, to produce lasting change it is essential to get to these core beliefs and deal with them.

In the session before Frances failed to attend, she had complained that her work as an administrator was boring. I asked why she didn’t try to get a more demanding and interesting job, something that drew more on her academic ability perhaps. She said vaguely that there was no point. Puzzled, I pursued this and we came to an example of a powerful underlying belief. Life is meaningless, she claimed. In the end we all die.
‘How do you know life is meaningless?’ I ask.
‘I just do.’
‘Come on. You know that won’t do. Let’s do some cognitive work on this. List ‘pros’ and ‘cons,’ for example.’
Frances says nothing. I try to read her face but I can’t. It’s expressionless.
‘Don’t you want to challenge this belief?’
‘I can’t see the point.’
‘To get better. To deal with your depression.’
‘Deal with it,’ she says sarcastically. ‘You don’t deal with the meaningless of our existence.’

I am startled by Frances’s tone. It’s the first time I’ve heard her talk in this angry way. I backtrack. ‘Okay. I’m sorry. A poor choice of words. But I do think we should examine this belief, don’t you? It seems central to your depression.’
Frances stares at me. For the first time in the therapy I feel unsure. More than that. I have a sense of unease.
‘Maybe,’ she says at last. ‘But not today. Can we leave it to next time?’
‘Okay.’
Later, I wonder if I should have agreed so readily. Was this avoidance on my part? Up to now the therapy had been going smoothly. Frances was the model patient. This was our first glitch. I’d told myself that it would be better not to push this. We could work on it in the next session. The only problem is that Frances failed to turn up for the next session.

I ring Frances. I don’t normally do this when patients fail to show up. I wait a couple of days and if they don’t contact me, I drop them a line. But Frances is a special case, my first cognitive therapy patient, and I’m worried about her. The phone rings on and on. I’m about to hang up when at last she answers, a slow ‘Yes, who is it?’ as though I have just woken her up.
‘Frances, it’s John. I was wondering if you were okay.’
‘What time is it?’
‘Just after two. Have you been asleep?’
A long pause. ‘Sorry. Just very tired.’
‘You didn’t make the session this morning. I wanted to know if you’re alright and if we should reschedule.’
Another long pause.
‘Are you feeling depressed?’
‘You could say that.’
‘Is that why you didn’t come to the session?’
‘What’s the point? I’m not going to get better.’
‘That’s your depression talking, Frances. You’ve had a downturn in mood. All the more important for you to see me at this time. We can work on it together and help you get out of it.’
‘I don’t know.’
‘I do.’ I’m being the decisive, no-nonsense therapist though it’s the last thing I feel at this moment. My shoulder muscles ache with tension. My heart is beating fast. At the back of my mind is the thought that Frances will kill herself. ‘How about later on today, at 6? Or tomorrow morning?’
‘No. I need a bit of space. I’ll come to next week’s session. Don’t worry, John. I’m not going to do anything stupid. I haven’t the courage to do that anyway.’
I try to persuade Frances to see me earlier but she’s adamant. She promises to come next week. I wring a further promise from her that she will contact me immediately if she feels suicidal.
What has happened? The therapy was going along really well. Is it just a blip, a random change in mood? Has something happened to Frances to trigger the increase in her depression? Was it related to our discussion of her core belief that life is meaningless? I ponder these matters but come to no conclusion.

When Frances comes to our next session, I immediately notice a change in her manner. There’s a slowness to her movements, a hesitancy that I have never seen before. She doesn’t look directly at me and when I study her face, all I can see is blankness. I ask her how she is. She takes a while to respond. She says she feels lousy, tired, depressed, no energy, completely zonked. All signs of depression.
‘I’m sorry you’re feeling so bad but I’m glad you came,’ I say. ‘It’s a chance to do some work and improve your mood.’
She looks at me and sighs. ‘The good doctor’s going to make me better. Hooray.’
‘Well, I’m going to try. Tell me right now and in all honesty what you think of coming here.’
‘A waste of time.’
‘Why?’
She shrugs. ‘Nothing works and anyway what’s the point. I get better for a bit and then I get worse. I’m just useless.’
‘Several very negative thoughts in that statement, I’d say. Do you remember how we dealt with, I mean, worked on your negative thought, I’ll never get better? We listed the ‘pros’ and ‘cons’ and came to a more realistic thought. I have it here.’
I search through my notes and read it out to her:
I can’t know that I’ll never get better and I recognise that this absolutist negative thought is a product of my mood state rather than a realistic appraisal of what will happen.
‘Do you believe that now?’
‘It’s irrelevant what I believe,’ she says in a lethargic tone. ‘Life’s meaningless anyway. We are microbes in the vast universe. Specks of cosmic dust. What does it matter? What does anything matter?’
‘Something mattered enough for you to come here today. You’re depressed, Frances. Something brought you right down in the last week. I don’t know what. But I am absolutely convinced that your view that life is meaningless is caused by your depression.’
‘It’s not,’ she says emphatically. ‘Life is meaningless. It’s not a product of depression. It’s true. And anyway I’ve always believed it so it can’t be a response to a change in mood.’
For the moment I’m stumped. I’m also feeling pissed off with Frances, with her certainty and resistance to my attempts to help her.
‘Always?’
‘Always.’
‘So you sprung from your mother’s womb with the thought Hey, why am I here? Life is meaningless. Let me back in?’ I have spoken without thinking. I’ve let my feelings show. I’ve broken a cardinal rule: don’t mock your patient. I’m a crap therapist. But a small smile appears on Frances’s face.
 

Training in psychodynamic psychotherapy, Oxford, 1990s

Sitting opposite me is Matthew, a tall young man, in a scruffy white T-shirt and faded jeans. In his hands he has a Rubik cube.  Each side of the cube is subdivided into nine coloured squares, the puzzle being to twist the arrangements to produce sides of all one colour. Matthew is fiddling with the cube, a frown of concentration on his face. He is my first proper psychodynamic psychotherapy patient. This is our first session.
“I wonder if it might be best if you put the Rubik cube down.”
I leave the faintest of inflections at the end of my remark to try and soften the suggestion. Matthew drops the cube into a battered shoulder bag that he has draped on the side of the chair.
“There,” he says, flashing me a brilliant smile. “I solved it yesterday. I thought I’d see if I could do it again. I must have gone wrong somewhere.”
I could pick up on the wider meaning of his last remark but decide that it is a bit too early to do so and, moreover, it is Matthew who should do the running, not me. I have already introduced myself and explained that we are to work together for up to a year, meeting once a week, holidays apart.
“How about you kicking off,” I say. “Just say whatever’s on your mind.”
We are seated face-to-face. There is a couch in the room but Matthew declined it. I was disappointed as the couch seemed so much a part of the psychodynamic approach.
“What do you want me to say?” he says brightly as though he is here to audition for a part in a play.
“The idea is for you to talk and we take it from there. Whatever is on your mind.”
This produces a long silence during which Matthew gazes around the room as though seeking something to latch onto.
“Crap painting,” he says pointing at a Monet print of a mother and young girl walking through a bright red poppy field. “I hate reproductions.”

Is Matthew saying something about himself in this remark, I wonder? That he is not a reproduction, but the real thing, a true original. Whether he is or not I decide not to comment. I think about what I already know about him from the assessment that Dr Franklin, the Psychotherapy Department’s senior registrar, carried out. He comes from a well-off, middle-class family. He is particularly close to his mother. She gives him a generous allowance and has let him stay, rent free, in a flat she owns in Headington. His father, a successful businessman, is largely absent from home. At school Matthew was regarded as very bright but dropped out in the 6th form. There are suggestions of drug taking and gambling. Since school, he has had periods of temporary work, mainly on building sites, though most recently he worked in an office. None of his jobs have lasted long. He is currently unemployed. Matthew’s major complaint is of extreme anxiety, often in the form of panic attacks. These have caused him to retreat to his flat, sometimes staying there for days on end, not seeing anyone.

My reverie is interrupted when Matthew says, looking quizzically at me: ““You’re not like Doctor Frankenstein. He asked me lots of questions, most of which, actually all of which, were stupid. In the end I just made things up. It seemed to make him happy.””
Jesus! Now I do not know what of Dr Franklin’s assessment is correct, which is, I suspect, exactly what Matthew wanted.
“I wonder why you did that.”
“I wonder why myself.” A cheeky smile, inviting me to join in the joke. I cannot help smiling back. There is something very disarming about Matthew. 
“When I was at school,” he says after a while, “I would make things up. Entertain the troops by telling a few fibs, playing the joker. It got to be a habit. I had this great ex-army greatcoat and me and the other lads hung about, doing dares and that. Wicked!”
He sounds about 16. Stuck in an adolescent time warp.
“Only I lost the coat. Then the bastards threw me out.”
Why did they throw you out?It’s on the tip of my tongue to ask but I stop myself. Above all, I want not to interfere, to let Matthew talk and me listen. So far he has not told me about anything serious. Not about his uncertain sexuality. Not about his intense feelings of panic. Nor about the time when he took an overdose of antidepressants (the tablets were his mother’s prescribed by the family GP). Dr Franklin had noted all these in his assessment but Matthew does not seem to want to talk about any of this. Of course they might all be fabrications (fibs to entertain the troops) but somehow I doubt it. Beneath the veneer of jokiness I sense his vulnerability and unhappiness. The difficulty might well be getting him to talk about it.

Matthew talks more about his school even though it is over three years since he left. He was brilliant at English and had two poems accepted by the school magazine. But he stopped working in the 6th form because it was all so puerile. Then the teachers tried to get him to see a school counsellor who turned out to be a real wanker. I am cast in the role of the eager listener to his tales of schoolboy derring-do. He tells a good story and I think I could just let him do that. But where would we have got to and what purpose would it have served other than to pass the time? The dilemma with the passive stance of the psychodynamic psychotherapist is that someone like Matthew could entertain the troops all day long. At a pause I venture to stir things up, unsure if I am doing the right thing and wary of how he will react.

“From what I’ve heard so far everything seems so hunky-dory that I wonder why you are here in psychotherapy at all. It hasn’t been all sweetness and light, has it?”
Matthew does not say anything, which causes my heart to beat faster. I run through the statement I have just made and castigate myself for its anodyne quality. Could I not have been more incisive?
“Hunky-dory,” he says, drawing out the word in a laconic manner. “Now that’s not a word in the psychotherapist’s lexicon, I would have thought? Or is it?” ” He looks at me expectantly, all sweetness and light of course.I feel the stiletto sliding subtly into me.” I tell myself to stay mum and then wonder at my choice of words. Mum’s the word. The phrase floats through my mind as though magically Matthew has projected it into me. Is this an unconscious communication? Do the words mean that we will be okay as long as I mother him, admire his precocity and wit, but if I, taking the paternal role, challenge him, he will hit back? All this flits through my mind in seconds, a blur of semi-conscious thought, as Matthew looks me straight in the eye and waits for me to respond. I say nothing, holding his gaze until he looks away. My beating heart gradually slows. In my previous persona as a cognitive-behavioural therapist, I would have been more active. I would have probably said that hunky-dory was certainly not a psychotherapeutic term, just a word that seemed appropriate. I would have smiled, wanting to maintain good rapport. I would have asked Matthew whether he minded the word or if he preferred another. Why do I not do this now? Because my primary role is not to be Matthew’s friendly helper, not to make him feel at ease. As a psychodynamic psychotherapist I am seeking to create a space in which we can explore deeper feelings. For that to happen I have to dispense with the niceties and tolerate the discomfort just as Matthew has to do too. I am finding this difficult. It is not just that Matthew, with his air of vulnerability and his boyish charm, invites me (and others, I imagine) to look after him. I realize I like looking after people. That is why I am in this job. Only in this instance looking after people means something very different. It is not about making them feel better, at least not immediately, but getting through their defences to the heart of their problems. To achieve this I shall have to use a few stilettos of my own.

The session stutters on. Matthew’s breezy insouciance dissolves. He retreats into scowling silences. When he speaks, there is anger and more than a hint of despair. He rails against both his parents, his father for his crass insensitivity and his mother because she is a very silly woman. I hear nothing of his brothers and sisters. He brightens up only when he talks about his best friend, Tom, who is about to return from college. Tom is going to stay with Matthew and they’ll have fun together again. I cannot help thinking that the fun will be rather hollow. A feeling of sadness pervades the room. Matthew’s defences are pretty brittle, I realize. I feel daunted at the task of treating him. After all, I am a novice at this form of therapy. Yet I desperately want to help him, not just because I am on a course and anxious to do well, but because I sense his despair. I end by saying a few words about the task ahead.
“These are your sessions, Matthew. We have up to a year to work together.”
“But what’s the point? It’s just talking. What can talking do?”
“It’s an opportunity for you to take a look at yourself, to explore how you feel, to examine what has happened to bring you to this point.”
“But I’ve told you all I know.”
“I don’t think so,” I say more assertively than I had intended. “Do you really think you have?”
A pause. “No. There are other things. Stuff I haven’t talked about. Horrible stuff. But I don’t think I’ll ever talk about that.”
“Let’s see. Next week at the same time?”
“Okay,” Matthew says. A flutter of hope, faint and tenuous. “I sit for a while in silence after Matthew leaves. I feel drained and empty.” Then I pull myself together, reach for my pen and start making the detailed notes I shall need for supervision.
 
John Marzillier
28 February, 2011

Collaborative Couple Therapy With High Conflict Couples

Posted on by Psychotherapy.net Team

What’s hard, when dealing with high conflict couples, is getting their attention. If they do register your presence, it is to recruit you to their cause, confiding in you conspiratorily, “Look what I have to put up with.” And if they do acknowledge what you say, it is to turn your comments into ammunition against their partners, assuring you, “I do what you’re saying, but he never does.” High-conflict couples attack each other at such high velocity that you don’t have time to think. And you may not get much chance to talk, either, if, as sometimes happens, they keep interrupting you. Here are various methods I have heard therapists use to deal with these couples:

1. Take control from the beginning by doing individual therapy with each in turn in the presence of the other or taking them through a structured sequence.

2. Separate the partners. See each individually for a session and then bring them together. Taking it a step further, some therapists tell certain high-conflict couples that they each need a course of individual therapy before even considering couple therapy.

3. Ask them how they met and what originally attracted them to each other. In so doing, you distract them from their fight and introduce something positive.

4. Establish and enforce ground rules such as “no name-calling.” In a videotape of her work with a high-conflict couple, Susan Heitler gave the couple two rules: 1) stop talking when I say to and 2) don’t interrupt when I’m talking to your partner.

5. Tell the partners “hold it” or “stop” or wave you hands between them. Forcefully take command, as does Terrence Real. Or wave off the interrupting partner (Robert-Jay Green does this, but then later adds the wonderful touch of apologizing to the partner he waved off).

6. Confront the partners with the counterproductive nature of their behavior, saying, for example, “Listen to yourself!” or “Blaming doesn’t help” or “Talk about yourself rather than about her” or “Do you want to be right or do you want to be married” or “You’re acting like a couple of three-year olds in a sandbox fighting over a pail and shovel.”

7. Hook them up to a heart-rate monitor and when either partner’s heart rate exceeds one hundred, get them to take a time out. John Gottman came up with this.

8. Interrupt a fight to play back the video of it. John Gottman and Stan Tatkin do this.

9. Pick up a book and tell them you’ll stop reading when they stop fighting and get down to business.

10. Tell them that things are going too fast for you to think. Rather than blame them for doing something wrong, you take responsibility for the need to slow things down.

11. Move in quickly when things suddenly erupt and say “What just happened?” Susan Johnson does this.

You have to be forceful when dealing with high-conflict couples who interrupt each other and interrupt you and thus make therapy difficult. My way is forcefully to enter on the side of both partners and develop what they are trying say rather than to confront them with the counterproductive nature of their behavior and urge them to restrain themselves.

Why do I want to develop what the partners are trying to say? Because anger is typically a fallback measure, in EFT terms a secondary emotion. It’s what you’re often left feeling when you can’t express what you need to say—you lose your voice—or when you can express it, but you can’t get your partner to listen. In a couple fight—and this is the definition of such a fight—there are two people who feel too unheard to listen.

So I try to get the partners to listen to each other. I try to show them how it would sound if they were to express what they needed to say and take in what the other is trying to say. I move over and speak for them, in a method similar to doubling in psychodrama. I try to turn their fight into an intimate conversation.

And I do something else. I try to shift the partners to the meta-level—what I call the platform—and get them talking collaboratively about their fight. I want to get them commiserating with each other about it.

So these are the things I try to do with high conflict couples (and, actually, with any couple):

  • Help them express what they need to say,
  • Help them take in what the other is trying to say
  • Create this platform.

There is a natural sequence of things I do in my effort to accomplish these purposes.

The first is to catch the fight in its early stages before it builds up steam. If I see the emotional temperature rising or if one of the partners lets loose a zinger, I jump in. If George says something angry to Rose, I move next to him and, doubling for him, that is, speaking as if I were he talking to Rose, I say, “As you can tell, I’m angry and that’s because I felt hurt by what you just said.” I turn his angry comment into a confiding one. If I can’t think of how to do this, I repeat some version of what he said but in a nonangry tone. Alternatively, I might help Rose deal with what George has said by asking her, “How much does what George just said seem an accusation and how much an understandable concern?”

If I’m unable to catch the fight before it starts and it really gets going, I try to translate the fight into a conversation—that’s number 2. I go back and forth between the partners, doubling for each in turn, trying to detoxify each person’s comments. This can go on for some time. Sometimes the fight goes too fast for me to keep up with. When that happens, I wait until I regain my bearings and then go back over what they just said, but detoxifying it (“first you said…, then you said…., then you said….”). I bring out the conversation hidden in their fight.

Third, if I am unable to translate the fight into a conversation, I make a statement for each showing how each partner’s position makes sense. “Jim, it’s understandable that you don’t like Brenda’s bringing up something you did 20 years ago. It makes you feel she’ll never let you live anything down. And Brenda, it’s understandable that you’re bringing it up because it’s the clearest example of what you feel Jim continues to do in more subtle ways today.”

If I fail to get the partners to appreciate how each of their positions make sense, I try to get the partners up on a platform—a meta-level—talking collaboratively about how they are being adversarial. That’s number four: talk about the fight:

  • I ask, “Are you getting something from this fight, a chance to say a few things or hear a few things? Or is this fight discouraging, what happens at home, and what you came to therapy to stop?”
  • Or I ask, “In what ways is this fight useful and in what ways is it not so useful?”
  • Or I ask, “You came in today feeling relatively good about each other, but little by little the good will disappeared and now you’re quite upset with each other. Do either of you have any idea of what brought about this shift?”
  • Or I ask, “What should we do about this fighting? Should I step in more quickly to stop it?”
  • Or I ask, “Am I doing my job in keeping things safe? Or am I allowing too much fighting.”

While I am doing all these other things, I look out for and focus on conciliatory moments. That’s number five. I say, “Hey, I want to go back to what happened just a minute ago. You made that sweet comment (or you had that sweet exchange). What allowed that to happen? What were you thinking and feeling just before you said it that led to it?” And to the other partner I say, “How did you feel hearing it?” I’m looking for moments when these fighting partners aren’t fighting—much like a narrative therapist or solution-focused therapist looking for an exception. At other times I try to create a conciliatory moment. When one of the partners says he or she feels lonely or disappointed, I harken back to earlier in the session, or earlier in the therapy, when the other partner expressed such a feeling. I jump at the chance to show that they share a particular reaction.

Turning now to the situation in which one (or both) partners makes long provocative statements, either repeating (belaboring) a complaint or stacking complaints one upon the other,  I try to find a collaborative way to interrupt them. That’s number six: “interrupt tirades in a collaborative manner.”

  • I say, “I’d like to interrupt you here because I’m afraid that we’re losing Linda; she seems to be sinking deeper and deeper into the couch”
  • Or “Let me interrupt you here to find out how Linda is doing hearing this”
  • Or “I’d like to interrupt you here because you’re making some important points but I’m concerned that they are getting lost; I’d like to repeat them and then get a response to each from Lois.”
  • Or, “In the last couple of sessions things got pretty intense when one of you laid out a number of complaints in a row, so I think when that happens this session that I’ll move in and interrupt so we can have more of a conversation. What do you think about my doing that?”
  • Or I move in after a partner has made one or two points (or has made one point but has repeated it several times) and before he or she can repeat it again or go on to make the next point and I say, “Let me work with that; you’re saying that…” Or, more simply, “Okay, so you’re saying…” or “Let me interrupt here.”

If all these various efforts fail to rein in the fight, and I feel overwhelmed and powerless and don’t know what to do, I give myself a little pep talk—that’s number seven: “Console myself.”

  • I remind myself that although I don’t know what to do at the moment, I’ve always in the past been able to come up with something a little later.
  • Or I remind myself that partners who appear to ignore or reject everything that I and their partners say, often come to the next session having made changes that show that they had heard, but just weren’t in a position at the time to acknowledge it.
  • Or I remind myself that partners who fight the whole session sometimes come to the next session saying, “We needed that—a chance to let off steam. We feel better now.”

If it looks like the session is going to end with the partners angry at and alienated from each other, I talk with them about that. That’s number eight: appealing to the partners as consultants in evaluating and dealing with the situation.

  • I say, “Given what’s happened here today are you sorry you came?”
  • Or “What does a session like this leave you feeling about what we are doing here and whether these sessions are helping or just making things worse?”
  • Or “It looks like you’re going to end the session feeling angry and alienated. Is there anything either of you can think to do in this last couple of minutes to change that, or is it something that we shouldn’t even try to change?”

Another thing I do if it looks like the session is going to end with the partners angry at and alienated from each other is to ask what is going to happen after the session. That’s number nine. I try to create a platform—a vantage point above the fray—from which to speculate about what is going to happen.

  • I say, “Given how upset you are with each other, what is it going to be like driving home together, and tonight, and the next couple of days?”
  • “How are you going to get over this and how long is it going to take?
  • “Who’s the one more likely to reach out to the other?”

By anticipating with them what is likely to happen, I am trying to keep the aftermath of the fight from being the lonely, alienating experience it usually is. The three of us would be talking about it ahead of time. I follow up the next session by asking what did happen—what evolved from last session?

In this next session, I might ask whether they want to return to the issue they were fighting over the previous session? Or do they think that’s a bad idea because doing so will just get them back into the fight? That’s number ten: attempting a recovery conversation—revisiting the issue when they are not upset. If they want to make such an attempt, I guide them through it. And I jump in quickly if it does begin to turn back into the fight. Developing an ability to have recovery conversations is a premier goal of Collaborative Couple Therapy. In a successful recovery conversation, both partner come away feeling that the positions of each made sense.

To put all this together, I move in to keep the fight from happening. If it does happen, I try to turn the fight into an intimate conversation. If I’m unable to do that, I make an elegant statement for each partner showing how his or her position makes sense. If that doesn’t turn the session around, I try to get the partners on the meta-level talking collaborative about their fight. All the while, I draw attention to collaborative moments and interrupt partners (in a collaborative way) when they belabor or amass complaints. At various points in difficult sessions, I console myself. If it looks like the session is going to end with the partners angry at and alienated from each other, I appeal to them as consultants in dealing with this problem and ask what is going to happen after the session. In the next session, and if it is possible to do so without rekindling the fight, I conduct a recovery conversation. A major goal of Collaborative Couple Therapy is to enable partners to have recovery conversations in which they turn fights, problems, misunderstandings, and glitches into opportunities for intimacy.

Working in the Here-and-Now of the Therapeutic Relationship

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When clients arrive at our office, they’re hoping we can help them feel better. Often they assume it’s their outer conditions they need to change: “if only my husband would…” or,  “once I find a new job…” or, “I don’t know why I’m feeling bad because I have a great life, but…” It’s not that we don’t listen to their concerns, but these are all situations that exist outside our consulting room.
 
In order to help clients change, we have to allow ourselves to be changed by what we, in the therapeutic relationship, do together. Working in the present, in the room directly with what is happening, demands that the therapist emotionally connect with the client and not just sit back, hidden by our professional role of “helper” or “expert.” It requires emotional involvement, reflection, vulnerability, transparency, and risk.
 
Research repeatedly tells us the therapeutic relationship is the curative factor over and above all theoretical orientations. A figure commonly cited in the literature is that up to 50% of clients drop out of therapy after the first session. These figures are established regardless of finances: in private practices, agencies, and free clinics. Researchers attribute these high numbers to two things: lack of emotional engagement and failure to deal with ruptures.1            
 
If the therapist and client only talk about relationships that exist outside the consulting room, they miss many opportunities to deepen their work together. As therapists, we need not make generalizations or assumptions about what the presenting problems of our clients mean or how they came to be. These scenarios are acted out and worked with in the transference and counter-transference of the therapeutic relationship.
 
We also risk losing our clients through impasses and unattended derailments. “The first phone call can be a deal breaker before things even get started, because clients’ relational patterns begin to be reenacted from the minute they make contact with us.” If we let these moments go by and don’t address them at an appropriate time, we sacrifice the teachable moment as it’s happening between us.
 
The mutual engagement in the here-and-now of the therapeutic relationship is a deep, internal conduit for change, and it entails our clients experiencing the impact they have on us. It empowers them in personal ways we can seldom predict that speak to the uniqueness of who they are. It’s different from a prescriptive, goal-oriented, solution-focused model where we therapists are the all-knowing ones with advice and answers. It is instead dealing in the moment with things as they are, in the client, in the therapist, and the space between the two.
 

Nick: A Case Study

We can see how this way of working played out with Nick, a 48-year-old divorced man who came to treatment complaining of “loneliness and relationship problems.”2 He wanted to know why he always ended up alone and what he did in relationships that made women leave. He was also confounded by his rejection of women before things even got going. An additional problem that came up later in our treatment was his compulsive overeating. I wondered why it had taken several months for his concern about his weight to come up between us. Later I learned he had tremendous shame around his body, had been cruelly taunted as a kid about being fat, and became inured to his body as if he was destined to carry this “dead weight” around.
 
In our first session, Nick appeared overweight, with little attention given to grooming: a rumpled denim shirt, an unpressed pair of chinos, and well-worn tennis shoes. His hair was combed but hadn’t seen a pair of scissors for a while. He sat near the door, in the chair furthest from mine. As he settled, his movement seemed labored and uncomfortable, squirming in his seat, as though his body was a rough place to inhabit. It’s bound to be painful in there, I thought as I observed him.
 
“I don’t seem able to sustain intimate relationships,” he said softly, gazing down at his shoes, puzzled by his own incapacity. When I asked why he thought this was the case, he replied, looking everywhere but at me, that he didn’t know, but then mentioned he was too picky when it came to women. He realized he was a perfectionist—not that he thought he was perfect, but he always found something about the women that became objectionable.
 
“They don’t have a decent job, or we have little in common, or they’re not smart enough, they have no sense of humor, they talk incessantly about themselves…” “He said this staring out the window, as if talking to the trees. I didn’t feel like I was in the room with him.” His list was endless, and I wondered if it was the tip of the iceberg, saying more about him than the women he was rejecting.           
 
During one session after we’d been working together for a year, he shook his head and proclaimed, “Relationships are too much work.” Much of our conversation took place while he fidgeted with his clothes, his hands, or the couch. Inquiring into these nonverbal motions in the past had yielded little information and alerted us to the likely disconnect he had with his body. He acknowledged however, he thought the nonverbal gestures were about his “discomfort with intimacy.” I had seen him through two short romantic skirmishes, only to find him alone yet again.
 
“I must be afraid to get close to people, so I’m always discovering excuses to find something wrong with them.”
 
I nodded, suspecting he was on to something. “Sounds like a good insight.” Then, almost wondering aloud, “How is it trying to get close to me?”
 
He thought as his leg started kicking back and forth. “Well, it seems easier compared to others.”
 
“How so?”
 
“You’re not judging me, you accept what I’m saying, don’t need anything from me.”
 
I confess I was pleased to hear this, but suspected there was more to the story.
 
“Do you feel close to me?” I literally felt my body heating up, as if we were moving closer to something important happening between us in the room.
 
“I guess,” he said, looking out the window, fidgeting in his seat.
 
“You’re not sure?” I asked, trying to keep him present and accounted for.
 
“Well, I know we’ve talked about coming twice a week and I think I’m afraid to do that.”

The last several weeks we had been discussing his aversion to adding a session, making it a twice-a-week treatment, an opportunity for us to become more intimate. I could see him bristle at my suggestion when he mentioned “not enough time” at the end of the last few sessions. I suspected this was one version of how his fears of intimacy got re-enacted between us. “And what scares you about being together twice a week?” I asked.
 
“That you will discover something really wrong with me,” he said softly, picking at his buttons.
 
“And what would I see that’s wrong with you?”
 
He thought. “I don’t know––that I’m missing a gene that’s required for intimacy and a healthy relationship,” he said. “Maybe I have some incapacity, or I’m damaged goods, unable to be resurrected for a real marriage.” He said this with a big sigh, hanging his head, shaking it back and forth.           
 
We explored what he meant by “damaged goods.” This was a painful process with long silences and quiet tears running down his face.
 
“Once you see that, you’d give up on me, feel I’m unable to change.” He said this under his breath, choking down the tears, almost as if his words are stuck in his throat. “Maybe you’d think I’m a hopeless case, give up on me and want to get rid of me.”
 
He was barely audible. Were these new thoughts for him? My heart ached for him. Now we were getting to how fear of intimacy played out between us.
 
“Is that what you think? Are you the one who thinks you’re a hopeless case?” I asked. He was afraid I’d reject him. Perhaps this was why he rejected some women so quickly so they didn’t have a chance to reject him first.
 
The conversation segued into his first marriage failing. For the nine years they were together, it had been harder and harder to extend the intimacy, both sexually and interpersonally. Here in the room, elbows on his knees, head in his hands, he was unable to say why he had withdrawn from his wife. I also wondered about the pain he had been holding regarding his failed marriage. He didn’t understand why he felt so bad about himself; he just did. He always remembered feeling this way: not wanted, made fun of for being heavy, not feeling worthwhile or responded to. I imagined his weight, which had been with him his entire life, was an insulator for many of these feelings.
 

Ruptures

A few weeks later, Nick came rushing in late—highly unusual for him—and stormed across the doorway to my office. He appeared excited, invigorated, as he waved his arms around and stumbled hard onto the couch.
 
“I don’t know what’s going on,” he said breathlessly, “but recently I’m feeling angry—angry all the time.” My eyebrows rose as I nodded, suspecting this was a good thing.
 
He settled himself, took a breath and added, “Truthfully, I think it’s just I’m aware I’m angry.” Normally, Nick struggled to connect with his feelings and suffered with a blunted affect that resulted in a lot of fatigue and apathy. I suspected the overeating fueled the fatigue and depression and served to numb out painful feelings. “Since our work together,” he continued, “I see how there’s always been this under current of anger, but now see I’m allowing it to register. Not the usual denial of how I feel, and so I’m seeing how pervasive it is.” I can see how the food allows me to bury my frustration. He appeared animated and incredulous.
 
“Sounds like a good insight,” I said. I waited. Silence.  “Are you feeling angry now?”            
 
He considered this. “I…I don’t know. I guess I am,” he said surprisingly, almost as if to himself. I waited.
 
“Is there something you’re angry with me about?” I asked, not having anything in mind, but thinking about his being late and coming in angry.
 
“Well, no,” he pondered, “that seems like a stretch. Why would you ask?”
 
“You’ve come late today, which is uncharacteristic of you; in fact I can’t recall you ever being late, and you’re talking about being angry right now. We’re the only two here, so I thought it might have something to do with us.”
 
“I’m thinking it’s more about the spat my boss and I had this morning. I’m feeling stirred up by that,” he said, repositioning himself. After a minute, he stilled himself, focused and continued, “You know, now that I think about it, I did leave here kind of ticked off last week.”
 
He talked about his disappointment with me because I hadn’t had a chance to read an article he had written. I had told him I’d be happy to read it, but hadn’t done so between our two appointments. I certainly understood his disenchantment with me; had I been honest, I would have told him I couldn’t read the article for a couple weeks. I now realized my counter-transference had prevented me from saying anything, not wanting to disappoint him—an old habit of avoiding and pleasing people so they’ll like me.
 
As he said this, I remembered the look of disappointment and surprise on his face at the end of our last session, after asking me for my feedback on the article. I had since forgotten this moment, his facial expression being so subtle and fleeting. The moment had slipped by me; it was possible I didn’t want to see or feel his anger coming at me, a feeling that’s difficult for me.
 
“I felt unimportant and dismissed by you, not valued,” he said somewhat sheepishly, as if I were going to explain myself or make him wrong.
 
In this situation it was necessary to feel my own frustration and guilt for not reading the article, watch how this impacted my client and not collude (by evading his anger), retaliate, or defend myself. I stayed with what was happening between us to further explore his anger and frustration with me.
 
“Here was a rupture between us, and if I hadn’t made a point of contacting what was happening in the room, this incident would have gone underground.” I suspect our relationship would have hit an unconscious impasse, creating a lack of trust and distance between us. As we talked about his anger and hurt with me, he saw he could acknowledge it, feel it, express it, and that I could hear it, and we could still stay connected despite the difficulty.
 
Tracking Nick’s feelings in the context of the intersubjective field showed us how my need to please and avoid anger and Nick’s unspoken hurt and disappointment manifested unconsciously between us. Coming in late and angry, despite neither of us knowing why, acted out Nick’s feelings. I represented the “Bad Mother,” as Melanie Klein calls it, by not attending to reading his article. This re-enacted the parental relationship he had growing up. In Nick’s formative years he hadn’t had responsive parents as a mirror to reflect what his own thoughts and feelings were. This left him feeling devalued and ignored, as well as cut off from his own sense of self—a feeling that had a long and painful history and showed up in his depression, isolation and eating habits.
 
As we can see in this re-enactment, it was not just Nick’s feelings being acted out, but mine as well. In my attempt not to disappoint him, I had done just that. The disjuncture was something we’d created together, a common experience within the therapeutic relationship. As therapists, we’re going to make mistakes. The important part is how we bring the current experience to good account. This is the working through of therapy in the relationship, in the moment, in the room—the unpacking of what just happened.
 
“As therapists, it’s important to carefully monitor what gets stimulated, not only in the client, but in ourselves as well.” We allow ourselves to be moved, provoked, bewildered and, above all, impacted by our clients. What emerges in a session is a result of our unconscious subjective world colliding with theirs. We notice our personal reactions and distinguish them from our clients’ in order to help our clients with theirs. Each session is a mutual discovery. This creates a present aliveness, illuminating the issues lurking in both of us, often occurring under our radar of knowing.
 

The Past as Present

A few months later, after Nick’s hours were reduced at work, he requested to see me every other week. He said he was feeling on shaky ground with finances and didn’t want to risk spending more money at this time. Money had never been discussed between us, other than the initial payment, and I was curious what his financial situation was. He reported that his house was paid for, no alimony, and he had investments, but felt it wasn’t a “good time” to be spending additional money.
 
I understood his concerns and wondered with him if there might be any other additional reasons for wanting to cut back sessions. To ask for additional reasons beyond the cost of therapy can be a rich window into emotional issues obscured between the therapist and client.
 
“No, it’s really just a monetary thing,” he said with a shrug.
 
During the transition to therapy every other week, I mistakenly charged him for an extra session, perhaps a result of my own anxiety about money or disappointment about the reduction in sessions. Since Nick didn’t mention my mistake, I brought it up towards the end of our next session and asked him if he had noticed it.
 
“I did, but figured you were the therapist and knew best so I wasn’t going to say anything about it.”
 
I told Nick that I felt bad about my error, let it go, and imagined we had handled it.
 
But here was a reenactment. He was going to ignore his own need and accommodate to mine, a painful, reoccurring pattern established early in his life.
 
At every moment in therapy, there are multiple levels to which the therapist can respond, including the content, process, body language, affect, or relational field.  Looking back, this moment with Nick was a missed opportunity to explore our relationship. Nick had a hard time speaking up for himself and was often oblivious to his emotional needs, looking to accommodate and please others before knowing or asking for what he wanted.  We had discovered together over the months how overeating often took the place of his ability to be aware, feel and speak up about his own needs. But one missed opportunity is no reason for despair; core issues undoubtedly find a way to come around again, especially when they aren’t handled.
 
A couple months went by and Nick neglected to pay for the month’s sessions. When I billed him for them, he objected, saying he remembered writing me a check. After several phone conversations, which I found stressful, afraid I hadn’t calculated correctly, he came to see he had indeed missed the payment. The check he wrote had been buried on his desk and was never delivered.
 
The following session he came in with a check, sat quietly and finally said, “I feel the therapy is moving along too slowly and not making enough of a difference. I’m not sure I should keep coming,” he said flatly, without affect.
 
Not feeling he’s getting his money’s worth, I thought. Aloud I said, “I’m surprised to hear this since you’ve repeatedly remarked how much therapy is helping you change by speaking up for yourself, feeling more (mostly anger,) and reaching out to people.”
 
“I said those things because I figured you wanted to hear them,” he said as his face reddened.
 
“What makes you say that?” I wondered out loud.
 
“Well, I like to keep people happy… it’s automatic pilot for me and easier than figuring out what I want or think.” He’s trying to give me what he thinks I want, while dismissing how he feels.
 
Again, I suspected this had something to do with how he learned to adapt to his early caregivers. I realized I had missed the transference and might lose him–– and was not feeling good about that.
 
His anger and disappointment with me were being acted out through his non-payment. His affect and compliance had been well hidden from me. As uncomfortable as it is for me to be the object of anyone’s anger, I knew it was necessary to endure. This was another window into working with Nick’s anger that had prevented anyone from getting close to him, myself included. He’d make a decision, not always conscious, to withdraw from relationships so he wouldn’t have to deal with his own aggression, and to soothe a hurt, scared self.
 
“At times the unpredictability of the here-and-now encounter in the therapeutic relationship forces us to emotionally confront ourselves in a way that no amount of training fully prepares us for.” If I had not allowed and distinguished my own internal responses from Nick’s in this moment, we would have been more prone to an unconscious enactment. In these scenarios, one of the likeliest impediments in the treatment is therapists’ fear of their own feelings, which could potentially steer the therapy in the wrong direction.3
 

An Ending or a New Beginning

Not long after that, Nick left me a voicemail saying he was dropping out of therapy. I called him back encouraging him to come in for at least one last session to wrap things up.  He did come in, and much to his credit, he was finally able to say what was on his mind, allowing us to complete the final chapter in the therapy. This was a tremendous achievement on Nick’s part, being willing to stay connected, even if only to terminate and tell me what was going on. He felt I didn’t have any answers for him and that he couldn’t get comfortable being the only one doing the revealing. We eventually came to understand how his acting out was an unarticulated way of telling me how angry he was with me for not giving him more direction. Nick felt I was too concealing and he wasn’t happy with the relationship being “so one-sided.”
 
The vulnerability had become intolerable for him (like in his marriage?) despite the knowledge that intimacy was something he longed for. It had become too uncomfortable emotionally; he felt exposed and at risk (i.e. with money). I wondered if it was easier for him to find fault with me, as he did with other women in his life, than to take a chance being vulnerable with me. Better he reject me first than be rejected by me.
 
“How do you think this reluctance to jump into ‘risky waters’ helps you?” I asked.
 
“It keeps me safe. I can stay home in my cave, play computer games, and eat junk food rather than come here, face you and feel how screwed up I am.”
 
“I can see how courageous you are to come in and admit all of this to me,” I said, knowing how true this was. I was touched by his admission.
 
As we talked, Nick began to see how his reluctance to engage with people let him off the hook; he could retreat to his comfortable, numb solitude by reducing sessions. He would distract himself with Sudoku, crossword puzzles, computer games, etc., and saw now how this contributed to his shutting down and isolation.
 
As we continued to discuss times he had been uncomfortable with me, for instance ending a session on time even if he was in the middle of something, or initially not being able to address his food issues, “Nick came to see how he erected a “demilitarized zone” around himself so he wouldn’t be hurt and judged by me (and others).” He saw how the distance “helped” him not to have to live with uncomfortable feelings, the meaning it had, and how he was the only one who could change it. He came to see his loneliness was located inside himself—self-imposed in an attempt not to be hurt anymore.
 
As Nick became aware of his loneliness, rather than making others responsible—particularly his ex-wife, imperfect girlfriends, or even me—he saw how the pattern was an unconscious state of mind and body that protected him. Once we linked his thinking and behavior to his history, and the template of habits it created, he recognized how it had been a successful strategy for survival growing up. This unconscious strategy had helped him live through the emotional neglect of his childhood, and protected him from the constant hurts of unresponsive, dismissive parents. He realized the distance he felt earlier with his ex-wife, and now with me, was an outworn way of taking care of himself so he wouldn’t be hurt again. Staying isolated allowed him to avoid the grief, shame and anger that got stimulated in close relationships; food became his biggest comfort and companion.
 
By linking what was happening in our relationship with his history, Nick’s behavior made sense to him. This changed his relationship to himself, replacing his anger and internal saboteur with compassion. Instead of hating himself, eating to dull the pain and withdrawing from relationships, he came to see how hard he was struggling, not only to connect with others, but to himself as well. By working with the relationship in the present, we saw how his past was alive today in the present.
 
Nick also saw how his protection of extra weight helped him adapt to the deprivations of his early life. What was once a strategy of soothing and protection now became a lifetime of habits, using food, withdrawal and emotional numbing in an unconscious attempt to avoid being  hurt. We had worked for two years without any success with his weight, however, this realization was the beginning of a life-long effort and success at slow weight loss. He no longer needed the extra padding to defend himself and terminated therapy shortly after he lost 40 pounds. It wasn’t that all his issues had been resolved, particularly the relational ones; but he felt he could manage things going forward. I felt good about the work we had done together, and he successfully terminated.
 

Working with Disjunctions and Derailments

Tracking the derailments in the therapeutic relationship is a way to bring the life of the transference and counter-transference right into the here-and-now of the inter-subjective field. The disjunctions between the therapist and client have to happen so we can understand how they’ve developed. We therapists stand in for the internal object through which the client’s conflicts are experienced. And then we get to repair what’s happened between us.  Nick wasn’t used to anyone wanting to know about his needs, so he tried to stop having them. When this became impossible, he simply walked away, a pattern that left him painfully lonely.
 
The disjunctions that occur in sessions usually have a long history attached to them; making the pattern explicit, in the present moment of the therapeutic relationship, helps the client identify the pattern. Just as a mother must hold, contain and partially work through the experience her child cannot hold and work through by himself, so must a therapist help digest and metabolize experiences for the client. While the relationship creates moments of disruption, we can use our mutual attentiveness to help the client own formerly disavowed feelings.4
 
For me the challenge comes when I get caught in my own complexes, my own feelings of inadequacy, anger, helplessness, of not knowing what to do, or of wanting progress to look a certain way. I have to set my agendas aside of wanting to help, heal, or have a specific outcome. I keep my meditation practice active so I can concentrate on the here-and-now, notice my own feelings and not let them intrude on my client’s, continue with my own growth and development and utilize consultation/supervision when I suspect my own material is interfering.
 
Noting what gets acted out in the therapeutic relationship, and helping the client to articulate what this might mean, is the working through that reveals these old patterns and frees the client to make healthier choices. Staying present in the relationship helps clients release long stored up affect, integrate the disowned parts of themselves, and inhibit the reactive patterns that spoil the natural joy of being. As clients learn to tolerate and digest their internal world, their connections with themselves and their world transform. More creative aliveness becomes available. As a result of sharing and participating in the joys and suffering together, discovering what’s unknown, unfelt and unpredictable, I feel humbled, privileged, and enlivened by our encounter. We are changed by each other.

Footnotes
1 Barrett, S., Wee-Jhong, C.,  Crits-Cristoph, P., & Gibbons, M.B. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training,45(2), 247—267. 

2 I have constructed Nick as a compilation of people, events and situations to protect confidentiality.

3 Russell, P. (1998). The role of paradox in the repetition compulsion. In J.G. Teicholz & D. Kriegman (Eds.), Trauma, repetition, and affect regulation: The work of Paul Russell(pp. 1-22). New York: Other Press.


4 Riesenberg-Malcolm, R., ed. Bott Spillius, E., (1999) On Bearing Unbearable States of Mind, London: Routledge.

Molyn Leszcz on Group Psychotherapy

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Core principles of Group Therapy

Victor Yalom: To get started, Molyn, can you give a general definition of what group therapy is, and what are some of the core principles of the way group therapy works? I know those are broad questions.
Molyn Lesczc: I think that the first statement to make is that group therapy is not a monolith; it is a range of different approaches that utilize the group. Some groups tend to be more skill-building and psycho-educational, for example, and use factors of peer presence support, camaraderie, and economy of scale to deliver an intervention. Then there are therapists who use the group as an agent for change, in which we aim to make better use of the processes of interaction, feedback, and learning from one another that occur within the group.
VY: That, in and of itself, is quite a different idea in terms of how we tend to think about therapy. Most of us are trained initially as individual therapists, so we think of the therapist and the therapeutic relationship as the agent of change. Here, we’re suddenly thinking the whole group is part of the change process.
ML: Absolutely. The group is an entity of its own shaped by the multiple relationships that occur between people in the group. The complexity is so much greater in groups like this, but the power comes from that as well.  The bread-and-butter group therapy is the kind of work that we describe in The Theory and Practice of Group Psychotherapy, where

The group becomes a social microcosm: an opportunity for people to learn about the interpersonal underpinnings of their psychological distress.

the group becomes a social microcosm; an opportunity for people to learn about the interpersonal underpinnings of their psychological distress; an opportunity for interpersonal learning—insight, feedback—and behavioral skill acquisition.

I see group therapy, really, as the ultimate integrative model, because it’s a treatment that provides an opportunity for people to gain insight, self-awareness, and behavioral skill and practice. It integrates cognitive, emotional and behavioral elements.
I think we’re always aspiring to do that in our work, but group therapy really delivers on that as effectively as any treatment.
VY: Right. Of course, you’re referring to the text originally written by my father, Irvin Yalom. And you came aboard as co-author for the latest, the Fifth Edition, of that book.
ML: That’s correct.
VY: He primarily espouses an interpersonal model of group psychotherapy.  Could you say a few words to summarize the core concepts of this approach?
ML:

Sure. First, let me say that the interpersonal approach has become more popular of late, and it’s important to distinguish the interpersonal approach to group therapy and other versions that have more to do with IPT—the Myrna Weissman approach to interpersonal therapy—which is non-here-and-now, but rather more skill-building and educational. I’m going to focus on the interpersonal model of group that that was really pioneered by your father. I had the great privilege of working with him, and then contributing to the Fifth Edition of this text.
In essence, what that work does is build upon a long tradition that focuses on our need, as relationally determined people, to engage, and how our engagement in our contemporary world is shaped by early life experiences.
Harry Stack Sullivan, through his influence on other people in Baltimore at Johns Hopkins, had a big role, as you know, in your dad’s view. He impacted Frieda Fromm-Reichmann and Jerome Frank. And your father took it to a remarkably accessible level. In essence, how I understand it is like this: every person operates in this world with a certain kind of roadmap, which consists of our beliefs about ourselves and the world that emerge from early life experience, and the interpersonal behaviors that follow from those beliefs.
If we are healthy and resilient with good self-esteem, then our behaviors reinforce adaptive beliefs about ourselves, and we engage a healthy, productive loop in our relational world.
VY: Right. And speaking of self-esteem, I recall some statement by Sullivan that our own sense of esteem is really, in some sense, a collective mirroring of the feedback we perceive from others.
ML: That’s right, the reflective self-appraisals.
VY: Do you agree with that, or do you think that’s overstated?
ML: Absolutely.
VY: Isn’t there also something we bring to our personhood that we’re born with?
ML:

Certainly there are constitutional and temperamental factors. How our early life environment reacts to that and reinforces that, I think, is pivotal.
You can take a highly energetic child—temperamentally a bit reckless, aggressive, assertive—and in a family that is able to corral that and harness it and see it as self-determination and strength of will, that person will grow up with a stronger sense of self and self-esteem than a child that grows up in a family where that is viewed as being burdensome, a nuisance, and something that a depressed parent doesn’t have time for.
So the pathogenic beliefs, which are the starting point of the roadmap, are shaped by early life events, the environment, culture, personal psychology, family psychology, temperament, constitution—all these things together.
But they have powerful influence, because they then shape the interpersonal behavior that follows:we seek what is familiar, not necessarily what nourishes our growth. Group therapy becomes a very powerful way to illuminate that link between pathogenic beliefs and interpersonal behaviors. And many contemporary models of psychotherapy echo that.
VY:

So an energetic, maybe excitable child in an optimal environment would be supported, maybe gradually shaped, so that he can succeed in the world; and in another set of circumstances, his development might go awry.
So, group therapy, of course—or any form of therapy—tries to deal with the situations where something goes awry, so they’re not functioning fully effectively, and also having some internal problems—distress—about what’s happening in their life.
ML: Right.
VY: If you start with this interpersonal model that asserts that we’re basically social animals, how does group address the situations when things go awry?
ML: I think the group therapy addresses that by creating an environment in which people are able to bring themselves as they genuinely are in the world at large. That’s the social microcosm. The group would not be useful if what happened in the group didn’t reflect what happens in people’s lives at large.
VY: The social microcosm refers to the idea that however people are in the world, including their behaviors that cause them problems, will get played out or enacted in the group.
ML:

And the more you’re able to get people to look at interpersonal processes and communication in the here-and-now, the more the microcosm comes to life.
If you had a highly structured group where people were given specific tasks, you’d have much less opportunity for people’s interpersonal style and interpersonal processes to emerge. I’m sure you’re familiar with the background at National Training Laboratories, the original work by Kurt Lewin in the late ‘40s.
VY: It was a bit before my time, but I’ve heard of NTL.  Weren’t they referred to as T-groups, or training groups?
ML: Yes, they were training groups for executives. In essence, they were being taught how to be better leaders. At the end of the day, all of the facilitators would meet and talk about the group dynamics, and how hard it was to get this guy to see things from other people’s perspective and the like. What emerged then is that executives found out that they were being discussed in the evenings. They said, “Give us access to that information.” So that really became the start of the encounter group mentality, where people were given feedback in the moment, rather than a focus on the transmission of content material alone.
VY: And I assume they found that feedback useful.
ML: Well, they found it useful and challenging.

Working in the Here-and-Now

VY: Getting back to the social microcosm, say I have a client who’s aggressive, has difficulty maintaining relationships, or another client who is a people-pleaser, never gets his or her needs met. A naïve reaction might be, “Well, we don’t want them to repeat that behavior in the group. We want them to change it.” But this model is saying, “First, we want to see what that behavior looks like.”
ML: That’s right. It begins by manifesting itself. We obviously don’t want it to persist, and we’re looking for every opportunity for change. But people are more likely to make changes when they have hard evidence for what the problem is.A classic example is the man who reports in the group how his wife is always hard on him, critical, and he doesn’t feel he gets a break. In fact, it’s illuminated even in the Schopenhaeur Cure video to a certain degree, with Gil and Pam. If you’re not careful, the group may sympathize with him and give him advice such as, “You’re married to a miserable woman. Get away from her.”

Whereas if you look at what’s happening in the here-and-now and ask this very powerful here-and-now question—if you asked the women in the group, “Based upon on what you know of this man, in his time in the group, what would you think it would be like to be married to him?”—then you get the feedback about what it would be like being married to an inanimate object:”He seems like a decent guy, but if I was married to him, I’d be withering on the vine because he’s so unresponsive and gives so little of himself.” It’s an intervention that your dad has used, and I’ve used many times.

VY: You’re referring, of course, to this video demonstration that we’re just releasing, which was an enactment of the characters in my father’s book, The Schopenhaeur Cure, which occurs largely in the context of a therapy group.
ML: Exactly. So

making things come alive in the here-and-now is, I think, the most important skill a group leader can develop.

making things come alive in the here-and-now is, I think, the most important skill a group leader can develop. It’s the most challenging aspect of the work, but I think once you’re able to do that, I think you really are able to move things to a very effective level in which, I think, people really make meaningful change.

VY: You’re describing one of the core skills of group therapists—according to this model, at least—which is how to bring the group into what’s called the here-and-now. Now, that’s a term that’s been bandied around a lot from Fritz Perls onwards. But in this model of group therapy, it has a very specific meaning.
ML: Yes, it does. What is meant by that is moving away from people telling their stories into talking about the experience of telling their stories—getting the group to reflect on itself, and the members’ experience with one another.So, for example, instead of you and I doing this interview in this way—you asking questions, me making comments, you making comments, me responding—a here-and-now approach would be, “What do you really think about my answers? How am relating to you?”

In a chapter I recently wrote I used the example of walking down the street and asking someone for directions. That’s a simple transaction at the level of content. But if we were working at that at the level of a here-and-now, what we’d be looking at is the following:How do I feel asking for directions? Am I concerned that my wife, kids, girlfriend will have a negative reaction to me for needing to ask for directions? When I ask somebody for directions, of all the people passing by, what am I using to determine who I will ask? What is it about their demeanor, about how they carry themselves that leads me to ask them the question?

VY: So if you take that lens of looking at group interactions, you’re thinking of how people engage in the group. Do they monopolize? Are they quiet? Are they assertive? Who are they drawn to? Who are they distant from, or afraid of?
ML: Exactly. What is the meaning of their behavior? What is driving them? And when I talked earlier about the roadmap, I believe that a group therapist needs to have a very good sense of each person’s roadmap in the group. I aspire to operate in this way:that,

in a moment-to-moment fashion, I’m thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.

in a moment-to-moment fashion, I’m thinking that whatever is happening in the group is either part of the solution or part of the problem. It is either creating opportunities for growth or it is reinforcing pathological behavior.

VY: Can you give an example of that?
ML: A woman came into a group, and the important elements of her story were that when she was a youngster, her older sister was diagnosed with leukemia. And the family was concerned, understandably, that this daughter would die. So, they threw all of their resources into caring for this daughter.My patient grew up with the sense that no one had interest in her; no one was invested in her; that her job was just to make things better for others, and not to ask for anything for herself.

So she comes into treatment with a history of disappointing relationships; failure to advance at work; chronic depression and self-harm. And at the heart of it is her belief that she is to be seen and not heard. In the group, that becomes the important focus of her work.

VY: How is that visible, then, in the here-and-now of the group interactions?
ML: Because she’s always helpful to other people. She rarely asks for time for herself. When somebody is crying, she is crying. When somebody is laughing, she is laughing. So she becomes like a Greek chorus rather than a person there in her own right, with her own entitlement.
VY: Now, I imagine that this is a likeable trait in some way, at least initially. People like someone who’s attentive to them.
ML: There’s a lot of positive reinforcement for her. But ultimately, you have to ask the question, “What is it like for you to be in this group, always giving support and not asking for much back? How do you think others in the group feel about you doing this? What’s it like for you coming to the group knowing that that’s what’s going to happen? What would it be like for you to actually ask for some time? Compare and contrast meetings where you’ve asked for things from us, and how you felt in the evening afterwards with those meetings where you come and just look after others.”
VY: So all of those are ways of getting her to focus on process—her experience of being in the group.
ML: That’s correct.
VY: And you do this with other people to give her feedback. Although they may like her attentiveness at first, I imagine they grow tired of it. They don’t feel like they ever get to know her.
ML: Exactly. And ultimately, it begins to feel inauthentic.Another incident occurred recently in a group—a man who had been badly sexually abused as a child came into a meeting feeling very annoyed, angry at how upbeat everyone was about the idea that the group leader presented. This was an early-stage meeting of a group that I supervised. The group leaders proposed that one task of the work in the group therapy was to emancipate themselves from the past. And everyone had been excited about that. But this man was then plagued that whole week with a resurgence of flashbacks and re-experiencing phenomena of the sexual abuse.

He came into the meeting saying, “I have to tell you how angry I am at you that you think it’s so easy to escape from the past. I’ve been reliving my past every day for the last 30 years.”

First, that was important because that was the opening for him to talk about the sexual abuse. It was also important because what he went on to say was that he was terrified that expressing his disagreement with us, disagreement with those in the group, would lead to attack. That was his experience, always. Whenever he protested the abuse, it resulted in more abuse.

So that was the first part. And this leads us to the next issue, which is the corrective emotional experience. Once you bring people into the social microcosm—once you illuminate their interpersonal processes, once people begin to push against their roadmap—it’s important then to reinforce that, and create an experience that this confirms their pathogenic beliefs, by virtue of insight and a relational experience.

Though with this man, we dived into what was it like for him coming to the group today, knowing that he was going to tell us he was angry with the way the meeting had gone the week before? Who did he think was going to be supportive? Who did he think might be challenging? What does he feel about the job that he’s done in protesting his opinion in the meeting today? And so on and so forth.

VY: These are, again, all process-oriented questions.
ML: All process-oriented questions.
VY: And this is done by the leader.
ML: It’s done by the leader, and ultimately, as the group matures, it’s done also by members of the group.
VY: So you’re shaping the group to start doing that work on their own.
ML: That is correct. The mature groups are able to do that on their own.
VY: And the corrective emotional experience you referred to is what? How does this help him?
ML: It helps by virtue of reinforcing the risk-taking, helping him to actually see that although making a protest in his youth led to a crushing attack, the group welcomes it now, and we do not want to silence him or marginalize his experience; we’re very interested in the meaning of things for him. And that taking this risk, in fact, makes him better known and closer to us, rather than the opposite—which is his fear that it’s going to lead to further abuse.

Training Group Therapists

VY: Let’s back up a sec. You’ve been training group therapists for how many years now?
ML: Thirty years.
VY: And I think you probably run, at the University of Toronto, perhaps the largest group therapy training program anywhere in the world?
ML: I don’t know about that. I’d be reluctant to say that because I can’t measure it against others, but we have the largest psychiatric residency program in North America, the second-largest in the world. We train about 25 to 30 residents in each of five years of training.
VY: And in your program, how many groups are going on at any one point in time?
ML: I think residents are doing groups of different sorts all over. It would be hard for me to estimate, but I would probably say residents are involved with maybe 30 groups a week.
VY: Let’s start with the skill of helping groups get into the here-and-now and talk about their experiences in the group with other members and their feelings about each other. This is a challenging skill to learn—both for beginning therapists and even experienced therapists who aren’t group therapists.
ML: It sure is, yeah.
VY: What does it look like actually getting the group to work that way? You’ve given a lot of examples of the types of questions you ask, but how does that happen, and what’s hardest thing for group therapists to learn in terms of doing that?
ML: I think that it’s difficult work. And one of the projects that I worked on in the last several years—through AGPA [American Group Psychotherapy Association]—was the creation of a document of clinical practice guidelines for the practice of group psychotherapy. What we’ve tried to compile in that are all of the elements that I think go into proper running of groups, and hence, proper training of group leaders.To run effective groups, you have to plan for them wisely, and you have to have support—of the system, of the administration. You have to be aware of how to use the therapeutic factors in group therapy—the importance of cohesion, and the principles that help to achieve and sustain cohesion. You need to be able to select wisely and prepare people properly. You need to be aware of the developmental stages that groups go through. You need to work well with group process. And you need to know how to use yourself effectively as a group therapist, and be mindful of the ethical demands of doing the work.

VY: I just read through this document and it’s quite comprehensive. And it does address initially a lot of the institutional challenges of getting groups going—administrative challenges. Just getting enough referrals, if you’re in a private practice setting, to start a group—that’s a real challenge. What are some of the key considerations and challenges to actually forming groups?
ML: People’s resistance to group therapy.
VY: Both patients and systems?
ML: Yeah. I think that there’s a general undervaluing of the effectiveness of group therapy. And group therapists suffer because their work is efficient; and people assume if it’s efficient and economical, then it’s going to be of lesser quality.

The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.

The research shows pretty convincingly that for most people, group therapy and individual therapy are equivalent, in terms of their effectiveness.

VY: And in terms of that, patients think, well, if there are eight people in the group or nine people in the group, I’m only going to get to talk an eighth of the time, so I can’t possibly get as much out of it as if I had the undivided time of the therapist.
ML: Right. They don’t have an appreciation yet—and that’s where preparation comes in—about how the group works, and how the synergies in the group can make that 90 minutes relevant. Each minute can be relevant to each person.Also, many of the people who really need group therapy don’t have positive experiences in their social groups. They haven’t been the most popular kid in high school. They’ve often felt, earlier in their life, that relationships were hard; or, because of depression, relationships have become hard. So the group is daunting for them.

Take a look at how groups are portrayed in the media and TV and movies. There’s a lot of the theme that we throw people out of groups. All the reality shows have to do with people getting extruded. It really feeds into people’s apprehension about being the weakest link, or being the first one thrown off the island.

VY: So those are patients’ fears. Then there are challenges of getting patients referred your way. Now, if you’re working in an institution or a setting where there are lots of patients, it’s easier. But if you’re in private practice, if you’re just relying on your own referrals—unless you have an extremely healthy practice—it’s quite challenging to get enough suitable people to get a group going.
ML: For sure. So you weigh it. You think, “Well, I can see these people individually and get paid for each of them by the hour rather than put them together into a group.” Groups are not necessarily more lucrative for practitioners in private practice. There’s great interest in their applicability in institutional settings, where there’s a high volume of patient flow. But it’s challenging to get started.
VY: So what advice would you have for a therapist who is, say, in private practice and really excited about doing groups, but doesn’t know how to get them off the ground?
ML: I would say get as connected as possible with other providers who will see you as an ally and a resource—whether it’s family physicians, primary care providers, or other mental health professionals. And think of a group that has something useful, both as a stand-alone, and also as something to be applied conjointly with other interventions. But you have to be deeply connected.Something else that I tell all of my trainees is, whenever somebody asks you to see somebody, whenever you have a consultation, make sure you send a note back to the referring professional. Those things really cement the relationship, and increase the likelihood of that person remembering to send people your way.

VY: I’ve always done one or two groups in my private practice, and always with a co-leader, for a couple of reasons. I enjoy the process of co-leading. So much of our work as therapists is solo, it’s been a richly rewarding experience to be able to share and learn from another therapist. But also, just logistically, if we’re both drawing on our own referrals, it’s been a lot easier to maintain the group over the years.
ML: That makes great sense.
VY: Let me just add one more point. As you well know, in major metropolitan areas, there’s a lot of competition among therapists. I’ve found that doing group therapy is one way to distinguish yourself, since not that many therapists in private practice are offering that.
ML: I think that’s a great point. At the University of Toronto, at my hospital, we get a real flow of referrals, because people recognize this is the place where people will be seen and get a good group therapy experience. In our hospital, I typically get 10 or 12 referrals a month for group therapy. So we’re able to start each year probably five or six time-limited groups, with eight or nine or ten people in them.
VY: I would guess if you’re doing that many groups, you have some different types of groups, or groups that are for people who are at different levels of functioning, so you’re able to assess people and place them into appropriate groups.
ML: Right, we do about five or six groups a year, time-limited, interpersonal group therapy. In addition, we run groups for trauma, groups in our day hospital program, groups in the inpatient setting, groups in our geriatric program, women with post-partum depression in our perinatal mental health program. We have a whole range of groups.And one of the things about groups is that they’re very malleable, that you can change your focus and emphasize homogeneous concerns. So I’ve done lots of groups with seniors with depression; with medically ill patients, women with metastatic breast cancer. We just published an article about using interpersonal group therapy to help people with alcohol abuse to maintain sobriety, and we showed that by dealing with these psychological interpersonal vulnerabilities effectively, we’re able to reduce heavy drinking and substance abuse.

VY: So even though many of these are what you called homogeneous groups—in that they revolve around a topic, a symptom, a life challenge—you still put a heavy focus on interpersonal here-and-now relations in the group.
ML: That’s right, absolutely.

Group Selection and Preparation

VY: Can you say a little about the selection and preparation of group members, because that’s so important to developing healthy, sustainable groups?
ML: I think a shorthand answer is to funnel everything that you do through the therapeutic alliance. The therapeutic alliance is the best predictor of outcomes, across all kinds of psychiatric treatment and psychotherapy. What we look for is the degree of agreement, between the treater and the patient, about the goals of treatment, the tasks of treatment, and the nature of the relationship.
VY: You’re doing that in the first assessment meeting?
ML: Yes, that’s something we’re doing right from the start. If their goals are not in sync with our goals, then the group’s not going to be an effective experience for them. They may need to be in another kind of group.Now, what do people need to be able to do to engage in the tasks of treatment? They need to be able to come reliably. They need to be able to sit in the group. They need to be able to speak. We’re talking about having the logistical, intellectual, and psychological ability to actually make use of what the group provides.

So I find it very helpful to be able to ask and answer the question, “Do we have convergence on the goals of treatment? Do you have convergence about the tasks of treatment?” Then I talk a little bit about what they can expect from me in terms of the therapeutic relationship and from the relationships in the group.

VY: But if someone is coming to you or your clinic because they’re depressed, for example, and you’re suggesting, “Gee, rather than go into individual therapy, I think you might really benefit from a group,” you need to explain to them how a group works, and how it might be helpful.
ML: Exactly.
VY: What are some ways you do that?
ML: Well, I think virtually everything that we’ve talked about in the interview so far, Victor, I would share with them:the research that shows it’s an effective modality of treatment; how it would work; how I think it would work for them specifically, with regard to understanding how their difficulties—with passivity, assertiveness, anger, self-esteem—contribute interpersonally to the difficulties that they’re having in their life at large; and that the lens that we’re going to look through is what’s happening at the level of interpersonal relationships.Then I’ll talk about the microcosm of the here-and-now, interpersonal learning, the corrective emotional experience.

VY: So you really lay it out for them—how the group works, how it might benefit them.
ML: Absolutely. There is an appendix in the Fifth Edition, of a preparation document that therapists can give to their clients. You can personalize it, but it really covers and nuts and bolts of what we feel needs to be communicated to people.And

there’s robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they’re more popular group members and much less likely to drop out.

there’s robust research evidence that well-prepared clients do much better in group therapy. They stay longer, they work better, they understand the tasks, they’re more popular group members and much less likely to drop out.

VY: Right. And dropouts can be a big problem in groups—not only for the clients who drop out, but it can be demoralizing, or threaten the very existence of the group.
ML: Yeah. It’s very hard, in particular when people are beginning to do group therapy, to have dropouts. The residents that I supervise are heartened by two comments. One is that dropouts are inevitable, and that no one in the literature, even in the most experienced hands, is able to eliminate dropouts, and the range is anywhere from 10 to 40 percent.The other point is that if you never have any dropouts, then it means you’re setting the bar for entry into your group too high, and you’re like a surgeon who only operates on people without any risk factors. And it means that you’re missing the opportunity to be helpful to a lot of people who would otherwise benefit from treatment.

VY: But if the bar is too low, and you let a lot of people into the group who don’t stay very long, it can be disruptive and demoralizing to the group.
ML: No question.
VY: You talked about preparation and the research showing how important that is. One thing I’ve heard about in some institutional settings people are doing intake over the phone and are sent to a group without much screening or meeting with the therapist. That seems like it can cause a lot of problems.
ML: I have to say, I understand the pressures that some organizations are under; but to me, it’s being penny-wise and pound-foolish. If you want preparation to really take hold, it should be provided by the person who is actually going to be doing the group. Part of the rationale for preparation is to begin to establish the therapeutic relationship, and you want to screen people in a more meaningful fashion. So I think if you cut the front-end short, you end up paying at the back-end.

Co-Leading Groups

VY: Another problem that I’ve heard about is interns in agencies being matched up with a staff member, a more experienced therapist—which is great, in theory. I mean, most of the time in our training we’re thrown in the room alone with the client, and we don’t have the chance to learn directly from working with experienced practitioners—which is how professionals generally are trained, whether in fields of law or surgery or accounting.But it often seems that interns are thrown into co-leading a group, and there isn’t sufficient time allotted to meet with the senior therapist for several sessions prior to starting a group to make sure they’re on the same wavelength. Or they may not have time to meet after the group to debrief. And there can be tensions between the group leaders that aren’t worked through.

ML: All those things happen, but I think they are by and large avoidable if people, number one, are working in good faith, and if there’s a commitment on the part of the more experienced group leader to promote the growth and development of the trainee. And the only way to enact that good faith is to actually have time to meet before the group and after the group. If you’re not doing that, then you’re not giving yourself a chance to be successful.
VY: In your training program, is there a lot of co-leading that goes on? Do you pair residents with staff or with each other?
ML: Mostly with each other. But for 30 years, I’ve led at least one or two groups a year with the residents. I often tell them that my first real experience leading a group involved, I think, the greatest gradient imaginable between my experience level and the experience level of the person I was co-leading with, which, of course, was your dad.When I began to do groups with your father, at the beginning of my fellowship at Stanford, I had had very little experience in groups. And I remember vividly—and I tell this story often—that one of the groups I co-led with your dad that he brought me into was a group he was leading for mental health professionals, all of whom had done group work. Some of them were even teaching group therapy.

I remember one group session when somebody came into the group with The Theory and Practice of Group Psychotherapy that they were using in a class that they were teaching. And I felt really de-skilled, small and marginalized, which was a very uncomfortable feeling.

But I talked about it with your dad, and he responded, in essence, “This group is too dependent on me, and that’s why they’re not making any room for you. It’s not good for you, it’s not good for them, it’s not good for me. So look for an opportunity.”

Ultimately, after several weeks, I identified that I felt no one in the group was paying any attention to what I had to say. And this goes to show you that there is an unconscious—I meant to say that people were just waiting and deferring for this “wise old therapist,” in reference to Irv.

But I didn’t say wise, I said wizened, and I didn’t realize it! Irv, afterwards, when we rehashed it, had a great laugh

But I didn’t say wise, I said wizened, and I didn’t realize it! Irv, afterwards, when we rehashed it, had a great laugh and teased me about the Oedipal strivings that were evident in that slip of the tongue.

I think in co-therapy you have to anticipate competition, rivalry, tension. But hopefully, as I say, if people are working in good faith, these don’t become insurmountable problems, but, in fact, become learning points.

I often tell residents, if you are a passive co-leader with a more active co-leader, what message does that give the quiet members of the group? It models for them that it’s okay to take a backseat. And that often has a powerful impact.

I think most people are also heartened to hear that I was able to address the gradient of my limited experience working with your father at Stanford in 1980. If I can do that, they can do what they have to do here.

VY: I hadn’t heard that story before from you, but we share that experience, because I led a group with him very early in my training, and certainly had similar experiences—that I knew very little and felt I had little to offer. It was a challenge for me to speak up and feel that I did have something to contribute.
ML: Absolutely. It’s part of the consequence of the very large shadow that your dad has cast.
VY: Indeed.You’ve trained many, many therapists over the years, group therapists. What are some of the things that are most challenging for them to learn about being effective group therapists?

ML: I would say the most difficult thing has to do with learning how to use oneself effectively as a therapist, and how to use language effectively—how to be able to communicate meaningfully with our patients; the risks that we need to take sometimes; how to be appropriately transparent, including the limits of transparency.
VY: What kind of risks?
ML: The risk of giving feedback to a patient. Oftentimes, especially young therapists are very reluctant to do that, because they feel that it’s going to fudge the boundaries.
VY: Do you think there are still some vestiges of the blank slate?
ML: Still some—and now with the added overlay of, “If I’m too personally present in the group, is that a slippery slope that’s going to lead to some boundary issues later?” Still dealing with the aftermath of the ’90s and all the focus on boundary crossings and boundary violations.
VY: What’s your take on that?
ML: I think that it’s impossible for a person to be in a room with another person and not to disclose. So I would rather be proactive and mindful about it rather than think it’s not happening.
VY: Rather than think that the way to avoid the possibility of some kind of inappropriate behavior is just to set a hard-and-fast rule that we’re neutral and we’re impartial bystanders.
ML: Exactly—to be stilted, distanced. I think fundamentally group therapy is a human experience, and we have to be humans in it.I think that probably the best line that a patient ever articulated in a group—this was a senior person who was close to leaving the group, who was welcoming somebody new into the group—she said, “You know, you’re beginning now. Likely, you’re going to be skeptical about this, the way I was skeptical for the longest time. My first impression was that the group was a very natural place for unnatural things to happen. And then,” she said, “with a little bit more time, I realized that, in fact, the group is an unnatural place—it’s constructed for this purpose—but that what happens here is very natural.”

A real endorsement of the meaning and the value of the relatedness.

VY: Yeah, because it is a contrived situation. People are paying money to be there. And yet the nature of the relationships, and the events that occur in the group, become extremely meaningful to people in a successful group.
ML: Incredibly so.

I’ve had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.

I’ve had many, many patients say to me that the group is what anchors them, and that they carry the group with them. They think about the group all the time.

In fact, one woman in a group that I run commented that she holds onto images of people in the group during the week to help her deal with adversity. And when that woman graduated from the group—a very successful ending; she was leaving to get married, having previously—a woman in her thirties—having never had any sexual contact—one of the other members of the group, who is an accomplished artist, gave her, as a going-away gift, these beautifully crafted popsicle-stick figures of each of the group members, made out of material and wood and painted. Just a beautiful embodiment of the internalization of the members of the group. Touching.

The Best Kind of Work to Do

VY: And, needless to say, as this has been the focus of your professional life, it can be a deeply rewarding experience for a group therapist.
ML: Absolutely. I think it’s the best kind of work to do.
VY: How has it been rewarding for you?
ML:

I think that we grow as our patients grow. You can’t do this work and be static.

I think that we grow as our patients grow. You can’t do this work and be static. All of the things that I’ve learned about people, about the world, have shaped me in very constructive fashions. Even dealing with people who are facing death—our metastatic breast cancer research—has made me more existentially aware; the meaning of their experience, I think, has added meaning to my experience.

Your father has written extensively, of course, about existential approaches to psychotherapy, and I think there is enormous value in that. Life is short. Make use of it. Author your life in a way that is meaningful to you; you’re personally responsible for authorship.

I often tell the story of the woman that I first encountered in the metastatic breast cancer group who subsequently graduated from that group. She is one of the long-term survivors from that group. Most of those women died within a year or two. This woman was diagnosed with metastatic breast cancer when she was 26, if you can believe it, and she’s still alive and thriving twenty years later.

I saw her September 12, 2001, right after 9/11—and she comments to me what a terrible tragedy the World Trade Center attacks were. But it crystallized for her that if she had been in the World Trade Center on 9/11 and had died, she took heart from the fact that she would not have had one moment’s regret of how she lived her life on September 10.

I think that’s something that I aspire to, and I think, if we’re able to help our patients aspire to that, then we’re going to help them a great deal.

VY: Well, I think that’s an inspiring and encouraging note to end on. I want to thank you so much for taking the time to share your wisdom and passion about group therapy.
ML: If we speak for a moment, too, Victor, about our here-and now, it’s a remarkable sequence. I’ve benefited so much from my relationship with your father, and to be able to talk about that work with you in your career, in this way, feels like another good loop.
VY: It feels absolutely that way for me. And that’s an example I can’t help noticing from a process lens:when you shifted the conversation away from the content—group therapy—to making it a personal connection between you and me, I found myself moved in an emotional way that I hadn’t previously in this conversation.
ML: I feel that, Victor, and I’m glad that it touched you in the same way. I would have not wanted our conversation to end without making the comment.
VY: Thank you very much.

Interacting Sensitivities in Couples Therapy

Posted on by Psychotherapy.net Team

It is a typical night at Tom and Betsy's house. Tom has his nose in a newspaper.  Betsy is leaning in the door of his study trying to talk to him, getting more and more frustrated at his periodic, vague “Uh huh.” After a few minutes of trying to entice him into a conversation, Betsy starts complaining, and then criticizing him for being cold. Tom snaps, “Can't you just once leave me alone?” Betsy yells, he withdraws further, and Betsy stalks out, thinking, “I'll give him all the alone time he wants!” 

Tom and Betsy are caught in “interlocking vulnerabilities” (Carol Jenkin’s term) or “interacting (or reciprocal) sensitivities” (my term). Each partner responds to having his or her sensitivity inflamed in a way that inflames that of the other. Tom is sensitive to criticism and responds by disengaging; Betsy is sensitive to disengagement and responds by criticizing. Michele Scheinkman and Mona Fishbane call this pattern “the vulnerability cycle.” Scott Woolley calls it “the EFT (Emotionally Focused Therapy) Cycle.” Robert-Jay Green calls it the “problematic couple interaction cycle.” “Pursuer-distancer” (coined by Thomas Fogarty) and “demanding-withdrawn” (researched by Andrew Christensen) are earlier ideas out of which the notion of interacting sensitivities developed.
 
My purpose here is to distinguish two major subtypes of interacting sensitivities—“pursue-withdraw” and “attack-withdraw”—and to describe how the pattern of interacting sensitivities plays out in the couple relationship. Awareness of this pattern will help the therapist follow the flow of the session and enable the partners to appreciate what they are caught in.
 
In “pursue-withdraw,” one partner is sensitive to the other’s withdrawal (feels ignored, shut out, abandoned, rejected, lonely, uncared for, unloved, unlovable, or just not as close and connected as he or she wants) and responds by pressing for connection (time together, intimate talking, affection, sex), and the other partner is sensitive to pressing (feels engulfed, smothered, suffocated, bombarded, besieged, flooded, controlled) and responds by withdrawing (disengaging, abandoning, shutting down, closing off). The self-reinforcing nature of this exchange is clear. The more Bob disengages, the more Gloria needs reassuring contact. The more Gloria presses, the more Bob needs to disengage.
 
In “attack-withdraw,” the other major form of interacting sensitivities, one partner is sensitive to attack (complaint, blame, criticism, anger, reproach, scolding, demands, sarcasm, rejection, disapproval, humiliation, exposure) and responds by withdrawing; the other partner is sensitive to withdrawal and responds by attacking. Again, the self-propelling nature is clear. The angrier Ben gets, the more Alan withdraws. The more Alan withdraws, the angrier Ben gets.
 
In a fight, the withdrawn partner typically seeks to end the fight or, at least, take a time out. He or she is the one more aware of the destructive and stalemated quality of the fight. The pursuing partner typically wants to keep talking. He or she dreads ending the exchange without a resolution and on bad terms.
 
In practice, “pursue-withdraw” typically morphs into “attack-withdraw.” At some point, and in some cases very soon, the pursuing partner becomes frustrated and shifts from pressing for connection to reproaching for failing to connect: “Why are you so defended?” “How come you never talk to me?” “Living with you is like living alone,” “Hello, are you alive over there?” Such reproach creates an “attack-withdraw” pattern (unless, of course, the other partner responds with anger rather than with withdrawal, which would then trigger an “attack-attack” pattern.  I’ll get to that in a moment). Here is an example of the shiftfrom “pursue-withdraw” to “attack-withdraw”.
 
Sally (inviting): What do you say we go for a walk?
Tom (vaguely): Maybe later.
Sally (encouraging): Come on. Let’s go now, while it’s still sunny out.
Tom: I want to read this book.
Sally (pressing): You can do that when we get home. Come on. You’ll feel different once we’re out there.
Tom: I’m really into this book.
Sally: (pressing): Well, okay, we don’t have to walk. Why don’t we just hang out and talk for a while?
Tom: I’m not in the mood.
Sally (shifting to attack): You’re never in the mood.
Tom (shrugs)
Sally (blurting out a hidden fear): Admit it—you just don’t want to do things with me anymore; that’s it, isn’t it…
Tom (looks up for a second): That’s not true.
Sally: Well, it is true. You’re like your father—the way he treats your mother. You’re getting to be more like him all the time.
Tom (Looks down at his book)
Sally: Aren’t you going to say anything?
Tom: I don’t know what I can say.
Sally (sarcastically): You could say, “Sure, let’s go for a walk. What a great idea! Thanks for suggesting it. You always make things such fun.”
Tom (looks unhappy)
 
Such “attack-withdraw” can go on for some time. At some point, and with some couples very soon, the attacking partner thinks, “I’m tired of being angry,” or “Oh my god, I’m sounding like my father,” or “This is starting to go nowhere fast,” or “I hate how whiny and needy I sound, even to myself,” or “You can’t change people, especially some people” or “You can’t get all your needs satisfied by just one person; I’ll call my sister,” Thinking such thoughts, the attacking person joins the withdrawn partner in disengaging. The result is a “withdraw-withdraw” pattern.  
 
At times, the pursuing partner purposely withdraws, creating what looks like a “withdraw-withdraw” pattern. He or she secretly hopes that the withdrawn partner will miss the engagement and start pursuing. But the withdrawn partner is usually just relieved by the decrease of pressure and doesn’t pursue.
 
While one partner has remained withdrawn, the other partner has shifted from “pursue” to “attack” to “withdraw.” At some point, and in some cases very soon, the latter partner again becomes distressed by the lack of emotional connection and again starts pursuing, which triggers a repeat of the three-part sequence. Couples can go on for years repeating the sequence of “pursue-withdraw,” “attack-withdraw,” and “withdraw-withdraw.”
 
At some point in this repetition, the pursuing partner may become so resentful about the withdrawn partner’s lack of engagement that he or she bypasses the “pursue” and goes directly to the “attack.” From then on, the partners shuttle between “attack-withdraw” and “withdraw-withdraw.” The “pursue-withdraw” has dropped out. At yet a later point, the “attack-withdraw” may drop out, too. The attacking partner becomes so discouraged that he or she gives up, and the couple slips into a chronic “withdraw-withdraw” devitalized state.
 
The discussion so far portrays one partner as remaining in the withdrawn state even when the other gets angry. In some cases, however, the withdrawn partner responds with anger of his or her own: “Why do you always have to get so angry about every little thing?” “Don’t yell at me!” “You could use a crash course in anger management—my treat.” In some cases, the withdrawn rather than the pursuing partner is the first toburst into anger: “Stop trying to control me,” “Get off my back!” “Give me room to breathe,” “Back off,” “You never let up, do you?” “Can’t you do anything by yourself?” “You’re the neediest person I’ve ever known.”  When the withdrawn partner attacks, the result is the pattern of “attack-attack” (if the other partner fights back), “attack-pursue” (if the other partner continues pursuing), or “withdraw-attack” (if the pursuing partner is now the one to withdraw).
 
Withdrawal and attack are not always clearly distinguishable. When you give your partner the silent treatment, you appear to withdraw. You relate to your partner in a grim, wooden, disengaged, monosyllabic way. But all the time, you are communicating anger. You are simultaneously withdrawing and attacking.
 
In summary, interacting sensitivities (the vulnerability cycle, interlocking vulnerabilities) has two main forms: “pursue-withdraw” and “attack-withdraw.” If the withdrawn partner remains withdrawn, the couple repeatedly passes through “pursue-withdraw” “attack-withdraw,” and “withdraw-withdraw.” As time goes on, the “pursue-withdraw” may drop out as may also the “attack-withdraw.” If the withdrawn partner doesn’t remain withdrawn, but instead attacks, the couple shifts into “attack-attack,” “pursue-attack,” or “withdraw-attack.”
 
We customarily think of a couple as being a particular type—for example, volatile, withdrawn, or pursuer-distancer. But if we look at what actually happens moment-to-moment, we see that couples often shift among several phases.
 
Knowledge of this shifting helps a therapist follow the flow of what is happening in the couple and understand how the partners are triggering each other—how, for example, Alex pursues because he feels abandoned and Judy withdraws because she feels cornered, which leads to mutual accusation, and, in an effort to avoid further damage, to mutual withdrawal. The therapeutic goal is to enable the partners themselves to observe their relationship in this way: to give them a compassionate vantage point above the fray—a platform—from which to monitor and manage their relationship. Such a vantage point is created by developing the couple’s ability to hold recovery conversations in which they go over their alienating interactions and appreciate how the position of each made sense.

The Lake Wobegon Effect

Posted on by Psychotherapy.net Team

How good a therapist are you?

Odds are, you think you’re pretty good. A recent study[i] of 129 therapists found that over 90% self-rated their psychotherapy skills at the 75th percentile or greater.  All of the therapists rated themselves above the 50th percentile.

In his fascinating new book on therapy outcome, Michael Lambert calls this positive self-assessment bias the “Lake Wobegon effect”. While it is true that the overall industry-wide effectiveness rates for psychotherapy are very good, our blindness to our weaknesses is dangerous.
 
Lambert points out that 30% to 50% of our clients don’t improve in treatment. Even more alarming, roughly 8% of clients get worse in treatment.  (Deterioration rates of children and adolescents may be as high as 12% to 24%.)
 
If all of us are above average, then who is causing the problems?  

Lambert cites a study in which 20 experienced therapists and 20 therapist trainees were asked to predict the progress of current clients in their caseloads. Of the 550 total clients, the therapists in the study predicted that only three were deteriorating. The actual number of clients who got worse was 40.

Notably, none of the experienced therapists predicted any of the clients in their caseload getting worse, even though they were reminded at the beginning of the study that the industry-wide average deterioration rate is 8%.

How can we fix our blindness towards our weaknesses?  The traditional method of addressing therapist deficits is supervision and consultation, but those only work when we can correctly identify which clients in our caseload are deteriorating.

Lambert proposes using an intriguing actuarial model, in which the clients’ session-by-session data on outcome measures is entered into a computer program. Using a large database of client outcome data, the program is able to alert the therapist when the probability of client deterioration is high. In his book, Lambert cites a few studies that indicate promise with this method.

Understandably, many therapists will be loath to make clinical decisions based on a computer’s calculations. But then how else do we overcome our self-assessment bias and seriously deal with the risk of client deterioration? Whatever tool we choose, this is an important question for our field to address.


[i] Walfish, S., McAlister, B., O’Donnell, P. & Lambert, M. Are all psychotherapists from Lake Wobegon?: An investigation of self-assessment bias in mental health providers. Submitted for publication.

Preventing Psychotherapy Dropouts with Client Feedback

Posted on by Psychotherapy.net Team

“You understand me thirty percent of the time.”

“I need to you to slow down.”

“I was sad and you cut me off.”

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

Anne: A Case Study

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

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

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

Existential Threat

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

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

The Ubiquitous Scourge

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

What Counts as a Dropout?

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

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

Insisting on Feedback

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

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

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

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

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

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

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

“What else?”

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

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

Four Rules for Receiving Feedback

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

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

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

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

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

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

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

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

Incorporating Feedback

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

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

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

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

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

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

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

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

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

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

2011 Update

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

Footnotes

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

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

Further Reading

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

Stan Tatkin on a Psychobiological Approach to Couples Therapy

Posted on by rezendevknowfully.com

A Psychobiological Approach to Couple Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Avoidant and Angry-Resistant Styles

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

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

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

Getting Couples to Manage Each Other

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

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

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

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

The Elephants in the Room

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Applications for Individual Therapy

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

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

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

Psychotherapy Training on Steroids: Remote Live Supervision

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

Trusting the Client as the Agent of Change

Posted on by Psychotherapy.net Team

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

Clients as Agents of Change

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

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

A Casual Conversation

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

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

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

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

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

Florence: A Single-Session Case

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Doors of Possibility

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

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

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

They need doors of possibility, and they need company.