Category: Approach

Michael Hoyt on Brief and Narrative Therapy

Posted on by rezendevknowfully.com

The Interview

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

Narrative Constructivism: Is it All in the Mind?

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

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

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

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

The Archaelogy of Hope

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

Some Stories Are Better Than Others

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

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

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

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

VY: My – how very sweet.
MH: Yeah!

Goals and The Discovery Process

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

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

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

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

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

Managed Care… Or is it ‘Mangled Care’?

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

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

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

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

Hoyt Under Pressure

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

Words of Wisdom

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

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

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

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

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

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

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

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

Susan Heitler on Couples Therapy

Posted on by rezendevknowfully.com

The Interview

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

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

Conflict Resolution and Marriage

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

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


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

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

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

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

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

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

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

Heitler takes on Gottman’s Unresolvable Problems

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

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

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

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

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

Hot Buttons: Geography and Religion

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

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

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

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

Changing the Argument Cycle

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

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

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

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

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

Sharing Therapist Reactions in Couples Work

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

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

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

Saving Marriages

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

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

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

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

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

What to do with Secrets in Couples Work?

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

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

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

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

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

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

Heitler’s Husband and Tennis Coach Teach Her Some Things

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

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





Still Having Fun

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

Kenneth V. Hardy on Multiculturalism and Psychotherapy

Posted on by rezendevknowfully.com

Trained to be a “pretty good white therapist”

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

I realized after working at the outpatient psychiatric clinic that

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

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

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

Social justice and diversity

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Silencing rage versus giving voice to rage

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

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

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

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

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

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

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

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

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

Talking about diversity concerns in psychotherapy

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

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

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

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

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

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

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

The psychotherapist as the broker of permission

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are we not all just basically human?

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

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

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

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

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

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

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

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

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

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

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

Cultural genogram

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

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

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

The personal and the professional self are one

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

John Gottman on Couples Therapy

Posted on by rezendevknowfully.com

The Interview

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

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

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

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

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

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

The Myth of Active Listening

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

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

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

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

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

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

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

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

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

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

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

What Gottman Learned from His Own Marriage

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

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

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

When Compromising Too Soon is a Problem

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

And

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

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

What Works in Couple’s Therapy?

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

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

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

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

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

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

Happy Marriages: What are They Made of?

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

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

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

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

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

Future Breakthroughs?

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

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

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

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

James Bugental on Existential-Humanistic Psychotherapy

Posted on by rezendevknowfully.com

The Interview

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

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

Larry Beutler on Science and Psychotherapy

Posted on by rezendevknowfully.com

The Making of a Psychologist

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

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

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

The Challenge of Training Psychologists

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

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

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

Making Science Matter

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

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

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

Matching Therapists, Treatment and Patients

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

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

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

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

Lessons from Horse Training

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

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

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

Therapy Research Across Cultures

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

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

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

The Future of Psychotherapy

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

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

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

Insoo Kim Berg on Brief Solution-Focused Therapy

Posted on by rezendevknowfully.com

White Rats to Social Work

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

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

Phenomenal Failures

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

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

Solution Focused Model

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

The Miracle Question

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

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

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

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

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

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

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

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

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

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

Dr. Rubin Joins In

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

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

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

Cultural Similarities Matter More than Differences

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

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

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

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

Living and Dying with Meaning

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

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

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

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

“I am Korean… You Dumb Ass”

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

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

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

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

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

Looking Out the Patient’s Window Redux: Self-disclosure and Genuineness

Posted on by Psychotherapy.net Team

Nancy

In my fifteen-minute break—before seeing Nancy, my last patient of the day—I checked my voice mail and listened to a message from a San Francisco radio station. "Dr. Yalom, hope you don't mind but we've decided to change the format of our program tomorrow morning: We've invited another psychiatrist to join us and, instead of an interview, we'll have a three-way discussion. See you tomorrow morning at eight thirty. I assume this is all okay with you."

Okay? It wasn't okay at all and the more I thought about it the less okay it felt. I had agreed to be interviewed on the radio show in order to publicize my new book, The Gift of Therapy. Though I'd been interviewed many times, I felt anxious about this interview. Though the interviewer was extremely skilled, he was highly demanding. Furthermore, it was an hour long, the size of the radio audience was enormous and, finally, it was in my hometown with many friends listening. This voice mail message further fueled my anxiety. I didn't know the other psychiatrist; but to juice up the interview they had, no doubt, invited someone with an opposing point of view. I brooded about it: The last thing I, or my book, needed was an hour-long hostile confrontation in front of a hundred thousand listeners. I phoned back but there was no answer.

I was not in a good frame of mind to see a patient but the hour struck six and I escorted Nancy into my office. Nancy, a fifty-year-old nursing school professor, first came to see me twenty years before following the death of her older sister who had died of a brain malignancy. I remember how she began: "Eight sessions. That's all I want. No more, no less. I want to talk about the loss of the dearest and closest person in my life. And I want to figure how to make sense of life without her." Those eight sessions clicked by quickly: Nancy brought an agenda to each session: important memories of her sister, their three fights—one of which initiated a frosty silent four-year era which only ended at the funeral of their mother, her sister's disapproval of her boyfriends, her deep love for her sister—a love she had never expressed openly. “Her family was a family of secrets and silences; feelings, especially positive ones, were rarely voiced.”

Nancy was smart and quick: A self-starter in therapy, she worked hard and appeared to want or need little input from me. At the end of the tenth session she thanked me and left, a satisfied customer. I wasn't entirely satisfied, however. I would have preferred more ambitious therapy and I had spotted several areas, especially in the realm of intimacy, where further work could have been done. Over the next twenty years she called me two other times for brief therapy and, repeating the same pattern, used the time efficiently. And then, a few months ago, she phoned once again and asked to meet for a longer time, perhaps six months, in order to work on some significant marital problems.

She and her husband, Arnold, had grown increasingly distant from one another and for many years had slept in different rooms on separate floors of their home. We had been meeting weekly for a few months and she had so improved her relationship with her husband and her adult children that, a couple of weeks previously, I had raised the question of termination. She agreed she was getting close but requested a few additional sessions to deal with one additional problem that had arisen: stage fright. She was awash with anxiety about an upcoming lecture to a large prestigious audience.

As soon as Nancy and I sat down she plunged immediately into anxiety about her upcoming lecture. I welcomed her energy: it diverted my attention from that damn radio show. She spoke of her insomnia, her fears of failure, her dislike of her voice, her embarrassment about her physical appearance. I knew exactly what to do and began to escort her down a familiar therapeutic path: I reminded her of her mastery of her material, that she knew far more about her topic than anyone in the audience. Though I was distracted by my own anxiety, I was able to remind her that she had always sparkled as a lecturer and was on the verge of pointing out the irrationality of her views of her voice and physical appearance when a wave of queasiness swept over me.

How hypocritical could I be? Hadn't my therapy mantra always been "it's the relationship that heals, it's the relationship that heals." Hadn't I always, in my writing and teaching, beat the drum of authenticity? “The solid, genuine, I-thou relationship—wasn't that the ticket, the significant ingredient in successful therapy?” And yet here I was—riddled with anxiety about that radio show and yet hiding it all behind my pasted-on compassionate therapist countenance. And with a patient who had almost identical concerns. And a patient who wanted to work on intimacy to boot! No, I could not continue with this hypocrisy.

So I took a deep breath and fessed up. I told her all about the voice mail message I received just before she entered and about my anxiety and anger for my dilemma. She listened intently to my words and then, in a solicitous voice, asked, "What are you going to do?"

"I'm considering refusing to go on the program if they insist on this new arrangement."

"Yes, that seems very reasonable to me," she said, "you agreed to another format entirely and the station has no right to make the change without clearance from you. I'd be really upset about that, too. Is there any downside of your refusing?"

"None that I can think of. Perhaps I won't be invited back for the next book but who knows when or if I'll write another."

"So, no downside of refusing and lots of possible downside in your agreeing to do this?"

"Seems that way. Thanks Nancy, that's helpful."

We sat together in silence for a few moments and I asked, "Before we turn back to your stage fright, let me ask you something: How did that feel to you? This has not been our everyday hour."

"I liked your doing that. It was very important to me," she replied, paused for a moment to collect her thoughts and added, "I have a lot of feelings about it. Honored that you shared so much of your self with me. And ‘normalized': Your performance anxiety makes me more accepting of my own. And I think your openness will be contagious. I mean, you've given me the courage to talk about something I didn't think I'd be able to bring up."

"Great. Let's get into it."

"Well," Nancy looked uncomfortable and squirmed in her chair. She inhaled and said, "Well, here goes . . ."

I sat back in my chair, eager with anticipation. It was like waiting for the curtain to rise on a good drama. One of my great pleasures. A good story in the wings ready to make an entrance is like no other anticipatory pleasure I know. And my anxiety and annoyance at the interview and the radio station? What interview? What radio station? I had totally forgotten it. The power of the narrative drowned all cares.

"Your mentioning your book, The Gift of Therapy, gives me the opportunity to tell you something. A couple of weeks ago I read the whole book in a single sitting, till three a.m." She paused.

"And?" I shamelessly fished for a compliment.

"Well, I liked it but I was . . . uh, curious, about your using my story of the two streams."

"Your story of the two streams? Nancy, that was someone else's story, a woman dead these many years—I described her in the book. I've used that story in therapy and teaching for more years than I can remember."

"No, Irv. It was my story. I told it to you during our first therapy, twenty years ago."

I shook my head. I knew it was Bonnie's story. Why, I could still visualize Bonnie's face as she told me the story, I could see her wistful eyes as she reminisced about her father, I could still see the violet turban around her head—she had lost her hair from chemotherapy.

"Nancy, I can still see this woman telling me the story, I can . . ."

"No, it was my story," Nancy said firmly. "And what's more, it wasn't even my father and me. It was my father and my aunt, his younger sister. And it wasn't on the way to college—it was a vacation they took in France."

I sat stunned. Nancy was a very precise person. The strength of her assertion caught my attention. I turned inwards searching for the truth, listening to the trickling of memory coursing in from outposts of my mind. It was an impasse: Nancy was certain she told me this. I was absolutely certain I heard it from Bonnie. But I knew I had to remain open-minded. One of Nietzsche's marvelous aphorisms entered my mind and served as a cautionary tale: “"Memory says, I did that. Pride replies, I could not have done that. Eventually memory yields."”

As Nancy and I continued to talk, a new and astounding thought dawned. Oh, my God, could there have been two stories? Yes, yes, that's it. There must have been! The first story was Bonnie's story about her father, her yearning for reconciliation, and their unsuccessful drive to college; the second story was Nancy's two-stream story about her father and aunt. Now, all at once, I realized exactly what had happened: My gestalt-hungry, story-seeking memory had conflated the two stories into a single event.

It's always a shock to experience the fragility of memory. I've worked with many patients who have been destabilized when they learned that their past was not what they had thought it was. I remember one patient whose wife told him (at the breakup of their marriage) that, throughout their three-year marriage, she had been obsessed with another man, her previous lover. He was shattered: All those shared memories (romantic sunsets, candlelit dinners, walks on the beaches of small Greek islands) were chimerical. His wife was not there at all. She was obsessing about someone else. He told me more than once that he suffered more from losing his past than from losing his wife. I didn't fully understand that at the time but now, as I sat with Nancy, I could finally empathize with him and appreciate how unsettling one feels when the past decomposes.

“The past: wasn't it a concrete entity, unforgettable events etched indelibly into stone-like leaves of experience? How tightly I clung to that solid view of existence.” But I knew now, I really knew, the fickleness of memory. Never again would I ever doubt the existence of false memories! What made it even more confounding was the way I had embroidered the false memory (for example, the wistful look on Bonnie's face) which made it entirely indistinguishable from a real memory. All of these things I said to Nancy along with my apology for not having obtained her permission for the story of the two streams. Nancy was untroubled by the issue of permission. She had written science fiction stories and was well aware of the blurring of remembrance and fiction. She instantaneously accepted my apology for publishing something of hers without her permission and then added that she liked her story being used. She took pride in it having prove helpful to my students and other patients.

Her acceptance of my apology left me in a mellow mood and I told her of a conversation a few hours previously with a visiting Danish psychologist. He was writing an article about my work for a Danish psychology journal and asked whether my intense closeness with patients made it more difficult for them to terminate. "Given the fact that we're near termination, Nancy, let me pose that very question to you. Is it true that our closeness interferes with your ending your meetings with me?"

She thought about it for a long time before responding, "I agree. I do feel close to you, perhaps as close as with any other person in my life. But your phrase, that therapy is a dress rehearsal for life, which you said so many times—I think you overdid it by the way . . . well, that phrase helped keep things in perspective. No, I'm going to be able to stop soon and keep a lot from here inside me. From day one of our last set of meetings you did keep focusing on my husband. You did keep focusing on our relationship, but scarcely an hour passed without your moving over to the intimacy between me and Arnold."

Nancy ended the hour by giving me a lovely dream (remember Nancy and Arnold slept in separate rooms).

"I was sitting on Arnold's bed. He was in the room and watching me. I didn't mind his being there and was busy with makeup. I was taking off a makeup mask, peeling it off in front of him."

The dream-maker inside of us (whoever, wherever, he or she is) has many constrictions in the construction of the finished product. One of the major constrictions faced is that the dream final product must be almost entirely visual. Hence, an important challenge in the dream work is to transform abstract concepts into a visual representation. What better way to depict increased openness and trust with one's spouse than to peel off a mask?

Discussion

Let's review the major points conveyed in this vignette. First, let's consider my self-disclosure of my personal anxiety evoked by an event that occurred just before the start of the therapy hour. Why choose to share this? First, there was the consideration of genuineness. I felt too phony, inauthentic, sitting on my anxiety while trying to help her deal with anxiety about a very similar issue. Second, there is the matter of effectiveness: I believe that my preoccupation with my personal issues was hampering my ability to work effectively. Third, there is the factor of role modeling. My experience over decades of doing therapy is that such revelation inevitably catalyzes patient revelation and accelerates therapy.

After my self-revelation there was, for a few minutes, a role reversal as Nancy offered me effective counsel. I thanked her and then initiated a discussion of our relationship by commenting that something unusual had just happened. (In the language of therapists, I did a "process check.") Earlier I made the point that therapy is, or should be, an alternating sequence of action and then reflection upon that action.

Her response was highly informative. First, she felt honored by my sharing my issues with her—that I would treat her as an equal and accept her counsel. Second, she felt "normalized"—that is, my anxiety made her more accepting of her own. Last, my revealing served as a model and an impetus for her further revealing. Research confirms that therapists who model personal transparency influence their patients to reveal more of themselves.

Nancy's response to my disclosure is, in my clinical experience, typical. For a great many years I have worked with patients who have had an unsatisfactory prior experience in therapy. What are their complaints? Almost invariably, they say that their previous therapist was too distant, too impersonal, too disinterested. “I believe that therapists have everything to gain and nothing to lose by appropriate self-disclosure.”

How much should therapists reveal? When to reveal? When not? The guiding in answering such questions is always the same: What is best for the patient? Nancy was a patient I had known for a long time and I had a strong intuition that my genuineness would facilitate her work. Timing was an important factor as well: Self-disclosure early in therapy, before we established a good working alliance, might have been counterproductive. The session with Nancy was an atypical session and I do not generally reveal my own personal disquiet to my patients: After all, we therapists are there to help, not to deal with our own internal conflicts. If we face personal problems of such magnitude that they interfere with therapy then obviously we should be seeking personal therapy.

That said, let me add that on countless occasions I have gone into a session troubled with some personal issues and, by the end of the session (without having mentioned a word about my discomfort), felt remarkably better! I've often wondered why that was so. Perhaps because of the diversion from my self-absorption, or the deep pleasure of being helpful to another, or the boost in self-regard from effectively employing my professional expertise, or the effect of increased connectivity that all of us want and need. This effect of therapy helping the therapist is, in my experience, even greater in group therapy. All of the reasons noted above are in effect but there is an additional factor in group therapy: A mature, caring therapy group in which members share their deepest inner concerns has a healing ambiance in which I have the privilege of immersing myself. 

Staring at the Sun: Overcoming the Terror of Death

Posted on by rezendevknowfully.com

THE MORTAL WOUND (from chapter 1)

Self-awareness is a supreme gift, a treasure as precious as life. This is what makes us human. But it comes with a costly price: the wound of mortality. Our existence is forever shadowed by the knowledge that we will grow, blossom, and, inevitably, diminish and die.

Mortality has haunted us from the beginning of history. Four thousand years ago, the Babylonian hero Gilgamesh reflected on the death of his friend Enkidu with the words from the epigraph above: “Thou hast become dark and cannot hear me. When I die shall I not be like Enkidu? Sorrow enters my heart. I am afraid of death.”

Gilgamesh speaks for all of us. As he feared death, so do we all—each and every man, woman, and child. For some of us the fear of death manifests only indirectly, either as generalized unrest or masqueraded as another psychological symptom; other individuals experience an explicit and conscious stream of anxiety about death; and for some of us the fear of death erupts into terror that negates all happiness and fulfillment.

For eons, thoughtful philosophers have attempted to dress the wound of mortality and to help us fashion lives of harmony and peace. As a psychotherapist treating many individuals struggling with death anxiety, I have found that ancient wisdom, particularly that of the ancient Greek philosophers, is thoroughly relevant today.

Indeed, in my work as a therapist, I take as my intellectual ancestors not so much the great psychiatrists and psychologists of the late nineteenth and early twentieth centuries—Pinel, Freud, Jung, Pavlov, Rorschach, and Skinner—but classical Greek philosophers, particularly Epicurus. The more I learn about this extraordinary Athenian thinker, the more strongly I recognize Epicurus as the proto-existentialist psychotherapist, and I will make use of his ideas throughout this work.

. . . Had I been a citizen of ancient Athens circa 300 B.C.E.(a time often called the golden age of philosophy) and experienced a death panic or a nightmare, to whom would I have turned to clear my mind of the web of fear? It’s likely I’d have trudged off to the agora, a section of ancient Athens where many of the important schools of philosophy were located. I’d have walked past the Academy founded by Plato, now directed by his nephew, Speucippus; and also the Lyceum, the school of Aristotle, once a student of Plato, but too philosophically divergent to be appointed his successor.

I’d have passed the schools of the Stoics and the Cynics and ignored any itinerant philosophers searching for students. Finally, I’d have reached the Garden of Epicurus, and there I think I would have found help. Where today do people with unmanageable death anxiety turn? Some seek help from their family and friends; others turn to their church or to therapy; still others may consult a book such as this. I’ve worked with a great many individuals terrified by death. I believe that the observations, reflections, and interventions I’ve developed in a lifetime of therapeutic work can offer significant help and insight to those who cannot dispel death anxiety on their own.

. . . Why, you may ask, take on this unpleasant, frightening subject? Why stare into the sun? Why not follow the advice of the venerable dean of American psychiatry, Adolph Meyer, who, a century ago, cautioned psychiatrists, “Don’t scratch where it doesn’t itch”? Why grapple with the most terrible, the darkest and most unchangeable aspect of life? Indeed, in recent years, the advent of managed care, brief therapy, symptom control, and attempts to alter thinking patterns have only exacerbated this blinkered point of view.

Death, however, does itch. It itches all the time; it is always with us, scratching at some inner door, whirring softly, barely audibly, just under the membrane of consciousness. Hidden and disguised, leaking out in a variety of symptoms, it is the wellspring of many of our worries, stresses, and conflicts.

I feel strongly—as a man who will himself die one day in the not-too-distant future and as a psychiatrist who has spent decades dealing with death anxiety— that confronting death allows us, not to open some noisome Pandora’s box, but to reenter life in a richer, more compassionate manner.

So I offer this book optimistically. I believe that it will help you stare death in the face and, in so doing, not only ameliorate terror but enrich your life.

OVERCOMING DEATH TERROR THROUGH CONNECTION (from Chapter 5)

THE POWER OF PRESENCE

One can offer no greater service to someone facing death (and from this point on I speak either of those suffering from a fatal illness or physically healthy individuals experiencing death terror) than to offer him or her your sheer presence.

The following vignette, which describes my attempt to assuage a woman’s death terror, provides guidelines to friends or family members offering aid to one another.

Reaching Out to Friends: Alice

Alice—the widow whose story I told in Chapter Three, who was distressed at having to sell her home and her memory-laden collection of musical instruments—was on the verge of moving into a retirement community. Shortly before her move, I left town for a few days’ vacation and, knowing this would be a difficult time for her, gave her my cell phone number in case of an emergency. As the movers began to empty her house, Alice experienced a paralyzing panic that her friends, physician, and massage therapist could not quell. She phoned me, and we had a twenty-minute talk:

“I can’t sit still,” she began. “I’m so edgy I feel I’m going to burst. I cannot find relief.”

“Look straight into the heart of your panic. Tell me what you see.”

“Ending. Everything ending. That’s all. The end of my house, all my things, my memories, my attachments to my past. The end of everything. The end of me—that’s the heart of it. You want to know what I fear. It’s simple: it’s no more me!”

“We’ve discussed this in other meetings, Alice, so I know I’m repeating myself, but I want to remind you that selling your house and moving to a retirement home is an extraordinary trauma, and of course you’re going to feel major dislocation and major shock. I would feel that way if I were in your place. Anyone would. But remember our talks about how it will look if you fast-forward to three weeks from now—”

“Irv,” she interrupted, “that doesn’t help—this pain is too raw. This is death surrounding me. Death everywhere. I want to scream.”

“Bear with me, Alice. Stay with me—I’m going to ask that same simplistic question I’ve asked before: what precisely is it about death that so frightens you? Let’s hone in on it.”

 “We’ve gone over this.” Alice sounded irritated and impatient.

“Not enough. Keep going, Alice. Humor me, please. Come on, let’s get to work.”

“Well, it’s not the pain of dying. I trust my oncologist; he will be there when I need morphine or something. And it has nothing to do with an afterlife—you know I let go of all that stuff a half century ago.”

“So it’s not the act of dying and not the fear of an afterlife. Keep going. What is it about death that terrifies you?”

“It’s not that I feel unfinished; I know I’ve had a full life. I’ve done what I’ve wanted to do. We’ve gone over all this.”

“Please keep going, Alice.”

“It’s what I just said: no more me. I just don’t want to leave this life . . . I’ll tell you what it is: I want to see the endings. I want to be here to see what happens to my son—will he decide to have children after all. It’s painful to realize I won’t ever be able to know.”

“But you won’t know you’re not here. You won’t know you won’t know. You say you believe (as I do) that death is complete cessation of consciousness.”

“I know, I know, you’ve said it so many times that I know the whole litany by heart: the state of nonexistence is not terrifying because we won’t know we are not existing, and so on and so on. And that means I won’t know that I am missing important things. And I remember also what you’ve already said about the state of nonbeing—that it’s identical to the state I was in before I was born. It helped before, but it just doesn’t help now—this feeling is too strong, Irv—ideas won’t crack it; they won’t even touch it.”

“Not yet they won’t. That only means we have to keep going, keep figuring it out. We can do it together. I’ll be in there with you and help you go as deep as you can.”

“It’s gripping terror. There is some menace I cannot name or find.”

“Alice, at the very base of all our feelings about death there is a biological fear that is hardwired into us. I know this fear is inchoate—I’ve experienced it too. It doesn’t have words. But every living creature wishes to persist in its own being—Spinoza said that around 350 years ago. We just have to know this, expect it. The hardwiring will zap us with terror from time to time. We all have it.”

After about twenty minutes, Alice sounded calmer, and we ended the call. A few hours later, however, she left a curt phone message telling me that the phone session felt like a slap in the face and that I was cold and unempathic. Almost as a postscript she added that, unaccountably, she felt better. The following day she left another message saying that her panic had entirely subsided—again, she said, for reasons unknown.

Now, why was Alice helped by this conversation? Was it the ideas I presented? Probably not. She dismissed my arguments from Epicurus—that, with her consciousness extinguished, she wouldn’t know that she’d never find out how the stories of people close to her ended, and that after death she would be in the same state as she was before her birth. Nor did any of my other suggestions—for example, that she project herself three weeks into the future to gain some perspective on her life—have any impact whatsoever. She was simply too panicky. As she put it, ““I know you’re trying, but these ideas won’t crack it; they don’t even touch what’s here—this anguished heaviness in my chest.””

So ideas didn’t help. But let’s examine the conversation from the perspective of relationship. First, I spoke to her on my vacation, thereby indicating my full willingness to be involved with her. I said, in effect, let’s you and I keep working on this together. I didn’t shrink from any aspect of her anxiety. I continued inquiring into her feelings about death. I acknowledged my own anxiety. I assured her that we were in this together, that she and I and everyone else are hardwired to feel anxious about death.

Second, behind my explicit offer of presence, there was a strong implicit message: “No matter how much terror you have, I will never shun or abandon you.” I was simply doing what the housemaid, Anna, did in Cries and Whispers. I held her, stayed with her.

Although I felt fully involved with her, I made sure that I kept her terror contained. I did not permit it to be contagious. I maintained an unruffled, matter-of-fact tone as I urged her to join me in dissecting and analyzing the terror. Although she criticized me the following day for being cold and unempathic, my calmness nonetheless steadied her and helped allay her terror.

“The lesson here is simple: connection is paramount. Whether you are a family member, a friend, or a therapist, jump in.” Get close in any way that feels appropriate. Speak from your heart. Reveal your own fears. Improvise. Hold the suffering one in any way that gives comfort.

Once, decades ago, as I was saying goodbye to a patient near death, she asked me to lie next to her on her bed for a while. I did as she requested and, I believe, offered her comfort. Sheer presence is the greatest gift you can offer anyone facing death (or a physically healthy person in a death panic).

SELF-DISCLOSURE

A great deal of a therapist’s training, as I’ll discuss in Chapter Seven, focuses on the centrality of connection. An essential part of that training should, in my opinion, focus on the therapist’s willingness and ability to increase connection through his or her own transparency. Because many therapists have trained in traditions that stress the importance of opaqueness and neutrality, friends willing to reveal themselves to one another may, in this regard, have an advantage over professional therapists.

In close relationships, the more one reveals of one’s inner feelings and thoughts, the easier it is for others to reveal themselves. Self-disclosure plays a crucial role in the development of intimacy. Generally, relationships build by a process of reciprocal self-revelations. One individual takes the leap and reveals some intimate material, thereby placing himself or herself at risk; the other closes the gap by reciprocating in kind; together, they deepen the relationship via a spiral of self-revelation. If the person at risk is left hanging without the other reciprocating, then the friendship often flounders.

The more you can be truly yourself, can share yourself fully, the deeper and more sustaining the friendship. In the presence of such intimacy, all words, all modes of comfort, and all ideas take on greater meaning.

Friends must keep reminding one another (and themselves) that they, too, experience the fear of death. Thus, in my conversation with Alice, I included myself in discussions of death’s inevitability. Such disclosure is not high risk: it is merely making explicit what is implicit. After all, we are all creatures who are frightened at the thought of “no more me.” We all face the sense of our smallness and insignificance when measured against the infinite extent of the universe (sometimes referred to as the “experience of the tremendum”). Each of us is but a speck, a grain of sand, in the vastness of the cosmos. As Pascal said in the seventeenth century, “the eternal silence of infinite spaces terrifies me.” The need for intimacy in the face of death is heartbreakingly described in a recent rehearsal of a new play, Let Me Down Easy, by Anna Deavere Smith. In this play, one of the characters portrayed was a remarkable woman who cared for African children with AIDS. Little help was available at her shelter. Children died every day. When asked what she did to ease the dying children’s terror, she answered with two phrases: “I never let them die alone in the dark, and I say to them, ‘You will always be with me here in my heart.’”

Even for those with a deeply ingrained block against openness—those who have always avoided deep friendships—the idea of death may be an awakening experience, catalyzing an enormous shift in their desire for intimacy and their willingness to make efforts to attain it. Many people who work with dying patients have found that those who were previously distant become strikingly and suddenly accessible to deep engagement.

RIPPLING IN ACTION

As I explained in the previous chapter, the belief that one may persist, not in one’s individual personhood, but through values and actions that ripple on and on through generations to come can be a powerful consolation to anyone anxious about his or her mortality.

Alleviating the Loneliness of Death

Although Everyman, the medieval morality play, dramatizes the loneliness of one’s encounter with death, it may also be read as portraying the consoling power of rippling. A theatrical crowd pleaser for centuries, Everyman played in front of churches before large throngs of parishioners. It tells the allegorical tale of Everyman, who is visited by the angel of death and learns that the time of his final journey has arrived.

Everyman pleads for a reprieve. “Nothing doing,” replies the angel of death. Then another request: “Can I invite someone to accompany me on this desperately “lonely journey?” The angel grins and readily agrees: “Oh, yes—if you can find someone.”

The remainder of the play consists of Everyman’s attempts to recruit someone to be his companion on the journey. Every friend and acquaintance declines; his cousin, for example, is indisposed by a cramp in her toe. Even metaphorical figures (Worldly Goods, Beauty, Strength, Knowledge) refuse his invitation. Finally, as he resigns himself to his lonely journey, he discovers one companion, Good Deeds, who is available and willing to accompany him, even unto death.

Everyman’s discovery that there is one companion, Good Deeds, who is able to accompany him is, of course, the Christian moral of this morality play: that you can take with you from this world nothing that you have received; you can take only what you have given. A secular interpretation of this drama suggests that rippling—that is, the realization of your good deeds, of your virtuous influence on others that persists beyond yourself—may soften the pain and loneliness of the final journey.

The Role of Gratitude

Rippling, like so many of the ideas I find useful, assumes far more power in the context of an intimate relationship where one can know at first hand how one’s life has benefited someone else. Friends may thank someone for what he or she has done or meant. But mere thanks is not the point. The truly effective message is, “I have taken some part of you into me. It has changed and enriched me, and I shall pass it on to others.”

Far too often, gratitude for how a person has sent influential ripples out into the world is expressed not when the person is still alive but only in a posthumous eulogy. How many times at funerals have you wished (or overheard others express the wish) that the dead person were there to hear the eulogies and expressions of gratitude? “How many of us have wished we could be like Scrooge and eavesdrop on our own funeral?” I have. One technique for overcoming this “too little, too late” problem with rippling is the “gratitude visit,” a splendid way to enhance rippling when one is alive. I first came upon this exercise at a workshop conducted by Martin Seligman, one of the leaders of the positive psychology movement. He asked a large audience to participate in an exercise that, as I recall, went along these lines:

Think of someone still living toward whom you feel great gratitude that you have never expressed. Spend ten minutes writing that person a gratitude letter and then pair up with someone here, and each of you read your letter to the other. The final step is that you pay a personal visit to that person sometime in the near future and read that letter aloud.

After the letters were read in pairs, several volunteers were selected from the audience to read their letters aloud to the entire audience. Without exception, each person choked up with emotion during the reading. I learned that such displays of emotion invariably occur in this exercise: very few participants get through the reading without being swept by a deep emotional current. I did the exercise myself and wrote such a letter to David Hamburg, who had been a superbly enabling chairman of the Department of Psychiatry during my first ten years at Stanford. When I next visited New York, where he lived at this time, we spent a moving evening together. I felt good expressing my gratitude, beamed with pleasure when reading my letter. As I age, I think more and more about rippling. As a paterfamilias, I always pick up the check when my family dines at a restaurant. My four children always thank me graciously (after offering only feeble resistance), and I always say to them, “Thank your grandfather Ben Yalom. I’m only a vessel passing on his generosity. He always picked up the check for me.” (And I, by the way, also offered only feeble resistance.)

Rippling and Modeling

In the first group I led for patients with terminal cancer, I often found the members’ despondency contagious. So many members were in despair; so many waited day after day listening for the approaching footsteps of death; so many claimed that life had become empty and stripped of all meaning. And then, one fine day, a member opened our meeting with an announcement: “I have decided that there is, after all, something that I can still offer. I can offer an example of how to die. I can set a model for my children and my friends by facing death with courage and dignity.”

It was a revelation that lifted her spirits, and mine, and those of the other members of the group. She had found a way to imbue her life, to its very end, with meaning.

The phenomenon of rippling was evident in the cancer group members’ attitude toward student observers. It is vital for the education of group therapists that they observe experienced clinicians leading groups, and I have usually had students observing my groups, sometimes using TV monitors but generally through a one-way mirror. Although groups in educational settings give permission for such observation, the group members generally grumble about the observers and, from time to time, openly voice resentment at the intrusion.

Not so with my groups of cancer patients: they welcomed observers. They felt that as a result of their confrontation with death, they had grown wise and had much to pass on to students and regretted only, as I mentioned earlier, that they had waited so long to learn how to live.

Note: Signed copies of Staring at the Sun and other Ivin Yalom books are available here.

The Gift of Therapy

Posted on by Psychotherapy.net Team

The Gift of Therapy has 85 short chapters, each offering a suggestion or tip for therapy. The first three chapters are reproduced here.

Remove the Obstacles to Growth

When I was finding my way as a young psychotherapy student, the most useful book I read was Karen Horney's Neurosis and Human Growth. And the single most useful concept in that book was the notion that the human being has an inbuilt propensity toward self-realization. If obstacles are removed, Horney believed, the individual will develop into a mature, fully realized adult, just as an acorn will develop into an oak tree.

"Just as an acorn develops into an oak." What a wonderfully liberating and clarifying image! It forever changed my approach to psychotherapy by offering me a new vision of my work: My task was to remove obstacles blocking my patient's path. I did not have to do the entire job; I did not have to inspirit the patient with the desire to grow, with curiosity, will, zest for life, caring, loyalty, or any of the myriad of characteristics that make us fully human. No, what I had to do was to identify and remove obstacles. The rest would follow automatically, fueled by the self-actualizing forces within the patient.

I remember a young widow with, as she put it, a "failed heart"—an inability ever to love again. It felt daunting to address the inability to love. I didn't know how to do that. But dedicating myself to identifying and uprooting her many blocks to loving? I could do that.

I soon learned that love felt treasonous to her. To love another was to betray her dead husband; it felt to her like pounding the final nails in her husband's coffin. To love another as deeply as she did her husband (and she would settle for nothing less) meant that her love for her husband had been in some way insufficient or flawed. To love another would be self-destructive because loss, and the searing pain of loss, was inevitable. To love again felt irresponsible: she was evil and jinxed, and her kiss was the kiss of death.

We worked hard for many months to identify all these obstacles to her loving another man. For months we wrestled with each irrational obstacle in turn. But once that was done, the patient's internal processes took over: she met a man, she fell in love, she married again. I didn't have to teach her to search, to give, to cherish, to love. I wouldn't have known how to do that.

Avoid Diagnosis (except for insurance companies)

Today's psychotherapy students are exposed to too much emphasis on diagnosis. Managed care administrators demand that therapists arrive quickly at a precise diagnosis and then proceed upon a course of brief, focused therapy that matches that particular diagnosis. Sounds good. Sounds logical and efficient. But it has precious little to do with reality. It represents instead an illusory attempt to legislate scientific precision into being when it is neither possible nor desirable.

Though diagnosis is unquestionably critical in treatment considerations for many severe conditions with a biological substrate (for example schizophrenia, bipolar disorders, major affective disorders, temporal lobe epilepsy, drug toxicity, organic or brain disease from toxins, degenerative causes or infectious agents) diagnosis is often counterproductive in the everyday psychotherapy of less severely impaired patients.

Why? For one thing, psychotherapy consists of a gradually unfolding process wherein the therapist attempts to know the patient as fully as possible. A diagnosis limits vision, it diminishes ability to relate to the other as a person. Once we make a diagnosis, we tend to selectively inattend to aspects of the patient which do not fit into that particular diagnosis, and we correspondingly over-attend to subtle features which appear to confirm an initial diagnosis. What's more, a diagnosis may act as a self-fulfilling prophecy. Relating to a patient as a "borderline" or a "hysteric" may serve to stimulate and perpetuate those very traits. Indeed, there is a long history of iatrogenic influence on the shape of clinical entities, including the current controversy about multiple personality disorder and repressed memories of sexual abuse. And keep in mind, too, the low reliability of the DSM personality disorders category (the very patients often engaging in longer-term psychotherapy.)

And what therapist has not been struck by how much easier it is to make a DSM-IV diagnosis following the first interview than much later, let us say, after the tenth session, when we know a great deal more about the individual? Is this not a strange kind of science? A colleague of mine brings this point home to his psychiatric residents by asking: "If you were in personal psychotherapy or are considering it, what DSM-IV diagnosis do you think your therapist could justifiably use to describe someone as complicated as you?" (C. P. Rosenbaum, personal communication, Nov. 2000)

In the therapeutic enterprise we must tread a fine line between some, but not too much, objectivity; if we take the DSM diagnostic system too seriously, if we really believe we are truly carving at the joints of nature, then we may threaten the human, the spontaneous, the creative and uncertain nature of the therapeutic venture. Remember that the clinicians involved in formulating previous, now discarded, diagnostic systems were competent, proud, and just as confident as the current members of DSM committees. Undoubtedly the time will come when the DSM-IV Chinese restaurant menu format will appear ludicrous to mental health professionals.

Therapist and Patient as "Fellow Travelers"

Andrè Malraux, the French novelist, described a country priest who had taken confession for many decades and summed up what he had learned about human nature in this manner: "First of all, people are much more unhappy than one thinks…and there is no such thing as a grown-up person." Everyone—and that includes therapists as well as patients—is destined to experience not only the exhilaration of life, but also its inevitable darkness: disillusionment, aging, illness, isolation, loss, meaninglessness, painful choices, and death.

No one put things more starkly and more bleakly than the German philosopher Arthur Schopenhauer:

In early youth, as we contemplate our coming life, we are like children in a theater before the curtain is raised, sitting there in high spirits and eagerly waiting for the play to begin. It is a blessing that we do not know what is really going to happen. Could we foresee it, there are times when children might seem like condemned prisoners, condemned, not to death, but to life, and as yet all unconscious of what their sentence means.

Or again:

We are like lambs in the field, disporting themselves under the eyes of the butcher, who picks out one first and then another for his prey. So it is that in our good days we are all unconscious of the evil that Fate may have presently in store for us — sickness, poverty, mutilation, loss of sight or reason.

Though Schopenhauer's view is colored heavily by his own personal unhappiness, still it is difficult to deny the inbuilt despair in the life of every self-conscious individual. My wife and I have sometimes amused ourselves by planning imaginary dinner parties for groups of people sharing similar propensities—for example, a party for monopolists, or flaming narcissists, or artful passive-aggressives we have known or, conversely, a "happy" party to which we invite only the truly happy people we have encountered. Though we've encountered no problems filling all sorts of other whimsical tables, we've never been able to populate a full table for our "happy people" party. Each time we identify a few characterologically cheerful people and place them on a waiting list while we continue our search to complete the table, we find that one or another of our happy guests is eventually stricken by some major life adversity—often a severe illness or that of a child or spouse.

This tragic but realistic view of life has long influenced my relationship to those who seek my help. Though there are many phrases for the therapeutic relationship (patient/therapist, client/counselor, analysand/analyst, client/facilitator, and the latest—and, by far, the most repulsive—user/provider), none of these phrases accurately convey my sense of the therapeutic relationship. Instead I prefer to think of my patients and myself as fellow travelers, a term that abolishes distinctions between "them" (the afflicted) and "us" (the healers). During my training I was often exposed to the idea of the fully analyzed therapist, but as I have progressed through life, formed intimate relationships with a good many of my therapist colleagues, met the senior figures in the field, been called upon to render help to my former therapists and teachers, and myself become a teacher and an elder, I have come to realize the mythic nature of this idea. We are all in this together and there is no therapist and no person immune to the inherent tragedies of existence.

One of my favorite tales of healing, found in Hermann Hesse's Magister Ludi, involves Joseph and Dion, two renowned healers, who lived in biblical times. Though both were highly effective, they worked in different ways. The younger healer, Joseph, healed through quiet, inspired listening. Pilgrims trusted Joseph. Suffering and anxiety poured into his ears vanished like water on the desert sand and penitents left his presence emptied and calmed. On the other hand, Dion, the older healer, actively confronted those who sought his help. He divined their unconfessed sins. He was a great judge, chastiser, scolder, and rectifier, and he healed through active intervention. Treating the penitents as children, he gave advice, punished by assigning penance, ordered pilgrimages and marriages, and compelled enemies to make up.

The two healers never met, and they worked as rivals for many years until Joseph grew spiritually ill, fell into dark despair, and was assailed with ideas of self-destruction. Unable to heal himself with his own therapeutic methods, he set out on a journey to the south to seek help from Dion.

On his pilgrimage, Joseph rested one evening at an oasis, where he fell into a conversation with an older traveler. When Joseph described the purpose and destination of his pilgrimage, the traveler offered himself as a guide to assist in the search for Dion. Later, in the midst of their long journey together the old traveler revealed his identity to Joseph. Mirabile dictu: he himself was Dion—the very man Joseph sought.

Without hesitation Dion invited his younger, despairing rival into his home, where they lived and worked together for many years. Dion first asked Joseph to be a servant. Later he elevated him to a student and, finally, to full colleagueship. Years later, Dion fell ill and on his deathbed called his young colleague to him in order to hear a confession. He spoke of Joseph's earlier terrible illness and his journey to old Dion to plead for help. He spoke of how Joseph had felt it was a miracle that his fellow traveler and guide turned out to be Dion himself.

Now that he was dying, the hour had come, Dion told Joseph, to break his silence about that miracle. Dion confessed that at the time it had seemed a miracle to him as well, for he, too, had fallen into despair. He, too, felt empty and spiritually dead and, unable to help himself, had set off on a journey to seek help. On the very night that they had met at the oasis he was on a pilgrimage to a famous healer named Joseph.

Hesse's tale has always moved me in a preternatural way. It strikes me as a deeply illuminating statement about giving and receiving help, about honesty and duplicity, and about the relationship between healer and patient. The two men received powerful help but in very different ways. The younger healer was nurtured, nursed, taught, mentored, and parented. The older healer, on the other hand, was helped through serving another, through obtaining a disciple from whom he received filial love, respect, and salve for his isolation.

But now, reconsidering the story, I question whether these two wounded healers could not have been of even more service to one another. Perhaps they missed the opportunity for something deeper, more authentic, more powerfully mutative. Perhaps the real therapy occurred at the deathbed scene, when they moved into honesty with the revelation that they were fellow travelers, both simply human, all too human. The twenty years of secrecy, helpful as they were, may have obstructed and prevented a more profound kind of help. What might have happened if Dion's deathbed confession had occurred twenty years earlier, if healer and seeker had joined together in facing the questions that have no answers?

All of this echoes Rilke's letters to a young poet in which he advises, "Have patience with everything unresolved and try to love the questions themselves." I would add: "Try to love the questioners as well."