Category: Psychodynamic

Therapeutic Reimagining

Posted on by Psychotherapy.net Team

An Introduction to Therapeutic Reimagining

I’m very proud to have recently published my first book, Reimagine Your Life: How to Change Your Past and Transform Your Future, in which I introduce a process that I have named “therapeutic reimagining.”

There are many reasons why I am proud of this book, but the greatest achievement is to have overcome the intergenerational narrative provided by my “working class” upbringing in the United Kingdom, with its self-limiting beliefs about myself, others and the world.

I come from a family of six siblings, three of whom left school virtually unable to read or write. My father was an Irish immigrant who worked on a building site doing unskilled work, and my mother left school at the age of 14 to look after cows on a local farm. I too was educationally backward as a child, and was never given a book, or helped with reading by my parents. So, if they were alive today and I told them that I have written a book about a new way of doing psychotherapy, it would be incomprehensible to them.

It has taken me 20 years of hard study and practice to put all of the puzzle pieces together and create this process that I call therapeutic reimagining. I simply couldn’t have done it earlier in my life. That is the gift of ageing: being able, over time, to integrate a multitude of different experiences.

Although writing Reimagine Your Life was conceived as a way of helping people who either couldn’t afford therapy or couldn’t access it for other reasons, the core process of therapeutic reimagining was born in my psychotherapy practice in Cambridge, England as a way of accelerating clients’ progress in therapy. Simply put, they were able to get much further forward in their healing journey by being empowered and encouraged to continue their transformational work outside of sessions.

The book cover has a clock face and the question, “How far would you wind back time and what would you change?” This gives us a clue that it is about overcoming trauma by redoing the past.

Often in people’s lives something goes wrong or there is trauma that leads to a whole downward trajectory of events. So, I invite my clients to wind back time to a point before it happened and explore an alternate timeline or alternate history.

This might sound like time travel and science fiction. However, it is actually science fact: the psychology of counterfactual thinking. You may have never heard of it, but it is something we do with our clients all the time. Every time we ask a question like “How do you wish your childhood was different” we are inviting them to imagine an alternate history with a new narrative.

In Gestalt Therapy, we ask the client to go back in time and “Be there now.” In Transactional Analysis, it is called “early scene work;” “enactments” in Psychodynamic Therapy, and “portrayals” in some other therapies.

However, where therapeutic reimagining is different from all of the above, is that it provides a roadmap of how to do the process, so that clients can create their own portrayals at home. It has worked so well with my clients that I wanted to write a self-help book that would allow those who can’t afford or can’t access one-to-one therapy to benefit from the process. It is safe to do at home because the reader is invited to imagine a more pleasant alternative to what actually happened.

The book contains nine stories, written by the clients themselves, explaining how they used therapeutic reimagining to overcome shame, guilt, fear, anxiety, overeating, and even medically unexplained physical symptoms.

One of the stories concerns a theme that many people encounter in later life, the illness and death of their life partner. Stephanie was 73 when she came to see me, full of toxic guilt related to the circumstances of the death of her husband several years earlier. Her guilt interfered with the grieving process and caused her a great deal of emotional pain and suffering. With Stephanie’s consent I am sharing her therapeutic reimagining journey.

Stephanie’s Story: Grief Without End

I was struggling with the knowledge that I had not done everything that I could have done for my husband in his last few days of life. He was in hospital, and the doctors told me he had kidney failure which they were planning to treat with dialysis.

I had no idea that he was going to die soon. On the fourth night, they called me into the hospital because he was dying. He died the next day. All the time that he was in the hospital I believed that they were trying to help him.

All the time he was in the hospital he was asking me to take him home. Once he had died, I realized that he knew he was dying, and he wanted to die at home. I had no way of knowing that he was dying at the time, and I persuaded him to stay in the hospital where I believed that he was getting treatment that would help him, and that although he was seriously ill with lymphoma and we knew that it could not be cured, we thought we had a few years more.

For more than three years after he died, I suffered profound guilt about my behavior during these days. This feeling haunted me, and even though I knew that I wasn’t aware that he was dying during his last days, I found it hard to forgive myself for not paying attention to his requests to be taken home. My intelligent self knew that if I had known, I would have acted differently, but this knowledge had little or no effect on the extremely painful feelings that I was experiencing day after day.

Anthony encouraged me to visualize an alternative narrative. To imagine moment by moment what would happen if I had taken him home instead of persuading him to stay in the hospital. I found this extremely difficult at first, I could imagine investigating the possibilities of bringing him home, of engaging a nurse and arranging for a hospital bed to be brought to our flat. I got as far as imagining the ambulance people bringing him up the flight of stairs to the room I had prepared for him. But it was really difficult to continue the story.

At first, I found it very difficult to imagine him actually in his bedroom and actually dying there. But I persisted and over a week I was able to visualize everything from the point of deciding to bring him home and preparing a room for him and then imagining his death at home. I was able to borrow from the actual experiences. For example, there was a very compassionate nurse who had helped him in the hospital. In my imagination, she was in the bedroom at home. I remembered the night I spent stroking and talking to him whilst he was dying and unconscious, but I reimagined these experiences and saw them in the bedroom in our flat with me sitting on one of our chairs and not the hospital chair.

This new experience became very real to me. Although I knew it was a new narrative, and I knew that it hadn’t happened this way, I was able to experience the events emotionally. It made such a difference, and afterwards I didn’t dwell on the original painful experience to the same extent. Over time that pain has receded: not the pain of his death, but the pain of the guilt that I felt around the circumstances of his death.

In some ways, it feels like magic. I know how things happened. I know the real story of how John died. But I have been able to overcome the extremely painful feelings of guilt and responsibility that had troubled me so deeply and for such a long time. Something had changed, and it has helped me to recover. I’m not sure I forgive myself entirely for not being aware enough at the time to act differently, but I’m not punishing myself for my oversight anymore.

Learning Points from Stephanie’s Story

I’ve re-read Stephanie’s story many times over the last few years, but I still feel very moved by it. Her story gives us an idea of how simple, yet powerful, therapeutic reimagining can be. Although she says, “At first I found it extremely difficult to imagine,” she persists over one week and is able to add all of the details. Crucially, she is able to include the very moving emotional elements of her husband actually dying in his bedroom at home.

As a human being, I felt some resistance to suggesting she imagine this very emotionally challenging scene, especially knowing I would not be with her when she did. However, as a therapist, I knew there was a very good chance that if she did, she would be freed from endless toxic guilt. She would no longer be “haunted” by it and would get the closure that she needed.

In session, as soon as Stephanie said, “If I had known he was going to die, I would have looked after him at home,” I was immediately alerted to the possibility of using counterfactual thinking to redo the past. This was a classic “If I knew then what I know now” example of a situation in which we can use counterfactual thinking to heal a painful regret. In fact, whenever a client says, “If only” or “I wish,” it is a cue for therapeutic reimagining.

However, I don’t wait for the client to stumble across the answer. Instead, I ask questions like “What should have happened?” and “What could have happened differently?” These are the key questions that I encourage clients to ask themselves, in order to reimagine their life.

Another way in which to conceptualize what needs to happen differently is: what happened that shouldn’t have happened, for example trauma; and what didn’t happen that should have, for example being loved by one’s parents as a child, or getting to say goodbye before the death of a loved one. Although she never wrote about it in her brief story, saying all the things she had wanted to say to her husband before he died was another aspect of Stephanie’s healing in her therapeutic reimagining. It helped give her closure and is sometimes called a completion portrayal when done in the therapy room. We had never discussed doing a completion portrayal in session. However, her creative unconscious guided her in doing it on her own.

Trusting the Client’s Creative Unconscious

Although I offer lots of ideas and suggestions, it is always the client’s choice of what new narrative they will create in their therapeutic reimagining at home. Sometimes, I suggest they write a letter to their younger self or even an internalized parent, imparting important information about their future that will help their younger self. However, they often come back the following week and rather sheepishly say, I did the homework, but not as you suggested. I usually say, “Great! I bet your creative unconscious mind came up with something even better than either of us could come up with in the session.” And often, they have.

This was the case in Viktor’s story. He had come to see me about his problem of forming relationships with women. After some time, we realized that part of the problem was connected with his relationship with his mother as a child. I suggested that maybe he should write a letter to his mother from his childhood, warning her that the way she was treating him would have serious consequences for him in the future.

However, he seemed to have intuitively known that his mother from the past wouldn’t have listened to his present-day self, so he chose to do the process in a very different way. He informed me that, instead, he had talked to his present-day mother (the version of her in his head) who “instantly knew what to do,” he said. She then talked to her younger self, explaining why she must desist from her harsh treatment of him. Victor explained that it was hard work even for his present-day mother to get through to her younger self, but eventually she succeeded. This all occurred at home as a conversation in his mind between these parts of himself, which he created entirely on his own.

Now that he had found a viable solution that was believable to him, Viktor was able to imagine his mother being different in his childhood, he was able to experience a number of therapeutically reimagined scenes, where she did not treat him so harshly. Victor reported that the effect of this work on his present-day relationships with women, had been rapid and transformational.

All of the nine stories in the book are very different and so the therapeutic reimagining scenes that they needed were also very different, but it is always the client who decides what they need. However, I do always encourage the client to experience the emotions of the new scenes, so that it feels real, as this is a key ingredient in making the outcome therapeutic.

Why ‘Therapeutic Reimagining’ Works

Some of the theory of why it works comes from the neuroscience of memory reconsolidation and the juxtaposition of old and new memories. Creating an imaginary alternate timeline with a new narrative may allow the brain to un-anchor from the old painful memory. However, it is more important to understand psychologically what was needed in the past and to know how to do the process of therapeutic reimagining than to understand why it works at a neuronal level. This is what the book provides, a roadmap for the process. The nine client stories offer lots of examples of what could be reimagined and how they did it.

Although I do explain some of the theory of why the technique works in the main chapters, I’ve gone a lot deeper into the theoretical underpinnings of the process for mental health professionals in “Appendix A for therapists” at the back of the book.

How Hard do Clients Find Therapeutic Reimagining?
For some clients like Stephanie, who had been dealing with chronic toxic guilt, the solution and resolution of the problem can be surprisingly rapid because they have always unconsciously known the solution. “If I had known he was going to die, I would have looked after him at home,” she said. If we stay alert, we can often notice that the client has already glimpsed an alternate timeline that will allow them to create a new narrative. All we need to do is encourage them to explore that new path.

With others, it may take longer as the client hits some blocks to doing therapeutic reimagining. We saw this in Victor’s story. Initially, he could not see his mother in his childhood treating him any differently, not even if he explained to her the consequences of her actions in a letter. However, he quickly came up with an ingenious solution of speaking to his internalized mother from the present who was able to persuade herself from the past. I’m often amazed and delighted by my client’s creative unconscious ability to find exactly what they need to set themselves free.

There have been a few clients for whom therapeutic reimagining didn’t work initially, until we figured out what the block was. For example, Fergus, who had a problem with catastrophizing events in the future. When he first tried to use the technique, instead of imagining therapeutic outcomes, he simply catastrophized the past instead of the future, and we abandoned using it for some time as it was not helpful. However, one day we did get to the bottom of what function catastrophizing was fulfilling for him, and then he was able to use the process therapeutically.

Is it Safe When the Client’s Sense of Reality is Distorted?
Some clients are already living constantly in a fantasy world, one where they are always the hero. This was beautifully depicted in the film, The Secret Life of Walter Mitty played by Ben Stiller. With such clients, it is important to first confront them with the reality of their actual life before using therapeutic reimagining otherwise they would most likely do what Fergus did above, take his defense into the reimagined past, which would have no therapeutic benefit.

The process of therapeutic reimagining was even used successfully with a client who was recovering from psychosis and hospitalization, and was still taking anti-psychotic medication. However, it was only after thoroughly assessing the client’s current grasp on reality that I considered using it with him. Additionally, I regularly checked with him to see that he was completely aware of the differences between his actual life and the therapeutically reimagined scenes that he created to resolve attachment issues with his father.

Clients who Might Struggle to do Therapeutic Reimagining

One category of clients who often find therapeutic reimagining more difficult to do at home on their own is people with ADHD. These clients, who struggle to remain focused enough to imagine scenes outside of sessions, may need the work to be done as a portrayal in the therapy room instead. Similarly, some clients might need the work to be done in session for their therapist to help them regulate their emotions. My experience, however, has shown me that our clients are often more resilient than we believe and able to reimagine scenes that are healing.

***

Although Reimagine Your Life was conceived as a book that could help a lot of people who can’t for some reason access therapy, therapeutic reimagining was born in my psychotherapy practice as a way of accelerating clients’ progress. Simply put, clients were able to get much further forward in their healing journey by empowering them and encouraging them to continue their transformational work outside of sessions.

Our Time is Up

Posted on by Psychotherapy.net Team

When I arrived at Joan’s, there was construction going on. The elevator I had usually taken was being worked on, so I had to take the service elevator. I asked the doorman what was happening and he said they were making the elevator self-service and doing some redecorating.

“What will John [the elevator operator] do then?” I asked naively.

“He’s retiring. He was over 70.”

Sad I had not said goodbye to him, I frowned. I had seen him three times a week for years and had just taken him for granted. I guess I thought he would always be there.

When I rang Joan’s bell, she startled me by opening the door herself rather than ringing me in. Her face was ashen, as if all the color had been siphoned out and her eyes had small dark pouches under them. I had a feeling of foreboding; I could hear my heart pounding.

“Hi, Rose,” she said with as much of a smile as she could muster.

She opened the door to her office for me to go in and when she walked over to her chair she was limping. I didn’t notice it before because she was sitting in her chair the last couple of times I arrived for my sessions. I wondered what that could be about. Maybe she hurt her leg or needed a hip replacement.

She said, “Instead of lying down today, why don’t you sit up?”

Then I knew this wasn’t about her leg or her hip. Propping up the pillow against the wall under the Georgia O’Keeffe poster, I tried not to breathe, as if that would delay the bad news. I noticed the philodendrons by the window were brown around the edges; she must have forgotten to water them.

“I thought I hurt myself exercising at the gym when I first felt a pain in my side.” Her tone was calm and accepting; I could feel myself exhale. Her gray roots were showing, and her hair was flat on one side as if she had slept on that side and not taken a shower and washed her hair that morning.

“When it didn’t get any better in a few weeks, I went to the doctor, and he said it was probably a hairline fracture. He took an X-ray. Then he called me to tell me it wasn’t a hairline fracture — the cancer has returned. It’s metastasized and it’s cracked my bones in the hip and pelvis.”

I let out a gasp. “Oh, fuck!” My lower back tightened.

She went on unruffled. “I’m going to need a partial hip replacement and they’re going to put a pin in my hip. I won’t be able to walk for several weeks.”

“Will you come back after that?” I asked hopefully, like a child asking her mother if she will come home after she goes away for a trip.

She looked down for a moment as if she were avoiding my eyes. Still not looking at me, she said hesitantly, “No . . . I won’t be coming back. It’s terminal.” Then she looked at me and her eyes were wet with tears. Her shoulders were hunched as if she had given up on trying to sit up straight.

I struggled for breath as a waterfall of tears careened off my face. “How will I go on without you?”

I got off the couch and kneeled in front of her chair, putting my head on her lap and my arms around her. I was quiet; I just wanted to hold onto her.

She stroked my hair and whispered, “You will be fine. You’ve come such a long way; you’re such a good analyst and you have Stephen. You’ll be okay.”

“Joan, I love you true and blue and like glue. I hope you know that.”

“Of course, I do.”

I noticed a run in her stocking and suddenly realized I might be hurting her by leaning on her that way, so I got up and walked over to sit on the couch.

I wondered if Joan felt guilty leaving me in the middle. The problem is you never know what’s the middle.

I pondered the question out loud to Joan. “Maybe that’s why sessions are purposely set up to end at an arbitrary moment — to end in the middle.”

“What do you mean?” The lines around Joan’s eyes had deepened considerably from the last time I’d looked at her face closely.

“Well, they always end after 45 minutes no matter what’s going on in the session. I used to get so angry at you for that. It felt so heartless. It felt like you didn’t care about me.”

Joan laughed and said, “Yes, I remember.” Then she added, more seriously: “There are things you can’t control. We have to live with that.” Her arms were crossed as if she were hugging herself.

“But you seem so calm. You don’t sound angry. Why?”

“Well, you know . . . Of course, you don’t know, but my mother died of breast cancer when I was 16,” she said, knitting her brows. “I think I’ve always known this was going to happen. It’s been a time bomb ticking my whole life. It isn’t a surprise.”  

I was torn between the pleasure at her telling me about herself and my compassion for her having spent her whole life waiting to die.

“How were you able to stand my anger at my mother when you lost yours at such a young age?” I asked.

She tilted her head as if she was considering the question, but then her face grimaced in pain when she tried shifting her body in her chair. “My mother never talked to me about her illness or about dying. My father died when I was 10 and there was never any discussion about it. My mother would say, ‘He’s dead, what’s there to talk about?’ And when she was dying, she never tried to help me, and my brother worked through the loss of her. She didn’t want to talk about it. So, I understood your anger at your mother.”

“So, you were angry at your mother too,” I said with raised eyebrows.

“Yes. Maybe that’s why your analysis has worked so well. I’ve always identified with you. Even rooted for you. My mother used to say, ‘You’ll break your arm patting yourself on the back.’ So, it’s been a struggle for me to feel pleasure at my accomplishments, but it’s been a delight to see yours. I feel so proud of you.”   

She smiled at me again, but her eyes looked sad. “I’m afraid we’re going to have to stop now.”

An old part of me erupted for a moment — I bawled. “You mean stop forever?”

“Yes.”

The eruption was over in a moment. I didn’t want to cause her any more pain than she was already suffering from.

“Can I visit you?” I pleaded.

“I don’t know yet. We’ll have to see. Do you think you can bear that?”

“I don’t know. I guess I’ll have to.”

“Why don’t you wait a month so I can see how I am doing after the surgery and when I start the chemo. Then I’ll know better.”

“Okay.” I got up from the couch and looked into her sad blue eyes and said in a choking voice, “Goodbye. Please remember I love you true and blue.” Then I turned and walked out the door of the office.

***

I contained myself until I reached the street. Weeping turned into bawling by the time I got to Broadway. People turned to look, but kept their distance, walking past me quickly as if they would catch whatever I had. I thought about what I said to her. By then I knew I didn’t need to see Joan in order to ward off my sense of isolation and exile. I had Stephen and a growing practice, and I was feeling full and capable of nurturing. Joan and I had been talking about terminating my treatment soon anyway. I wanted to see her because I cared about her; I wanted to give her my love, but I had stopped feeling desperate for her.

I thought about Frume Minkowitz and my guilt when I had to leave her in the middle of the semester. One day I walked out of my classroom at Brooklyn College and a young woman was standing in the hall with a baby in a snuggly on her chest and two toddlers holding her hands. She was wearing a sheitel and a long-sleeved blouse although it was a warm spring day. She looked familiar, but I didn’t know who she was.  

“Rose?” Her large brown eyes looked intensely into mine, “I’m Frume.”

She had come to tell me she had not only survived the aftermath of my leaving her, but she had thrived. Her smile was radiant as she introduced her three children.

She said, “I’d like you to meet my children. This is Avram, he’s 3.” She raised her right hand to indicate the little boy with peyos was Avram. Then she raised her left hand to indicate the four- or five-year-old with the long pink dress and matching tights and said, “And this is Shoshanna.” She looked down at the sleeping baby in the snuggly and said, “And last but not least, this is Joshua.”

“Oh, my god,” I gasped and immediately felt embarrassed at the inappropriateness of using G-d’s name in response to her.

“I wanted you to know,” she said with a knowing smile, “that you changed my life, and I never forgot you. I had a rough patch for a while but now I have Shmule and our children and I’m very happy. I wanted you to know that.” A tear ran down her left cheek.

This excerpt is taken from "Our Time is Up" by Roberta Satow (2024) and published here with explicit permission of IPBooks.  

Seven Lessons for Making a Meaningful Life: A Therapist’s Guide

Posted on by Psychotherapy.net Team

What makes your life meaningful? It is a question that I first asked myself in my late thirties after my partner died, and all the way through the difficult mid-life years in my forties and early fifties. I have also put the same question to over 130 other therapists, academics, and advocates for better mental health on my weekly podcast.

What I never expected was how fruitful the question would be for my own personal development or how asking it to other therapists would change my life. So, what are the seven things I have learned from other therapists that I wish I’d known years ago? And how have they changed how I look at myself, how I deal with my own problems, and how I work with my clients?

The First Four Important Lessons for a Meaningful Life

1. Therapists need therapy so much that they turn it into their profession, and in this way, can be in it full time.

When I interviewed the psychotherapist, Terry Real (the founder of an approach called Relational Life Therapy), he joked that, “therapists need therapy so much that we turn it into our profession so that we can be in therapy all the time.” We laughed but it is true. I came from a family where no one ever talked about emotions. Now, I talk about them all day with my clients and in my spare time started a podcast where I speak about, guess what, feelings! “Perhaps we should pay our clients for everything we learn from them,” Terry added.

2. Your earliest childhood memory is the key to the work.

Galit Atlas is a psychoanalyst, faculty member of the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis, and author of “Emotional Inheritance.” One of her techniques is to unpack the first memory of her clients. I have yet to use the technique with a client, but I took it to my own psychoanalysis.

I have two memories from the same day. The first one is coming into my parents’ room on Christmas morning but finding that my mother was not there. My father reminded me that she had gone to hospital to collect my baby sister. I would have, therefore, been two and three-quarters years old. Later in the day, my mother came back from hospital, and I remember going to her bedroom, wanting to show her all my presents but she was too tired and turned her back to me.

So, both memories were about her being unavailable — which was a surprise because my mother was always there. I would come home for lunch from school (and so would my father) and she tried to be there when my sister and I got home, but the memories spoke to how I got my physical needs met but not my emotional ones.

A few months after taking my first memory to my analyst, I had a healing dream about my mother’s return from the hospital, but this time she pulled back the covers and invited me into bed for a cuddle.

3. Don’t take things so personally.

My witness on “The Meaningful Life” was Olivier Clerc, founder of an international programme called Circles of Forgiveness. His journey started when he translated Don Miquel Ruiz’s book “The Four Agreements.” These include the advice: Don’t take things personally.

Unfortunately, because we are at the centre of our own lives, we imagine that the actions of other people are all about us. In reality, we are often just collateral damage. Clerc got me thinking because he flew from France to Mexico to do one of Ruiz’s workshops because he wanted to meet someone who did not take things personally. I have spent a lot of time since the interview meditating on what it would be like to meet someone like that or to be like that myself. It would certainly make forgiveness easier.

I have started using one of Clerc’s forgiveness rituals. I ask my clients to look into each other’s eyes and repeat after me four sentences: “I’m sorry.” “Please forgive me.” “I love you.” “Thank you.” I have been surprised by how powerful this simple ceremony is — nearly every time one or both clients have cried. Secondly, it is not important as I imagined specifying what you are sorry about.

4. Understand your navigation principle.

When you have a difficult decision to make, how do you make your mind up? Matthew McKay, who is a clinical psychologist, couples therapist, and professor of psychology at the Wright Institute, talks about “Navigation Principles.” The most common ways of deciding “what next” include avoiding pain; going for power, control, or wealth; choosing the safe option or what other people want.

Some people try to be rational. Most of my clients have no idea what their navigation principle might be, but with a little delving, come up with answers that speak to their core beliefs. For example: growth, love, and curiosity. It helps them have confidence in their choices and when facing a blank page to know in what direction to head.

How to Mine the Unconscious Mind

5. I can ask my unconscious a question.

I can’t remember my training as a marital therapist covering the unconscious — beyond in passing. It was more focused on the argument between the couple on the couch in front of me, making certain both parties were heard, and helping negotiate change. So, the unconscious remained a shadowy presence, I never really thought I could ask mine a question until two different guests came up with two radically different techniques.

Machiel Klerk is a licensed mental health therapist, founder of the Jung Platform, and the author of “Dream Guidance: Connecting to the Soul through Dream Incubation.” Instead of waiting for a dream that might shed light on a current dilemma, he suggested putting a specific question to your dreams before going to sleep.

Meanwhile, William Pullen, a London-based psychotherapist, suggested asking my jog (or in my case the brisk morning dog walk) for advice when I was stuck or directionless. With both techniques, the conscious mind is off-line, and the unconscious has time to work on the underlying dilemmas. I have put together four steps from their advice and my own experiences to pose to clients:

Ask open ended questions. These start with who, why, what, where, and when. For example: what might be the consequence of putting all my money into buying this apartment? Rather than a leading question, would it be a mistake to buy this apartment?

Ask one question at a time. It sounds obvious because you don’t know which one your unconscious is answering, but this is something that I have to stop my clients doing with each other all the time. Another trap, according to Machiel, is asking a plural question for example, about “limiting beliefs.” A better option would be, “what belief is limiting me the most at the moment?”

Split big questions into smaller ones. With big questions like health issues, job changes, and finding love, it is better to start with diagnostic questions and then ask about steps along the way.

Look out for answers from other places. Once you have started meditating on a well-formulated question, there are others ways beyond dreams and exercise through which your unconscious can speak to you. There is synchronicity (meaningful coincidences) and one that works for me: certain sentences in a book I’m reading or a podcast that I’m listening to seem to light up or trigger a small click in my brain. Sometimes, they don’t always make immediate sense — a bit like a dream — but I write them down and look at them. More times than not, they are a response to my question.

Being Brave Opens the Door to Insight and Change

6. Be bolder.

It is easy to get stuck in a groove with clients, using the tools that have been proven to work and not questioning your underlying beliefs. But listening to how other people work has made me think about my own practice. I will give two examples.

Back to Terry Real who highlighted failing strategies that couples use to resolve disputes. These include, “I’m right and you’re wrong.” Neither Terry nor I have ever had a couple where one partner stopped a fight and said, “You know what, I’m wrong about this.” (If they feel they are losing, they just throw in some other dispute where they might have a stronger case.) While I have allowed couples to continue an “I’m right and you’re wrong” dispute — in the hope of finding a breakthrough into a third way — Terry just calls the game out straight away and saves lots of time. I immediately thought, “I’m fed up too.” I need to be braver and speak up.

The second guest who encouraged me to be bolder was Avrum Weiss, a psychotherapist and author of “Hidden in Plain Sight: How men’s fear of women shape their intimate relationships.” When Weiss’ male clients talked about their relationship problems, he was surprised not only to discover they had not told their wives about their grievances but gave him a look that suggested he was crazy to even to suggest it.

“You don’t casually suggest to another woman that he’s afraid of a woman,” he told me. “But each time I did, I got the same response. They would get defensive, but very quickly I would see the idea go across their face and they would say how that made a lot of sense.”

When I thought about my own experiences in the therapy room, I have spent 35 years seeing couples. I have often seen the dynamic where the man would go to extraordinary lengths to avoid his wife’s anger, but I had never had the courage to call it out. But since meeting Weiss, I had been bolder and helped several men understand their fear of being controlled by their wife and why they need her so much.

Between Trigger and Reaction Lies Choice

7. Mine the golden gap.

When an idea comes up from multiple guests, it must be good. In a nutshell, the idea is that we have automatic reactions to conflict or adversity — normally learned as a child (which sort of worked). For example, we will shut down, go on the attack, people please, get defensive, distract ourselves. The list is endless. We don’t consciously choose this reaction; it is like a whistle goes off and before we know it the train has left the station. We are stuck in the same reflex action and there is no going back. As I say to my clients, when the train has left the platform, have you ever seen it reversing back?

So the golden gap is the moment between trigger and reaction. With practice, you can stretch the gap. “Take a deep breath. Where is the feeling? What is it? Please name it.” At this point, the gap has become large enough to make a choice — and therefore has turned golden. Yes, you might want to do the same old actions, but you know where that ends. What might your well-adjusted adult self (rather than your frightened child state) decide to do? How can you experiment and break the old patterns?

***

These days, and perhaps most influential among the seven lessons is the golden gap technique which I use with all my clients. The feedback is that this is one of the tools which brings the greatest reward for their relationship. I am currently working on using it in my own relationship too.

Addressing Countertransference in Grief Counseling

Posted on by Psychotherapy.net Team

Jordan’s Angry Grief

Jordan walked into my office, smiled, and sat down in the chair across from me. Then she burst into tears. She sobbed uncontrollably for about two minutes, but it felt like hours. Ripping tissues from the box on the small table in front of her, she seemed intent, perhaps aggressively so, on showing me just how much she was suffering. When she finally looked at me, her face was blotchy, her nose was still running, and she hiccuped with the last of her sobs. “I’ve been waiting for days to be able to do this,” she said.

I asked her if she could tell me what she was so upset about. “You know!” she said, “we’ve talked about it so much. I’m still mourning my dad’s passing.”

Jordan was right. We had talked about her father’s illness and death many times in the course of our work together. But I found myself wondering if our talking was doing any good. Jordan’s father had died when she was in her mid-twenties. She was now in her early thirties. There was no question that his death had been painful and perhaps even traumatic for Jordan, but it seemed to me that it sometimes became more significant when Jordan needed to avoid dealing with a present-day difficulty. Further, I found myself thinking — with some guilt for even having the thought — that Jordan became particularly distressed about having lost her father when she felt criticized, whether at work or by someone with whom she was in a relationship, for instance, her mother, sister, or girlfriend.

As these thoughts passed through my mind, I asked myself, not for the first time since I’d begun working with Jordan, what was the matter with me? What kind of therapist was I that I couldn’t feel sympathy for a client who was so clearly suffering? I’m not normally so hard-hearted, so as I listened to her sobs and murmured sympathetic words, I wondered how to explain what was making it so hard to empathize.

As a psychotherapist, I recognize that my reactions to clients are based on a complex combination of factors, including their personalities, psychodynamics, personal styles, and histories — both mine and theirs. The interaction between who I am and who they are, what I have experienced and what they have experienced, and what we both expect from and see in our relationships can create a fascinating, complicated, and often confusing experience for both me and the client. The image I find most helpful when I’m thinking about this co-created experience is Winnicott’s concept of “the squiggle.”1

Winnicott worked for a time with young children, and during that time he devised a game that he called “the squiggle.” He used it to explain to therapists how we and our clients co-create an experience that has part of each of us in it but is not created or owned by either of us. In this game the therapist and the child each have a pen or a pencil, and they have a piece of paper between them. The child makes a mark on the paper, and the therapist makes a mark connecting to the child’s mark. Taking turns, they gradually make a design over the entire paper. It’s a design that they create together. Winnicott suggested that this is what happens in therapy.

In the room and in our work, Jordan and I were not yet able to talk about — or even formulate for ourselves — the ways that we were co-creating an experience that in some ways replicated old experiences, and in some ways represented new possibilities for us both. My job was to step back enough from what we were creating to be able to be curious about it. That curiosity, as the relational psychoanalyst Stephen Mitchell suggested in much of his writing, is a huge part of what makes therapy therapeutic.2

Changing the metaphor, Mitchell likened therapy to a dance. He suggests that a therapist’s job is to stop every so often, and ask “Why are we dancing to this music? And why this step?”

Instead of asking myself what the matter with me was — or, as I might also have done, what was the matter with Jordan — my job was to ask why Jordan and I were engaged in this particular relational interaction; this particular dance step, so to speak. But when you have a visceral reaction to someone, as I was having to Jordan’s pain, it’s hard to take that step back. It’s hard to ask those questions, and harder to get a reasonable response from yourself.

Magda’s Quiet Pain

As I was struggling to understand my powerful reaction to Jordan, Magda, a client of mine in her fifties, was grieving and trying to put her life back together after her husband died of a massive heart attack. I remember how she had walked into my office and started to cry. Unlike Jordan, Magda was embarrassed about crying and quickly got her tears under control. She smiled and said, “I don’t cry anywhere else but here. You keep encouraging me to let myself cry, so I do, with you. But I’m not sure what the point is.”

My reaction to Magda was very different from my reaction to Jordan. It wasn’t simply that I felt more sympathy toward Magda than Jordan. I felt something angry or aggressive in Jordan’s pain, almost as if she was trying to push it onto or into me, and I wanted to ward it off. Magda, on the other hand, was careful with what she brought into my office and gave to me to hold. With her, I had more of an impulse to let her know that I could handle her sadness, and that I thought she would find it helpful to share it rather than keep it inside her.

In other words, I wanted to stop Jordan’s outburst and I wanted to encourage Magda to allow her emotions into the room.

Among my psychodynamically-oriented colleagues, there is a recognition that our responses to our clients contain helpful information about them as well as about us. What did my reactions have to tell me that could help me work differently with each of them?

Many clinicians suggest the use of diagnoses to help clarify what techniques are most useful with what clients. While I agree that an assessment of a client’s personality structure and psychodynamics can help pinpoint important factors that will influence their ability to respond to one sort of intervention over another, I also think it’s important to remember that assessments of clients can — and should — change over time. As a relationship with a client deepens as we get to know them and, conversely, they get to know us, some of the dynamics that may initially seem paramount turn out to be part of a temporary self-protection or façade that kept other things out of our awareness.

Further, diagnosis may capture our own hostility or negativity about a client. For instance, I found myself diagnosing Jordan as having a personality disorder, but when I questioned myself about this diagnosis, I realized it was a way of giving myself permission to keep my distance from her. The most obvious truth was that because of my own personality structure and dynamics, I was more comfortable with Magda’s sadness than with Jordan’s angry grief.

Dueling Countertransference

But there was, of course, more going on. Interestingly, I identified with the losses both women were facing. Like Jordan, I was mourning my father, who had died sometime before her father died. Our relationships with our fathers were quite different, but the sense of loss had many parallels. On the other hand, Jordan told me that she had always been “daddy’s little girl,” and that she didn’t think she could live without his constant praise and reinforcement that she was special. My relationship with my own father had been different, and I asked myself if I was envious of the special connection Jordan kept talking about.

As I opened myself up to the possibility that some of my reaction to Jordan was related to envy, I began to hear some of her words and view her actions differently. I began to wonder if Jordan unconsciously wanted me — or someone I represented — to feel envious of her relationship with her father. And if so, why? Was she angry at, or hurt by that other person? Did she need that reaction to get revenge on them? Or did she need to see their (my) envy to feel special? Was there something she had not internalized about the special relationship? Or was the relationship really not so special after all?

For quite a while I didn’t say anything about any of my thoughts to Jordan. As I was letting these ideas begin to gel, I was also working with Magda and exploring some of my countertransference reactions to her. While it’s easy to coast with positive feelings about a client, it can also be useful to try to understand what makes that person so much easier for us than someone else. I asked myself why I was so much more empathic to Magda’s quiet grieving than to Jordan’s loud, almost aggressive pain. There was the fact that it fit better with my own personality structure, but was there more to it?

I tried to put into words for myself what I admired about Magda’s way of expressing her feelings, and the words that immediately came to my mind were “elegant, self-contained, quiet dignity.” I realized that there were several personal connections in my life to those words, and that my countertransference to Magda also had something to do with my relationship with my own father. But as I was thinking more about some of these issues, I was also reading more about grief, and I realized that perhaps even more than the most obvious relational dynamics that were emerging in the work with each woman was the question of each of our relationship to grief itself.

I have always found the idea of stages of grief simultaneously useful and disturbing. On the one hand, it can be useful to know that some of the difficult emotions that emerge after a loss are a normal part of a process, and that many of them will gradually diminish as the process moves forward. On the other hand, I have never known anyone who goes through a neatly organized process of grieving that follows a particular outline. Of course, many of the current experts on grieving point this out as well. But once I began to add the idea of grieving to the “squiggles” that were emerging in my work with each client, our discussions took on more shape.

Making Space in Therapy for Pain

I began to gently explore with both Magda and Jordan some of the complexities not only of their relationships with the people they were mourning, but also with their respective feelings of loss. Not surprisingly, Jordan reacted angrily, telling me that I was trying to push her through the stages of grief, not letting her manage them on her own time. She was surprised when I replied that she might be right. “I’m not really sure what stage you’re in right now,” I said. “Can you tell me?”

Jordan turned out to be well-read in grief literature. “I think I’m in denial,” she said more quietly than usual. “I don’t want it to be true.” It turned out that Jordan had been angrily fighting the feeling of sadness, despite all the tears and sobbing.

Magda, too, had been fighting her feelings of grief. “If I don’t cry,” she said, “I think I won’t feel it. But when I come into your office, I get hit with all those feelings.”

“Is that a good or bad thing?” I asked.

“Probably good,” she said. “I think I need to let myself feel them.”

Listening to both women talk in very different ways about their styles of mourning made me realize that an important part of my countertransference had been about my own ways of dealing with grief. According to some grief specialists, the hardest thing for most of us is to make emotional space for grief, and yet, making space for it is the only way to let ourselves move forward. As many of these specialists tell us, making space for grief allows us to make room to grow and to live, even with loss. Paying attention to my countertransference reactions to each of these very different clients’ grieving styles allowed all of us to find a new way to make space for this painful but unavoidable emotion. And making space allowed for growth. Jordan and I continued to struggle with many distinct aspects of our relationship, while Magda and I felt like a much more comfortable fit. But as we made space for the pain in our different ways, Jordan and I found moments of connection, while Magda and I found moments of difference. And all of us grew in a variety of interesting and often different ways.

References

1 Winnicott, D.W. (1989) “The Squiggle Game.” In Psychoanalytic Explorations, Routledge.

2 Mitchell, S. (1995). Hope and Dread in Psychoanalysis. Basic Books, Inc.

Travis Heath on Psychotherapy as an Act of Rebellion

Posted on by rezendevknowfully.com

An Act of Rebellion

Lawrence Rubin: Hi Travis, thanks for joining me today. I first became aware of you and your work after reading “Reimagining Narrative Therapy” that you co-edited with Tom Carlson and David Epston. There you said that therapy is, or at least should be, an act of rebellion?
Travis Heath: I wrote that, huh? It’s always interesting to reflect on one’s own words. Should it be an act of rebellion? Maybe it shouldn’t be in every case. Yet, I think there could be therapeutic advantages to therapy being an act of rebellion. What I mean is that sometimes, usually unwittingly, therapy can become an act of reinforcing normative ways of being. What we might describe as “mentally healthy” may actually be a normative societal way of behaving. So then, an act of rebellion is when people move against the norm, right? To go against the status quo. And there could be — whether it be in therapy or elsewhere — immense therapeutic value when that rebellious act is consistent with who the person most knows themselves to be. Now, I’ll say that an act of rebellion for the sake of rebellion, like a contrarian act of rebellion around every turn, may not always useful. But one that is truly consistent with who a person is can have a positive impact on one’s mental health.
LR: And sometimes people come to therapy not sure of who they are, or which story is the one that is the healthiest for them to live by. Are you suggesting that for some people a therapeutic relationship allows them to rebel against norms that are oppressing them or holding them down?
TH: I think a therapeutic relationship can help with that, although I don’t know if that is enough alone. As someone who is informed by narrative ways of working, therapeutic questions are very important to me. Most of my questions are average at best and probably don’t lead to much change in people’s lives. But all I need is one really good question. Not one that I’ve conjured up, but one that just comes up quickly in the moment from the relationship I am having with the person that I just throw out there. A good question can open up a way of living that a person hadn’t articulated in a particular way before. Maybe they felt it somewhere or tried to imagine it, but now they’ve put words to a particular direction.
LR: This may be a tough one to pull out of your hat, but can you give me an example of a client that you recently worked with, or that stands out in memory, where you came up with the right question at the right time?
TH: Yeah, that’s a good question. I was working with a women-identified person in her 40s. In our culture, there are certain ideas about bodies — how they should look, and how bodies should and shouldn’t be shaped. I think this is especially so for women. That pressure seems to be increasing for those of us who are male-identified as well, but it’s been very tough for women for some time. She was really distressed when she came to me and was talking about eating peanut butter. Like, “I’m really distressed because I’m eating peanut butter.” And I remember saying to her, “Okay, I hear you and I want to understand what’s distressing about this?”
I remember saying to her, “Can I share something with you? I eat peanut butter too sometimes.” And she kind of smiled, but added, “No, I mean I eat too much peanut butter.” And I said, “Okay, again, I hear you. Help me understand. What’s too much peanut butter?” She said, “Well, I might eat a spoonful or two spoonfuls of peanut butter.” And I said, “Hey, I won’t want to tell you how to eat or what you should or shouldn’t be eating. I’m just really trying to understand. And I wonder, is it possible that you could eat a spoonful or two spoonfuls of peanut butter and that might in some way be okay? Now, if you told me you ate the whole jar or something and you were doing this nightly, I would understand how that would be distressing. But do you suppose it might be okay that you eat a spoonful or two of peanut butter?”
With that question, she burst into tears. It was a simple question, not something you’d see in a textbook as an exemplar. But it was really just a question that in some small way, maybe larger than I initially realized, invited her to think about how she came to understand what’s too much peanut butter and what’s not enough peanut butter. The question was asking her to consider how she came to understand that eating peanut butter might begin to define her as not a good person. How did she come to understand that process? And we really had a session just about peanut butter, which sounds sort of wild, but it wasn’t initially an act of rebellion. It became an act of rebellion for her because she was resisting some of these discourses about food and about her body.
I remember asking her, “Okay, so how often do you do this?” She said once or twice a month, so I said, “All right. Let’s just say that you stopped doing that. Do you then think your body would, over time, or maybe quickly, begin to conform to this body that you’ve been told you should have?” She really thought about that and said, “No, it probably wouldn’t.” “Well, what kind of acts of torture or anything else could you put your body through to make it look like these bodies you’re telling me would make you a good person?” In that moment, with that question and the questions and answers that followed, it was essentially about, “If I looked this way, I’d be a good person.” But she couldn’t initially articulate that. It was the question about “peanut butter” which enabled her to communicate those feelings of insecurity that she constantly experienced yet couldn’t ever explain. In that way, our conversation about eating, and even just existing in her body, became an act of rebellion against normative prescriptions of what society tells women is a good body.  
LR: You know, Travis, I would imagine at one level you were very aware that you weren’t really talking about a spoonful of peanut butter. Instead, you were creating a space in which she could really question the legitimacy of her rigid thinking, and maybe even dive more deeply into a conversation about self-worth, body image, and perhaps gender with its discontents.
TH: Lawrence, I might say it just a little bit differently. Not so much her own self-talk, but the talk of the culture that she had adopted and the cultural meaning of “self-talk.”. Because when people say “self” in front of anything — self-talk, self-esteem — I get skeptical. Self-talk isn’t really her talk, although it may feel like her talk because Lord knows how long that talk has been kicking around. But she didn’t come out of the womb with that talk. That talk came from someplace, and now it’s become a part of her. So, I think that this act of rebellion you’re talking about, when it is really shining, can help people see that and say, “Oh gosh, I didn’t come out of the womb with this. Actually, these aren’t my ideas.” Then that can lead to, “And I don’t even have to subscribe to these ideas,” which can be very liberating.  

Confessions of an Anti-Manualist

LR: So, you created a space in which she was given permission to rebel against certain language that has been forced on her or force-fed to her. Shifting gears a bit, has traditional therapy’s search for the grail of evidence-based techniques enhanced or diminished the craft of psychotherapy?
TH: I like the question, and I think it’s an important one. Without trying to be too long-winded, I do think that historically the idea of “evidence-based techniques” came from a good place. By that, I mean hey, there was a time when psychotherapy was viewed in a certain kind of way—the work of charlatans. Hell, there were psychologists, not clinical psychologists, but there were psychologists — I think Cattell and some of those other folks — that weren’t necessarily huge fans of psychotherapy. And so, I think there was a time when it was important to show that there was some kind of scientific evidence base, that therapy wasn’t just akin to palm-reading. Maybe I shouldn’t dismiss that out of hand, but that’s a different conversation. The point being, there was a real reason for attempting to create psychotherapeutic techniques with evidence as their primary foundation.
At some point, this idea of evidence-based practice got tangled up with late capitalist ideas, and people discovered that you could sell a hell of a lot of workbooks. You could also bring a hell of a lot of legitimacy to what you were doing, and it helped your personal brand that was tangled up with the brand of your therapy. That’s where I think it started to become problematic. So, the idea of having evidence is not necessarily bad. But when it’s done for these sorts of capitalist reasons, I become concerned about it.
Now to your question of the art, if you will, of psychotherapy. I’ll share a quick story from a class I was teaching probably 10 years ago. It was an undergraduate intro to clinical and counseling class, and as we discussed I have never been too keen on these evidence-based models. So, I started the class by bringing in treatment manuals and handing them to everyone. “All right class let’s look these over. What do you think about them?” Most of the students, and I think this says a lot, were comforted by this. “Oh, great. I could do this. I could follow this script.”
Then one intrepid young woman who sat in the front of the class asked, “Well, what happens if you’re using this and it doesn’t work with someone?” And I said, “Well, okay, that leaves us at a bit of an impasse, doesn’t it? I personally don’t believe there are just two ways to do therapy. But let’s just look at two possibilities. So, one possibility is we use this manualized approach that we’re looking at. And it works to a certain degree for some people, maybe even most people. And you do a mediocre, good enough job, your whole career. And then, every now and again, you find someone it really doesn’t work for, and I guess you just abort mission. Or another option — it’s not the only other option — is that we learn how to do this on sort of a moment-to-moment basis. We’re really being in touch with the other person.” I said some other shit, too, but the students almost universally agreed that one sounds better, but it also sounds scarier. It sounds like a lot more work. And how do I know if I’m doing it right? They had all these questions, which were all very fair.
My worry is that somewhere, usually early on in people’s formal training, without even realizing, without even really being presented it, they’re nudged to make the choice of one manualized treatment over another. They’re nudged to go down one of these pre-determined roads — and they’re sort of nudged often. And then if you’re trained in that way, it’s hard to put the genie back in the bottle. It’s not really that one way of doing therapy is superior, but if you’ve worked with enough people, you come to understand that you aren’t going to be able to take the same damn thing and apply it to everyone who walks through the door, or even most people.  
LR: So, would you say that you are an anti-manualist, or that you practice an anti-manualized form of therapy? I know Narrative Therapy is, by definition, an anti-manualized intervention.
TH: I have never heard it put that way. I like the term. I accept the term. I don’t know if I always live up to that as much as I could. I mean look, there are certainly patterns to my work. And people who know my work well and who have watched it behind mirrors or whatever they’ve done over the years, could point to patterns in my work. I don’t know if patterns are manuals because I’m not necessarily adhering to a prescriptive one, two, three, four, this is the order of how you do things. But there’s a certain soul to the way that I work. And there are patterns in how I work. I won’t deny that. At one point, however many years ago, I said, “Well, I never do the same therapy twice.” That feels a little self-aggrandizing. Like why am I saying that? Yes, there are elements that overlap. So, to be an anti-manualist, yes. I like that idea. And, I have to acknowledge that not everything I do with every single person is completely new and creative. There are some patterns that you see.

De-Colonializing Therapy

LR: There are likely many clinicians in our audience who are really into manuals. It seems that once a therapy has an acronym, a workbook, and a “seal of approval” by some credentialing body, it becomes the stuff of grail. In this vein, and based on our conversation and my reading of your work, are we speaking about detraditionalizing therapy practice?
TH: Thanks for asking these questions. To detraditionalize, for me, is something that if it doesn’t happen, then a therapy dies. But let’s get outside of therapy for a moment. I think almost anything dies. Maybe some of the folks who would frequent this interview may not be sports fans, so excuse the sports analogy, but I’m a big basketball fan — played basketball my whole life. And people will watch the modern NBA and they’ll say, “these guys shoot too many three-point shots. Back in my day, we never shot 30-foot shots.
That may be true enough, but the game has to evolve. It must evolve. It cannot stay stagnant. Now, did it have to evolve in the way it did? Maybe not. But it must evolve, or it dies. And I think it’s the same with therapy. So, to detraditionalize, it’s not that we can’t do it with intention, we can. But I think for an approach to therapy to remain viable over the years, it must change and evolve. A lot of psychoanalytic psychodynamic approaches are probably misunderstood in the modern world. But the best practitioners I know who appreciate and look through that lens, they’re not doing the same shit Freud was doing. They might have taken some of those ideas and some of those cues, but they’ve detraditionalized them. In a way, they’ve modernized them. So, that’s the first thing I want to say.
The second is, like in my work, I think traditionally there is a healer and a person to be healed. And then the person that’s the healer is somehow supposed to have the answers or write the prescription. And to me — I’ll take a line from my mentor friend and colleague David Epston — a lot of Narrative Therapy is about elevating the knowledge of the other. And so much of my practice, and a part of it that I think is maybe detraditionalized, is not to rely on psychological knowledges, or psychiatric knowledges or descriptions, but to try to elevate the knowledge of the other.
And the other doesn’t just include the person who’s in front of you. There’s a whole ancestral presence that often comes with that person who sits in front of you. Whether they realize it or not, it travels with them, it informs them with insider knowledge about how they may approach distress or problems that they’re up against in the world. And even so with therapists that would make the claim, “Well, I’m client-centered, I focus on the client.” Yes, but if you actually watch it unfold, it’s still based on a counseling prescription or a psychiatric or psychological prescription about how the session should go. It isn’t necessarily elevating the knowledge of the other. 
LR: You said something earlier, and I don’t necessarily want to skip around too much, but it seems like we’re entering a cross-conversation about multiculturalism. When we talk about “elevating the other,”, are we getting at your ideas about working with “the other,” and what you have referred to as “decolonializing” psychotherapy?
TH: The phrase I’ve liked most recently is “anti-colonialize.” De-colonialize is fine, but I don’t like post-colonial, because post-colonial implies that somehow, we’ve moved past colonial logic, which we haven’t. Anti-colonial to me just seems like a little bit of a stricter stance against past, present, and future colonial logic and colonial attempts at living. So, I’ll start with that. But de-colonial is fine. I like that word, too.
You’ve heard me use the phrase “colonial logic,” but I’d like to weave in yet another term here: “multicultural.” If we look at the term “multicultural,” and a multicultural approach to therapy or counseling, often what that is saying is, “Hey, those of you from non-European descent, you can come, we welcome you. You can come and heal in these Eurocentric mediums of healing.” On the surface of it, that’s a nice offer. But it doesn’t make a ton of sense. And really what it’s doing is replicating colonial logic in that, “Hey, these European ways of being, behaving, and these European standards of living, these are the right standards. And we’re going to help you through therapy live up to these standards and these ways of being.”
To me, an anti-colonial approach would seek to first try to find the colonial logic that’s at play. And nobody bats a thousand at that, I would argue. But because it’s so embedded in the culture, we don’t think to critique it, although that has been happening more in the last couple of years. Anti-colonial, then, talks about culturally democratic approaches to therapy. A friend of mine, Makungu Akinyela in Georgia, has a type of therapy called “Testimony Therapy” which he equates to being next of kin to narrative therapy and African-centered therapy approaches. He says that a culturally democratic approach is to invite people to speak on behalf of their own healing.
And so, if we hope to practice an anti-colonial approach, which to me is like the big umbrella term, then a culturally democratic practice seems important because people are allowed to speak on behalf of their own healing. Speak in their mother tongues. Speak through the cultural knowledges that they have come up with.
One thing about psychiatry and psychology, if we’re not careful, is we can get a little too big for our britches. We can think that healing’s only taken place in the last century-and-a-half, or whatever it’s been. No, it’s like, hey, come on, you think just because we’ve now labeled these things as depression or anxiety or PTSD, people haven’t been up against these things throughout time? 
LR: Like we invented these afflictions.
TH: Right. And did these people with depression and anxiety all just curl up in a ball and not live their lives? No, people have experience with healing. And they have knowledge about healing. It doesn’t have to exist in a Eurocentric way. And often what therapists are doing — almost always unwittingly — when they’re reproducing colonial logics in their practice is recolonizing people. And often the therapist doesn’t realize this is happening, nor does the client. And yet, this process is playing out. It’s assimilation. We talk about, should people assimilate when coming to a new country…Well, really that’s what therapy has often been doing, again unwittingly. I don’t think this has been done with malice.
LR: This is psychiatric assimilation.
TH: Right, exactly. And so traditional therapy reproduces this colonial logic, which then sometimes — again, completely unwittingly almost always — is reproducing internalized racism where people might already experience feelings of inferiority. It doesn’t always have to be around race, of course. It could be any number of other factors. So, I hope that there’s some justice to your question.
LR: So, traditional multicultural counseling, if I’m hearing you right, is, “Sure, come into my session, wear your native garb, let me learn a couple of buzzwords that are unique to your culture. And sure, tell me your story. But in the end, I’m going to lay some ACT on you.”
TH: Yeah. And again, almost never is this done with malice. But that’s some of the demanding work I think we have to do. And another thing is like, okay, I am of mixed racial background. I have the blood of the colonizer and the colonized that runs through me, which is a complicated place.
One of my colleagues out here in San Diego now, Vid Zamani, he was the first one I heard say that if we are reproducing traditional Eurocentric ways of doing therapy, then we are a de facto White. And I really appreciated that, because it was like, well, just because of my own background, that doesn’t make me immune from practicing colonial logic. And he said, of course, that makes total sense.
But if we’re not careful, then what happens is in the field’s attempt to diversify—sure, we might look diversified on the surface, but our practices aren’t that diversified—we’re still practicing the same colonial logics. The practice really isn’t changing, even if superficially the people doing the practice look different.   
LR: So, until the psychotherapist recognizes that they are colonializing their clients, until the traditional colonializing psychotherapist rebels against their own inherited narratives of what psychotherapy is, they will continue to colonialize their clients. And colonialize the psyches of their clients.
TH: Yes. And this is, I’ve found, a largely unpopular idea. Especially among folks who have been doing this for a while. I’ll share this story that I think drives home your point. I was doing a job interview. Not for the institution I’m currently at, but for a past institution. I was doing a presentation that talked about some of this stuff that we’re talking about now. And when I got to the end of it, a dude says to me — an older white man in his 60s, “Hey, I’m going to throw you a softball question.” And right away I was like, okay, yeah, what’s this guy up to? And then he says, “Well, what am I supposed to do when you tell my students that I am practicing a therapy that’s colonizing folks?” And I thought about it for about five seconds, and then respectfully I said, “Well, if I can share something with you, I can guarantee you I’m practicing in colonizing ways. And in fact, I can guarantee you I’m doing it in ways I’m not yet aware of. So, in that sense, I wouldn’t be asking you to do anything that I am not practicing myself.” But I found that there are folks that are resistant to the fact that their work could be colonizing at all.

Communities of Care

LR: In the context of this thing called multicultural practice and colonization, what do you mean when you talk about the dignification of the client? I think that was your word.
TH: No, it’s David Epston’s word, although I might have used it. What’s interesting about that, Lawrence, is that I met David in 2015, so that’s seven or so years ago. I had been out of graduate school a good six, seven years at that point. I had been practicing in the community for the same amount of time. I had been a university professor for seven or eight years. I had been around this a minute, and I had never — and I mean literally never — heard a person use the word “dignity” regarding clients in therapy. I was taken aback by the word the first time I heard it in this context. Dignification is even a little better than dignity.
When someone’s up against something, some kind of distress — I’ve worked with a decent number of people in the criminal legal system — they are often stripped of their dignity. And so, dignification is really an effort to afford the person that dignity within the conversation. And when we engage in dignification and people can feel that they have dignity, that helps to open additional stories in their lives. And maybe those stories were already there, but if they don’t feel as though they have dignity, then those stories are inaccessible to us. Even if they’re there someplace.
I noticed this with people in the penal system—it doesn’t happen after one meeting and could actually take months — but when they really started to feel dignity, and that they were living a life with dignity, and respected as a person with dignity, we would start to see a turning point in what we were doing. Because there aren’t many systems that are practicing un-dignification more than the criminal legal system. And so, it was actually a great place for me to see that juxtaposition of when people are afforded dignity. And these probation officers would ask me, “Hey, how did you get this young man to take responsibility for his actions?” And I said, “Well, first by never mentioning the term ‘personal responsibility.’ That’s probably not a great way to go, even if that’s what you’re hoping for. And secondarily, by taking them seriously. Treating them with dignity. Listening to their ideas. Taking that insider knowledge they have and really using it as something that could move us forward in a way that would make sense in their lives.
LR: Your dislike of the notion of “personal responsibility” brings me to something you said about the difference between self-care and communities of care. What is that difference?
TH: Well, it depends. What’s the goal? If the goal is to make money and sell lots of products, then we’re not moving in the wrong direction at all. I think Ronald Purser is the dude’s name, he wrote the book “McMindfulness.” He articulates this as well as anybody I’ve heard. It’s worth the read.
Look, self-care is another one of those things I feel like came from a good place. And when I talk about my issues with self-care, I preface it by saying, if you want to take a bubble bath, that could be lovely. If you want to watch a movie or do whatever, great. I’m not against that. Where I find this to be problematic, and our field has done this as much as any that I’ve seen, is a student, for example, in a master’s or doctoral training program in our field starts struggling. And often the response by those in charge has been, “Well, are you doing your self-care? What are you doing to take care of yourself?” But then you look at a PhD student. They come here, work 18 hours a day, doing all their school stuff. We don’t pay them enough to survive, we give them a small stipend. Now they have to go work another job. But we remind them “please don’t forget to take care of yourself.”
Essentially and systemically, we outsource the responsibility for the oppressiveness of the system and then turn around and say, “It’s your responsibility.” As opposed to a community of care — and this is something I try to think about in my role as chair now of an academic department — which is, “Okay, if we have faculty that are drowning or students that are drowning, what are we doing to do to help, rather than lay the responsibility on the student to adapt to a system that is rather oppressive?” So, do we need to scale back some of what we’re requiring? Do we need to change the ways that the system operates? What can we be doing, other than once a school year bringing puppies in? “Hey, that’s lovely.” Or they’ll have a little massage chair set up. Fine.
I was talking to someone this morning, and the language that she used was so passive. We say, “I’m experiencing burnout.” And my thought about that is, no, you’re being burned out. That’s not the same thing. It’s about experiencing burnout versus being burned out. Our systems are burning us out. And so,  if our systems are burning us out and we’re asking people to handle this individually while the system that’s doing this for its own gain takes no responsibility, well, then this is just going to keep repeating.
And I’ll come full circle to say that I think, not individual people, necessarily, but folks with something to sell don’t mind that. Because if the person is continually being burned out, guess what? They’re going to consume more of the product that we want. So, the system is actually set up beautifully for making money. I don’t necessarily think it’s set up good for quote-unquote “mental health.” 
LR: So, in a sense, graduate trainees, like therapy clients, are typically colonized and oppressed by structures of authority. What do you mean when you say that therapy — and graduate education in the context of this conversation — should be an act of shared humanness?
TH: Yeah, I think again, the culture that we’re in is so ruggedly individualist, that often the human experience gets defined solely within the individual. And I worry about that. And to me, therapy at its best is shared humanness. I used to do this early on when I was a therapist. I came up for my first master’s class in 2002 with all these journals under my arm. I was going to save the world by going into these communities in South Los Angeles. And it didn’t take me long to figure out that shit wasn’t going to work, and I had to do something else. I learned that quickly.
The way I think about the shared humanness now is, we can’t be doing what we’re doing right now in this conversation without shared humanness. The same goes for a therapeutic conversation. When there is shared humanness and it comes together, something exponential is possible. But I would not be able to say everything I’m saying today during our time together without your questions. Your question takes me somewhere that I couldn’t have gone just by myself. Maybe I could have generally gone there, but something about your questions and the give–and-take transports us there. And the shared humanness in therapy is exactly the same. You bring these two people together. And what we could each accomplish on our own could be fine, or even good. But what we can accomplish in this shared human way is exponential.    

Wholehearted Therapy

LR: Very similar to what Irvin Yalom refers to as the here–and–now—that the therapeutic relationship is lived in the moment — the fruits of psychotherapy grow from the back and forth. Is this related to what you describe as “wholehearted therapy practice?” And what does a therapist look like when they’re practicing halfhearted therapy?
TH: I think halfhearted therapy, or quarterhearted, or two-thirdshearted could happen for a lot of different reasons. But to me, wholehearted therapy is bringing all of yourself to the practice. One of our students asked a fair question just a couple of weeks ago; “How do I know how to be in therapy relative to how and who I am out in the world?” They asked it a little differently, but basically what they were asking was based on their feeling, “I don’t know how to not bring all of who I am into the room.”
And so, I think halfhearted therapy can happen when we think that there are parts of us that somehow can’t come into the room. Now, what I’m not saying is that there are certain topics we might not talk about in the room. Now, I would even question some of those and whether they are truly off limits, and I do frequently. But obviously there would be some topics that would be off-limits for us. Therapists could decide that. But I’m not so much talking about the topics of discussion. I’m talking about how much of themselves that they’re bringing. And I fear that therapists are often taught not to bring important parts of themselves.
With regard to halfhearted therapy, they could be doing therapy in a system in which they’re chronically underpaid and overworked, and their spirits are just really sucked dry. And then they just don’t have that spirit to bring. In no way would I blame the therapist for that. But if I think about the times when I’ve engaged in halfhearted or quarterhearted, or however much hearted therapy practice, it’s often been for those reasons. Now, earlier on in my career, it was because I was asking myself, well, can I be this in the room? And of course, that’s a ludicrous question, because I am this. So, one way or another, the person that I’m in conversation with starts to deduce that anyway.
LR: In the recently released “Reimagining Narrative Therapy Through Practice, Stories, and Autoethnography,” you wrote a chapter entitled, “Maybe We Are Okay: Contemporary Narrative Therapy in the Time of Trump,” in which you narrated the therapeutic interaction you had with a person whose political views, specifically, their Republican views, clashed very dramatically with your Democratic views. So much so that the conversations about who you voted for 2016 became part of the therapeutic relationship. And in that relationship, you nicely demonstrated how you can disagree with someone’s political views, but still respect them as a person. Was that an example of wholehearted practice?
TH: It was interesting how that chapter came about. You know how therapists can get together and start talking in between seeing clients. Well, I noticed a lot of my colleagues saying something like, “Well, if Trump came to therapy, would you work with him?” I didn’t say anything when my colleagues were saying, “NO, I would never do that! Who could do that?” But then, I thought about it, and I was like, yeah, I think I’d work with him. I don’t know if he’d want to work with me. Maybe he’d tell me to get lost, but I think I’d try.
I just remember how outraged they were. And when they asked the question of how I would do that, I would say, “Well, I haven’t worked with Trump, but I’ve worked with plenty of people who have views that are very different than mine.” So, that was the inspiration for this, to try to explain shit to myself. Even after writing the chapter, I’m not sure I understand how I always engage in this work. But, to go back to bringing one’s full self into the room, we didn’t get deeper into the party politics in that chapter. But if we happened to in our sessions, I wasn’t super-enthused about voting for Hillary. I felt like a lot of people — like I have to decide between two people that I’m not really enthused about. Okay, I’ll take the one that I’m a little more enthused about. I’ll engage in a minimization-of-harm vote, is kind of how I felt.
But clearly, in the chapter you’re describing, my client and I voted for different people. When that moment came up, the question was, “Do I talk about it or do I not?” And the thing about that is, okay, I could decide not to talk about it. I could decide to do the thing as, “Oh, that’s an interesting question. I wonder why you’re asking?” But she knew. She had a sense of this, of who I voted for. And I’ve heard people say this kind of thing who haven’t read the chapter, but have said, “Well, you know, you’ve got to be careful. You’re pressing your political views on them.” But I disagree. What I’m doing in therapy is I’m simply showing up as I am, and she can show up as she is. And then we have to figure out how that meshes, and how we do the work together that we’ve been charged with doing with one another.
And that doesn’t require me being neutral. And by the way, I’m not neutral. It’s just a matter of whether I admit I’m not. I’ve seen a lot of discourse around this lately about neutrality and people debating what it means and all this kind of stuff. But to me, it’s an impossibility. We are not neutral. And so rather than try and pretend as though I am — not unsolicited would I share such a thing, but when it works its way into the session — when she brings this up, it’s like okay, let’s talk about the shit that we’re not supposed to talk about. Let’s talk about religion. Let’s talk about politics. To me, therapy seems like a great place to do that. And not just in the sense of me just passively listening or looking for pathology in the patient and how they talk about this. But rather, let’s have an actual conversation with two wholehearted human beings about the thing that we’re not supposed to have a conversation.
 
LR: In a sense, you are co-rebelling against the mandates of traditional therapy with a client by self-disclosing and by being fully present.
TH: And neither of us has to change our political party. Although for me, I’m not that enamored with the Democratic Party, either. But I’m not sure I have a party that represents my interests, to be honest. I certainly wouldn’t say I’m an Independent. That has its own set of connotations. But I don’t feel like I have a party that represents my interests. And I didn’t say that explicitly. At least I don’t recall saying that in my work with her. But perhaps it came out. Perhaps this is more complicated than we give it credit for.
And to me, probably these last two or three years, I’ve constantly been on the lookout in my therapeutic work for people with binaries. Because our culture relies so heavily on them. And I often find that when people bring those up, that’s at the root of something that they’re really struggling with. And it’s built into our language, Lawrence. We say, “Well, I need to hear both sides of the story.” And to me I’m like, I’d like to hear all the sides of the story that I could hear. I’d like to hear many sides of the story. I found that often people are thrust into these binaries, and it almost feels like there’s not another option. So part of my job is to have these discussions and then look outside of those binaries for what could be there. And I don’t think therapists do this on purpose, or clients do it on purpose. It seems to be a real cultural thing.  
LR: I used to joke with my classes — sorta — by saying, “There are two types of people in the world. Those who believe there are two types of people in the world, and those who don’t.” Does this wholeheartedness, the kind you described in your work with this particular client involve what you refer to as “radical respect?”
TH: I can tell you the story about where that term came from. I don’t know if we mentioned it in the book, but it came from Art Frank, a brilliant writer. He’s not a therapist but when he would read transcripts of sessions or watched sessions, he said, “When I see David [Epston] practicing, Tom [Stone Carlson] practicing, what I see is radical respect.” And so that term actually came from someone outside of the therapeutic community altogether, which I think is worth noting.
I think part of what he’s getting at is there is that no matter where the person moves, no matter where they might take the conversation, no matter what the stories are that they might wish to live through, or that are living through them, that narrative therapy endeavors — it isn’t always successful — but endeavors to hold this deep respect for people and why they are behaving the way they are. Why they’re living through the stories that they are. Why they’re feeling the way they are. And that radical respect then to me promotes curiosity.
So, in the chapter that you were referencing, the Trump chapter as it’s getting to be called, I hope there were some examples of radical respect in there. I’ll give you an example from the chapter of my attempt at it. When I came to realize that by completely dismissing her perspective — which I don’t think I did, but I could have because I found a lot of things Trump did objectionable — I might have been engaging in some sort of erasure of her family. And that would have been highly disrespectful. And so even when it was something that I fundamentally disagree with, there was still a way I could practice respect. This was opposed to going, “Well, but you’re on the wrong side of history.” I also think radical respect is a feeling that both the therapist and client experience, sometimes without words.
Art Bochner talks about “evocative autoethnography” which is not about the therapist simply being a fly on the wall, but instead being moved by the client’s story, their narrative. Let’s say you were reading that chapter about me and the woman, and you had never seen either of us before, and then you see us walk out of a room. You’d know it was us. But the point is, that’s what we’re endeavoring with autoethnography. We get out of the world of jargon so both partners in the therapeutic moment can feel and experience it.  
LR: As we near the end of our time, Travis, I want you to know that I’ve had a lot of fun in this interview. Do you have any questions for me?
TH: No, but I will say one thing quickly, though. If therapy is really an act of rebellion, then there has to be something at stake, there has to be risk involved. It has to mean that you could be out of compliance in some way — with tradition, with certification standards, with accreditation expectations. And if we’re not doing anything, if what we’re doing is completely devoid of risk, or we’re afraid to take any of that, then we won’t move any of these things forward. And I know plenty of people who are, in their own ways, challenging these different systems. And this is not to knock the accrediting bodies. They have their role. But we have to take some of these risks. To detraditionalize, as we were talking about earlier. Risk is inevitable, right?
LR: On that note, I think I’m going to say goodbye. I thoroughly enjoyed this conversation, Travis. It reignites me.
TH: Stay in touch. Holler at me with whatever.

QUESTIONS FOR CLINICAL THOUGHT

  • How does Dr. Heath’s description of his work resonate with your own therapeutic approach?
  • Which of his concepts strikes a particular chord with you and why?
  • How might you have worked with the client who struggled with peanut butter consumption?
  • How do you engage in radical respect with your own clients? Do you have difficulty doing so with a particular type of client?
  • Can you think of a client with whom you have worked, or continue to work, wholeheartedly or halfheartedly?
  • What about Narrative Therapy interests you and challenges you to learn more about the model?

Laurie Helgoe on the Power and Challenges of Introversion

Posted on by rezendevknowfully.com

An Inner Laboratory

Lawrence Rubin: How would you, as a person, a clinician, a researcher, and a writer, define introversion?
Laurie Helgoe:
if you think of where you do your processing, where you work things out, where your laboratory is—it’s internal for an introvert
Introversion at its simplest is an inward orientation. If you think of where you do your processing, where you work things out, where your laboratory is—it’s internal for an introvert. In contrast, the extrovert’s laboratory is more external, and this difference translates to a lot of things. Introverts go inward to think things through. If there’s a question to be answered, like the one you just asked me, I might pause and kind of go inside myself to try to work out the answer before I speak. An extrovert might do that work interactively by giving you a partial answer and then engaging you in a back-and-forth until that answer is fully worked out. There’s not one “right” way, but the challenge for an introvert is if there’s not that space to go inside.

So, there’s a lot that goes with that. Many introverts talk about feeling energized through solitude. Part of that is just because they don’t have anything intruding on their thought process and kind of relax into it more easily.
LR: Being energized through solitude is interesting because we seem to live in a society in which we’re taught, or encouraged, or modeled, to seek energizing through connection, through activity, through accomplishment, through the immediacy of social media. So does that inherently place introverts against the current in our society?
LH: I think so, and that is why many introverts end up feeling bad about themselves or feeling that there’s something wrong, because we have these portrayals of the fun in life, the energizing aspects of life, as being social. I remember when one of the major phone carriers had this “friends and family” ad where one person was surrounded by this mob of people. That just sold me because it did just the opposite of what it intended because that looked like hell to me. Somehow, having that easy connection with this mob of friends and family was supposed to be what people wanted. And then when I think of the sitcom Friends, which just had a reunion show, there was the idea that people could just randomly pop into my space and I would always enjoy having them on the couch.

I think there are a lot of ways that introverts wonder things like, “Why aren’t I having fun at this party?” and “Why can’t I wait to get home and have what is considered fun for me?”
None of that fit for me, so I think there are a lot of ways that introverts wonder things like, “Why aren’t I having fun at this party?” and “Why can’t I wait to get home and have what is considered fun for me?” And in their case, that would mean getting back to a great book, or walking their dog, or just reading with space around them.
LR: I go back to that interesting analogy you made of the introvert having this internal laboratory. Is that contrasted with the extrovert, whose laboratory is the stage rather than a private enclave, and if so, does the introvert shy away from the public stage because that’s not where they process and how they process?
LH: Right. That’s an interesting question, because I happen to enjoy acting and I’m an introvert. But I think, and this is what reveals the complexity of introverts and extroverts, is that each may have different aspects, different ways in which people are introverted or extroverted. For example, public speaking is a common fear that is not confined to introverts. There are many extroverts who are terrified of public speaking despite the interest in and programming for obtaining external rewards—to get those smiles, to get those responses from others. In fact, there are dopaminergic pathways that reinforce external rewards, and these light up for the extrovert when they are socially stimulated.

I think introverts like me who enjoy the stage like teaching, acting, and performing in front of others, and particularly like the fact that they can do it in a structured way
There are fMRI findings and studies which show that introverts respond pretty much the same to images of flowers or people, whereas extroverts are very much more responsive to people-related stimuli. But while these positive, people-related stimuli can engage extroverts, they can also distract them from seeing the whole picture. Extroverts can in a way distort reality toward the positive because they really like these people-related rewards. It would be an extroverted kind of characteristic for someone to like the stage. That said, I think introverts like me who enjoy the stage like teaching, acting, and performing in front of others, and particularly like the fact that they can do it in a structured way, one that they planned and practiced for as opposed to being put on the spot. This is because when introverts are put on the spot, they don’t have time to go to their laboratory.

Misconceptions

LR: I’m fascinated by the notion of the inner laboratory—it has almost an Eastern sound to it. This makes me wonder if the so-called “extrovert ideal” is more of the dominant Western narrative, and that the benefits of introversion have only recently been recognized along with mindfulness practice and the integration of Buddhism into the clinical landscape.
LH:
in Eastern cultures, it can be the opposite, where extroverts are seen as a little weird or really out there
It’s so interesting you raise that, because there has been a lot of research suggesting just what you’re saying, which is that there is a very strong bias toward happiness in our culture—but a specific kind of happiness. Even the studies that have shown extroverts to be happier only tend to look at one facet of happiness, which is a high arousal-positive affect. But the research doesn’t look at low arousal-positive affect such as feeling tranquil and at peace, the chill feelings that are more valued by introverts. And so, you have this kind of culture-personality mismatch, which can lead introverts to feeling badly about themselves. In Eastern cultures, it can be the opposite, where extroverts are seen as a little weird or really out there. And there’s a puzzlement about this so-called American (extrovert) personality. So yes, I think there is some balance that is slowly being introduced as we look toward and value more contemplative practice in our society.
LR: Since we are this doing-connecting-running-accomplishing-externalizing type of culture, what misconceptions do clinicians need to know surrounding introversion and the introvert, such as the introvert and the schizoid personality are similar?
LH: I’m sure you were attuned to this when the DSM-5 was in development, but there was a proposal on the table to include the term “introversion” in a number of diagnostic categories as an indicator, as a symptom. But there was a loud outcry to that because what really was being referred to in the DSM was a kind of disengagement, and the problem with seeing introversion as disengagement is that it’s actually just the opposite. A healthy introvert may be quiet in a conversation, although not all introverts are disengaged. There is a continuum. Oftentimes, the reason why introverts are quiet is because we ARE engaged, because we’re processing, because we’re trying to make sense of what the other person is saying rather than the opposite, which is disengagement. We may put on good poker faces so that it seems that we’re kind of schizoid or not there. And sometimes introverts do need to make the point of narrating our process. Saying “Yeah, I’m thinking about this, just give me a second.”

so this idea that introversion is a pathological indicator is extremely problematic
So this idea that introversion is a pathological indicator is extremely problematic. I think most people who study introversion and extroversion see them as neutral categories and that there can be problems associated with either. If we look at mental health disorders, some of the impulse control disorders like substance use are more prevalent in extroverts, whereas for introverts, the internalizing disorders like depression and anxiety can be more prevalent.
LR: I am reminded of the Achenbach scales, which suggest that the externalizing disorders are more typically relegated to men and the internalizing disorders, like depression and anxiety, are more common among women. So, I wonder if there is a gender line that also contributes to the introversion/extroversion schism?
LH:
women have a harder time getting permission to be introverted
The gender differences aren’t as great as you might think. While I don’t have those figures right in front of me, one thing that’s notable is that women have a harder time getting permission to be introverted. We tend to think of the man as the strong, silent type, whereas a woman might just be considered the B-word or a snob if she’s not engaged. We have a lot of expectations on women to be the social kind of glue in our society. I think actually men are a little bit more prevalent in terms of the numbers, but they are not that different.
LR: I think I might have jumped ahead of myself. Can we go back and discuss other misconceptions around introversion?
LH: So, I think one is that there’s some kind of pathological disengagement. Another one is that introverts are shy, which is probably the most common misconception. While introverts can indeed be shy, so too can extroverts. The way that introversion is classically understood is that we are internally oriented, and our social way of engaging may be a bit different. We like a little more space in our interactions. We probably like fewer people. But all of that comes back to the level of stimulation. And I think of Hans Eysenck's level of cortical arousal and the idea that the sweet spot for everyone is in the middle, where we’re not too stimulated and we’re not bored. But extroverts tend to get cortically bored. They tend to crave more stimulation, so they’re trying to move in the direction of more stimulation to get to their middle, whereas introverts are trying to tone things down more to get to their middle.

So, for example, I’m at a party and I’m with a shy person. I, being pretty socially introverted, might be hanging on the sidelines because I kind of like being there. And there’s probably somebody there who’s a little quieter who I might want to talk to. I might really enjoy observing or just taking a break. A shy extrovert standing next to me might really, really want to be in there and just doesn’t know how. There might be a lot of self-consciousness and that kind of thing. Now again, these variables can overlap, but I think it’s much more helpful to see them as separate.
LR: This may be the pushy extroversive side of me, Laurie, but can you think of any others before we move?
LH:
there’s even a misconception or assumption that introverts really don’t have a personality—you know, that they’re kind of bland
Another one is that introverts are snobs. And this again might be due to the poker face. In the U.S., we love smile emojis, and we expect this very exuberant, outward-oriented evidence that a person is engaged, or present, or responsive. And if we don’t get that, the readiness is to assume that that person maybe doesn’t like me or is non-approving and stuck up. There’s even a misconception or assumption that introverts really don’t have a personality—you know, that they’re kind of bland. But if you just took a peek inside the laboratory, you’d find otherwise.
LR: I don’t know if this is a misconception, but there’s been a little bit of buzz in the literature about the overlap in some ways between introversion and autism. Is that a dangerous connection to make clinically?
LH: I know there has been talk that introversion is like [what used to be called] Asperger’s. I think if it helps us understand the autism spectrum in a different way, it may be useful. But I don’t know that it is the case and honestly, I haven’t gone that direction myself because we’re trying to link something up that may not be helpful and could be quite the opposite.

I’m all for the direction of us de-pathologizing most things, right? I think there is agreement around communication difficulties associated with autism spectrum disorders and there may also be some for some introverts. There may be some ways in which the spectrum would explain some aspects of their behavior.

LR: I can see what you’re saying in terms of this societal tendency to pathologize anything that’s considered different. We just tend to “other” the hell out of each other, so clinicians need to be very wary of looking for or building connections between introversion and pathology or problematic issues based upon misconceptions.

Introverts and COVID

LR: How did introverts fare during the isolation and social distancing of the COVID pandemic—heaven or hell?
LH: In fact, I was just looking at some recent findings on that, and introverts did for the most part thrive, although there certainly are variations. While extroverts had a hard time, with reported deterioration in their mental health, there were certain challenges that isolation created for introverts. Surprisingly, there was a time in history where all of a sudden, introverts were being asked, “How do you do this? How do you manage being alone? How do you manage this?” So, if nothing else, I think there was a sense that what we have is valued and has survival value—because we did. We all were safer because people stayed in their zones because they were able to socially distance themselves and to spend more time alone.
LR:
so, during this time of forced isolation, those who have historically been quite fine with solitary and internal lives became the experts in teaching the rest of society
So, during this time of forced isolation, those who have historically been quite fine with solitary and internal lives became the experts in teaching the rest of society. You mentioned the word “thrive,” and that introverts were called upon for their expertise.
LH: I can use myself as an example. I am still mostly working from home, where I teach and work with a lot of students. In my traditional face-to-face classrooms, we have an open office plan, which does not necessarily work well at all for having conversations and is overstimulating for introverts. But what is paradoxically true for me and others of my colleagues is that from home, I now engage better because I can have a conversation on-screen with a student or a colleague from the quiet of my home office. I don’t have to worry about privacy or having to find a special room because of that open floor plan. From home, I can be in a place that reflects me—we might even talk about my paintings that are sitting behind me or the view outside the student’s window, which might be snow, while I’m in Barbados. We get to connect in a more personal way because we have this home-to-home kind of connection. So I have actually found that this forced isolation has enhanced my relationships, because they have become a little more contained and kind of safe in cyberspace.
LR: Is safety a concern for introverts? And as I even ask the question, I wonder if some clinicians out there are wondering if this need for safety suggests some kind of earlier trauma.
LH:
introverts tend to be more guardians of privacy
What I mean by safety is the freedom from bombardment and overstimulation, but it can also mean the protection of privacy. Introverts tend to be more guardians of privacy, both for themselves and in relationships.
LR: Prior to COVID, I had a strict closed-door policy for that very reason, while other colleagues whose doors were always open seemed to spend far more time gabbing than working. Did you find any other differences in the ways that introverts and extroverts fared during the pandemic?
LH: One thing I know from academia is that there’s evidence that everybody’s working more since we’ve gone online. Introducing new platforms and having a lot of Zoom meetings can definitely result in social fatigue when you’re constantly on screen.

the introverts I know who have struggled the most are the ones who have extroverted family members at home
But the introverts I know who have struggled the most are the ones who have extroverted family members at home, or kids that they are locked in with and from whom they normally get a break from. I know I’ve missed some of my introvert haunts, like the coffee shop I go to work and the movie theater. I like places in the world where I can be quiet and where I can view, you know, kind of be a flâneur (I wish we had an English word equivalent). I like the idea of the passionate observer who is out and about, but not engaged in a direct way—I do get energized by that. So, I think there definitely are ways in which introverts have missed out. And certainly, we have close relationships, so it’s been very hard to be separated from family and friends, because introverts are not necessarily loners. I’ve talked to introverts who have grieved a loved one who they described as their “comfortable person.” For introverts, it’s hard work to do small talk, so we rely more on our comfortable people.

LR: And I would imagine that older people who have historically been accustomed to face-to-face contact don’t find the same level of comfort on the screen.

In Therapy

LR: I don’t imagine that people come to therapy because they are suffering from introversion. And while I was initially going to begin by asking about the challenges that introverts bring to therapy, I’d like instead to ask how therapy can tap into the strengths and resources that introverts possess?
LH:
analysis was a space where I could sort out the fact that I was at odds with the way my lifestyle was set up and how it wasn’t working for me
The first thing that came to mind when you said, “Introverts aren’t necessarily going to come in and say I’m suffering from introversion,” was that they might in some way say, “I’m suffering from society,” which is what was going on for me when I went through psychoanalysis. I talk about it in my book and how it really was the starting point for the book and for a lot of healing for me. Analysis was a space where I could sort out the fact that I was at odds with the way my lifestyle was set up and how it wasn’t working for me. It was important to finally put a name to it—that I was an introvert. I realized that I needed things that my life wasn’t providing, so I started to make some radical changes in my life.

So in therapy, you might have people saying things like they are getting hassled at work because they’re not outgoing enough, or who feel bad about themselves because they are at odds with society. It can be very, very helpful for clients to be able to put a name to it. I can point to so many people who have talked about that transformative moment when they said, “Ah, I’m an introvert. That’s why. Okay.” But, I think it typically depends on how that’s delivered.

That’s the beauty of a Myers-Briggs Type indicator, although some have criticized its psychometric properties. It really does describe each personality type in a strengths-oriented way, so people then can see themselves mirrored in that positive way. Instead of thinking that they are the problem that needs to be fixed, they have permission instead to engage in their lives in a way that works better for them.
LR: Do you ever feel compelled to point out to a client that they are introverted, or is that not always necessary?
LH: I would, and it may not even be that the word “introversion” is necessary. But I think it does help because there are a lot of characteristics that come with somebody who’s an internal processor. They might not think on their feet so well or they need space in conversations. If they have a spouse that always wants to do things or who always wants to talk, the introvert may wonder, “Why don’t I love my spouse or my partner because I don’t want to talk or do things all the time, and sometimes I want space for myself?” I might tell them, “Well, it sounds like you’re an introvert,” and they might say, “Oh, what’s that?” While most people know, I’m surprised that some people haven’t or don’t really reflect on being an introvert. I didn’t, and I’m a psychologist who didn’t really reflect on what that meant about me until well into my practice years.
LR: Do you find that it’s liberating for these clients once you tell them or suggest to them that they are introverted?
LH:
I get letters from readers all the time that say, “All I needed to know is that there really isn’t anything wrong with me, and there are other people like me.”
It’s tremendously liberating. I get letters from readers all the time that say, “All I needed to know is that there really isn’t anything wrong with me, and there are other people like me.” And there are people in our society who believe that the introvert is the rare person, kind of sitting down in the basement avoiding people, when in any given room introverts make up about half of the people in that room. So I think that knowing does shift a person’s thinking. They may finally understand, “That’s why I prefer to send an email than speaking my thoughts,” or “That might be why, after a meeting, I really feel like I need a break to think through what happened and write down some notes.” We get so much mirroring of what it means to be an extrovert, but don’t get that much about what it means to be an introvert.
LR: Would you necessarily treat a depressed, anxious or perhaps substance-abusing introvert differently than you would treat a non-introvert with similar symptomatology?
LH: I think a lot of the treatments apply well to both. But I think that for introverts, part of our treatment is to help them align their lives with what gives them joy, even though we need to be very careful about ascribing to them what we think that would be. That would be like the parent saying to the child, “You need to go out more to be with your friends,” when maybe that child simply relishes reading a book and living in this wonderful imaginative space. The parent would end up trying to pull that child out of that comfortable and happy place and telling them what their definition of happiness is. Similarly, we have to be very careful as therapists to not impose what we think the introvert’s happiness should be.
LR: I could see an overzealous introverted therapist trying to impose their expectations or beliefs on a client; sort of introversion-based countertransference?
LH:
introverts tend to be quite versatile because we bend and have to be psychologically bilingual, which is actually a strength
If the therapist had some kind of mission, that could definitely be a trap, because we do know that introverts can gain a good feeling through social engagement. Even acting like an extrovert can give you a lift. I think the difference with introverts is that it can be helpful for them to know about their introversion without feeling like they have to change who they are. Introverts tend to be quite versatile because we bend and have to be psychologically bilingual, which is actually a strength. It’s easier for introverts to act like extroverts in general than it is for extroverts to act like introverts. We saw this with COVID. It was not easy for those extroverts to flex in the introverted direction, while introverts have had to do it all their lives. Through my book and my activism, I have wanted to simply reinforce the idea that introversion is a viable option. That’s not to say that introverts have to be introverted all the time or that they won’t benefit, but the problem is that many haven’t gotten permission to be who they are in the first place. So, if you’re not who you are in the first place, how do you transcend that?
LR: Are there any other challenges or issues that introverts are more likely to bring to therapy?
LH:
maybe we introverts are entitled to a little bit of that juice that the extroverts are drinking
I think introverts, for better and for worse, can be self-scrutinizers. We are reflective. We think about our conversations. We reflect on events. And so, that may give us a more realistic view of things, and it also can induce anxiety and depression. I think this is where mindfulness techniques are so helpful—we can do that reflection without getting so attached to those thoughts and, as a result, can come back to the present. And at times, we can deliberately seek those joyful experiences and do what extroverts do. Maybe we introverts are entitled to a little bit of that juice that the extroverts are drinking.
LR: In addition to mindfulness, are there particular modalities of therapy that introverts might be more drawn to?
LH:
a very extroverted therapist who really wants a back-and-forth kind of dialogue may lose an introverted client
As an introvert myself, I always gravitated toward the psychodynamic psychotherapies in part because they provide so much space for the internal life. As number nine in a family of ten who was constantly overstimulated, I relished the luxury of having a person listen to me in a place where I got to lay back on the couch and just let my mind take up the whole room. In terms of space, that was a wonderful thing.

Not all introverts would necessarily like that. Some introverts do actually appreciate some structure or inquisitiveness from a therapist. I think that a general rule is that when working therapeutically with an introvert, there needs to be a certain level of patience to let the client consult with their inner laboratory and find out what they’re thinking. A very extroverted therapist who really wants a back-and-forth kind of dialogue may lose an introverted client.
LR: What about the opposite situation in which an introverted therapist has a very extroverted, performative, gregarious, energetic, over-stimulating client?
LH: I’ve actually had to contend with that because for me and a lot of introverts, interrupting is taboo. But some extroverts expect to be interrupted. They kind of like just letting go and knowing that you’re going to get your word in whether you want or not. Some extroverts love talking to introverts because the introvert gives the full space. But the introverted therapist may also have to be more active than they prefer with that type of client.
LR: I closed my physical practice a few years ago. It was so highly personalized, and some might argue overstimulating. If you were to be a consultant for designing therapy spaces for introverts, what tips might you offer?
LH: I love that question, because I think it’s a neglected one. One thing is that introverts are already likely coming into your office over-stimulated. If you have bright lights and a lot of clutter in your office, you’re probably not going to have somebody who’s going to be very able to settle into the space. I am very attentive to lighting so have a softly lit space, and because some introverts may not always want to make eye contact because they have to think and because sometimes our eyes will distract them, I do have some things that allow the patient or client to look away from me. They want to be oriented towards you. Introverts tend to be very absorbent of what’s going on around them. And so, they almost need to close themselves off. So, not facing the chair directly at them is helpful—kind of fanning them out so that the client can look off and go inside instead of always looking at you but can also easily enough look over at you. That kind of thing can really make an introvert feel more comfortable and open in this space.
LR: Maybe we can go into the office setup-for-introverts feng shui business.
LH: Love it.

Introverts at Home

LR: Do introverted parents bring unique challenges to therapy?
LH:
parents don’t often give permission and encouragement to help their child develop solitude skills
I do think parents feel a lot of pressure, from the whole playdate revolution, to having the most fun birthday party. I remember, and say this with a little bit of shame, but I was always relieved after Halloween was done because there was this pressure to create the best costume. One thing that I always note is that parents feel such a responsibility to help their child develop social skills, and certainly that is an important coping mechanism. But parents don’t often give permission and encouragement to help their child develop solitude skills. We can’t always entertain them. And if we are, we are developing a child who doesn’t have much resilience, because the reality is, we’re going to be alone for a good part of our lives. So, I think that it is important to help both introverted and extroverted parents foster that quiet space for their child(ren).

I remember the psychotherapy theorist, I think it was Fred Pine, who talked about the importance of quiet pleasures. Winnicott also talked about that. I like the idea that the child and you can be doing parallel things in this quiet space, and that child internalizes the ability to be alone, because they learn that they can be alone together. They learn that there is a sense of somebody who can tolerate their aloneness, which I think is such a beautiful but rare thing in parenting. That we can just do nothing together?

I was just watching the movie Christopher Robin. I love the way that Christopher Robin and Pooh talk about doing nothing because when you do nothing, something happens. I love when somebody asks me what I’m doing, and I say nothing, and then I do it. It is the idea of the generative, the fertile void. The way that boredom is a precursor to creativity. So I always ask, are we allowing kids boredom? If parents took some pressure off themselves to stop entertaining kids, kids might paradoxically end up being more self-entertained.
LR: I just wrote the introduction to a friend’s book on nature-based play therapy, and as we chat, Richard Louv’s work on the importance of nature in child development rings so loudly in my ears. I think kids (and adults) need to be in nature where there is quiet, and there is awe, and there is, like you said, an external space where they can be internal.
LH: Yes. I find for myself that having an evening walk when things are quiet is when I do feel that the laboratory is wide and vast, and I don’t have to tuck it away.
LR: Moving from parenting to relationships, what challenges have you found working with couples who are mismatched temperamentally?
LH:
an introvert/extrovert couple are going to have more conflict if they are going to be close, because they need to negotiate
I think there are a lot of introvert/extrovert couples that do quite well. But knowing from experience, an introvert/extrovert couple are going to have more conflict if they are going to be close, because they need to negotiate. So, if the extrovert wants to go out and be with friends, how often will the introvert be willing to do that? The introvert may indeed want to go to a movie or just have a quiet dinner or just stay at home and read together, which is a legitimate date, in my opinion.

There can be real advantages to that, because we might appreciate at times being pulled out of ourselves. Or pulled in, pulled back from ourselves. And so a couple that represents both those functions can become flexible in that way. What I notice is that there may be more of an ease in introvert/introvert couples. But that may also come with a lesser growth curve. The other thing can happen, though, is like with systems therapy, where one plays more of the function of introvert or extrovert. So, you have all different variations on the theme. But I think that naming this process becomes important in clinical work with couples, especially if their temperaments put them at odds. It took my husband and I twenty-five years and the writing of my book to discover that when I’m quiet, I’m not telling him he needs to explain things more.
LR: Or that you’re not withholding something from him or pushing him away.
LH: Instead, that he has been understood, and that I’m not telling him that I am disengaged. I’m actually thinking about what he says. So now when I’m quiet, he’ll say, “Oh, you’re thinking about it, right?” And I’m like, yes.
LR: So, your book in part was a marriage survival guide for yourself?
LH: Yeah, it’s very interesting to me that after writing the book, I found applications in my own life that I hadn’t yet discovered.
LR: Well, you probably were aware of those, but not consciously because you’re an introvert. They were bubbling up in some beaker deep in the back of your laboratory.
LH: There you go.
LR: As we come to an end, Laurie, what would you leave those clinicians out there who haven’t yet given too much thought to this whole introversion/extroversion area with?
LH: I think that we all benefit from having a richer world. And we have a richer world when we can embrace the internal and the external. I think too often we don’t, and we aren’t curious enough, or wait long enough to find out. I find in teaching interviewing skills to medical students that if they wait just a little bit longer, they’re going to find the story, the punchline, the meaning that, if they had spoken two seconds sooner, would have been missed. So keep in mind that the world is vast and wonderful out there. But it’s also vast and wonderful in there.
LR: If there are any questions that I wasn’t clear on, can I reach out to you after we finish today?
LH: Absolutely, because as an introvert, sometimes things get clearer later on.

Has Psychotherapy Lost Its Mind?

Posted on by Psychotherapy.net Team

Losing Our Mind

It’s happening so slowly that we are almost unaware of it. Little by little, psychotherapists seem to be losing their minds. Recent progress in neuroscience has led to the opinion that the mind is out and the brain is in.

We used to think in dualistic terms of body and mind, apart and together, or as two sides of the same coin. Now the mind is viewed as an expression of the brain, and not the other way around. Gilbert Ryle’s concept of the mind has triumphed: there is no ghost in the machine. The downgraded mind has become no more than a scientific misconception. According to Antonio Damasio, it is a remnant of Descartes’ error, the dualist split of mind and body. The only thing that truly seems to matter today is what’s happening within the brain. The mind is relevant only insofar as it has a physical correlate. The brain has won, and the mind has lost in their ancient competition for ascendancy. Maybe it’s just another stage in the evolution of Homo sapiens, or perhaps a paradigm shift in the way we conceive of ourselves as human beings?

The growing prominence of the brain and the body is not only happening within psychosomatic medicine, biological psychiatry, and neuropsychology. Psychotherapists of all persuasions have also been influenced by this paradigm change. Having lost faith in natural observation studies and self-administered tests, an increasing number of mental health professionals have gradually adopted data from biochemistry laboratories and neuroimaging data to explain why people do what they do. Psychological theories are now disposed of as primitive and unfounded folk psychology and have been replaced by scientific evidence from neuroscientific discoveries. The recent popularization of epigenetics has only reinforced this conviction. At every stage of these new findings, it seems as though psychotherapists are gradually losing another piece of their minds. Perhaps large-scale genomic analysis will deliver the final death blow to the mind?

Talking Neuro-Talk

Overenthusiastic media reports have convinced us that we are driven by blueprints in our genes and by various physiological processes. As heard in TED Talks and on YouTube, everybody now thinks that what’s going on in our minds is actually an expression of what’s going on in our brains and bodies. People now assume that when we are stressed out, something has gone wrong within the neural circuitry of our brains. When someone is too excited, for example, it is explained as an overactive amygdala, a deficient regulation of the prefrontal cortex, and abnormal hippocampus mediation. Faulty neurotransmitter messages explain what makes us fearful or sad. Action potentials and neural circuits have become more appealing than analyzing free associations. In the world of psychology today, there should be some kind of biological correlate of every mental occurrence. Psychotherapy should be informed by neurobiology and become neuropsychotherapy.

Perhaps the brain has become so popular because, as a physical organ, it can store data and process thoughts just like a computer? It’s even more powerful than a computer. It can also regulate emotions, modify the neuroendocrine and autonomic nervous systems, and enhance our overall brain functioning by engaging the temporal, frontal, parietal, cerebellar, and limbic structures. This is impressive stuff. As a result, we are no longer categorized as pessimists or optimists. Instead, Elaine Fox suggested we have “rainy” or “sunny” brains. Since brain cells are merely responding to electrochemical signals, Daniel Dennett called consciousness a user-illusion. As a result of these assumptions, Daniel Amen recommended that if we only change our brains, we will also change our lives.

Such neuro-talk is highly appealing to us because we have always had a problem with words such as the soul, spirit, consciousness, self, and personality. Neuronal circuits, on the other hand, or specific parts of the brain, can be observed and investigated. It is, therefore, easier for us to accept that they may in fact regulate what we do, think, and feel. This new language has been extended to everything that is happening in psychotherapy. As a substitute for talking about unconscious childhood trauma that causes later emotional problems, we now search for the various long-term biological effects of early life stress. Instead of talking about the id, ego, and superego, we now regard them as functions of the amygdala, the hippocampus, and the prefrontal cortex. Instead of suggesting that the unconscious is running our lives, we now investigate how the autonomic nervous system, the endocrine system, and the neural circuits in various parts of our brains are affecting us. Freud’s recommendation of putting the ego in the place of the id is now replaced with advocating a better homeostatic balance within all physiological systems. To remain relevant, neuro-psychoanalysis has assimilated this new language into its work.

As a result of this embracing of the brain, more hands-on avenues of healing are now called for when people feel down; psychopharmacological solutions, transcranial magnetic stimulation (TMS), or neurosurgical interventions, to name a few. Anything might work that takes the mind out of the equation. If classical psychotherapy is nevertheless recommended, the goal is no longer to achieve an open mind, but a well-regulated body in balance with environmental stress. It should be firmly based on a medical model of diagnosis, with a focused treatment plan and a follow-up outcome evaluation. Only evidence-based approaches that have been scientifically proven to be effective for specific disorders are recommended. Psychotherapy should be brief, focused, and goal-directed. Even the names of the recommended methods are abbreviated with only a few acronyms (e.g. ACT, CBT, DBT, EMDR, NLP, PE, PT, or SIT). They require following a strict protocol in which the therapist is implementing specific interventions to achieve the desired neurobiological results. If consciousness is at all endorsed, it is achieved through the manipulation of neurotransmitters (e.g. serotonin, norepinephrine, dopamine, and glutamate), rather than by gaining more personal insights. Everything should work quickly, efficiently, and…mindlessly. Therapists have no patience with a prolonged process of analyzing abstract dreams or unconscious fantasies. When the word “head-shrinking” is at all mentioned today, it refers to a reduction of brain cells and the decrease of synaptic connections in aging. It has even been suggested that a neuroscience-based diagnostic approach would be more useful than the present descriptive approach.

Personal memories, which were regarded as the most important parts of our minds, remain relevant only insofar as they can be neuroanatomically located. Such memories have been reduced to engrams: the electrochemical nerve-endings that store and deliver messages between one another. They are now studied as either explicit or implicit and in terms of their affiliation to the old reptilian brain, the limbic system, or the neo-cortex. Rather than talking about past traumatic experiences, episodic memories of fear are assumed to be located in the hippocampus. Nothing escapes such neuroscientific investigations. Even the location of consciousness itself has been sought. Contradicting Descartes’ view that it was situated in the pineal gland, some researchers have suggested that it may be found within the posterior cortical hot zone.

Whereas classical psychology was separated from the physiology of the nervous system, it now seeks to explain how the brain makes us behave, think, and feel. As a result, “neuroscience has also become dominant in academic psychology”. The hard science of the brain is where the grant money is, and it’s the only thing that truly matters. Research on genetic and environmental interactions has replaced studies in social psychology. Brain imaging has replaced dynamic psychiatry. Cognitive neuroscience has replaced cognitive psychology, and social neuroscience is searching for the neural basis for social interactions. The shift in focus to a biological and/or evolutionary bias is apparent among the 50 most influential living psychologists in the world today.

In our overstimulated world, we are not even asked to keep things on our minds anymore. It’s all stored in our computers and smartphones, before disappearing into the “cloud.” As our lives have become less mindful (and less meaningful), many have turned to mindfulness training. But as long as it is practiced as a quick fix within a biological and “evidence-based” framework, its effectiveness will be more doubtful than mindful.

Humanistic psychology, group therapy, and family therapy have been out of fashion for a long time. The interpersonal feedback promoted in these approaches has been replaced by bio-feedback, such as brainwaves, skin conductance, and heart rate monitors. This feedback is now regarded as more reliable than a compilation of biased human beings.

All of this is, of course driven, by technological progress. Sophisticated machines, such as large computers, optogenetics, electron microscopy, and fMRI, can uncover parts of our minds that were previously hidden. Neuroscientists all over the world are searching vigorously for the neural correlates of all mental phenomena and publish their findings in neuroscience journals such as Psychoneuroendocrinology or Cerebral Cortex, where they later become popularized through the online access of neuroscience blogs.

In today’s cynical world of disillusionments, we have downgraded our minds and our common-sense understanding of humankind because we have realized that our minds can be so easily manipulated. We have been told to stop trusting our own minds, to the extent that we sometimes doubt that they exist at all. At this time and age, some may even recommend getting rid of our minds altogether. It’s almost a relief, since the mind has created so much trouble for us in our lives. Without it, we would be able to cease remembering the past (an end to depression) and stop worrying about the future (an end to anxiety). Perhaps that’s why the power of now has become so appealing?

If we can completely lose our minds, we will be able to celebrate the creation of a true bionic human-machine: a mindless zombie without any complex human spirit. We’ve heard this before. In Vance Packard’s 1959 The Hidden Persuaders, he predicted that eventually, the depth of manipulation of the psychological variety will seem amusingly old-fashioned, and the biophysicists will take over with “biocontrol,” the new science of controlling mental processes by bio-electrical signals.

Reclaiming the Mind

At this point, predictions of the end of the mind have not materialized. Despite all the recent signs of humankind losing their minds, the mind is still very much alive and kicking (even if it is not always doing well).

Researchers couldn’t find the source of Einstein’s genius by analyzing his brain. Nor have they been able to diagnose or treat the personal beliefs, feelings, and thoughts of people by analyzing their brains. While a brain scan (or any other biomedical assessment procedure) may detect electrical currents and anatomical irregularities, they don’t necessarily add much additional information about our subjective vital force.

With all neuroscience research’s progress, we would assume that it could significantly improve the diagnosis and therapy of various mental disorders. However, at least until now, the data gathered from neuroscience have not made a substantial contribution to psychiatry¹. Most psychiatric disorders cannot be validated by laboratory tests, and diagnostic biomarkers are absent from psychiatry.

I had my own neuro-mance for a couple of years. But the honeymoon ended when I realized that there could be no definite biomarkers of Holocaust traumatization². As long as neuroscience cannot answer the “hard question”³of what it’s like to be conscious and experience something, neuroscience will remain neuroscience-fiction for mental health professionals. And since neurobiology cannot directly investigate mental events without reducing them to “something else,” our personal minds remain beyond its reach. Psychotherapists who justify what they do with presently available neuroscientific findings are speaking pseudoscientific neurobabble, similar to what we used to call psychobabble. To my ears, they sound like faith healers preaching gospels wrapped up in abstract medical jargon. Describing people as being “hard-wired” for a specific behavior or dominated by one side of their brains, remains a neuro-myth until these statements can be proven with reliable and valid devices and shown to be manifested in specific individuals.

The mind and body are probably interconnected and interdependent. And even though neuroscience cannot prove the existence of consciousness itself, it has presented valuable data on how our brains function. But at the end of the day, psychotherapists still need a more integrative bio-psycho-social explanatory model in their efforts to understand their clients.

References

1. Schmidt, U., Vermetten, E. (2017). Integrating NIMH Research Domain Criteria (RDoC) into PTSD Research. Current Topics in Behavioral Neurosciences, 38, 69-91. doi:10.1007/7854_2017_1

2. Kellermann, N.P.F. (2018). The search for biomarkers of Holocaust trauma. Journal of Traumatic Stress Disorders and Treatment, 7(1), 1-13.

3. Chalmers, D. (1995). Facing up to the problem of consciousness. Journal of Consciousness Studies, 2(3), 200-219.

Usha Tummala-Narra on Living Multicultural Competence

Posted on by Psychotherapy.net Team
Lawrence Rubin: I want to thank you very much, Usha, for being with us today and sharing your time and expertise with our audience of psychotherapists.
Usha Tummala-Narra: Thank you for inviting me.

Towards a Definition

LR: Multicultural competence seems to have become somewhat of a buzzword in the field of counseling and psychotherapy, defined differently by different clinicians; but since it’s the nexus of your own clinical and research work, can you tell our readers what you think it is and what you think it isn’t?
UT: Indeed, there’ve been many different definitions. I arrived at cultural competence from a psychoanalytic perspective. Given that, I think of multicultural competence as a way of understanding, a way of engaging with sociocultural context and how it shapes interpersonal processes as well as intrapsychic life and extending into the therapeutic relationship. How do the sociocultural context and dynamics that are evident in broader society get mirrored in the relationship between the therapist and the client? So, cultural competence to me looks at the various layers of an individual’s life, both intrapsychically and interpersonally.
LR: Irvin Yalom talks about the therapeutic relationship as a microcosm for the client’s interpersonal world, so I’m wondering if what you’re saying is that a multiculturally competent clinician strives to build a connection with the client’s broader contextualized experience.
UT: That’s certainly a part of it. I think the other piece is the person of the therapist in terms of their own socio-cultural history. This includes their own history of social oppression – what they find as positive and identify positively with in terms of their cultural background, their religious background or linguistic background. It’s about how all those sets of cultural and socio-cultural experiences shape the therapist and their subjectivity and how that in turn interacts with the subjectivity of the client. There’s this kind of interaction between multiple cultural worlds happening regardless of who we’re working with therapeutically. And this is not specific to working with clients from a particular socio-cultural background, but rather I see it as broader than that. It’s about engaging our broader context within the therapeutic relationship.
And so for me, cultural competence isn’t a specialty, it’s just part of professional competence. I just really see it as a regular part of psychotherapy.
LR: So, it’s more than just two people coming together, but it’s almost like two worlds coming together in the therapeutic encounter.
UT: Yes, that’s right.

Revealing Full Personhood

LR: Traditional therapeutic practice, particularly dynamically-informed practice, is built upon the premise of therapeutic neutrality; so how can a clinician bring their full contextual personhood into the relationship with a client and still be faithful to the ethics and the tenets of psychotherapy?
UT: That’s a great question. We should consider what neutrality actually looks like and feels like for the client. We’ve been socialized as therapists to put everything about ourselves to the side so that we’re not imposing our agenda onto the client. And so, therapists have this idea that “if I was to initiate a discussion about race or culture or gender, that it’s really my personal wish that’s being filled in some way, or my personal longing to engage in those discussions rather than the client’s needs and what might be actually helpful to the client.” But in fact, what I have found is that so many clients in fact need to talk about issues of race and culture and religion but have been told all their lives in one way or another that they shouldn’t. As a result, people’s experiences of racism are often kept hidden, are kept silent, and are more often spoken about within somebody’s home or with a circle of friends.
But, we should consider that psychotherapy is actually a place where we can talk about things that we have been told not to because therapy is not an ordinary conversation, as Freud himself pointed out. For me, then, we must think about what’s not being spoken about when we neglect to address issues of sociocultural context and background. If we’re not talking about something like social class and how it impacts our clients, then perhaps neither will our clients. I don’t see those particular issues as being separate from what may be going on internally for a person – what they might be struggling with. I just see the two as quite intertwined in terms of a person’s suffering and conflicts and relational issues. They’re very intertwined for me.
 
LR:  It’s interesting how you’re saying that people who differ from the so-called mainstream are taught to be invisible, to homogenize themselves and hide the rich context of their life. And the same seems to go for therapists who are taught to blend into the background, to neutralize the rich cultural, racial, gendered, religious aspects of themselves so they may be fully available. But you’re also saying that both client and therapist need to step out of that invisibility and reveal themselves to each other.
UT: Yes. If we’re interested in exploring a full range of experience within our client’s lives, then we must actually explore all of those different aspects of our own life. And I don’t see how we can separate the individual from their context. One other thing that comes to my mind is how we might even from the very start think about developmental history. When we do an intake assessment and ask questions about a person’s development, we typically ask questions about their family, school experiences, work and health history – things of the like. But we tend not to ask more specific cultural, racial and contextual questions like, was the family struggling financially, did they have resources in the community, what was it like growing up in this particular family?
It can be so important to ask about the immigration history not only of the client and their immediate family, but of the extended family. Deep and culturally-informed questions can be so valuable like, was there any bullying related to racism or to sexism or homophobia? These are the kinds of questions I think that could extend what we already do, but into a realm that considers the fact that development is occurring in multiple contexts and that we ought to know and learn about what’s happening in those contexts, especially for kids. But also for adult patients, who have been internalizing all sorts of things as a function of being in and living through those contexts. 

Becoming Culturally Competent

LR: It goes back to what we talked about before—the need to de-neutralize the relational encounter with our clients. What are some of the challenges that you’ve seen clinicians deal with, or that you want to caution clinicians to be careful of?
UT: Actually, something you said pointed to part of my response to this in that I don’t see cultural competence as necessarily an outcome, but as a process. It’s a journey, as you say. And I think one of the things that clinicians are challenged with is this idea that somehow cultural competence only relates to certain outcomes related to people of color, or people holding some kind of minority status, rather than this being relevant to all people of all backgrounds. And so, I think that an important challenge to overcome is the assumptions we make about what is cultural competence and who it is relevant for. If we don’t see it as relevant to all of us, then it becomes a situation for certain people at certain times rather than thinking more broadly. I also don’t see it as only a professional endeavor, but a personal endeavor as well, because if we are not learning to listen to issues of context and culture in our everyday lives, then it’s very difficult to know how to listen for that in our professional work. So, to think that we just need a set of competencies to apply in a technical way in the therapeutic relationship, that’s really not what I think of as cultural competence. To me that’s a mechanical way of being rather than investing the self into the work.
LR: A more fluid way of living multiculturally rather than simply turning on the multicultural switch when in therapy! What do you see as some of the blind spots clinicians may have in working with the “other,” basically someone who’s different from yourself in any regard?
UT: I think that’s a great way to phrase it because so much of the time, the assumption or presumption in our literature is that the clinician is white, and the client is the racial minority person or something like that. Whereas certainly in my case, it might be reversed or there are two racial minority people in the room. So, you can have any combination. I think one blind spot may have to do with our human tendency to overgeneralize about groups or our conceptions about certain, if not all, socio-cultural groups. It is the notion that if someone is affiliated with or identified with a particular group, then they carry certain characteristics or that they have this or that particular set of values. I do think it’s important to have some working knowledge about the history of different cultural groups and a good working sense of that. To me, those form just a beginning framework, a beginning sense, rather than a story or rather than really understanding what belonging to that particular cultural group means for and feels like to the person.
Everybody has a unique experience of their own culture or their own religion or belonging to a particular racial group or being multiracial. I think this is why for me, a psychoanalytic perspective is particularly well-suited to this line of inquiry, because it does allow us to think about experiences that are deeply embedded in relationships, within early life relationships, but also throughout one’s lifespan and one’s evolving relationship with the broader context as well.
Another blind spot that comes to mind has to do with working with somebody who is, in some way, of similar background and making an assumption of sameness, which can get in the way of differentiating ourselves from the other. This is the flip side of overgeneralizing about the other, sort of more about merging – two people whom you think might be similar in some dimension which may not necessarily be true. 
LR: Overgeneralizing about the other and undergeneralizing about someone we perceive to be like ourselves or with whom we share certain demographics. Like me working with a white Jewish male and not inquiring into their whiteness, Judaism or their maleness and as a result, missing out on a lot of potentially good information about what it is like for them.
UT: And sometimes the clients are making assumptions about the therapist, too. So, you might hear a client say, “Oh, you know what it’s like to be Christian,” or biracial, or gay? And I could say, “Well, I know what it’s like for me, but I’m still learning about what it might be like for you and trying to understand that more.” And certainly, with some of my white clients, I routinely ask about their ethnic background. I will ask them to describe it. Some of these clients will say, “Well, I’m just white you know; that’s just who I am.” And to me it always reflects how we’re socialized around race, particularly in this country, to believe that some people don’t have a history beyond just being white. So any previous family history is really kind of disavowed, which people may actually have a lot of complicated feelings about.
LR: And if we don’t allow that into the conversation, then it just continues to be a force of oppression. Just out of…
UT: Disavowal of some kind.

Bearing Witness

LR: Along these lines, what have you learned about social oppression, racism and trauma in working with immigrants and refugees that could help our audience of therapists along their own journeys towards multicultural awareness and competence?
UT: The journey I’ve had has been an incredible one. I feel very grateful for the opportunity to have learned from the people I’ve worked with in therapy. They have been an incredible resource in transforming my understanding of immigration and trauma. One of the things that I have learned along the way is how incredibly complicated the process of immigration is psychologically.
Immigration is rife with hope and optimism and resilience, but also with deep separation and loss. And the ways that people reconcile this are unique to that individual and depend on so many different factors. It depends on their families, the quality of their relational life, their own personalities and what they bring to those relationships. It also very much depends on the traumatic experiences, the support they’ve received and the willingness of people to listen to them and to hear their perspectives. So much of what’s happened in more recent years, certainly since Trump’s election, is we have enormous anxiety among immigrants and refugees.
This anxiety is not only about status, the fear of deportation and separation from loved ones, but also related to the underlying anxiety that immigrants have always felt around not belonging and not being wanted. You know, feeling as though one must find other ways to sustain the self. And that’s been important for me to understand and bear witness to. So, listening to the stories of immigrants and refugees is not just about hearing what happened, but about witnessing and bearing what is happening now and what has happened in the past. There’s tremendous transformation that occurs across the lifespan for immigrants and refugees, as well as developmental points and junctures where their kids and their grandkids are also challenged. And that itself transforms one’s own experience of what it means to be an immigrant or refugee. So, there’s a lot that we still have to understand and learn and research. Actually, I think about these changes that occur as a function of time and cultural shifts and political context and social oppression – all those things.
LR: On a more personal level, if I may, how has or is being an Indian, Hindu female, informed your own multicultural journey as a clinician and a researcher?
UT: Well, certainly it informs a great deal of my whole self, which you know, I bring to my work as well. I immigrated to the United States when I was seven years old from India and grew up first in New York City and then in New Jersey and then moved to Michigan. And we traveled around quite a lot while growing up in the US as well. So, I think that one of the things that stood out to me in that process of adjusting to being in America was how incredibly resourceful my family as well as people in my community — my Indian community, the Hindu temple — were. We really found ways to take care of each other and be very present with each other in one sense. And yet in another way, people also have difficulty talking about painful losses and traumas, so there was this really interesting paradox within the community where I grew up.
I think it’s true for many communities that there’s this sense of cohesion and an incredible connection that feels positive that brings a great deal of strength for people. And yet at the same time, when there are issues of trauma such as violence in the home, racism, sexual abuse, or political oppression that people might have faced prior to immigrating, these things become much more complicated to talk about openly and become stigmatized. So, I became increasingly interested in figuring out what can we do about that and why is that the case? A lot of what I do in my research and in my practice has to do with trying to figure out those gaps and try to make mental health care more accessible to people who typically wouldn’t seek it out or who may not trust the typical mental health professional to understand their context, their values and their families.
I think anything that’s not considered mainstream American is not necessarily considered positive or normal in some cases or normative. People within immigrant communities have a lot of concerns. Racial minority communities as well.
I have concerns that if an immigrant sees a therapist, are they going to be seen as abnormal, or are their families going to be devalued? Is their culture going to be devalued in some way because of the very theories that we use to conduct psychotherapy? And so, there’s a lot of concern around that for people in addition to around providers’ not having awareness of the impact of trauma or the impact of emotional suffering on individuals and families. This is one way I think about my own journey interfacing with and guiding my professional life and is clearly very important to me. 

A Different Worldview

LR: What are the elements of the Indian and Indian American worldview that psychotherapists need to understand?
UT: I think there are some common shared elements. But I think that it’s also important to point out that, as you say, there isn’t one worldview. Somebody may say something like, “what’s it like to be an Indian person?” Well, you can ask a million Indian people and you’ll hear different things about what that means. So, I would say that there’s no one thing that’s definitive. There are many things, but I will try to narrow it down to a Hindu Indian perspective — but again, it depends on how much a person identifies with a particular religion or a particular ethnicity, and even a region within India and language, all those things.
One of the things that comes to mind as a common or a shared element of Indian culture is the ways in which families interact with each other. There is traditionally a respect for older members of a family, in a way — a deference.
And this leads us to think about conflict within families. While there is the tradition of deference to older members of the family, younger members may want to do something that’s not approved of by the older members, but they may then go ahead and do it. But in this instance, they tend to avoid speaking about the conflict. So, there are ways of communicating that are more culturally accepted or valued.
From a Hindu perspective, there’s also a belief in Karma, or a belief in the inevitability of suffering in human life. This is very interesting to me because it parallels psychoanalysis in a particular kind of way in that there is an acceptance of the fact that suffering happens and that there’s value in bearing suffering, at least to a certain extent in service of others, in service of a greater good. So, this feeling of being a part of something greater than yourself or bigger than yourself is something that I think a lot of Indians more broadly, but certainly Hindus, tend to value as well.
These are a couple of more common types of shared elements. There’s also a third thing I could highlight, which is a different sense of ideology around parenting. Parents are typically pretty involved in their children’s lives throughout their lifespan. The Hindu Indian notions of parenting don’t necessarily follow the same developmental lines of being 18 and going to college or being 21 and experiencing a definitive separation from the family. And so, in a lot of Indian families the separation may happen later, or it may take a different form in some other way later in life. So, that can look a little bit different from Western notions of parent involvement. And sometimes it’s extended family too, like aunts and uncles who play a significant role in the attachment and separation experiences within families. 

Sitting with Suffering

LR: Along these lines of differences in worldview, I understand that in Hinduism, as in some other religions, suffering for the greater good is seen as a virtue, as aspirational. Western psychotherapy, in contrast, seems bent on eliminating suffering, resolving irrational thoughts, helping the person to regulate themselves, helping the person to change their behaviors so they don’t suffer. And even though the third wave of cognitive behavior therapy incorporates mindfulness and acceptance, do you still see a tension between traditional Western psychotherapies that are designed to eliminate suffering and therapeutic orientations that embrace suffering for growth?
UT: To see some type of suffering as a normative part of life feels very aligned to me with the reality of what I see every day. But the idea that somehow to live a happy, fulfilled life you must eliminate all suffering, just doesn’t add up. I think it’s sort of a setup for people to actually feel even worse, and it creates more suffering because there’s a way in which this expectation creates the unrealistic expectation that one should never feel bad or one should never have negative experiences. And in fact, we all do and we all will and that’s sort of a foundational idea. So, I do see it as a problem of trying to eliminate the suffering as quickly as possible rather than trying to understand what’s happening. I do see that as a big tension.
LR: I wonder then if Western psychotherapists need to be aware of the intrinsic pressure of our models to sanitize living. An example, perhaps, is our seemingly uncomfortable relationship with death, dying and grieving. We remove people to facilities. We don’t talk about death. We have special grief counselors, which is okay, but what about conversations in families around loss and death? I worry that many therapists in our audience may be too caught up in that need to sanitize and cleanse the person of suffering.
UT: I think we probably feel some pressure to have to relieve people of how bad it feels. And I understand that. And of course, there are certain situations where that suffering is so overwhelming that we do need to help and relieve people. But if it’s something that is a natural part of a loss or separation that happens, we can help people to bear those and know that they will come through it. And so, you’re certainly instilling hope. But you’re not also giving this false hope that somehow everything will be fine after this. Because in fact, it often isn’t, you know?
LR: I wonder if therapists working with refugees and immigrants who have been trafficked, tormented or brutalized simply find it so hard to be in the presence of someone who’s suffered that they try purge them (and themselves by association) of their suffering? Or might some therapists simply not be cut out to work with these clients for reasons related to countertransference?
UT: I do think there are certainly some types of suffering that feel too much to bear for therapists, but that varies for each of us. Some things are going to just feel harder. And perhaps it’s because we’ve been through something similar or that we just don’t want to imagine, you know, and bear witness to that. And certainly, that happens. I’m thinking also of situations where a therapist may not know what to do with that suffering, so they minimize it or push it aside.
LR: Ignore it.
UT: Ignore it. I’m thinking of a situation where clients will talk about experiences of racism at the workplace or at school and wonder within themselves, was that racism? Was that why I feel so badly?
LR: It goes back to something we were talking about earlier in the conversation — core competencies of a clinician who is aspiring to cultural competence. So maybe we should add to this conversation the willingness and ability to sit in the presence of pain, someone else’s pain, our own pain, and bear witness to it — to embrace it, to allow it into the conversation. And in doing so, honor the client who has been oppressed, who’s been trafficked, who’s been marginalized, who’s been hunted.
UT: You’re right. You’re mentioning situations of extreme trauma like trafficking that feel, in some way, so foreign to so many people, as though it’s happening out there somewhere. And in fact, it’s happening in our own neighborhoods and in our own microcosms. I think that it speaks back to that earlier point we touched on which has to do with our own personal investment in these issues. If we don’t take the time to learn about what’s happening to people within our broader society, then it’s going to be very hard to listen for these experiences.
LR: You speak about our broader society. I worry that some psychotherapists consider our broader society maybe a few states away, or “all the way” out to the Coast. But when you expand the definition of “our broader society” to humanity beyond borders, then it’s really a commitment to considering that there but for the grace of Allah or Brahma or Yahweh, go I — that we are all potential sufferers.
UT: Yes.
LR: I wonder if certain therapists would actually benefit from working with such clients and to consider doing so to be a gift of enlightenment for them. A potential gift of the opportunity for awareness and growth.
UT: I think it’s so pivotal to growth as a human being and as a therapist. It’s transformative when you listen to people’s stories from various places and contexts; it is unbelievably transformative.

Final Thoughts

LR: Given that patriarchy and the masculine worldview have historically infused psychotherapy and religion, how does male privilege impact the practice of psychotherapy for you? What are some of the learning lessons we need to learn?
UT: It’s a big framework kind of question. When I think about male privilege more broadly, I see it in the context of our traditional theories that I think hold so much weight over how we think today. I don’t think, oh, well these were some of the older theories or theorists and that was a long time ago. But in fact, I think about how we’ve all been and continue to be socialized under certain models of thinking. In the research world, for example, there is still a valuing of a certain type of research which is quantitative and includes randomized clinical trials as the gold standard. Only certain types of methodologies fall under that umbrella, whereas qualitative research such as case studies are actually more feminized and seen as less valuable. Storytelling and listening and witnessing and participatory action research, which is not valued as highly as quantitative research, is really rooted in community psychology and feminist psychology.

So, I’ve been really interested in using the feminized methodologies and rethinking the issue of being privileged, how it applies to our research paradigms and ultimately to our clinical practices. You know, what narratives and whose narratives are being privileged, and why? Not to say that there isn’t value in all these different paradigms. I see great value and I learn a great deal from each of them, but I do think that the issue of male privilege brings up a broader question about privilege in terms of what therapies are available to different communities. I think about what research is considered to be gold standard and acceptable, and how that all translates to public welfare and people’s wellbeing. I think there are many ways to challenge the status quo in terms of that.

LR: A dichotomy between quantitative and qualitative as masculine and feminine. It seems that the newer therapies are much more relational, inter-psychic, narrative and contextual than the traditional therapies. This makes me wonder about you as a psychotherapist. When a client walks into a room with you, a Hindu, Indian female, what can they expect from you based on the intersectionality of you, of your Usha-hood?
UT: When someone comes to me for psychotherapy, I think they can expect someone who is really interested, curious about their life, about their perspective, how they make meaning of things in their life, and what’s important to them. And I want to hear their story. I want to know who they are as fully as I can know them and as they will let me know them. I want them to understand that we’re all vulnerable in some way or another, but also that being in psychotherapy itself can feel really precarious and that I understand that. I hope to make it a space where they can connect with as much of themselves as they can and make decisions that feel more fulfilling.
LR: So, you are curious, and you are caring, and you are contextual, and you are collaborative.
UT: I would say so, yeah. That’s what I try to be.
LR: Well, it’s about the journey, not about the destination. Right?
UT: True. Very true.
LR: Do you have any questions of me before we stop, Usha?
UT: I have one question. I am curious about how you’re finding this mode of interacting with your audience and what you’ve been learning from that.
LR: This mode of communication, the interviews I conduct, is the pinnacle of the work I do for Psychotherapy.net, because each interaction expands me as a teacher, clinician and as a person. Learning from some of the experts in the field, those who are passionate and committed has ignited my own passion and commitment to learn and grow. It has also made me painfully aware of my biases and limitations, but also of my gifts and strengths. It has made me all the more sensitive to stories, to context, and to the importance of deeply felt personal experiences. I hope that answered the question.
UT: It does and very much aligns with how I’m experiencing you. So, I just want to say that. It’s really been lovely to talk to you.
LR: Same here, Usha. I hope we can speak again.
UT: Me too.

© 2020 Psychotherapy.net, LLC

Unlearning to Learn

Posted on by Psychotherapy.net Team

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

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

Wabi-Sabi

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

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

Awe and Authenticity

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

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

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

Power and Fallibility

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

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

Curiosity and Trust

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

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

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

Unlearning to Learn

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

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

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

The Power of Witnessing

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

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

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

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

References

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

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

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

What Do I Say Now? Coping with Uncertainty in Unstructured Psychotherapy

Posted on by Psychotherapy.net Team

Come On, Be Helpful!

“I’ve been thinking about what we discussed last time,” the client began. “I think it would be best if I came here for long term therapy and I have to leave in half an hour.”

For a moment I was mind boggled by this dramatic expression of ambivalence. But I shouldn’t have been entirely surprised. The client, a 23-year-old woman named Sandra, had been disconcertingly difficult to pin down in the previous session, our first. She had come to therapy at the suggestion of other people, had described vague symptoms, and, when questioned about issues that sounded significant, had consistently denied that they troubled her much.

My work with Sandra occurred while I was in graduate school, and relatively new to doing therapy. At that time, I was still struggling with a problem that many of us experience early in our careers, especially when doing unstructured and/or non-behavioral psychotherapy: anxiety about how to respond to a client who gives you no clear focus and leaves you feeling increasingly lost.

I had encountered several such clients. Unlike the “easy” clients I’d always imagined and sometimes actually gotten—that is, clients who responded readily to questions and who moved quickly into important issues—many other clients were not so easy, and some especially not. For example, they might have trouble articulating their concerns, or, after articulating them, might find it hard to talk. Or, they might become superficial or tangential, or might seem unable to voice any clear focus or sense of what I could do to help them. “I knew it was my job to find the right questions to clarify their issues”. I was committed to exploring their concerns from a humanistic and psychodynamic perspective because I knew from my own experience how valuable such exploration could be. But this approach to psychotherapy rarely gives definite answers; rather, it emphasizes the importance of gradual self-discovery. And my training in these orientations now seemed hopelessly abstract and irrelevant in the face of these more difficult clients, and of their confusion—and my own—about what exactly we needed to do. My confusion was often accompanied by a nagging feeling of anxiety that sometimes bordered on a panicky sense of paralysis: Come on, Michael, do something helpful! But what?!

At the time, I did not know how common this anxiety is among inexperienced therapists—especially those of us who are inclined toward hyper-responsibility. In his excellent book Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy, Jon Allen recalls how lost and anxious he felt when he treated his first patient with systematic desensitization only to find that the patient was not satisfied with structured treatment and just wanted to talk about his problems. Allen went on to describe how he spent much of his early career hoping to find a clear-cut structured procedure for working with such patients, only to realize, eventually, the “utter folly” of his quest.

Exhausting Learning Curves

Much later in my own career, I saw the same struggle in many of my students when I taught an undergraduate course in elementary counseling techniques. The students were eager learners, and many had been in therapy themselves. When I cautioned them early in the semester that good counseling cannot be achieved simply by applying rules and techniques, they expressed understanding and agreement. But when they embarked on regular practice sessions in which each of them had to counsel another student about a real issue, these students had to face, for the first time, something that every counselor and therapist has to confront at one time or another: the anxiety of sitting face-to-face with another human being who is struggling with a real issue, and realizing that you haven’t the faintest idea what to say or do next. A few of the students had impressive natural skills and took to unstructured work like ducks to water; but most of the others experienced varying degrees of anxiety, sometimes expressing intense frustration that they were not learning enough.

I tried to explain to them that there is a learning curve and that as you increase your knowledge and experience in counseling, your anxiety is gradually replaced by a disciplined sensitivity and intuition that begins to guide your exploration. But the problem with this kind of reassurance is that the learning curve to which it refers is maddeningly difficult to describe. I will attempt to do so below, but it may be helpful to start by telling a story that clarifies the kind of learning curve I am talking about.

A few years ago, a young woman approached me in a coffee shop and identified herself as a student who had taken my counseling class ten years previously. She told me that she had gone on to attain a masters degree in a mental health profession, and she said that she wanted to thank me because my undergraduate counseling class had taught her more about doing psychotherapy than any of the courses she had taken in her graduate program. Naturally, I was delighted to learn that she had gotten so much from my class. But what really surprised me was that I remembered this student quite well, and that her course evaluation, which I still have, had expressed great anger about how little she had learned in my class!

So, what is this mysterious learning curve to which I refer? Well, it involves a number of things: learning how to create a supportive atmosphere; learning how to draw the client out with the right kind of questions; learning how to listen—really listen—to what the client is saying; and learning how to follow the many hints and leads in what the client is saying that may not be entirely obvious to the client himself or herself. Of course, these “hints and leads” are different for every client, which is why they cannot be specified in advance. But it is possible to show examples of this discovery process by looking at specific cases; and this brings me back to the client I described at the beginning of this article, Sandra.

An Introspective Swamp

As I have already mentioned, Sandra had presented in her first session in a way that was elusive and confusing. She had voiced vague complaints of anxiety and a general sense that she did not know if she could open up to a therapist. She was equally vague about the history of her anxiety, stating that both her mother and a friend named Matt had encouraged her to seek therapy after she had experienced abusive treatment by a man she had dated briefly. When I asked her about this and other experiences in her life, she had touched on several apparently important topics, including a sense that her relationships with men never seemed to work out; yet she denied that any of these issues had troubled her much. She expressed a feeling that it would be nice to talk to a therapist about these things, but she also questioned whether therapy might just lead into unnecessary rumination and depression. Given her ambivalence, I had suggested that we meet for three to five sessions to evaluate her concerns and then decide about possible further therapy.

As noted at the start of this article, she had begun her second session with the disorienting announcement that she had decided on long-term therapy and that she had to leave early. The remainder of this session did little to clarify where she was coming from. I began by asking her what had made her decide she needed long term therapy. She replied that she had had a long and intense conversation with her friend Matt in which they had discussed her personality. Matt had told her that she was “neurotic,” that she had “the worst self-image of anyone that he had ever met,” and that she needed therapy. After this, “Sandra had fallen into an “introspective swamp” and had been depressed for most of the week”, eventually concluding that she must be “messed up” and in need of long-term therapy.

Remembering that she had wondered in her first session about therapy leading to unnecessary rumination and depression, I reflected that she seemed to have mixed feelings about therapy. On the one hand, she felt she needed long term therapy, but on the other hand, she worried that too much introspection might lead into a “swamp” of depression, as had apparently happened with Matt. She quickly dismissed this possibility, however, and said that therapy once a week would not be too much introspection. Her dismissal seemed a little too easy.

Since I wanted to determine if her wish for therapy was coming primarily from her—as opposed to Matt—I asked if she could tell me which areas of her life might be problematic.

“Define problematic,” she said.

“I’d rather leave that to you to define.”

“Well, do you mean my childhood, or what?”

“I wasn’t necessarily thinking of your childhood. I was wondering about problem areas in your present life.”

“I’m not sure. I can’t think of any.”

“Well, last time you mentioned that your present life is not too happy in certain areas”

“True, but they’re not that bad. They only seemed that way when I thought back on them.”

“My confusion was increasing rather than decreasing”. She wanted therapy but seemed to be saying that she had nothing to work on. I tried again.

“How was it that Matt convinced you that you were neurotic?”

“Why do you ask?”

“Well, I understand that Matt thinks you’re neurotic, but I don’t know how you see yourself, what you think your problems are.”

“I don’t know what my problems are. That’s why I’m here!”

My head was starting to spin. I tried a different tack.

“What do you want in life?”

“Well, I’d like to graduate, to get good grades, to get a good job that pays well, and to have happy relationships.”

“Are you getting what you want?”

“Academically, yes. I have friends, and I’m getting along with my parents all right.”

“What about happy relationships?”

“Well, my love life is not perfect. But I believe it will get better.”

“What do you suppose is interfering in your love life right now?”

“I really don’t know,” she said. “Maybe it’s just a coincidence that nothing has worked out so far.” As I was pondering this, she added, “Is this normal?”

I observed that she seemed to be concerned about the process of the evaluation. She replied “Yes, you’re right. I shouldn’t do that.” I replied that there was nothing wrong with being concerned about it but that it might be helpful if we talked about it more in our next session. She said “No, that’s okay. I promise not to ask so many questions next time.” As our time was up, the session ended on this note.

Managing Uncertainty

Over the next week, I thought a lot about this case. I was baffled by Sandra, and frankly had no idea where to go from here. It wasn’t even clear to me that she needed therapy or, if so, why, since she was unable to identify a focus and seemed to have come to the clinic under significant pressure from her friend Matt.

I was starting to experience some of the anxious confusion described above—the kind of distress that early-career therapists experience, particularly in sessions where the client’s concerns seem persistently vague and elusive. Like Jon Allen, I could feel myself longing for reassuring structure. I considered referring Sandra for psychological testing, but as I thought about it I realized that this was more to still my own anxiety than to aid in evaluating her. I thought about doing a more traditional evaluation, asking her about various areas of her life (work, family, friends), but we had already done some of this and it appeared to be leading nowhere. I thought about focusing further on her feelings about being evaluated, but there was a very real possibility that we might end up spending the rest of the evaluation talking about the process of us talking about the evaluation!

As previously mentioned, this case occurred while I was still in graduate school, and I can add now that it was at just the point when the learning curve was beginning to bend for me. I had experienced confusing clients before and knew that the anxiety they evoked in me could signal important dynamics, both within our interactions and within the client. I knew that if I could read these signals correctly and use them to guide further therapeutic actions, they could become an aid rather than a hindrance in the treatment. I had absorbed a significant amount of clinical theory that had helped to guide this process. And one theoretical insight that had struck me as particularly relevant to coping with my own anxiety in doing unstructured psychotherapy was a central tenet of existential psychotherapy—the idea that every act in life, and in psychotherapy, is, in some sense, a “leap of faith,” a “jump from being into nonbeing.” There is no way of knowing where it will lead; what really matters is how we handle the uncertainty.

I thought about this now and realized that the most important thing that I could give this client was the willingness to continue the unstructured work, to step once again “from being into nonbeing” with her, and to see where it led.

Sandra arrived early for our third session. When we met, I began by asking if she had had any thoughts about our previous meeting. She said that she had. She had decided that Matt’s “thing” was therapy and that he had influenced her too much. She had also thought about the questions I had asked about her life and her relationships and had decided that most of her questions were “Dear Abby type questions,” like how to act on a date and when to kiss someone. She said that she would like to have a longer-term relationship, but she added that her relationships were not too brief and that brief relationships could be fun too. When I asked about the anxiety she had mentioned before, she said that she did feel “sort of” anxious at times, but “not too often,” and she speculated that maybe she just got too wrapped up in thinking about it.

At this point she suddenly asked, “What do you think of me?” I replied that she seemed concerned about being analyzed and noted that she had wondered about normality in our last session. She agreed that she had wondered about this—especially when she was in high school, a time when she had been shyer and more introverted—but that this was not much of a problem anymore. I said that I had the impression, however, that there was something attractive to her about the idea of therapy. She admitted there was, and asked what other people talked about. I replied that they talked about a wide variety of things and that I wondered if she was concerned, again, about whether she was normal.

“Yes, I probably am,” she replied. “I’m only here because of Matt. He called me just before I came today and said, ‘Don’t back out.’ I told him “Now listen, I’m going to go by whatever the counselor says. It’s up to him.”

“Why didn’t you tell him it was up to you?”

“Matt would never accept my judgment.”

“Suppose he didn’t. What would happen then?”

“He would say ‘You’re making a big mistake, you’ll be sorry!’ Then I’d have to defend myself to him, especially if things went badly and I became upset later.”

“Wow!” I said. “That sounds pretty uncomfortable. You’d have to defend yourself, maybe at a time when you were already feeling upset about something else. I can understand why you wouldn’t want to be in that position.”

“Yes, it would be uncomfortable! “I don’t know why I’d have to defend myself to Matt. It’s not up to him. We’re not doubles”.”

“What do you mean?”

“He seems to regard us as emotional doubles. When I first told him about the abuse I experienced, he described how he had been in a similar situation once. But we’re not that much alike. He doesn’t necessarily know what’s best for me. No one knows everything.” She sounded a little surprised by this insight.

At that point, I reminded her that when she had first come to the clinic she had said that her mother had also recommended that she come in for counseling. She said that that was true, that her mother had also felt that Sandra had been traumatized by her recent experience of abuse. When I asked why, Sandra explained that her parents had known she was upset and that her mother had attributed many little reactions of Sandra’s to the abuse. She added that her parents were surprised that the abuse had not “blown her away” or “freaked her out.” She had always been “sort of high-strung” and they had expected her to react a lot more negatively than she had. I commented that sometimes people in families fall into certain roles; the family expects them to be a certain way and then they begin to see themselves that way. I wondered if this had happened in her family and if it had had anything to do with her concern about how normal she was. She seemed quite interested in this idea and said that it might. She said that her whole family was somewhat volatile and that she was just a little more open about her feelings than the others.

By this time, we were nearing the end of the session and she said to me, once again, “What do you think of me?” It seemed appropriate to give her more feedback at this point. I told her that I thought she was very influenced by other people’s evaluation of her. I added that I suspected this had something to do with her experiences in her family and that it had operated regarding Matt. She said “Well, Matt is kind of a unique case” and then stopped mid-sentence and corrected herself, saying that a boyfriend she had had in the past had done the same thing. I suggested that we discuss this further in our next session. She said thoughtfully, “Yeah, they don’t have divine inspiration.”

Lessons Learned

Sandra and I met two more times. During the first of these sessions, Sandra reported that she was in a good mood and felt good about our previous session. But, she had realized that her parents had imposed labels on her many times, such as “hyper” and “emotional.” We explored her relationships with men and how she might better, or at least differently, handle feelings of insecurity. We also discussed whether further therapy would be helpful. I emphasized that her own judgment about this was most important.

In our final session, Sandra said she had been feeling good and that she had been taking things more in stride since our sessions. She had tentatively decided not to pursue longer term therapy, but she asked if she would be able to see me if she decided to come back later. I said she could, and we decidedly left the door open; however, she expressed satisfaction with things at present and a sense that she could deal with things on her own. She did not return.

I have described this case in some detail because it embodies a moment when I became particularly aware of how one can manage one’s anxiety about doing unstructured treatment while feeling lost at sea in a complicated therapeutic dynamic. Sandra’s presentation, particularly during her first two sessions, had evoked significant anxiety in me due to its elusive and confusing character. Before our third session, I had given much thought to this and realized that “I had to accept my anxiety, recommit to the unstructured approach, and follow it through to increasing clarity about Sandra and her concerns”. Reflecting on the case now from a more experienced vantage point, I see three factors that made this possible.

First, I had already accumulated a degree of confidence from my previous experience working as a volunteer counselor and a graduate intern. Of course, confidence is a double-edged sword. It does not always match good performance and can even reinforce poor work, a fact which therapists—especially new therapists—cannot afford to ignore. But in my previous work, I had gained real experience and had supportive supervision that had taught me a great deal. Looking back on my work with Sandra, I now see that even amidst the confusion of our first two sessions, I had laid more groundwork with her than I had initially realized—if nothing else than by taking her concerns seriously and working hard to understand them. And Sandra’s movement toward greater openness, her willingness to revisit material I had not understood, her remaining in the session she had planned to leave early, her arriving ahead of time for her next session and her increasing interest in therapy all suggested that she was feeling a greater sense of trust in our work. I believe, therefore, that some confidence was justified. But perhaps more importantly, if this had not been the case—if things had been moving in the opposite direction toward greater confusion and discomfort in the sessions—I believe I had also acquired some justified confidence in my ability to recognize when these kinds of problems develop, to point them out, and to carefully engage her in an exploration of why.

Second, by this time in my career I had studied a variety of theoretical perspectives on psychotherapy and I was able to draw on several of them during my work with Sandra. Having these perspectives available gave me the tools to ask questions that seemed to move the process forward; and furthermore, they had sensitized me to important clues in what Sandra had already said—the “hints and leads” to which I alluded above. In the third session, particularly, I can now see that—while I was not conscious of it at the time—I drew on several different theoretical perspectives in the following interventions to better understand and work with Sandra: (1) Rogerian reflection (to deepen our understanding of her concerns about normality, rumination, depression and social influence); (2) existential confrontation (to point out that the decision about further therapy was hers, not Matt’s or mine); (3) Rogerian empathy (to validate her concerns about Matt’s criticism); (4) psychodynamic exploration (of the childhood sources of her self-doubts), and (5) systems theory (to consider the role she might have fallen into within her family).

Though I drew on diverse perspectives, “I believe I escaped the dangers of shallow eclecticism” and/or using various techniques mechanically (as I was later to warn my students against) because I was also developing my own overarching theoretical perspective, which was primarily psychodynamic. From this perspective, I was forming a rudimentary sense of Sandra which could point the way forward in using these interventions productively and which was roughly as follows: She was a young woman whose family circumstances and social experiences had left her with some issues of hurt, shame and over-reliance on the opinions of others; but her inherent strengths and intelligence were also enabling her to develop an increasingly strong sense of autonomy. Her ambivalent presentation in therapy reflected feeling caught between, on the one hand, wanting to explore in detail the sources of her insecurity; and on the other hand, wanting to assert her autonomy and move on with her life. Between the second and third sessions, I came to realize that the most helpful thing I could do for Sandra was to sideline my own anxiety, to stay with her exactly in the middle of her ambivalence, and to use what I knew about psychotherapy to help her discover precisely what she wanted to do.

The third and most important factor that made this possible was the inherent strength of the client herself. Even though she was, at times, exasperatingly vague and ambivalent, she also showed a consistent commitment to hang in with the therapy and continue exploring her concerns. In fact, Sandra’s investment in the treatment and her ability to use it successfully highlight a crucial truth for me about psychotherapy, one that should be both sobering and reassuring to any relatively new therapist: in the final analysis, the most important factor in successful treatment is not the work of the therapist but rather the work of the client.

This point can hardly be overemphasized. Anxiety in new therapists is almost always accompanied by an overestimation of the importance of their own interventions. Of course, interventions are important, but not as important as the client’s ability to use them. This fact may be a blow to our therapeutic egos, but it should also be deeply reassuring. My students sometimes feared that they would make a mistake that would damage the client. I assured them that all therapists make mistakes and that these mistakes, in themselves, are rarely damaging. What is truly damaging is when we fail to realize that we have made a mistake and go on to make it again and again—usually as a result of inadequate training, impaired self-reflection, narcissistic overconfidence, or some combination of the three.

Barring serious mistakes by the therapist, most clients will get better if they are motivated to do so. Even without psychotherapy, most people who suffer from psychological problems will tend to show improvement over time. But competent psychotherapeutic help from any number of theoretical orientations can significantly strengthen and reinforce this process, especially when the relationship and fit between the client and the therapist is good. And in unstructured psychotherapy, the commitment of the therapist to step with the client “from being into non-being” can play an important and helpful role.