David Wallin on Attachment and Psychotherapy

Only connect

Randall C. Wyatt: It’s good to be here with you, David, to talk about Attachment in Psychotherapy, which is also the title of your new book. We want to focus on the clinical meanings of attachment, and how focusing on attachment and mindfulness makes psychotherapy different—for the therapist, for the client, for change.
David J. Wallin: Gotcha.
RW: But let’s start with a quote from the very beginning of your book, from E.M. Forster: “Only connect. That was the whole of the sermon.” Can you speak to what this quote means to you?
DW: When I first read the quote and was drawn to it, I thought what it meant was “only connect to other people,” but actually, I think what Forster had in mind was to connect the various parts of oneself. I liked the ambiguous, double meaning of that: how we connect or don't connect to other people, but also the ways in which we connect or don't connect to various aspects of our own personalities.

RW: How did you first come to be interested in how attachment ideas affected psychotherapy?
DW: My own development as a therapist traced a pretty common pathway from a classical psychoanalytic approach, then to ego psychology and object relations theory, self psychology and the intersubjective and relational perspective. I felt I'd found a home when I'd found relationality and the intersubjective perspective, because it seemed to speak to the essentially relational quality of the practice of psychotherapy.

I'd read John Bowlby as an undergraduate, and I'd probably dipped into Bowlby at various points along the way, but I was not terribly familiar with attachment theory. Then I began subletting hours in my office to Nancy Kaplan, who happened to be one of the three authors of the Adult Attachment Interview. I went out to lunch with her one day and said to her, “I wonder, is there a particular book or an article that you would recommend to me to begin to wrap my mind around attachment theory? Because I'm very interested in it.”

And Nancy said, “Well, I can't really think of a particular book, but let me pull some stuff together for you.”
The next day I came to my office and there was a grocery bag full of books, a stack a foot and a half high of chapters and articles.
The next day I came to my office and there was a grocery bag full of books, a stack a foot and a half high of chapters and articles.

So I started reading, and very quickly I realized that intersubjectivity theory and attachment theory were a conceptual marriage made in heaven. Attachment filled in the largely missing developmental and diagnostic dimension of intersubjectivity theory, and intersubjectivity filled in the largely missing clinical dimension of attachment theory. So wedding the two provided a framework for understanding what goes on in development, psychopathology, and psychotherapy.

Intersubjectivity and attachment

Victor Yalom: What was missing in attachment theory that intersubjectivity provided and vice versa?
David J. Wallin: Attachment theory was and is primarily a theory of development. Secondarily, it's a theory about how development goes awry and results in what we might call psychopathology. It's also generated a lot of research. But it's not primarily a clinical theory.

Bowlby had written a book called A Secure Base, where he talks about attachment theory in relation to psychotherapy, but he doesn't go that far with it. Attachment theory is a relational theory about how we develop in the context of relationships. Intersubjectivity theory and the relational perspective are theories about how people change in psychotherapy. If you transpose a lot of what the relational, intersubjective theorists have to say about how the therapy process works to the developmental context provided by attachment theory, you've got an extraordinarily rich framework for guiding your interventions in psychotherapy. At the same time, that way of putting it, I think, makes it sound like one's work as a therapist is probably more guided by theory than in fact it is.
RW: In a certain way, both intersubjectivity and attachment ideas are about two-person relationships, whereas initially in psychoanalytic thought, there was the idea of the blank screen, one patient projecting onto the neutral therapist. The mother/child and the therapist/patient, they’re both about very close relationships that seek to facilitate development of the child or patient.
DW: Precisely. I think that's part of the important meaningfulness of both theories. Indeed, Bowlby was very discontent with the analytic explanations of his day, which seemed to explain development and psychopathology exclusively on the basis of what went on inside people, and their fantasies about what went on between them and other people.
RW: Intrapsychically more than interpersonally.
DW: Exactly. The focus was on the child's fantasies and how those shaped the course of development, and the focus in psychotherapy was on the patient's fantasies and how those shaped the unfolding transference-countertransference situation. Bowlby realized that that was a ridiculously incomplete way of thinking about what actually happens in relationships between parents and kids, or patients and therapists. Similarly, intersubjectivity theory is a very lengthy retort to Freud's notion about the necessity that the therapist function as a blank screen, surgeon-like, staying above the fray, which I think is impossible.
VY: I think many people have a general sense of attachment theory in Bowlby’s ideas or attachment work, but didn’t delve into a whole shopping bag. When you did, what were some of the ideas that excited you?
DW: I think the short version is that it was the research that I found interesting. It wasn't so much Bowlby's books as the work of people like Mary Main, Peter Fonagy, Mary Ainsworth—others who were testing Bowlby's ideas and extending them, in ways that had tremendous clinical usefulness.

Mary Ainsworth initially identified two ways in which development goes awry in childhood, what she called avoidant attachment and ambivalent attachment. Mary Main discovered a third way in which development goes awry: disorganized attachment. And those scientifically researched variations on the developmental theme I found very compelling, and certainly more compelling than conventional diagnosis, which had once been very interesting to me.
VY: You’re talking about DSM-type diagnosis?
DW: I'm talking about hysterics, obsessives, borderlines, schizoids, paranoids, and so forth.
VY: The DSM point of view is pretty descriptive, where attachment categories are more of an underpinning to what forms these take in relationships.
DW: The attachment categories gave me a way to both understand the states of mind in which my patients seemed to be lodged at particular times, or the states of mind in which I seemed to be lodged at particular times—and also to imagine something about the childhood relationships that might have given rise to those particular states of mind.

For example, I began to think about the patients in my practice who might be described as dismissing. The dismissing state of mind is the adult corollary to the avoidant attachment classification in infancy. I found myself thinking about these patients who seemed to be remote from themselves and remote from other people as adults, who as children had needed to remain at something of a distance from their parents, but also from aspects of their own internal experience that might have driven them to try to get closer to their parents.

I was able to look at my patients' experiences through a theoretical lens that was orienting and helpful—and, ultimately, in my thinking through of this whole matter, allowed me to come up with some theoretical guidelines for how one might helpfully intervene with a patient who's in a particular state of mind with respect to attachment. I also had to think about my own states of mind with respect to attachment, in ways that seemed to have some implications for how I might attempt to conduct myself.

Putting words to our experience

RW: So you’re saying that certain states of attachment—dismissive, avoidant, disorganized—or secure, for that matter—point to different ways to intervene with patients based on this way of looking at them? Can you give an example of a dismissive patient and what you might do?
DW: That's right. For example, somebody who is fairly dismissive, seems very cool, who begins the session, by saying, “How are you doing?” “I'm okay. And yourself?” “Fine. Doing fine” despite things going poorly in their life. With somebody who's really at a distance from his or her own internal experience, emotions, bodily sensations, and so on, I tend to assume that I'm going to have to learn about what's going on in the patient in significant measure on the basis of what I become aware of going on inside myself.
VY: I notice you gesture a lot, which the readers won’t be able to see, but when you gesture with your hands that your patient is pushing you away, is there a visceral sense that you often get?
DW: I think that's true. I think with a patient in a dismissing state of mind—I notice I'm making that same gesture—I think one can feel pushed away. This might be somebody for whom connecting in psychotherapy to what's going on inside is going to be very important to the patient, but the patient is often not going to be able to do that on his own. Everything inside the patient and in the patient's history works against making those connections between their conscious self and their internal experience.

I also tend to assume that what we can't allow into our awareness of our experience—which also means what we can't talk about, what we can't think about—we tend to evoke in other people. So I'm inclined to believe that by paying attention to what's going on inside myself, I may get some clues as to what's going on that is most salient inside them.

I might be feeling pushed away because the patient's pushing me away. But this is, I guess, that old standby, projective identification. Often what I find myself experiencing is in some way a reflection of what the patient is really experiencing, in Freudian terms, in a kind of a preconscious way. In other words, it's kind of on the tip of the patient's tongue, emotionally speaking, but he or she is out of touch with it.
RW: And you think there’s great value in speaking what’s preconscious or preverbal for the patient. Why, or how, do you think that’s valuable?
DW: I think that when we lack words for our experience, our experience tends to be much more gripping, much more overwhelming. I think having words is a way to communicate about our experience, so that putting hitherto unverbalized experience into words allows us to feel less alone with it. And feeling less alone helps us to feel less overwhelmed.
Putting experience into words is a part of how we integrate experience.
Putting experience into words is a part of how we integrate experience.
RW: I think most therapists would go with that. The traditional therapist, over time, would ask the client, “Well, what are you feeling? What are you thinking? What are your free associations? Tell me your dreams,” to get at that. But you are clearly saying that the therapist should voice some of those thoughts and feelings. What’s behind that?
DW: Number one, it creates an emotionally live exchange, which is a big part of what I think can be missing in the therapy with patients in this dismissing state of mind. Therapy can be a conversation of talking heads—low on life, low on emotion. So when the therapist leads with his or her own emotional experience, that can open things up for the patient. I think there's a kind of modeling there: it may be safer for the patient to think and feel, or safer to feel certain things, than he or she may have thought possible. And if the therapist models that, it opens up possibilities for the patient.

There's this great quote from Bowlby, where he quotes Freud saying that, for the patient who is discovering what he previously believed forgotten, there's almost always the same sensation, or the same words might be spoken, which are I've always known that, but I never thought it.
RW: Kind of knew it pre-verbally, bodily.
DW: Yes. Christopher Bollas, with his book, The Shadow of the Object: Psychoanalysis of the Unthought Unknown, may well have read that same passage in Freud. In any case, the idea there is that patients often know more than they can put into words about their internal experience. So when the therapist articulates some aspect of what's going on in experience, the patient often recognizes it.
RW: Can you give us an idea of a particular patient that this was relevant for?
DW: I remember talking to this one patient—this was a guy who had me feeling, first of all, like he was about to walk out the door any minute. He was only in therapy because his wife insisted that he get into therapy.

Virtually from the beginning of therapy, I had had this sensation that I was only able to describe to myself by the third session. The sensation was that
I was on the witness stand dealing with an exceptionally brilliant and aggressive prosecutor, and my language had, consequently, to be bullet-proof.
I was on the witness stand dealing with an exceptionally brilliant and aggressive prosecutor, and my language had, consequently, to be bullet-proof. At a certain point, I felt like the patient was probably going to quit anyway, so I might as well say what was on my mind. So I told the patient that this was my experience. And he said something like, “That's incredible. You're describing my experience.” But he had never been able to put anything remotely like that to me previously, so that was the point at which something clicked in the therapy, and the patient wound up sticking around for a couple of productive years.
RW: It reminds me of hearing a song that really connects about loss, love or life and feeling like the singer knows just what you feel, that is powerful, it means a lot. More to your point, the therapist’s subjective experience can be a valuable part of the equation in the client’s understanding their subjective experience.
DW: Absolutely. I think the therapist's subjective experience when working with patients is almost always a valuable resource.
VY: Whether it’s spot-on or not.
DW: Yes, whether it's spot-on or not.
VY: If it’s not quite right, they can say, “Yeah, that doesn’t feel quite right; that’s not quite my experience,” and then elaborate.
DW: Exactly. And sometimes what I have to say really rings a bell, strikes a responsive chord, and other times, although more rarely, it doesn't seem to fit. It's my sense that there is almost always a meaningful, rather than an accidental, relationship between what the therapist is experiencing in the session and what the patient is experiencing.
VY: Now, going back a bit, when you told that story, that was a great image about the patient as a prosecutor. I think these images come up all the time to therapists, whether we express them or not. But you said he was about to leave anyways, so you didn’t have anything to lose. And then you say, “Well, I might as well take a risk.” And yet, why does it have to get to that point? Why not express those feelings more freely? I think there’s been a bias in our profession not to show that.
DW: Yeah, that's a good question. That's for sure. And I think that, as time has gone on, I've been personally less and less gripped by that bias, but there are certainly times when I'm still enthralled by it and may hesitate to disclose something of my own experience.

For what it's worth, I have found that when I have disclosed my experience, far, far more often than not, it seems to have a fruitful outcome. In other words, the emotional involvement of the patient and me seems to deepen, or we get into some material around which some meaning seems to emerge that hadn't previously been apparent to either of us.

I must say, though, that
there have been a handful of occasions on which it's kind of blown up in my face
there have been a handful of occasions on which it's kind of blown up in my face, but generally that's happened when the disclosure has come out without the slightest reflection and bursts forth, perhaps angrily, from my side. And there have been a couple of occasions when that's turned out to be extremely problematic.
RW: I guess that’s where clinical judgment will come in. Because sometimes you disclose—any of us, any therapist—and it could be a mistake or not have the intended effect, and how to deal with that is part of it too.
DW: But of course that's true of any intervention.
RW: It’s true of being silent and listening and not saying anything.
DW: Or interpretation, or a joke, or advice, anything.
VY: Yet the most common complaint I hear about clients who have seen previous therapists is they didn’t say enough.
DW: “You're not one of those therapists who never says anything, are you?” (laughter)
RW: “Do you interact with your clients?” they ask.
DW: I've heard that question before.
RW: Do you have any rules of thumb for self-disclosure or judgment in that respect?
DW: The primary criterion for me is, “Do I think this is going to be in the patient's interest?” How I gauge whether or not it's in the patient's interest is probably difficult to say.

Certainly there are some disclosures where you blurt something out. And sometimes that's okay and then comes spontaneous interaction; it's probably a healthy feature of many successful therapies. But I think if I'm considering in my own mind, “Is it going to be useful to say something about my experience here with a patient?” generally the criterion is, “Can the patient make use of this? Do I expect that the patient will be able to make use of my experience? How is the patient going to be able to make use of this?”
RW: That is part on an intuition developed over time, or personal experience, in life and therapy.
DW: I think there's a real skill involved in presenting one's experience to the patient in a form that's usable. I think there are the nuances of language that come pretty automatically to me, which I think wind up having the patient feeling that what I'm contributing, what I'm disclosing, is not a threat. It's not a criticism.
It's not a demand. It's something for the two of us to see together if we can make use of or not.
It's not a demand. It's something for the two of us to see together if we can make use of or not. But I think those same nuances in language are probably vitally important when you're making an interpretation or asking a question, or whatever. There's ways to talk that are more or less easy to listen to.

How is a therapist like a parent?

RW: Let’s move to another key attachment idea, expressed where Bowlby wrote, “The therapist’s role is analogous to that of the mother who provides her child with a secure base from which to explore the world.” Jeremy Holmes (John Bowlby and Attachment Theory) wrote from a bit of a different angle, “So what good therapists do with their patients is analogous to what successful parents do with their children.” These seem to be foundational to your applying attachment theory and research to psychotherapy. How do you think about this connection?
DW: When you write a book, it can be a wonderful magnet for other people's responses. I got an email out of the blue from Louis Breger, whose book, From Instinct to Identity, I had read when I was a graduate student at The Wright Institute in the ‘70s. He liked my book very much, but he raised the question,

“To what extent do we make the mistake of assuming that there's no difference between the adult patient and the baby?”



My response was that if we think about therapy as kind of a new attachment relationship, it's a new attachment relationship that's between two adults, but also a relationship between the therapist as parent and the patient as baby. Or maybe, in some ways, it's also a relationship between the therapist as baby and the patient as a baby—in other words, those baby parts of our selves. You know, we don't leave those behind entirely.
RW: The vulnerabilities, certainly.
VY: Fears, anxieties.
DW: And the preverbal experience that remains inside us undigested. We bring those yearnings, those fears, to adult relationships. I think it's meaningful to think of that as, in a sense, the baby part of us. When that very young part of us can come alive in the relationship with a therapist, there's an opportunity for that part of us to change and to develop.

The other thing that I have found useful is to think about the research on the features of the most developmentally facilitative parent/child relationships, and use that research as a springboard to some ideas about what's most developmentally facilitative to bring to the relationship with the adult patient. There are lots of other writers—Holmes, Allan Schore, Winnicott—who've pointed to the symmetry between what we provide as good parents and as good therapists.
RW: A good-enough mother. A good-enough therapist. In what sense do you as a therapist try to embody that connection, that idea? I mean, you’re not a parent in this role, you’re a therapist.
DW: Yes, of course. In my book I lay out four ingredients of growth-promoting relationships in childhood from which one can draw lessons for psychotherapy. One of them is the fact that the relationships between parents and kids that seem to generate the healthiest, the most flexible, the most secure, the most resilient offspring, tend to be relationships that are maximally inclusive. In other words, they make as much room as possible for the depth and breadth of the kid's feelings, desires, views, behavior. The kid is allowed to experience a whole lot of himself in the context of a relationship with a parent who is curious about that kid's experience and is making room for that kid's experience.

I think the same thing is true of psychotherapy. You can look at psychotherapy as a relationship in which the therapist, as an attachment figure, is attempting to make room for experiences the patient's original attachment figures couldn't make room for. So to that end, I'm interested in getting to know as much as I can about what the patient is feeling, hoping for, afraid of; what the patient wants from me, what the patient's sense of our relationship is at any given moment, what's going on inside the patient's body. I just want to make as much room for that as possible, because I think it's conducive to the integration of previously dissociated experience.
RW: Previously dissociated experiences… Can you talk about that and how it might play out in therapy?
DW: Mary Main as well as Bowlby and a host of psychoanalysts makes the clinically useful point that we can think of the internal world as a registering or duplicating of what has occurred in our first relationships. But Main goes on to add that there's another way to think about the internal world, which is as a registering of rules for processing information.

In our first relationships, we learn what's ruled in and what's ruled out: what we can safely feel, speak, and want. I think of dissociated experience as experience that has been ruled out on the basis of what's occurred our early relationships. It is also a consequence of experience that is traumatic, whether it occurs in the context of early attachment relationships or later attachment relationships or, for that matter, outside the context of attachment relationships.

A lot of us are most profoundly affected, although often in ways that lie outside our awareness, by dissociated experiences that we've never been able to fully know
A lot of us are most profoundly affected, although often in ways that lie outside our awareness, by dissociated experiences that we've never been able to fully know, experiences that we've never been able to fully think about or feel, or be articulate about. Dissociated experience often really has a grip on us. It determines a lot of what we do and don't do, say and don't say, feel and don't feel, think and don't think. So as a therapist, I always have my eye out for what the patient doesn't seem free to think, feel, want, know and so forth.

In therapy, dissociated experience is often an experience the patient can't put into words, or an experience that can't even be put into thoughts or feelings. My attention often is on what is being evoked in me, because I think what people can't own and articulate, they often evoke in others. I've also got my attention on what's being enacted between me and the patient, since that's another way in which dissociated experience gets expressed.

Finally, I've got my attention on what's going on in my own body and what's going on in the patient's body, because I think often what can't be consciously known, the body knows. In some way, it becomes part of the person's somatic experience: the way he carries himself, the sensations in his body.
RW: It’s pretty profound, that is, your attention to the therapist’s experiences as an important source of information about what is dissociated in the patient related to attachment, their past, and therapy.
DW: I refer to it as somatic countertransference—what's going on in the therapist's body. I think these categories—what's evoked, what's enacted, what's embodied—tend to overlap. Sometimes what's evoked in the therapist, what the therapist experiences is a bodily sensation.
VY: And some therapists are much more in tune to their body, some are more in tune to their emotions, and some their thoughts.
DW: Yes. I remember a number of years ago, I went to a presentation by Elizabeth Mayer who died a few years ago. She was making the point that different therapists have different resources, as you say. Some are really good at paying attention to what's going on inside the bodies in the room, and some are really good at paying attention to dynamics of transference and countertransference, and others are really, really good at working with dreams. And whatever your resources are, that's what you bring to bear on the encounter.

Psychotherapy with an attachment focus

RW: Your work is focused on how to enhance and increase one’s skill and engagement in this attachment world. So what is different about your work?
VY: Another way to ask this might be, “If you’re a fly on the wall watching an attachment-oriented therapist, would it look any different?”
DW: That's sort of a hard question to answer because I don't know how other therapists work.
VY: That’s the mystery of our profession.
DW: So, in a way, all I can say is how I work.
RW: A very honest answer. Let me thank you for not acting like you know distinctively what’s so different. That said, something guides you and makes you attend to different things than others.
DW: Right. I think there's probably a pretty close relationship between what an attachment-oriented therapist, on the one hand, and a relational, or intersubjectively oriented, therapist, on the other hand, might do. The primary similarity is that there's a lot of attention to what's going on in the here-and-now relationship, what's going on in the patient right here, right now, and what's going on in the therapist right here, right now.

When I'm working at my best, I'm very inclusive and integrated. There's a focus on my own internal experience. There's a focus on the patient's internal experience. There's a focus on evocations, enactments, embodiments. And then there's also a focus on this whole matter of my relationship to my own experience as I'm sitting with a patient and the patient's relationship to his or her own experience as we're sitting together. The whole question of mentalizing and mindfulness is one that's very often on my mind as I'm sitting with and working with a patient.
RW: Now, you said a lot of things there: the client’s experience, your experience, our experience. To raise a more practical question, are you also working with the person on their divorce, or job loss, or panic, and so on? How is the content or context of the patient’s life brought in?
DW: Of course. I have a couple thoughts about that question. One is, as a therapist, I'm sure I have a lot in common here with psychoanalysts like Owen Renik (see Interview with Owen Renik) or Michael Bader, who write about the importance of symptom relief in therapy.

Very often, I'll find myself saying to the individuals or couples with whom I'm working that I tend to work at two related levels. One is a practical level: what's troubling you? What's getting in the way? What's bothering you? What can we do about that together?

And then there's another level which is more psychological, having to do with the relationship between what you're experiencing that's difficult and what you've experienced growing up, the ways you've learned to think and feel, and what you've come to believe about yourself and other people. I think if I'm leaving one or the other out, I'm not doing you any favors. So I'm going to be trying to focus on both of those goals.
RW: To go a step further, your assumption—and your experience, I would think—is that focusing on the psychological, the interpersonal, the intersubjective affects the patient’s lives in terms of depression, panic, relationships.
DW: Absolutely. I think of these as two intertwining braids of the same rope.

I always feel like I have to start where the patient is, so I'm trying to get a sense, sort of intuitively throughout any given session, what's most emotionally salient for the patient? What's most interesting or troubling? Or if the patient seems far away from any experience, as if nothing is interesting or nothing is troubling, that gets my attention. But I think the focus on starting where the patient is at means that you're focusing largely on what's bothering people.

The therapeutic relationship and the patient’s relationships

RW: How does the therapeutic relationship get translated to their own relational world—in their relationships, in love, in parenting?
DW: I think there are probably a bunch of ways in which the practical level of things is ameliorated through a focus on what's going on in the therapeutic relationship. For one thing, we're talking about somebody's relationship to himself or somebody's relationship to other people, generally, that's what bugs people. That's what troubles people.

It's my relationship with myself: I'm feeling depressed, I'm always getting anxious. Or it's my relationship with other people: I'm always feeling insecure with other people, or I just feel really distrustful of other people, or I'm angry at other people, or I feel let down by other people, or other people seem more important and smarter than I am, or whatever it might be. It seems like people are bugged by aspects of their relationships with themselves or relationships with other people.

If I, as a therapist, start to pay attention to what's going on in my relationship with a patient, it provides a kind of here-and-now experience of aspects of the patient's relationship to other people, or the patient's relationship to himself, that are troubled.
RW: Can you give us an example of this from your work?
DW: I am thinking of man who has a hard time feeling close to his wife and I notice is somewhat remote from me and remote from his own feelings. If I can find a way to talk to the patient about the fact that—for example, “God, we're talking about this very troubling stuff and you seem utterly unaffected. I asked you what you're feeling about it and you say ‘I'm thinking' or ‘I'm reflecting,' but you're not feeling it. I just have to wonder what's going on there; whether you don't feel safe to have your feelings when you're with me or whether you are having a hard time connecting with what you're feeling generally.”

And then later I might say something like, “If you're not feeling a whole lot about some stuff I've been saying that I would imagine would evoke a whole lot, it leaves me feeling sort of disconnected from you.”
VY: What happens when you make those kind of statements?
DW: Ideally, I think the patient gets really interested: “Wow. God, I seem to be emotionally cut off from experiences that, at least according to you, ought to be really getting to me. I wonder what that's all about?”
VY: And after they get interested?
DW: As time goes on, often bridges are made between what goes on in the therapy relationship and what goes on in other important relationships the patient has; some of those bridges are made to the past. As the patient talks about his or her experience, the therapist has ways of being with that experience, tolerating that experience, that allows the patient's experience to deepen.
RW: So that’s the secure base that the therapist is seeking to provide in the relationship with the patient.
DW: That's a part of it, providing a secure base. I think that means generating a relationship in which the patient feels both safe enough, challenged enough, engaged enough, understood enough, accepted enough to venture where he or she has previously felt it was too dangerous to go.
RW: I had a client who, in the first few sessions, revealed a lot of painful stuff about trauma and childhood and abuse in his family, and then soon after, he told me he was just horrified that week, from nightmares, everything…
DW: As he connected with his traumatic experience.
RW: As he connected to the traumatic experience, which was very overwhelming. And then he wrote a song about it, starting out, “I was born in living hell” and it sounded like it. At first he felt he just wanted to run away from the therapy: “This therapy thing is too much. Hey, I had a few sessions of therapy and now I’m overwhelmed.” He stuck with it, though, and explored his life, which was, for him extremely risky, and I certainly sought to provide a space to do this.
DW: Right. I think patients have to sort of figure out, on the basis of their experience with us, whether, in fact, it is safe. Do our responses allow the patient to feel understood, accepted, or not? There is a kind of common experience with patients who have been traumatized, that it's extraordinarily difficult for them to feel safe, and I think they often manage to find unsafety in situations that we might imagine are safe. For example, they might feel that we're seducing them into a relationship with us, which they expect, on the basis of their own experience, to actually and inevitablybe a dangerous experience, a dangerous relationship.
RW: So it’s a real risk they’re taking that needs a lot of safety to dive in—not to be underestimated.
DW: Based on my experience with a lot of different patients, confronting trauma almost invariably raises questions about the safety of the relationship with the therapist. Often these are two intertwining processes: so when you're dealing with the question of safety or danger in the relationship with the therapist, that regularly reels in issues of past trauma.

I think there's a common model, which has some meaningfulness, that we create a relationship of some safety, which provides a container within which, at some point, the patient will feel appropriately secure enough to confront the traumatic experience of the past. But I think that that model makes a whole lot more sense if you think of this not as two-stage process but rather as two facets of one process that you're going through over and over and over and over again.

In other words,
if you're paying attention, you are repeatedly noticing the patient's concern with issues of safety and danger in a relationship
if you're paying attention, you are repeatedly noticing the patient's concern with issues of safety and danger in a relationship with you on the one hand, and you're repeatedly either hearing echoes of or explicit references to the patient's traumatic history on the other hand, and you're going to be touching on one and then the other, for a good long time.

The role of mindfulness

RW: You’ve made mindfulness central to your work with patients. Let’s focus on the important role you see for mindfulness in therapy.
DW: When I first contemplated writing this book, mindfulness had no place in my thinking whatsoever. And it was only very accidentally—or maybe there's some synchronicity at work here, or grace, or God knows what—that i stumbled upon the whole matter of mindfulness. I just happened to be thinking one day about some of the ideas that I was writing about at the time. I was thinking about some of Fonagy's ideas…

I remember I was sitting out on my deck and I was feeling very relaxed when I had this fanciful image of three concentric circles. The outermost circle represented external reality. Within that, there was a second circle representing the representational world of mental models, and so on. And then within those two circles was a third, which stood for what Fonagy calls the reflective self, which is that part of the personality which is capable of reflecting on the relationship between the representational world and external reality.

And as I was thinking about these three circles, what seemed like the inevitable questions came to mind: Who or what is it that is doing the reflecting on the relationship between the representational world and external reality? What is the reflective self? Who or what is doing that reflecting? What's the reflective self made of?

And as I asked myself these questions, I got an answer, not in the form of a conceptual understanding but an experience.
I had this sort of dizzying sense of an imploding self.
I had this sort of dizzying sense of an imploding self. It's very hard to describe, but it was as if my ordinary sense of self was collapsing down to a single point, which represented nothing but impersonal awareness. And so it seemed like the answer to the question, “Who's doing the reflecting?” was, no one, or no personal self.

Maybe a year after this, I was watching this movie, Fierce Grace, which is about Ram Dass post-stroke. He talked about his first psychedelic experience in which he'd had an almost identical implosion of self, a disappearance of a sense of personal identity, personal history, in which his self seemed to be reduced to nothing but awareness.

As I was having this experience, I also felt this tremendous sense of well being, a much-enhanced feeling of connection to other people. I began to feel like, you, I, and everyone we know, and maybe our pets, are all basically the same at their core. So there was this much-enhanced sense of connection to other people. There was much-reduced defensiveness.

All in all, it was a powerful and liberating kind of awareness that I was able to hold onto for probably a couple of weeks; at first I couldn't stop talking about it because it was so compelling. And it seemed like the people who understood what I was talking about were people who were meditators or had some kind of spiritual practice, as it's called. And so I ended up becoming a committed meditator because it seemed to me this state of mind was devoutly to be sought. It also seemed to me that this state of mind I experienced was associated with what in the Buddhist tradition, is called mindfulness.

Meditation seems like a route to that awareness of awareness, and it seems to be a route to a capacity to be present with a modicum of acceptance. Mindfulness also fits in perfectly with the whole idea which has been so thoroughly researched in the attachment field: the idea that people's experience is changed to the extent that their relationship to their experience is changed.
VY: What was the link, then, from this amazing experience to attachment ideas?
DW: In the attachment research, there's been a lot of work done on the impact of the development of what's called a reflective stance–what Mary Main calls a metacognitive, and Peter Fonagy calls a mentalizing stance—toward experience. And what seems to be true is that
a reflective stance toward experience buffers one against the worst impacts of trauma.
a reflective stance toward experience buffers one against the worst impacts of trauma. This stance also seems to ultimately be capable of allowing those of us who have experienced inauspicious beginnings of the sort that might be predicted to lead to insecurity, to raise secure kids.

So a big part of the thinking that went into my book on psychotherapy and attachment was around this whole concept of a reflective, mentalizing or mindful stance as one that transforms our relationship to our experience in such a way that we are liberated from many of the constraints that are generated in the course of our personal histories. So I'd refer sort of fancifully to mentalizing and mindfulness as the double helix of personal liberation or psychological liberation.
RW: Is that something that you talk to clients about or you just use it indirectly—mindfulness and mentalizing?
DW: Mostly I use it indirectly. There are a handful of patients at any given time in my practice with whom I begin each session with maybe five minutes or so of meditation. There's a somewhat larger number of patients to whom I suggest that meditative practice might be of use.
RW: How do you approach your own sense of mindfulness in the session?
DW: I think the whole matter of mindfulness is one that's almost always with me in any given session. I'm thinking about the extent to which I'm actually capable of being present with a patient at any given moment, or am I somewhere else. Is the patient present or is the patient somewhere else? I'm attempting to do what I can to be present, and I'm attempting to be mindful. And I'm attempting to do what I can to help the patient be present—also known as helping the patient to be more mindful—in the same way that I'm attempting to help people become more effective mentalizers of their own experience.
VY: Certainly this idea of mindfulness is present in many schools of psychology. I studied very closely with James Bugental, and what he called presence in the client and the therapist seems quite similar.
RW: I would agree, as in presence, or being versus becoming, noticing versus evaluating. But it goes even further, I believe. Mindfulness seems to have roots in every major religion in a way—thinking of Islamic surrendering, Christian grace, mystic prayers, Buddhist acceptance, Jewish sense of God’s will, or Hindu karma. There seems to be something really powerful about a client accepting, “I was traumatized,” or “I’m experiencing something in my body now” or “I’m depressed and afraid”—just noticing and being with whatever is.
VY: Or “I’m feeling right now, in this relationship, x and y.”
RW: While I think it is all good and fine to learn and grow, it seems to be freeing to be here now, as Ram Dass used to say.
DW: Yes. Yes. Yes. It's very interesting to me that, even as we speak about mindfulness, I feel more present with the two of you.
RW: Yes, I noticed.
DW: Isn't that remarkable? And when I teach about this stuff or focus in this way with a patient, it's like once I start talking about it, if I can get mindful, things change. It's a little magical.
RW: There’s something freeing about it; it loosens up possibilities to accept life as is.
DW: When I get mindful or when you guys get mindful, I think part of what happens is we get present. And what that means is that, among other things, subjectively speaking, the past and the future are sheared away, which I think tends to reduce a lot of anxiety, depression. Because often, where we are in the present moment is not that bad. It's not that dangerous. It's okay. So I think there's a measure of emotional or internal freedom that comes with this presence.
RW: I’m thinking now that such mindful living and being able to be present might actually increase the secure base?
DW: Oh, exactly, precisely. I tend to think that as you meditate, or just have the experience over and over and over again of being present and noticing, and especially when you become aware over and over again of awareness, that has the potential to become a version of the internalized secure base.
VY: I think for some clients—the withdrawing, schizoid person—meditation doesn’t always help. They can retreat into that world of meditation and it does not necessarily help them connect more with others.
DW: I think you'd have to look at the nature of their meditative practice. Yet, I do think that what you're talking about is a reality. In certain communities, that's talked about as spiritual bypass: they're bypassing their own internal experience by spacing out or dissociating. That's a different animal, it seems to me.
RW: You address spiritual bypass well in your book—that it’s about a yin and yang balance. You’re not suggesting mentalizing or mindfulness so you can avoid life. It is the engagement and connection to oneself and others. As you said, you had your experience and then you were very connected. It wasn’t an escape. If it is merely an escape, that is another matter.
DW: Yes. Sometimes what I'll do actually between sessions is meditate for even just a few minutes. That often grounds me in such a fashion that I'm actually capable of being more present with the people with whom I'm working.

Three pearls for therapist practice

VY: I know you do a lot of teaching these days. Before we wrap this up, what are the important points about your work that are most crucial to convey to those you are teaching about an attachment approach?
DW: There's a book that I've been asked to be part of that is going to be coming out in the future, which is called something like Clinical Pearls of Wisdom: Essential Insights from Leading Therapists, and I was asked to offer my own clinical pearls.
VY: We want a preview, then.
DW: Okay, here you go. For me, the clinical pearls are as follows: First is that the therapist's own attachment patterns are frequently, if not always, the primary influence shaping his or her potential to be of help as a therapist. In other words, our own attachment histories and the dissociations they have imposed, and the way that we have worked through some of those dissociations—all of that generates the therapist's potential to be insightful as well as vulnerable to being stuck in an impasse with a patient. So I'm talking about the centrality of the therapist's own psyche as both a facilitator of and a constraint upon what he or she is capable of doing with patients that's going to be helpful. Secondly…
VY: Would you be willing to share one thing about yourself—in understanding this better—that helped you be a better therapist?
DW: Sure. And I'll try not to cry. This idea became extremely vivid for me in the context of work with a particular patient with whom I had felt myself to be stuck. This was a patient with a history of trauma and some very serious obstacles that he was introducing into his own life that were very much limiting his capacity to have a decent relationship and to know himself.

At roughly the same time, I was working in my own personal therapy, in such a fashion that I bumped up against some extremely painful, difficult feelings about myself that had to do with experiences I had when I was very young—experiences that left me with a set of feelings about myself that were profoundly shameful and practically unbearable, and had me thinking some very self-destructive thoughts. And in the course of working through this experience in my own therapy, I've gotten somewhere that's been very useful.

Around the same time, I was in a peer consultation group describing my feelings of anger and envy in relation to this traumatized patient. He happened to be an extraordinarily wealthy guy who could just about do whatever he wanted to do. And one of my consultants said, “Okay, we really have a sense of what it's like for you to be with this patient, and we have a sense of who the patient is today, but you haven't said a word about his childhood, how he got to be the way he is.” And it was that question that prompted me to make bridges between my own experiences and the experiences of this patient.

As I talked about the trauma this patient had experienced as a child, I started to cry. I became aware of the ways in which I identified with this patient—how the impasse in which I found myself with him was in some ways a product of my own experiences.
I didn't want to drag the patient into that particular torture chamber that I was getting to know so well.
I didn't want to drag the patient into that particular torture chamber that I was getting to know so well.

And the rather remarkable thing is that the next time I saw the patient, practically before I could say a word, I had a sense that the encounter that we were having was occurring at a deeper level. I was able to see the patient not as somebody toward whom I felt angry and envious and whose power I was very much aware of, but instead, I was able to see the patient as a kind of scared, humiliated young kid.

The awareness of the ways in which I was avoiding—I mean, this is the nutshell version—inviting this patient into an encounter with his own feelings of shame as a function of my own difficulty moving into that terrain—that was keeping our therapy stuck. And once I began to integrate that part of myself, I was able to make room for that part of the patient in the therapy.
RW: Beautiful and poignant. Two other pearls?
DW: Okay. So the second pearl is a question to ask when you are trying to figure out how your own attachment patterns are having an impact on the therapy. The question to ask yourself is extraordinarily simple: “What am I actually doing with this particular patient?” It's not always a question that you can get a complete answer to, because the answer is often hidden in the foggy realm of the dissociated, but I think you can certainly see the tip of the iceberg when you ask yourself, “What am I actually doing with this patient?”

I think the literature on enactments often focuses on what it is about the patient that is being enacted that's hooking something in the therapist. What I'm suggesting is there's a much more direct route to understanding what's going on in our enactments with our patients, which is simply to ask ourselves, “What am I actually doing with this particular patient?”

And then the third pearl is that often getting into a mindful state of mind is an aid to answering that question in a productive fashion. If you can actually get present and ask yourself, “What am I doing with this patient?” often there's a clarity that wouldn't otherwise be available to you.
RW: Thanks for sharing your pearls with us today. We didn’t get a chance to get to everything about your work today, but quite a bit, I’d say.
DW: Thanks, yes, we got to a lot.
VY: Thanks for sharing this wealth of knowledge and wisdom.

Hanna Levenson on Time Limited Dynamic Psychotherapy

The Interview

Randall C. Wyatt: Good morning Hanna, nice to have with you with us. Did I pronounce it right?
Hanna Levenson: Either way. My real first name is Hanna-Mae. It’s a hyphenated first name. Hardly anyone knows that.
RW: I like that name, now we all know it. Let’s get right to the work you are most known for, Time Limited Dynamic Psychotherapy, otherwise known as TLDP. Usually when people think of psychodynamic psychotherapy, they think long term, psychoanalysis, or at least that the therapist wants it to be long-term. So it almost seems like an error, a typo or something.
HL: Yes, people do sometimes have trouble putting those two together, although Freud certainly did very, very brief therapies when he first started, and many were quite effective. His length of the therapy elongated as the theoretical parameters became more and more encumbered. So, it doesn’t have to be an oxymoron.
RW: Right. How did you first discover that it wasn’t an oxymoron, Time Limited Dynamic Therapy?
HL: My original entrance into the field is kind of indirect. I was originally trained as an experimental psychologist with emphasis on social psychology and personality theory. And then later on, as my interests and responsibilities grew more and more clinical, I, what they called, retreaded – lovely term – I retreaded into clinical psychology. So I didn’t become steeped in the tradition of long-term analytic therapy. I was used to working with groups, with individuals in a much more pragmatic way, more from a research standpoint than from an academic standpoint. But the whole arena of psychodynamics fascinated me. The emphasis on the unconscious, on conflict, and on transference and countertransference. So it just seemed natural to take that and adapt it to my understanding of social contexts. Plus my own style, I think, is more of a pragmatic, impatient, let’s-get-to-it style so that led me to the brief part.
RW: Impatient? What do you mean, impatient?
HL: It can cut both ways, because I often get feedback that I’m very, very patient in the clinical work, or when I’m teaching, but I’m impatient in that I’m really looking to make every session count. How can I get the most mileage, whether I’m teaching or doing clinical work? How can I help someone get from A to B in an efficient and yet as respectful way as possible? So I like seeing results, but I’m also fascinated with the process, so when I seek results I don’t necessarily mean just focusing on the end point. In those micro-interactions, can I see that the work has deepened? Can I see that the work is furthering?
RW: Well, impatience is a word that generally isn’t used in therapeutic lingo, not that I’m against it, since sometimes patience has its limitations as well. But I imagine you’re using impatience in the sense that it’s a good thing.
HL: Absolutely. I mean, people come in and they’re suffering; that’s the major reason people come in to therapy. They’re suffering, they’re in pain. And how can we be of help to them as soon as possible? Yet also having respect, not just for symptom relief, but for the bigger picture.
RW: What’s the bigger picture to you?
HL: The bigger picture to me includes what is the context in which the person lives? The social milieu? What is their personal background? What are the stressors that they’re dealing with? So, all of that.
Victor Yalom: You focus a lot on their long-term interactional or interpersonal patterns.
Hanna Levenson: Right. What is there about those that might cause someone to come in with symptoms of depression, anxiety or emptiness?

An Integrationist Point of View

VY: So it seems like you try to do two things. You’re trying to cover both bases – you’re trying to work with symptom relief, which there’s a lot of emphasis on in cognitive therapy. But you also try to do some structural personality changes.
HL: Right, and I also should say that originally I was very enamored of cognitive-behavioral techniques, as well as systems theory, which I come by legitimately with my interest in social psychology. So I don’t see these all at variance with one another. It somewhat puzzles me, to tell you the truth, that so many of my colleagues identify with a kind of strict orientation. So there’s the cognitive behaviorists, and then there’s the psychoanalysts, the humanists, and people who are interested in systems. And for me it all kind of really flows together, that these are all valuable orientations, ways of looking at the person, and all orientations are trying to be of help.And so it seems natural for me to look at schema theory. It makes a lot of sense when you’re talking about someone’s pervasive dysfunctional style. It certainly makes sense to look at conflict and unconscious processes. It certainly makes sense to look at the system which might maintain that dysfunctional way of being. So it all just makes sense to hold it together in a more integrationist point of view.

RW: I certainly know what you mean, that a lot of people identify very closely with their own church be it CBT or psychoanalysis, or existential. Well, everybody has a favorite, but do you sense that they aren’t open to other theories, or they’re only open to one?
HL: I have a colleague who very much identifies as a cognitive therapist, but I tease her that she’s a psychodynamic therapist in cognitive clothing. Let me back up. If you open up the door of the experienced therapist and listen in, it’s often very hard to actually discern their orientation. Because I think we all get to be rather flexible and pragmatic and tuned in to what the client needs, with more and more experience. So I think it’s more the neophyte therapist that kind of latches onto a more rigid adherence to a theoretical orientation, and appropriately so, developmentally. Don’t get me wrong. I think that’s an important way of learning – to really steep oneself in one approach, and really push the limits of that approach.

The Essence of Time Limited Dynamic Psychotherapy

VY: Before we start comparing your approach to other approaches, what is the essence of Time Limited Dynamic Psychotherapy?
HL: The way I practice it, I really see it basically as psychodynamic in orientation, which is to say, looking at things like transference, countertransference, conflict, processes that are out of awareness, and combining that with aspects of cognitive and systems orientations. I don’t view people as being fixated in some early intrapsychic stage which is unchangeable. The person may develop a style, a way of being early in life, but that’s always open to change, depending upon other people, other social environments, other trauma that they might come in contact with, or other healing environments, and in my case, psychotherapy. I’m also very interested in the affective component of how someone puts their world together, and very much from attachment theory. So it all just makes sense that it hangs together for me.
RW: What do you take from attachment theory?
HL: I take from attachment theory that basically what drives human beings is not sexual and aggressive impulses, nor how to construe the environment in a more cognitive way, but rather the need to attach to other human beings, the need to be accepted, the need to feel close, and especially the need to feel secure. But that is inborn, and we all seek that. It’s just that things might go awry in that process.
RW: So how does this need for relationships play out in therapy, then, for you?
HL: Well, the person enters therapy and has a way of interacting with me, as well as what they tell me about their past way of interacting with others. I try, from those two sources of information, to formulate what have been some difficulties with attachment in the past, what kinds of security operations might the person need to have developed in order to stay as much connected as possible, and what might be necessary experientially and cognitively that would help them shift from maybe this lifelong dysfunctional pattern in life.
RW: Can you give an example of that?
HL: Let’s say there is a boy who was raised by very authoritarian, dogmatic, punitive, harsh parents. And so he develops a style, a way of being that is subservient, anxiety-ridden, placating. It makes sense given the pushes and pulls from his parents. It might be the only way for him to stay safe in that family, since at a very young age he’s totally dependent on them. He needs to come up with some kind of compromise – compromise on maybe his true emotional feelings, so that the more angry feelings, the more assertive feelings get suppressed. So he goes through his childhood in that way, and then in adulthood, since he’s now got a well-ingrained style and pattern, he continues to manifest this anxiety-ridden, placating way of presenting himself to others, and may even, unconsciously, seek out people who are more punitive, arbitrary, superior — not because he’s masochistic, but because it’s what’s comfortable. It’s what he knows. So then he enters the therapy room, again being this placating, subservient, anxiety-ridden man.
VY: So what do you do about that, and how do you use the therapeutic relationship? How do you address these issues?
HL: In the sessions, I, the therapist, might find myself becoming more the expert than usual. I might find myself becoming more reassuring, maybe more advice-giving. Already I am adopting a style that would be the reciprocal, the complement, of this patient’s style. So, I not only observe his style and way of being and formulate according to that, but I’m also very cognizant of my own reactions to him, what I call interactive countertransference. And then by being aware of seeing how his behavior and interactions affect my own interactive countertransference, I think about what would need to shift in the here-and-now, in the therapy room, that could give him a new experience of himself, that could give him, perhaps, in this case more a sense of being assertive, more a sense of being angry even, and certainly more a sense of me as the therapist as not having all the answers, of not thinking less of him, of not shaming him.
VY: How am I going to do this with a client?
HL: So that’s one thing. This is keeping me on my toes. Secondly, I would want him to have some insight into what’s going on. I want him to have a kind of cognitive understanding—
VY: From the experience and the insight or understanding?
HL: Exactly, both of those. And that makes my approach somewhat different than the traditional psychodynamic approach that is more insight-oriented. You know, the belief that insight will set you free. Well, we know now that insight unfortunately doesn’t set us free. I think it helps a lot, and it’s very interesting, but it doesn’t necessarily mean we’re going to be less depressed and less anxious, and so forth. So I want to go an experiential route, because nothing succeeds like having a new experience of something. And the truth be known, these are two sides of the same coin. It would be very hard to have a true new experience without some understanding and very hard to have a true insight without having an affective component.
VY: I always refer to a quote by Frieda Fromm-Reichman that patients need an experience, not an explanation.
HL: Right. Right, exactly. I’m very fond of that quote. I’m fond of a quote from Hans Strupp, “The supply of interpretations far exceeds the demand.” Speaking of Hans Strupp, it’s very sad, he died last week. A real pioneer in our field. Eminent researcher, theoretician, but also just a mensch. Just a very decent human being. I was very saddened to hear it, he had such an impact on my work.
RW: You studied with Strupp?
HL: I didn’t study with him per se. He was doing his NIMH study in the mid 1980s, and I had read a draft of his book, which came out later in 1985, Psychotherapy in a New Key. Wonderful book. And so I had the chutzpah at the time to just invite myself to Nashville and say, “I think I’m doing something similar to what you’re doing. Can I come and take a look?” And at that point no one had done that, so they were a bit intrigued and very open. And I went, and had the chance to sit in on all of their training groups that were going on, and it was the beginning of a wonderful collegial relationship. And then we ended up publishing some papers together and some chapters together, and so we had a 20-year relationship.
RW: Do you see your work as similar to Strupp’s and his colleague’s work, or different?
HL: Yes, it’s similar in that the way I formulate is very much an adaptation of their way, really looking at what the interpersonal story is that the person is telling and the way he or she acts in the world. Where I differ is what I mentioned previously, is that they were emphasizing that if you have a good enough relationship, a good enough alliance, then go for the insight, go for the understanding. And I’m saying yes, a good enough relationship is of course critical no matter what kind of therapy you’re doing, but above and beyond that, I think you can be more focused in the experiential learning part. I don’t think it’s one size fits all. I think we can really hone in and be much more specific, kind of like an experiential version of insight. Something very unique to the individual.
VY: This might be a good segue back to the case you were presenting on, how you would do something experientially to address the interpersonal problems and patterns.
HL: Right, and in fact, Victor, you just nicely demonstrated one of the ways I do it, which is to maintain a focus. You got us back on the focus where we had left off, after a little side trip, and by your saying that, you bring me back to where we left off. This focusing is an extremely important factor in how most brief therapists work; bringing the person back to a central theme. And so that’s one of the ways I would do it in treating this anxiety-ridden man, for example.One way I would keep a focus is to look for themes. What am I hearing about the redundancies in the way he acts in the world: what are his thoughts, his feelings, his wishes, his behaviors, chiefly of an interpersonal sort, since this is an interpersonal model. Second, what are his expectations about how others will behave? Third, what is the behavior of others? Of course, as seen though the eyes of a patient, we don’t have the others there, except for the therapist. How do they respond? And then fourth, how does that leave the person feeling about themselves? What is that person’s introject? How do they treat themselves? And then that, in turn, causes them to act, think, feel, etc, so we really have described a story about the person interpersonally.

RW: Where does the cyclical part come into play?
HL: I act, think, feel in a certain way and expect other people will treat me in such and such a way. In fact, they treat me in this way, and all of this leaves me feeling X about myself, which causes me to act, feel, think, and then what we have is a cyclical maladaptive pattern.It’s cyclical; it feeds on itself. It’s maladaptive because it doesn’t work well for the person, and it’s a pattern because it occurs over time, over place, over people. So that’s what I’d be trying to do, from an insight-oriented place, help this client see this pattern. At the same time, I will be experientially working on reinforcing and highlighting those places where he is behaving differently, where he is moving out of this rut, and I’d be very mindful of myself and my own reactions, to see if I end up reenacting something dysfunctional with him, or can I step back and help provide him with some new experiential learning?

Working Psychodynamically in the Here-and-Now

VY: One thing I recall from the video that you made, Time Limited Dynamic Psychotherapy was that you actually articulate, put into words, your awareness about your own reactions. And I think that’s different, at least, from people’s stereotype of how more psychodynamic or analytic therapists use countertransference. That you really engage in the here-and-now with the patient, rather than kind of making a transference or countertransference interpretation that is more distant or in the third person, or leaves the therapist out of the equation.
HL: Right, for example, I might say to a patient, “You know, I notice I’m telling you a lot of what to do, and I seem overly sure of myself compared to how I usually am. I’m wondering what might be going on.” And in doing that, I not only allow us to take a look at the here-and-now situation between the patient and myself, but I’m also saying, “I’m contributing to this dynamic between us.”So this is perhaps another, different point of view from the caricature of the analyst, which is that I’m not neutral. I’m not this benign, neutral, mirror representation. I am someone who gets hooked into acting and reacting to the pushes and pulls of the client.

VY: Well, I think it’s a really key point, because I think some of the modern dynamic people, the intersubjective folks, certainly the Gestalt and the existential and humanistic therapists, have talked for years about working in the here-and-now in the relationship. And I think one of the things therapists have the hardest time is really learning how to do that. Do you agree with that?
HL: Yes. I think somewhere students learned either at their parents’ knee or from their supervisors or teachers, if you can’t say anything nice, don’t say anything at all. And of course one always has to be tactful, in therapy as well as in life, because you want to be heard. But we are really depriving our clients of such critical, important information if we don’t share: “Well, this is what I’m struggling with as I interact with you.” And clients are often very grateful for that feedback given all the usual caveats about the timing of it and the nature of the alliance, and all those things we need to be mindful of. But yes, I find it’s hard for beginning students to do that, and sometimes it’s hard for advanced therapists to do that, because what it does mean is you enter the fray.You have to get down into the trenches with the client. You can’t stay up here in a lofty position, and it’s dirtier down there. It’s messier down there, and you don’t know exactly what’s going to happen down there.

VY: And you have to be more vulnerable as a therapist.
HL: Absolutely.
RW: So during the session as a therapist, you’re feeling more vulnerable. In what ways does that serve or not serve the therapy.
HL: Yes, in a healthy, open way. I don’t mean vulnerable in like, “Oh my goodness, I need to become protective. I need to erect a wall because I’m going to be hurt.” That kind of vulnerability would not be helpful, and in fact sometimes I think the therapist seeks the expert position from on high because the therapist does feel too vulnerable. And then you have a defensive or what I call a security operation that sets in, that actually promotes keeping that distance. Rather, I am speaking of an open vulnerability. It’s a trust in the process – let’s put it that way. It’s a trust in the process.
RW: I’m thinking of the intersubjective wing of psychoanalysis and the well-known and prolific analyst Roy Schafer who talked about changing how we therapists speak about ourselves and our clients. Certainly there’s this line of thinking going on in a lot of existential-humanistic, and definitely psychoanalysis, as well. Can you give an example of any time recently where you’ve felt something in the room and you’ve shared it with a client, and it was either negative or difficult to say?
HL: Yes. There are many. Let’s see. A woman I saw, who was rather egocentric, and if one were to diagnose her, they would probably say that she has a narcissistic style.
Early on in our work she found that most everything I said was ineffective to her and sadly lacking. She said my comments were not deep enough, not on point, not psychoanalytic enough. This was a woman who had been in analysis.
VY: She was critical of you?
HL: Yes, she was quite critical of my interventions and of me; she wouldn’t broach it directly, but indirectly with side snide comments and a heavy hand. But of course this was one of the reasons that she had come into therapy. She was having significant difficulties with her daughters and her husband. One of her agendas in coming to therapy was to really shape up her daughters and her husband.But as I was feeling this barrage from her, I could feel myself moving further and further back in my chair and becoming more and more unable to say anything. Certainly I was trying to get a good alliance with her, but it was becoming increasingly difficult.

So I finally said to her, “You know, you’re a force to be reckoned with, aren’t you?” And it kind of startled her. She said, “What do you mean?” And I described my reaction and that I was very aware that I was feeling very ineffective and not competent. Well, this came as a complete surprise to her. She had no intention of wanting to do that, and it was very useful information and something we referred back to time and time again in our work.

Those moments become earmarked, which allows me to say another aside, that I’ve often found that being this open about my countertransferential reactions, can actually build an alliance. It isn’t like you have to wait to have a good alliance before you could say something like this, but like with this woman, you need to find a way to bring yourself back into the room, find a way to bring yourself back into relationship with the person.

VY: It’s hard to genuinely engage her if you’re feeling like you have to stifle all these negative feelings you’re having.
HL: Absolutely.

Becoming Aware of and Using Countertransference

VY: Given that you agree that this is a hard skill for therapists to learn, other than having personal supervision with you, for example, what are some ways that you find that are helpful for therapists to learn how to do this? Because it’s very different than what therapists usually learn in grad school or most post-graduate education.
HL: That’s a great question, Victor. I find that if you can record, preferably videotape, but at least audio-record your work, it’s enormously helpful. When we’re in the therapy room, especially for beginning therapists, it is so difficult to keep track of all that is happening: one’s own feelings, what’s going on in the transference, what’s going on affectively with the client, nonverbal information, etc. So being able to listen to an audiotape after a session, or even better yet watch a videotape of what goes on while the therapist or trainee as observer is in a different emotional state, really allows therapists to see all kinds of things.
VY: And what do you listen for, or watch for?
HL: The therapist’s nonverbal behavior. I might wonder: What am I doing? Why am I doing that, rubbing my hands a lot? What’s going on there? I’m having trouble looking at the client. What’s going on there? What’s that tone in my voice? I sound tremulous. I sound angry.
RW: It sounds like the first step is to be more aware of what kind of countertransference reactions are getting engendered. So then the second step is how to find a way to put those feelings into words in a way that’s going to be helpful.
HL: Yes, and also acknowledging that there is a reality to the client’s perception. That’s another thing. So that when the client says, “Well, am I boring you?” Rather than saying “Well, what makes you say that?” And then they’ll say, “Well, you’re yawning and your eyes are at half-mast.” Then what do you say? “Do other people always look bored to you?” Do you take it out of the room? Do you take it to a safe place distant from you, or do you say something like, “You know, I think you’re right. I wasn’t aware of it but I think I was drifting off. Can we go back and take a look at what was just going on between the two of us? When did you notice that I was not as present? When did you notice that I was looking bored?” It is giving some validity, as an interpersonal slice of life, to the client’s perceptions. It isn’t all projection.
RW: That’s an amazing, amazing concept in itself, which I say with some irony, that the therapist will acknowledge that the client’s perceptions are accurate or have some validity, and aren’t just something to be questioned and wondered about.
VY: In fact, to deny what actually is, is anti-therapeutic in a sense. If they are having an accurate perception and you’re denying it, well, that’s no help to them.
HL: Right, and you said, “If they’re having an accurate perception.” From an interpersonal therapist’s point of view, you would not even wonder right there about the accuracy.
RW: There’s no one objective reality. There are two interpersonal realities.
HL: Right, because if I say they’re having an accurate perception, that means that I have to be all-knowing. I have to know all of my unconscious processes, I have to be aware of everything, and I can determine as the therapist on high what is accurate and what isn’t. So my assumption is that maybe it doesn’t fit for where you are. I know sometimes when I’m listening very intently, I can look angry. I might furrow my brow, and so I know enough about myself that when I’m really looking and listening intently, it can come across as angry.So when the person says, “Gee, you look angry with me,” I may know there’s something being misperceived. But nonetheless, I take what they’re saying as important, and we can explore that and we can process that, and maybe at some point it gets to my actually sharing with them, “I’m really listening very intently, but I know I can come across as angry, and what’s that like for you?” And I can also say to them, “You know, I’m not feeling angry at all, but I really appreciate your courage, your willingness to take the chance of letting me know that.”

What to Self Disclose and what to Hold Back

RW: Let’s go to another level of self-disclosure. How do you decide what to disclose to the client or to keep hidden? Obviously you don’t say every single thing on your mind. You don’t do that with anybody.
HL: Right.
RW: What guides you in disclosing to the client about your own process?
HL: Excellent question. What guides me is the formulation. In fact, the formulation guides me in everything. The formulation leads to my goal, the goals lead me to my interventions. So that in getting that formulation, going back to that cyclical maladaptive pattern, if I have an idea about what is the style, what the person invites in others, what is their own self-concept, etc., then that is going to allow me to devise some experiential and insight oriented goals, and then that is what’s going to guide me.So for example, with the person who comes in who’s placating and subservient, I’ll be listening for any opportunity where he might say something assertively. Anything where he might say, “I want,” especially if it might seem to contradict something I’m saying, for example. So I would want to highlight those times, capture those times, elongate those times, dwell on those times. However, let’s say there’s someone who comes in who is quite hostile, that that’s part of their cyclical maladaptive pattern, and in reciprocation they invite hostility or subservience, and that’s what gets them into difficulty. Then if they keep challenging me, then that might not be something that I’d want to reinforce, that I might want to focus on.

VY: You might instead reinforce the time when they’re more vulnerable or softer.
HL: Exactly, exactly. So what happens in a session is really driven from how I am formulating the case, and what are my goals. So I really need to keep those at the forefront. This also gives me the opportunity to maybe make a little segue in this interview and say that I use this approach even when I’m doing long-term therapy, and I enjoy doing very long-term therapy, as well as briefer therapies. But I do tend to keep a more focused approach when I’m aware of the formulation and my goals.
RW: And so what’s the difference? The way you practice sounds not so different than the way I practice, using insight, experience, here-and-now work, transference, and countertransference. What makes it short term? What makes it time-limited or long?
HL: In general, and a gross overstatement, I try and make every session count, because I don’t know how long I’m going to see the person; that’s up to the client, for the most part. So we know that 80 to 90 percent of clients drop out before the 12th session, whether or not they’re in managed care. People stop when they have gotten enough out of therapy, or it’s reached that kind of threshold between cost-benefit, it wasn’t what they had in mind, they’re not being helped and so forth.So people drop out of therapy and therapists frame it as a premature termination, which again is a little presumptuous. I’m trying to make every session count, not knowing if I’ll see them for five sessions or five years, at the outset. Certainly as time goes on, you have a better idea if you’ll be seeing them longer term or not. So for me there isn’t so much of a clear dividing line between brief and long term therapies.

VY: How do you decide? Do you decide in advance, this is going to be a time-limited therapy?
HL: For some modes of brief therapy, Mann’s model for example, the time-limited nature of the therapy is very critical. In TLDP, it’s not critical. In fact, I think if Hans Strupp and Jeffrey Binder had a chance to rename their approach, it would be something more like “Focused Dynamic Therapy.” And take the “time-limit” out of it, because it doesn’t so much weigh on the brevity of time. Really what heats up the session is the focus on what’s happening in the here-and-now, and being very aware of that in the here-and-now.To get to your question, Victor, about do I decide ahead of time or do I decide as the person comes in, it’s a mutual decision. Again, it’s not a unilateral decision. So what is the person interested in? Where do they see they want to go? I do believe in having windows of opportunity where we might stop the ongoing process of the work and reflect, where are we? Are we at an ending place? Or a client might say, “Gee, I think I’m at a place where I can end.” Or we might just say, “So where are we and what have we gotten out of our work?” There should be windows of opportunity all along the way to reevaluate. It helps keep everyone on the same page, and I think also helps us put our clients’ needs first.

VY: So we’re not just assuming longer is better.
HL: Definitely not assuming longer is better. As my colleague Michael Hoyt has said, “Better is better.”
RW: Better is better, Hoyt can make that a book title.
HL: I think he has. Yes, better is better, not longer is better!

Is Cognitive Behavioral Therapy the Gold Standard?

VY: In the media, almost every time there’s an article now – somehow brief and cognitive therapy especially, seem to take all the limelight. It’s referred to repeatedly as the gold standard, proven, that it’s empirically validated. Psychoanalysis is often set up as the straw man, where Woody Allen goes forever and never gets better. You’ve been involved in lots of research, and my sense is that good therapy is always good therapy, regardless of these orientation differences. Do you agree that the research shows that cognitive therapy is so superior, and if not, why is it getting all the attention?
HL: Well, it certainly is getting a lot of attention. I do keep up on this literature and I write an updated review chapter on cognitive therapy about every ten years for the Review of General Psychiatry. One of the reasons that the research is coming out favoring cognitive therapy has a lot to do with NIMH funding. NIMH uses the medical model and experimental design as the gold standard and cognitive therapy certainly lends itself to discreet interventions that are made in experimental control designs. In addition, the research design often involves having patients who do not suffer from any other condition other than one diagnosis. So no complex cases, you must find subjects who have an anxiety disorder but who are not addicted to substances, who are depressed but don’t have marital difficulties, who do not have a medical problem, and so on.
VY: Pretty hard to find.
HL: Yeah, pretty hard to find, but you can find them for research purposes. So while the studies are easier to do, easier to analyze, and the results can be shown in a clear-cut way, the transition for the practicing therapist dealing with the populations in the real world, is problematic and might not hold much water. The studies do not generalize or apply readily to real clinical populations. However, I also want to say it could certainly lead to wondering about certain interventions that could be incorporated into messy or real clinical situations.I should note that I’m very impressed by the research of Louis Castonguay and Marv Goldfried who have done a beautiful job of really looking at a more sophisticated version of cognitive therapy which takes into account factors such as the therapeutic relationship, the alliance. Safran’s book on interpersonal processes and cognitive therapy is also one of my favorites.

RW: It is my read that APA’s position on evidence based interventions, in particular, Norcross’ work, has room for the therapeutic alliance and relationship as part of these protocols and manuals in addition to the more CBT technique like approaches.
HL: Unfortunately, the evidence based focus on the therapeutic relationship had to come up as a reaction to much pressure — it would have been nice if we could have been more proactive and been out in front of the curve.
VY: Back to the protocols, I’m interested. From your experience in the CBT world, do CBT therapists follow the protocol, perhaps, that’s not “better” to them as well.
HL: Right, that would not be the best approach for their clients. You have to do an idiosyncratic formulation. You have to know when, for this particular individual who’s sitting across from you, when to follow the protocol and when not to, or when the protocol must be adjusted. Jackie Persons’ work in this area is superb.
VY: So I take it you’re not a big fan of manualized treatment?
HL: I’m not a big fan of rote manualized treatments. I think manualized treatments can be wonderful to teach from but not with the point of view of follow it exactly, do this, then this, then this – kind of in a robotic fashion.
VY: Unless you’re treating robots. Even in these severe research conditions you describe, is it in fact the case that cognitive behavioral approaches show superior results to just an experienced, integrated eclectic clinician?
HL: Depends on the study. Some of them show clear-cut advantage. For others the results are more complex. I’m also very mindful as a researcher that who conducts the outcome research, is very critical – that one of the best predictors of the outcome of the study is the theoretical allegiance of the investigator.
VY: So when you read these same articles that I do in Newsweek and the popular media referring to CBT as the gold standard in therapy, what’s your reaction to that?
HL: Take it with a grain of salt. I’m going to have to leave soon, just to give you a head’s up.

Running out of Time

RW: What time to you have to be out of here?
HL: I probably should leave here at noon.
RW: So, can we ask a few more questions? Seems there is a limit on our time here as well.
HL: Please.
RW: What types of client is TLDP intended for? Adults, kids, couples, families?
HL: Good question. Yes, it can be done with individuals, couples, families and groups because of the systems orientation, so it’s going to be looking at interpersonal interactions. It was designed for individuals. I have taken it to the level of dealing with couples, and I know others talk about the similarities with Irvin Yalom’s approach to group therapy, but I don’t know anyone who is purposefully looking at a TLDP perspective within groups per se.
RW: What’s the most satisfying part about doing clinical work for you?
HL: Just the honor of being let into people’s lives. It is really so phenomenal to be let into the depths of their lives like so few people are, and I feel very honored by that.
VY: You’ve obviously been practicing for a few years now, and you’ve trained hundreds of therapists. What are some things that you know now about doing therapy that you didn’t know originally or when you were younger? What are some key points for young or developing therapists that you could pass on to them?
HL: Don’t be afraid. Don’t be afraid to share who you are, to really make who you are work for you. Yes, the theories are important, the expertise is important, the learning is critical, but that which is uniquely within you, make that work for you. If you have a good sense of humor, make that work for you. If you’re more reserved, make that work for you. Whatever it is, that’s what makes for the best therapy possible.
RW: That’s a very good point. Some theories of therapy are extroverted therapies in what they call on the therapist to do. Psychoanalysis pulls for a more of an introverted approach, meaning the therapist is more reserved and less interactive. CBT is a more of an extroverted approach, where you’re coaching more, and so forth. Yet some quiet CBT therapists are wonderful, and some analysts find a way to practice using their extroverted personality.
HL: Yes, make it work for you.

If you can bring the combination of who you are and your unique gifts combined with the expertise, that’s unbeatable.

If you can bring the combination of who you are and your unique gifts combined with the expertise, that’s unbeatable.

RW: I think you’re right. Many of the master therapists that we’ve interviewed have focused on the therapist bringing themselves to the encounter of psychotherapy. That whatever you do–the more you can bring yourself into your work, the better it is. And I think it has a lot to do with countering much of what we have been taught, but also it has to do with being vulnerable and being willing to take risks. Well I see we’re at the limit of our time today, so I want to thank you for engaging in this thought-provoking discussion.
HL: I’ve enjoyed it myself. Thank you.

Psychotherapy with Medically Ill Patients: Hope in the Trenches

Psychotherapists who work with medically ill clients often feel adrift between two seas. One ocean is the fast-paced world of medicine, in which we, as medical consultants, must efficiently develop complete answers to complex questions. The other ocean involves the deep and dark undertow of emotions: our clients are often dealing with terrifying bodily limitations and unknown outcomes. As therapists, we are called upon to integrate and understand the hypomanic world of medicine, while helping our clients tolerate the unfair and arbitrary aspects of illness and, more ominously, the inevitability of death. Though providing psychotherapy to these clients can at times feel overwhelmingly tragic, it is the solace we are able to offer those beset with illness and death that makes the work so gratifying and meaningful.

As therapists we are privileged to have access to some of the most intimate recesses of the human mind. However, those of us who work with medical patients also have to bear the burden of our clients' concrete suffering. The toll on us is significant: having to tolerate the arbitrariness of illness can either make us cynical and scared, or jolt us into appreciating the finite aspects of life. Working with people beset by medical illness can make us, as therapists and people, able to appreciate life with all its benefits, limitations, joys and disappointments. Working with clients who are medically ill not only requires us to learn more about the seemingly distant and disembodied relational aspects of medicine, but also forces us to confront painful existential realities on a daily basis.

Illness in Psychology and Medicine

When I was not yet 30 years old and had been in private practice only a couple of years, I met Anne*, a pleasant and motivated 70-year-old whom I saw as an outpatient for mild depression. I had known her only briefly, but was very fond of her. Like many elders, Anne had gotten depressed after the death of her husband. Though she had not been in therapy before, she was open to learning how her mood might impact her ability to take care of herself. And like many older clients, she was unsure how talking could help her. But she often noted that after our meetings she felt better, even if she just talked about how she was struggling with getting used to taking care of the finances herself or how much she missed her husband. She also took our appointments very seriously.

One day, Anne uncharacteristically missed an appointment and I had been unable to get in touch with her. The next day, while at a nurse's station in the cardiology unit of the hospital I worked in, I saw her primary care physician, who had referred Anne to me. Upon seeing me, the physician said, “"Oh, Tamara, your patient, the older lady, she died two days ago. She had a heart attack." He then walked away as I stood at the chaotic nurse's station, stunned and tearful.” I had known Anne only a few months, but I had been feeling hopeful about her treatment. Given that she did not have any previous history of heart disease, I couldn't believe that she had died so suddenly.

Anne's death and her physician's manner of disclosure illustrate aspects of medicine that many of us in the field know all too well. The fast-paced, energetic facet of medicine in the U.S. can be characterized as being "hypomanic." Although I am referring loosely to the familiar Diagnostic and Statistical Manual of Mental Disorders1 criteria of hypomania, my understanding of the intensely energetic nature of medicine is more akin to the ideas of Melanie Klein and what she called "manic" defenses. Briefly, Klein described manic defenses as when idealization, feelings of being powerful, and hyperactivity are employed to ward off sadness, worries about aggression, and ambivalence2. In other words, manic defenses are used to avoid difficult feelings. And since difficult feelings abound in medicine, energetic defenses offer a perfect antidote to sadness and loss.

Even minimal experience in the medical profession inevitably leads one to appreciate the consequences of a hypomanic culture. Particularly in hospitals, people talk fast, move fast, and think fast. Many healthcare workers are constantly engaged in goal-directed activity. Even in outpatient settings, patients remark that they spend only five to fifteen minutes with their physicians and commonly complain that doctors are pressed for time. This pressure- and speed-driven culture has a rational component: when a patient is critically ill, physicians and medical staff need to move quickly in order to administer urgent care, which could be life saving. Additionally, many physicians, especially those who work in inpatient settings, are chronically sleep-deprived due to the demands of long hours, call schedules, and other professional and personal responsibilities. In the outpatient setting, physicians are often tightly scheduled to see a large number of patients in a limited amount of time.

As medicine has advanced, the kinds of interpersonal connections within the profession have changed as well. Donald Winnicott described the way he noticed interpersonal differences as a result of modern medical practice:

It is a sad result of the advances in modern medicine that there is no personal clash between patient and doctor as whole persons; there is a visit to the doctor, a disease process found, treatment is given, and the disease is cured, but no one has met anyone, no one person has bumped into another person.3

What I experienced in my conversation with Anne's physician after her death seems to be a common symptom of modern medicine as Winnicott described. Medicine demands a great deal from its practitioners, and a hypomanic style in the personalities of medical professionals can be viewed as a kind of acculturation to seemingly endless demands. On the other hand, the perpetually fast pace in medical facilities also reflects a tendency and desire to not engage with patients in an emotional way.

Bodies Breaking Down: Challenges for Therapists

Although physicians often experience the hypomanic trappings of medicine, as therapists we are also subject to these intense pressures. When I worked in medical settings with a large number of clients both as inpatients and in my outpatient practice, I often found myself wishing I could offer something simple and concrete to ease my clients' suffering. But I also wanted to ease my suffering; at times it felt like helping people who were ill was too much to bear. Sitting with someone with a rare autoimmune disease who had a guarded prognosis and uncertain future, helping someone with lung cancer who was overwhelmed with self-blame regarding years of heavy smoking, or trying to soothe a young adult randomly afflicted with heart disease forced me to face the complex reality of health and illness: we can all try to take care of ourselves and do the right things in terms of our health, but the sad truth is there are many variables we cannot control. Even when clients might have endangered their health knowingly or unknowingly (as in the case of older adults with lung cancer, who grew up seeing physician advertisements for cigarettes), they still have to deal with the fact that illness has happened to them and that their body has let them down and they might not live—or, for some, live with limitations they may never have dreamed possible.

I felt more emotionally vulnerable regarding death and serious illness in my clients when I was younger. Especially then, I had a hard time knowing how to manage the feelings that were stirred up in me. This was probably exacerbated by the difficulties with mourning that are present in medicine, as I had little support in a culture in which people simply move on to the next task, even after someone dies.

One way my intense anxiety manifested at the time was that I frequently feared that I would develop the same diseases of those I was treating. Especially when I worked with people who had been subject to random or mysterious illnesses (often those thought not to have links to lifestyle behaviors), I worried that I too, would be subject to the same bad luck. When I was seeing large numbers of patients in the hospital, it often seemed unbelievable to me that anyone could be in good health, and not sick with some terrible disease! Clinicians I have supervised in hospital settings, in which they were working with severely ill people, have echoed similar sentiments. These feelings and anxieties seem especially prevalent in younger clinicians and those who have not experienced illness or death in their personal lives. However, all of us, in working with people with medical illnesses, need to come to terms with the intense anxieties and overstimulation that are associated with treating this population.

Though our feelings and experiences are filtered through our own psychology, there are many common reactions to working in medical settings and with clients who are severely ill. “Intense fear, anxiety, and thoughts and images of our own death are common reactions and not necessarily related to our own psychological problems; what we encounter is simply difficult to bear.” Serious illness and the possibility of death inherently evoke intense and disorganizing emotions in therapists when we are with our very ill clients. Since many people experience considerable shame in confronting these emotions, reinforced by a cultural mandate to move on, therapists need to create an internal and external space for these intense feelings. This involves a lot of interpersonal work, and often requires a lot of our own psychotherapy.

Those of us who work with medical patients suffer vicarious trauma. We don't talk about it much, as we are not so sure that our colleagues won't pathologize us. In fact, I felt quite misunderstood by a therapist I was seeing when I first started working with severely ill clients in a hospital setting. “When I tried to articulate my terror regarding seeing people my own age who were dying, my therapist interpreted these fears as "unrealistic."” My view was, how could my fears be unrealistic? The young people I was seeing had not engaged in risky lifestyle behaviors; they just were victims of bad luck. How was I to know that this could not happen to me?

Therapists who don't work with medically ill clients often remark that those of us who do have a skewed view of the world or that we don't have good boundaries between our clients and ourselves. Regarding the former idea, our colleagues are right. Therapists who specialize in work with medically ill adults primarily see people who have been subjected arbitrarily to illness. I did have a skewed view of the world, especially when I was younger. As I have gotten older, I realize that many medical illnesses are rare and unfortunate, and I feel privileged to have been able to help my clients at a time in their lives in which they needed someone who could tolerate randomness and unfairness of disease and illness, to acknowledge the potential of death, and most importantly to help them know they are not to blame. Indeed, many people feel that random illness must be caused by something they have done. Feeling that they have caused the illness is a way to believe that they can stop it. Sadly, this is not true. But the idea that we can predict and know of our potential to cause (and cure) our own illnesses is seductive.

A younger colleague, who works with people who have rare lung cancer, said to me recently, "When I cough, I think I have lung cancer." When she said this, I was reminded of the claims launched at me over the years by well-meaning colleagues: that my work was reducing me to a state of lowered boundaries, and that it was crazy to think I might be in the same boat as my clients. And though on one level I can understand these criticisms, on the other it feels so profoundly misplaced and misunderstood. As I said to my younger colleague, "Of course you feel this way. There is no way to work with such an unfairly beleaguered population and not feel scared about what this can mean for you. Bad things just happen."

Psychology, and especially psychoanalytic psychology, can be funny in that “we as therapists are "allowed" (especially in training) to indulge in whatever ideas and fantasies we might have about our own psychological problems, but we immediately pathologize whoever is talking if they have worries about their own bodily health”—they must be too "concrete," they must have some difficult psychological problem that allows them to somatacize. The reality, however, is the opposite of what people often perceive. When we work with medically ill people and are confronted with the random nature of illness and the cruel distribution of severe illness, it is natural that as therapists we would imagine ourselves in the same situation. After all, what else can be described as the true seed of empathy? And in my experience and those of students I know, it is this kind of empathy, "What would it mean if this were happening to me?" that is the most profound and ideal empathy we need to have inside of us to help our clients manage the painful and difficult aspects of illness they are confronted with.

The Difficulty of Engaging Clients

A few years ago I was teaching a class on psychodynamic perspectives of medical illness and mentioned a common phenomenon: many cancer patients who engage in therapy do so when they are in the active stages of their medical treatment (e.g., chemotherapy or radiation); once these stages are completed, many of them leave therapy. The therapists in the class who had worked with people with cancer laughed and seemed relieved to know that this is a common experience and not necessarily based on the therapist's individual psychotherapeutic style or practice.

While it is true that many people with medical illness (not just those who have cancer) present for psychological treatment in the more acute phases of illness and then leave when illness becomes chronic, is in remission, or in the best of circumstances, is cured, it raises the question of why this happens and how it affects the psychological health of people we try to help. One possibility is that those who are acutely ill and undergoing intensive kinds of treatment need acute and intensive psychological support, and once that phase of medical treatment is finished, they may feel that less intensive psychological treatment is needed. Although this rationale may appear to make sense, I have been surprised over the years at the number of people who have left psychotherapy after the acute phases of medical treatment, as some of these clients clearly had issues that would have benefited from longer-term psychotherapy. And even though it is true that some people, particularly those who have had psychotherapy in the past, might be inclined to continue with therapy after the acute phases of treatment, how are we to understand those who do not? And are there things we can do to increase the chance of engaging some of these people in a more meaningful and helpful therapeutic relationship?

People with medical illnesses are hesitant to engage in longer-term treatment with mental health clinicians for a number of reasons. As described, the culture of medicine and modern healthcare reflects a hypomanic culture in which "cures" are provided in a quick and often rushed manner. The practice of psychology within medicine, though valuable, offers a culturally inconsistent approach for people with severe medical illnesses. Even with the approaches often advocated within health psychology and medical care (specifically cognitive-behavioral approaches), the integration of psychology in medicine remains largely difficult.

Integration of psychological approaches and applications in healthcare has improved dramatically over recent years, yet psychological services are largely viewed as an elective treatment within the medical system. To some extent this makes sense. From a practical standpoint, many people undergoing medical care are overwhelmed with medical appointments, as well as the financial expenses involved in receiving care for an illness. Time and money spent on psychotherapy may not seem to be a priority. Physicians may not consider referrals to mental health professionals for those patients who seem to be coping well, even though therapy could be of great benefit.

However, even for people who have financial resources and time for it, therapy is often construed as not only elective, but also a burden. Psychotherapy requires a tremendous amount of resources, both internal and external. “People with severe illnesses are often taxed with the impact of bodily changes and decline, physical pain, and fear of death: surviving from day to day involves tremendous physical energy, and as a result, psychological energy that might be employed to address emotional issues is reduced.”

This relates to the idea that medical patients often present as being more psychologically "concrete." The term concrete has been associated with thinking in patients who are more severely disturbed, such as those who are psychotic or those with personality disorders. However, this way of viewing concrete thinking is very limited—and in itself concrete! A more modern perspective is that, especially under times of stress, we all can regress to a more concrete way of operating, and this is often the case with severe physical illness. In such states, we feel more sensitive to intrusions, more focused on pragmatic aspects of functioning, with less emotional space for reflection.

Trauma researchers have long known that traumatic events make it difficult for people to think in a symbolic way4. The burden is on us, as therapists, then, to help make space for symbolic thought, as opposed to demanding that our clients do so for us.

What Seems Concrete Is

Sara* was a 30-year-old doctorate-level professional when I met her. After a routine doctor visit, her physician had told her that she could not go back to work that day, but needed to be hospitalized immediately for dangerously low blood cell counts. She was diagnosed with leukemia. I met her a few days later in the hospital; she was referred for what her nurses described as almost nonstop crying and excessive controlling behaviors, such as continually asking the nurses to verify the accuracy of her medications, even when they had already told her what they were giving her and confirmed that the dosages were correct.

When I met with Sara, she was guarded and extremely anxious. Although she felt that she wanted help by talking with me, she appeared in genuine shock (as would be expected) but also panicked. When I suggested that she might feel overwhelmingly anxious, and that perhaps she even thought that the feelings she was having would cause her to die immediately, she agreed. She said that at times she felt that she could just "die right there," even though she knew she was getting treated for her disease. The panicked feelings made it difficult for Sara to cope in the hospital. Staff became increasingly concerned because she often asked for higher levels of anxiolytics and pain medications, presumably to manage her anxiety. Sara acknowledged that she just wanted to feel "numb." Although I had suggested an antidepressant, which might provide longer-term and more consistent relief from her symptoms, she refused, objecting that she did not want to feel "controlled" through medication.

As for my role while she was in the hospital, Sara was able to talk to some extent about her anxiety. However, discussions tended to focus on aspects of her life that needed to be managed and taken care of, such as who was paying her bills, what was happening in a recent financial transaction, and how others were managing her projects at work. And although I willingly discussed these topics with her, I felt as if there was little I could do to help ease her tremendous anxiety.

Sara's situation illustrates that when someone is overwhelmingly terrified in response to a serious and life-threatening illness, his or her ability to think about meaning is reduced. Sara's panicked state and her constant checking on the nurses prevented her from slowing down long enough to realize that she was not going to die immediately. They also prevented her from thinking about what she could do to help herself in her situation. She felt that her life was already over, even though she had a long road of treatment ahead of her. Feelings of hopelessness in medically ill clients are common and can be detected by a feeling of helplessness in the therapist, which I felt acutely while I was with her.

Sara attempted to manage her anxiety by becoming more watchful of her environment, including frequently checking that the nurses would not make any mistakes. Not only was Sara terrified and attempting to manage her terror, but I understood that underneath her need to be more in control of her environment was a sense of profound confusion regarding what was happening to her. Attempts at control were a way to reduce the confusion she felt. In her conversations with me, Sara felt the need to go over events in her life that she could not currently control as a way to try to maintain control. She was stuck in this way of thinking and needed me to give ample attention to these external events.

Talking about the more real issue of what she could not control (her body) was not possible, as it made her unbearably anxious and confused. Sara had been caught completely off guard by this diagnosis. As a relatively young woman, she'd had little experience with major illnesses or death. She had no risk factors for malignancies, something she eventually told me she often thought about. Not knowing why or how this had happened to her was a tremendous source of distress. The level of her confusion was so intense that at times she felt as if it would overwhelm her. This is one meaning of panic attacks that sometimes occur in people with medical problems; “anxiety, confusion, and feeling out of control become so powerful that people sometimes feel as if they will die then and there.” It is as if the idea, "Well, I might as well just die now," takes over. The price of such a way of thinking, however, is that Sara and others like her forget that they are still alive, and can maximize coping resources to fight their illness.

Although it is understandable that many people experiencing a life-threatening illness would be terrified, the kind of terror I am describing is the kind where one cannot find refuge in a logical reminder that they are not dying at that moment or that others are helping to keep them alive (meaning, in these cases, medical treatment). This is because the disorienting feelings in reaction to a traumatic illness can become overpowering. Sara could not find solace in the fact that she was being treated for a disease. Sara was so tortured by her anxiety that she feared others, even though these others were desperately trying to help her. She became wary and guarded.

Though I knew that the nurses and doctors caring for her at the time were extremely sympathetic, Sara could not absorb sympathy. Her fears had rendered her helpless, feeling paralyzed and tortured. In this state, no one can really be trusted. Additionally, in this state of mind, the act of thinking as well as having ideas, of any kind, can feel like torture. In other words, the process of thinking as we understand it can feel persecuting, because in a situation in which the body has failed, it is hard to know who to trust. Sometimes in such scenarios, people are even hesitant to access their own thoughts, as thoughts themselves (being present in one's mind) can feel equally as terrifying and persecuting.

This kind of state presents a unique problem to us as therapists, in that the people we may want to help the most are intensely (and often unconsciously) unable to take in what we have to offer. “Their terror becomes our cross to bear. In other words, the intense and barely known emotions become something we have to share and know in order to help. With Sara, I had to tolerate feeling helpless, enraged, outraged, and terrified about what was happening to her.” At the time I knew her in the hospital, she could barely acknowledge these feelings in herself. So I absorbed them and hoped for the best for her, and hoped as well that at some point she could feel her own emotional turmoil.

Sara did well with her medical treatment in the hospital, but was never able to follow up for therapy as an outpatient. And because of that, I can never quite be sure whether my work was helpful to her or not. Such is the case when working with people who are seriously ill. I do not know how Sara fared, or even whether she is still alive. This is another difficult fact of working with severely ill clients, especially in hospital work. As mental health clinicians, we are often not privy to the medical outcomes of those whose lives we become invested in. Clients struggling with illness can't necessarily follow-up in longer-term psychotherapy, for both physical and psychological reasons. As helpers in the world of medicine, we often have to tolerate not knowing whether our clients live or die.

Psychological Ramifications of Cancer Diagnoses

Most of us who are born without chronic illnesses take the functioning of our bodies for granted. When the body stops working in adulthood, this jars one's sense of self. And if the inside of the body does not work, it is very hard to know how and what to trust on the outside. Many cancer patients talk about the eerie feeling that cancer cells have been growing in their bodies without them knowing it. This may be related to both ideas and fears of cancer in our culture. Although heart disease is the number-one cause of death in industrialized countries, many people verbalize not a fear of heart disease, but of cancer.

This is most likely because the imagery associated with cancer, in which bad cells insidiously destroy good cells, resonates with the fear of the internal workings of the body being attacked by itself. This idea has roots in early developmental theories of childhood. Aggression is something we all struggle with as younger beings. Dependency, a sense of not being in control, and anger about that fact that we need to rely on others are facets of young childhood. When things go right in childhood, we can emerge relatively unscathed and able to tolerate our own (and others') limitations and need for dependency.

But when things don't go right, or when parents are preoccupied, we then struggle to tolerate the fact that at times we will need others. The sense that the body is attacking itself is common among clients with medical problems. When this feeling is excessive or pervasive, it can sometimes be a sign that, as children, these clients were often left alone to deal with angry feelings. These feelings can and do often come back to us as adults, especially when dealing with something amiss in the body that we cannot understand. “A sense that the body can attack itself feels like our own toxic anger is turning inward in ourselves, and results in disorientation and mistrust of people in the "outside" world. For some, this results in confusion, collapse, and a feeling that nothing can be trusted either internally or externally.”

Sara tried to remedy these disorganized, helpless, and out-of-control feelings by managing the nurses' behaviors with an attempt to control, in a literal way, what was being put into her body. Such patients need to be able to feel that they can control what we, as mental health clinicians, "put into" them as well.

In these situations, we need to tolerate the fact that due to a patient's suspicions and sense of terror, it may feel at times that we have little to offer. However, just being able to engage with patients like Sara goes a long way. It means a lot to listen and tolerate unbearable feelings when no one else can. People caught up in medical crises often cannot turn to their physicians, as their work requires a kind of detachment. Family members are often so scared themselves that they often tell me they can't bear to hear my clients utter anything other than positive statements. Thus, our clients need us to bear the confusion, terror and disorganization to which they are subjected.

Hope In The Trenches: The Meaning of Our Work

Janet*, a client of mine, died recently after a long battle with cancer. When I saw her for the last time, she told me she was scared of death, but relieved to have an end to her suffering. She grabbed my hand and said, "I can do this now. Thanks for helping me to know that I can let go." Our work together lasted less than a year.

I met Janet in the context of several medical problems while she lived in a skilled nursing facility, but in the process of our working together, she was diagnosed with recurrent cancer. Although she had been told that her cancer had not been cured, and that she would eventually die from the disease, she had convinced herself that her prognosis was otherwise. When she was told that her cancer was not only back, but raging with virulent intensity, I gently suggested that her lifespan was shorter than she had previously thought, and that she might want to say goodbye to those who were important to her. In the context of our relatively close therapeutic relationship, she could hear this, and no longer needed to be in denial about what would be her fate. She was able to say goodbye to those she loved, and was even able to say she was sorry to people she perceived she had hurt.

I could not continue to work with people who were enduring this kind of suffering unless it felt like there was some help I was able to provide, and it appeared that I had helped Janet to relinquish the denial she had so desperately clung to, and had eased her feeling that she was dying alone. These moments remind me of why I got into the practice of working with medical clients to begin with. And more importantly, when I come home every night to my husband, I am so grateful for what we have, now.

*Client names have been changed to protect confidentiality.

Excerpts from this article are taken (with permission) from Psychodynamic Perspectives on Aging and Illness, Springer, 2009. The paperback version of this book was released in June, 2010.

References

Diagnostic and Statistical Manual of Mental Disorders 4th ed.; DSM-IV; American Psychiatric Association, 1994.
Klein M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis, 21,125-153.
Winnicott, D.W. (1966). On cardiac neurosis in children. In R. Shepard, J. Johns, & H.T. Robinson (Eds.), Thinking about children. New York: Addison Wesley
van der Kolk, B.A., Hostetler, A., Herron, N., & Fisler, R.E. (1994). Trauma and the development of borderline personality disorder. Psychiatry Clinics of North America, 17, (4), 715-730.

Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy

The Interview

Chanda Rankin: I’m Chanda Rankin, and it’s a real pleasure to have you here for this interview today with Psychotherapy.net. Earlier you mentioned you were born in Vienna, Austria. I wanted to know how much sociocultural influences at that time affected and influenced you to go into the field of psychotherapy and analysis.
Otto Kernberg: To begin with, I left Austria when I was ten years old. My parents and I had to escape from the Nazi regime. We did so at the last moment and immigrated to Chile. I trained in psychiatry at the Chilean Psychoanalytic Society. I came to the States for the first time in 1959 on a Rockefeller Foundation fellowship to study research in psychotherapy with Jerry Frank at Johns Hopkins. Then in 1973 I moved to New York, where I was at Columbia. Now, I'm Director of the Personality Disorders Institute where we're carrying out the research of personality disorders.

Certainly my cultural influences are Austrian, German, and that has influenced me in many ways. But my psychiatric training was integration of classical descriptive German psychiatry and psychoanalytic psychiatry/psychodynamic psychiatry. Later I became immersed in ego-psychology and Klein's work. I also visited Chestnut Lodge where I became acquainted with the culturist orientation, Sullivanian, Frieda Fromm-Reichman as well as the ego/object relations psychologists, Edith Jacobsen and Margaret Mahler. So it was natural to try to synthesize an object relations approach between the great ego psychological Kleinian and so-called British 'middle group' or independent approaches. Then many years later, to this was added a certain influence from French psychoanalysis.

Kernberg’s Gold Mine

CR: I’ve always been very curious about what is it about working with personality disorders do you find so compelling that you’ve made this the focus of your life’s work?
OK: It was a combination of various influences. First of all, perhaps the most important one was that the psychotherapy research project at the Menninger Foundation that I joined and eventually directed consisted of the treatment of 42 patients—21 treated with various types of psychotherapy from a psychoanalytic basis, and 21 patients were treated with standard psychoanalysis. Now, it so happened that many of the patients sent to the Menninger Foundation suffered from severe borderline conditions. Severe personality disorders, right now called Borderline Personality Organization…the concept had originally been developed there by Robert Knight and his coworkers. Many patients with severe personality disorders were included in that project, and the diagnosis was made very, how shall I put it, tentatively or fleetingly. When the project started in 1954, there were no clear-cut criteria being used. It was very helpful because it turned out that half of the patient population on the therapy side, and half of the patient population on the psychoanalysis side suffered from severe borderline conditions.
CR: How fortunate for the researchers.
OK: Yes. And each of these cases had typed process notes of each session, of treatment over many years. Big fat books. So by the time I got there, I had 42 cases studied in detail, and it was just a gold mine! I noticed regularities about what happens in the treatment, what would have facilitated the diagnosis, so I combined my interest in object relations theory with the interest in clarifying this group, to develop some hypothesis about treatment. We then did the statistical and quantitative analysis of the project. It provided me with important confirmations and disconfirmations of the hypothesis.
CR: And this population was not well understood at the time.
OK: No, so I was very lucky to have this patient population. And when I started out, I wasn't aware myself that I was getting into a very interesting subject.
CR: How did you become involved with the study of narcissistic personality disorders?
OK: Just by chance. One of the patients who I saw in a controlled analysis while I was a student at the Psychoanalytic Institute in Santiago, Chile, had been diagnosed as an obsessive-compulsive personality. I was unable to help him—he didn't change one inch over years and his memory persecuted me. Then, I perceived that he was very much like other patients I saw at the Menninger Foundation. Hermann Van Der Waals, who had written an important article on the narcissistic personality told me, 'These are narcissistic personalities.' Nobody had described these characteristics in the literature well.

I then took another patient into analysis, exactly like my previous one, and on the basis of my then-developing psychoanalytic knowledge, I developed a particular thesis on how to treat that patient. And this is how I developed the treatment of narcissistic personality, the diagnostic observations, the differential diagnosis between narcissistic and borderline typology, the generalization of the concept of borderline personality organization. So it was a combination of luck and interest.

CR: A very rich time, and a confluence of things coming together to make that happen. What or who influenced your clinical style which seems to be neutral in many ways but not passive or impersonal?
OK: One individual who I have not yet mentioned, who is very little known at this point, although he was a leader of American psychiatry, is John White, the Chair of Public Psychiatry of Johns Hopkins when I was there. He developed a method for clinical interviewing that inspired me for developing structural interviewing. He was the best interviewer I've ever seen. He would start talking with the patient, and the interview would go on until he had a sense that he knew what he wanted to do. It went on for two or three hours. John White had a way of putting himself into the background, disappearing, so to speak. He was very direct, very honest, and understood something about people, in depth. No showmanship. Just raising questions that permitted the development of the patient. He had a tremendous capacity to permit the patient to develop his present personality, rather than asking what happened 50,000 years ago. That also influenced me in interviewing. Sharpened my approach to the study of the present personality.

But, perhaps also what has been very important to me is the excitement with the fact that there you have these patients with severe distortions, that ruin their lives. No doubt about it. This is not phony pathology for wealthy patients who have nothing to do but to go to a psychoanalyst. These people have not been able to maintain work, a profession, a love relation. And with the psychoanalytic psychotherapy and psychoanalysis you are able to change their personality, improve their lives. I think that is an extremely important contribution of psychoanalysis. And we need to do empirical research on this. One of the things that I have been very critical about is the lack of systematic and empirical research within the psychoanalytic world.

How People Change!

CR: Do you think that there’s any one specific thing, if at all, that contributes more than any other thing to change with a personality-disordered patient?
OK: People change in many ways with common sense, with friends, with help, with luck, with good experiences in life. I think that psychoanalytic psychotherapy and psychoanalysis are probably the methods that promote the best changes in case of severe personality disorders, through the mechanism of analyzing of the transference, the split off, dissociated, primitive object relations that determine and are an expression of identity-fusion, bringing about normalization of the patient's identity, integrating his self and concept of significant others. In that context, permitting the advance from primitive to advanced defense mechanisms, and strengthening of ego function in terms of increased impulse control, moderating affective responses, and facilitating sublimatory engagements.

So I think that's probably the best approach nowadays to bring about fundamental personality change. There are indications and contra-indications; not all patients can be helped. I think that the prognosis depends on the type of personality disorder, on intelligence, on secondary gain, on the severity of anti-social features, on the quality of object relations, on the extent to which some degree of freedom of the sexual life has developed or not. So there are many features that make indication, contra-indication and prognosis for the individual cases different. We are in the middle of trying to spin all of these out.

“Psychotherapy Training is Going Down the Drain”

CR: You often emphasize the importance of training, really making sure that the therapists know what they are doing and what they are dealing with in terms of the patient. Can you speak to that issue?
OK: First of all, yes, I am very critical of chaotic gimmickry in treating patients based upon chaotic theory. Each person who invents a treatment method invents his own ad hoc theory for treatment. I find that this damages the field, the treatment, the patients. It's bad science, on top of it. One thing I like about psychoanalysis is that it's an integrated theory of development, structure, psychopathology, that lends itself to develop a theory of technique of intervention. I'm not saying it's the only one, but that's one of its strengths.

I think that when people apply various techniques from different theoretical models, they cannot but end up in a chaotic situation in which transference and countertransference is going to drive the relationship in one direction or another. I'm not saying that you can't help patients with this. But you cannot learn how to develop a certain approach. I've seen so many bad consequences from that. Because then you don't match technique with the needs of the patient. And you don't give patients as much. So I prefer to have a cognitive-behavioral therapist, let's say, a well-integrated general theory that applies to his field, rather than one of these esoteric schools everybody has. In this field there is so much voodoo and so much fashion and quackery. It's paid for, and of course, it requires research. Now, unfortunately, most of the research that's been done on short-term psychotherapy done by non-therapists with non-patients in university settings, to grind out papers… so the real treatment that is done clinically has only been researched in a limited way… I think that's our major task. And I believe that we need to develop manualized treatments for long-term psychotherapists, whatever their background. And test them scientifically.

So, regarding training, I think that training should focus on theory of personality, personality change as a basis of technique. And then, apply it to clinical situations.

CR: What do you think of the impact of managed care on psychotherapy?
OK: Psychotherapy training is going down the drain in this country, under the corrupting effect of managed care, this terrible system for profit that goes under the mask of 'managed care,' but really it's managed cost. Under its pressure, long-term psychotherapy is now reserved for those who can pay for it privately. So we are depriving a significant segment of the population of treatment. I trust that that system is going to explode by its own corruptive effects and structure. This is already occurring. And that in the long run, our knowledge and our scientific development of psychotherapy will restore an optimal level of psychiatric practice and psychotherapeutic practice. I think that in the meantime we live in a happy-go-lucky, democratic fashion in which everything goes. Which creates distrust in the public, cynicism in the profession, and is not healthy to patients.
CR: Have you considered ways to reverse this trend?
OK: I think the solution is, in the long run, scientific research.

In my own Institute of Personality Disorder, we're trying to contribute in a modest way by carrying out empirical research. We have randomized three groups of 40 patients each, all of them with the diagnosis of Borderline Personality Disorder. One group to be treated with transference-focused psychotherapy, which is a psychoanalytic psychotherapy that we have developed and tested. The second group by DBT, Dialectical Behavioral Therapy, developed by Marsha Linehan for suicidal Borderline patients. And third, supportive psychotherapy based on psychoanalytic principles. We're going to compare these treatments, not simply in a kind of horserace, but we're trying to study what process mechanisms are connected with what mechanisms of change.

I don't believe that one treatment is 'better' than the others, but there are specific types of patients who respond better to one or another or that treatments may be equally good on the basis of different mechanisms of change. In this regard, I'm very critical of the assumption that non-specific aspects of psychotherapy are by far the overriding cause of its effectiveness. Because all the studies on which these conclusions are based are short-term psychotherapists of very questionable nature. Nobody has studied yet the comparison of long-term psychotherapists from the solid bases, as I have tried to define.

Critiquing the Media and Pop Culture

CR: To go back to something we were talking about earlier, I was wondering if you could say something about psychotherapists portrayal in the media? What are your thoughts on how psychotherapists are portrayed in movies and television? Along those same lines, you have noted how eclecticism in the field is leading to a diffusion and misrepresentation.
OK: In general, psychotherapists are portrayed in simplified and almost caricatured ways in movies. What is very fashionable in this country right now is the so-called intersubjectivist approach, in which the therapist lets 'everything hang out' and people are impressed with how real the therapists are. I think that reflects a dominant culture of doing things quickly, immediately, the culture of faith, good faith, warmth, belief in the human being helps everybody along. Which is different from the reality when we treat patients who suffer under severe regressive conflicts, whose major need is to destroy the therapeutic relationship, who envy the therapist's capacity to help them—those kinds of cases we don't see in the movies, except that by the time we see that kind of patient, they are shown as monsters and people get horrified. And there is a strong cultural critique of psychoanalysis that is not new, but now takes the form of "psychoanalysis is lengthy, expensive, hasn't demonstrated its efficacy and effectiveness, and patients can be helped by brief psychotherapists." Often they present psychotherapy as shamanism.

At the same time, the combination of the important development in biological psychiatry, the financial pressures reducing availability of psychotherapeutic treatment, the cultural critique of subjectivity and wish for quick solutions, adaptation—all that has tended to decrease the participation of psychodynamic psychiatry and psychodynamic psychotherapy and the training of psychiatrists. It has brought about the old-fashioned split between biological psychiatry (centering on basic research and psychopharmacological treatment) and psychotherapy (pushed off to other professions and being disconnected from medicine and psychiatry). I think that's unfortunate. That leads to a kind of mind/body divide when they should come together.

CR: Can you say more about this mind/body divide?
OK: The impact of the new neurosciences on psychotherapy is very misunderstood. I think there is a lot of premature, reductionist excitement with all these new findings. We have important new findings of the central nervous system, as an effect of psychotherapy, correlations between psychiatric disorders and brain functioning. But these new developments do not, as yet, have any practical implications in terms of both theory and technique, technical interventions, so we have to keep that in mind.
CR: How do you view issues of the mind/body applying in the clinical situation?
OK: Of course you could say that it applies insofar as psychopharmacological drugs derived from our better understanding of neurotransmitters. That is certainly true for the case of schizophrenia, major affective disorders, syndromes of depression and anxiety in general, but it's not true for personality disorders, the many sexual difficulties and inhibitions that go with them. And, to the contrary, there, medication has a very limited symptomatic effect on anxiety and depression, but not at all on the basic psychopathology. The illusion that eventually everything is going to be cured by a pill is an illusion that has existed for a long time, and I think that there are good theoretical as well as practical, clinical, reasons to question it.

The Question of Love

CR: I want to turn to a different interest of yours which you explore in your new book Love Relations: Normality and Pathology. I was very curious how that came about, and in the body of all your other work to be writing a book on love seemed like such a drastic change. What was the impetus for this book?
OK: As I mentioned in the Introduction to the book, I have been accused of being only concerned with hatred and aggression, so I thought it would be fun to write about love!
CR: Was it fun to research and write this book?
OK: It was fun, but it was also difficult, because when I got into the subject, I realized how complicated it is, and how I had to renounce exploring many areas that I would have loved to explore. So the book has important limitations. I observation that the degree of pathology of the personality disorder, of one or both participants of the couple, does not permit us to establish a prognosis of how the couple would do. Two perfectly healthy people get together and it's like hell on earth; two extremely troubled people get together and have a wonderful relationship! So that clinical observation created my curiosity, because of course it's a problem that borderline patients face—establishing couples, getting married.

I also became interested in the subject of sexual relations, because I found out there were two types of borderline patients—I'm using the term loosely to mean severe personality disorders. One with an extremely severe primary inhibition of all sexual capacity, no capacity for sensual activation or enjoyment, no sexual desire, no capacity for masturbation. These patients had a bad prognosis because in the treatment, as everything was consolidating, more repressive mechanisms inhibits that sexuality even further. On the other hand, you had those with wild promiscuous sexuality—polymorphous perverse, invert, pan-sexuality, with masochistic, sadistic, voyeuristic, exhibitionistic, fetishistic, homosexual, heterosexual, everything…those with such a chaotic sexual life seem to have a terrible prognosis, but the opposite was true. These patients did extremely well, once their personality was functioning better. So it raised my interest, why this extremely severe sexual inhibition, what could be done about this? And, also, a more basic question about how much a couple can contribute to inhibit each other or to help each other to free themselves sexually. That's it, in a nutshell.

What are Good Therapists and Analysts Made Of?

CR: Do you have any thoughts about personality characteristics that an analyst or a therapist needs to have in order to work with severe personality disorders, or even mild personality disorders?
OK: That's a good question. As I look at our experience, we've trained many therapists. We've had 20 years of training and supervision. I think that people with very different personalities can become very good therapists. I don't have anything deep or new to say about this that couldn't be said by anybody with some experience in this field. I think it's important, first of all, that the therapist be intelligent, it helps. Second, that they are emotionally open. That they be a personality that is sufficiently mature, on the one hand, and open to primitive experience, in contrast to someone who is extremely restricted. It helps not to be excessively paranoid, infantile, or obsessive-compulsive. Although, I'm saying excessive because we have all kinds of therapists—all basically, honest with themselves and others, with a willingness to learn. Therefore, it helps not to have too much pathological narcissism. If you are too narcissistic, you don't have the patience to work with very troubled patients, and your capacity for empathy is limited.
CR: But it also seems like you need a healthy dose of those things.
OK: Yeah, some of us are exploring that. I really don't have a good answer to that. But there are some people who have a talent for it, like people have talent for playing piano. I don't know whether experts would say, what personality does it take to play the piano? There are some people who have the talent. Some people are able to do it almost without any training. It's almost frightening that they know things before we teach them. It's bad for our self-esteem! I've had therapists with whom I've had a sense that there is such an inborn capacity that with little…they would flourish. And others who never learned, even though they were intelligent and hard-working. And I'm not able, at this point, to spin out what it is. But, we can discover it.

Very simply, we tell people who want to train, "Bring us a tape. The best tape you have, of any session that you are carrying out, a videotape with a patient in treatment." And we have developed methods of the psychotherapeutic interaction by which we can sort out who does have the talent for doing it. We can evaluate very quickly with manualized treatment whether the therapist is able to adhere and whether the therapist is competent. Competence is seen by the therapist talking, focusing on what is relevant, focusing on what is relevant with clarity, doing it relatively quickly and in depth. Relevance, clarity, speed, depth. The combination of them tell us who is a good therapist. It's terribly simple, and it works.

And I'll tell you, some experienced psychoanalysts are terrible; and some young trainees are very good. This creates the problem: does one have to be a psychoanalyst to do this kind of treatment? I would say it helps to have psychoanalytic training, but it's not indispensable. There are some people who have so much talent they can do it without psychoanalytic training, although, a personal psychotherapeutic experience always helps, particularly if people have a kind of "blind spot" in a certain area. Sometimes a psychoanalytic treatment or psychoanalytic psychotherapy helps.

CR: You have written about the importance of therapist safety. It really hit home with me, and I had not actually heard anyone articulate that clearly before. The ability to be able to sense when safety is an issue seems so primary. So all the things that you’re talking about—your own self-awareness, to be able to have the insight into these areas, to know when something is a problem. It’s very important for safety as a therapist and also the amount of safety you can provide for your patient.
OK: Exactly right. It permits you to maintain the frame of the treatment. It's absolutely essential. The therapist has to maintain the control over the therapeutic situation. The therapist has to be in charge. There is a realistic authority of the therapist that has to be differentiated from authoritarianism, namely, the abuse of that authority. There is kind of a cultural move toward "democratization" of the psychotherapeutic relationship. I think that's just silly. Because patients come to us because of a certain expertise, otherwise they wouldn't come to us, and they shouldn't. There's a difference between authority and authoritarianism. And part of the authority of the therapist depends on the therapist's being able to maintain the frame of the treatment. And our own safety is essential in this regard. When you treat severe personality disorders it becomes crucial…physical, psychological, legal safety, in this country which is so litigious. It's the most paranoid culture that I know within the civilized world. I've not been in the jungle…
CR: We might be close!
OK: Perhaps so, we live in a very paranoid culture.
CR: Thank you so much for your time.
OK: You're most welcome.

Practical Psychoanalysis for Therapists and Patients

The Stuff of New Yorker Cartoons

No surprise, then, that psychoanalysis has come to be regarded by the public at large as an esoteric practice which promotes a self-involved escape from real life, rather than a treatment method that helps the patient live real life more happily. No surprise, either, that all over the world fewer and fewer patients seek psychoanalytic treatment, and that those who do are for the most part people who want to become psychoanalysts themselves or fellow travelers who have an intellectual interest in the field. Clinical psychoanalysis has become, deservedly, the stuff of New Yorker cartoons.

This unfortunate state of affairs is ironic, considering that psychoanalysis got its start on the basis of its therapeutic efficacy. In the course of their researches, Breuer and Freud stumbled upon a method for relieving notoriously difficult to treat hysterical symptoms. Though Freud was a fascinating and imaginative writer who developed far-reaching ideas about culture and society, as well as about individual psychology, the world originally paid attention to him because of the extraordinary cures he and Breuer achieved—and achieved very rapidly, too, in contrast to the expectations of contemporary psychoanalysts.

Unscientific Analysis

Clinical psychoanalysis has become impractical, but it does not have to be impractical. In order to offer patients practical psychoanalysis, however, clinicians cannot conduct treatment on the basis of received wisdom. To begin with, psychoanalysts cannot assume the virtue of any particular set of procedures—use of the couch, frequency of sessions, even the method of free association. These are techniques, and in the progressive development of any scientifically based clinical practice, techniques will alter, even alter dramatically, as empirical evidence accumulates; some prove valuable and are retained, others are discarded. Only two hundred years ago, for example, the best available medical science indicated that bleeding the patient through use of leeches or by venicotomy was part of the responsible standard of care for most illnesses. Almost every patient who consulted a physician was bled. We now know that this technique, which was practiced as state of the art by the best physicians for centuries, was useless in almost all cases and dangerously detrimental in many.

Beyond Theory

If practical psychoanalysis cannot be defined in terms of any particular theory or technique, how can it be defined? The sensible way to define practical psychoanalysis is in terms of its area of study and its objectives. Sciences are usually defined in terms of their subject areas and applied sciences in terms of their objectives (e.g., chemistry is the study of compounds and pharmaceutics is the creation of useful drugs by applying chemical knowledge). Psychoanalysis is a scientific study of the mind, and clinical psychoanalysis an application of psychoanalytic science to therapy. “Practical clinical psychoanalysis is a treatment that aims to help the patient feel less distress and more satisfaction in daily life through improved understanding of how his or her mind works.” Another way to put this is to say that in a successful practical analysis the patient is able to revise various aspects of the way he or she constructs reality, with the result that the patient feels better.

We might even take a traditional view, following Freud, and add that practical analysis brings the unconscious into consciousness. However, if we want to continue to use that conception, we must be prepared to update our definition of “the unconscious.” It was Freud’s idea that clinical psychoanalysis brings into conscious awareness certain thoughts that are available to consciousness but remain unconscious because the patient is motivated not to be aware of them—what Freud termed repressed thoughts or the dynamic unconscious. And it is true that successful practical analysis usually does, to a certain extent, involve the patient identifying ideas, feelings, memories, etc. that he or she has been holding out of conscious awareness for one reason or another. But it is also true that a very significant part of what happens in practical analysis consists of the patient becoming conscious of thoughts that have never been repressed, thoughts that the patient simply never had the opportunity to think before. These thoughts arise from novel perspectives provided by the analyst—explicitly or implicitly, intentionally or unintentionally—in the course of an intimate, mutually engaged exploration with the patient of his or her difficulties.

Doing What Works

Unfortunately, practical psychoanalysts tend not to publicize what they do with patients; instead, they quietly set many traditional psychoanalytic theories and techniques aside and go about doing what works. Good for practical psychoanalysts and for their patients! But not good for the field. There are many clinicians who would like to learn more about how to conduct a practical psychoanalytic treatment, and many patients who would like to know how to recognize one. This book is addressed to readers in both categories.

In the chapters that follow, I will discuss what I have found to be basic principles of practical psychoanalytic treatment. I will use a casebook format, presenting concepts via illustrative clinical examples. I do that for two reasons: first, because I find that abstract formulations about psychoanalytic theory and technique, by themselves, are difficult to understand, let alone apply on the line in work with patients; and second, because my recommendations are not based upon findings from systematic, controlled empirical research (nobody’s recommendations are, in psychoanalysis, since adequate research methods have not yet been developed) and I want to share with readers, as best I can, the clinical experiences that have led me to reach my conclusions.

This is not intended as a scholarly volume. I haven’t presented a survey of the literature, noting whose ideas have been the same or similar to mine and whose have been different. No background in psychoanalysis is required to understand what I have written. When I speak of an “analyst,” I do not refer to someone who has attended an official psychoanalytic training program; I only mean a psychoanalytically informed psychotherapist—and since most of Freud’s important ideas have long since percolated into the cultural surround, any contemporary psychotherapist who is at all eclectic in his or her orientation will inevitably be psychoanalytically informed. My aim is to discuss in a down-to-earth way what, in my experience, can be useful for both analyst and patient to keep in mind when collaborating in an effort to help the latter feel better; and I think the best way for me to do that is to offer a collection of anecdotes, together with my thoughts about them.

Excerpted and adapted from Practical Psychoanalysis for Therapists and Patients by Owen Renik, MD. Published on Psychotherapy.net with written permission from the author. 

Also see An Interview with Owen Renik, MD.

Please note that the CE test covers BOTH this article and the interview noted above.

Clinical Wisdom: A Psychoanalyst Learns from his Mistakes

Identifying and trying to learn from one’s own clinical mistakes is often a painful experience, but can be an invaluable source of clinical wisdom. Here, I will share with you several significant mistakes that I have made over the 40 years that I have been practicing and teaching psychotherapy and psychoanalysis which have been extremely helpful to me and my supervisees. I hope that my self-disclosures and self-discoveries will evoke in you an active reflection on your own work and provide a source of professional growth.

My Two Most Difficult Patients

This was the beginning of the end of our relationship. His demeaning, hostile sarcasm, already intense, increased; there were fewer moments of his working on his real concerns and increased attacks on me. “John said, as he had frequently over the two year course of treatment, that the therapy was not helping, that I was totally incompetent and that he was going to quit therapy with me.” He responded to my attempts at exploration with depreciation of me and threats to leave therapy. But this time he meant it. He quit. He did not show for his next appointment nor answer my several phone calls. I felt both guilty and much relieved at the same time!

Mary, a single teacher in her mid-forties, was referred to me by a female colleague who had treated her for several years and now believed that Mary needed to work with a male therapist because she had never succeeded in having any long-term relationships with men, despite her longing for this. Though the first few years of our relationship were stormy, with her rages alternating with moderate depression, externalization and fluctuating mistrust of me, Mary made encouraging progress. She and I were both pleased that she developed a relationship with a real boyfriend for the first time, leading her to experience sex for the first time in her life, while at the same time she was becoming less argumentative with her fellow teachers. Sometime later, an event took place that was the beginning of the catastrophic end of our therapy. Her brother and his wife gave birth to a baby, which thrilled her parents. She became furious with her brother for what she experienced as a total loss in the rivalry for her parents’ attention and love. Through a friend who knew me, she found out that I also had a young child. Her hostile and at times rageful feelings toward her brother generalized to me. This morphed into a psychotic-like transference in which I not only had a young child like her brother but she said that I started to look like him.

When I questioned her about this, she said that my gestures and sitting posture were just like her “shitty” brother. My efforts at compassionate communication for her parental loss, reality testing and transference interpretation over several months had little effect upon Mary, leaving me frustrated and seriously discouraged. Mary quit therapy within a few months, saying that the therapy was no longer helping and that she would never see another therapist. Again I felt relief, but questioned—What could I have done differently? Could I have helped her continue her previous progress?

So, what did I learn from these two experiences? Obviously with John I needed to find a second hour, but I did not because he would not try to understand his almost constant demeaning of me and therapy, which I could not tolerate. With Mary I learned two lessons. One, psychotic-like transferences, when not resolved, can lead to the destruction of even a moderately successful therapy. Secondly, I needed help with my intense frustration and discouragement. However, the salient lesson with both patients was that when working with extremely difficult patients, careful self-reflection and occasional consultation are often not enough. I really needed continuous consultation or supervision to help both with the challenging technical issues and my uncomfortable countertransference. “My false pride that I should not need such regular consultation interfered with the possibility of breaking through the impasse in both therapies.” Since I had been supervising therapists and analysts, I felt that I should not need regular consultation. And I believe that, unfortunately, such a position is implicitly supported in some analytic institutes and other post-graduate training centers.

But if I had had a weekly or bi-weekly consultant, what could have been different? For one, the consultant might have helped me understand the dynamic issues and specific approaches that I was not seeing. Secondly, he could have assisted me with my powerful countertransferences through understanding and compassionate support. Would the outcome have been different? I am not sure, but I would have felt more confident that I did all I could for my patient and in my role as a psychotherapist.

Benevolent Values Can Interfere with Effective Treatment

How do I understand this premature termination? I believe my value of loving parents raising healthy children interfered with my being attuned with Kathy’s needs. Later I learned that Kathy was so determined not to have children that she underwent a tubal ligation. “Even our so-called benevolent values may be incongruent with our patients’ values and can mess up the treatment.” In retrospect, I see that in my eagerness to encourage a lovely young woman to carry out my value to become a mother, I responded to my wishes and lost track of Kathy’s needs not to become a mother. I certainly should not have pursued this issue the second time around.

Over-identification with Our Own Therapists

Therefore, it is not surprising that as a neophyte analyst I identified, and in fact over-identified, with both of them. David was a wonderful empathic listener who infrequently questioned and interpreted. I experienced him as a warm compassionate presence, genuinely interested in me. This analysis helped me immeasurably to discover and accept the deeper shadow aspects of myself, as well as resolve some minor symptoms. So, I too became a very good listener who seldom interpreted with my patients. A supervisor pointed out that, unlike me, some of my patients needed a more active use of inquiry and interpretation in addition to careful listening. She was certainly right. While we can learn from our own personal analysis or therapy, we need to be aware that what is good for us is not always best for others.

Becca, my group therapist, by contrast actively intervened and was emotionally very expressive. She also believed in few traditional limits in group therapy, such as the rule against socializing outside the group. This group experience which included extra-group socializing was very beneficial to me and to most of the high-functioning group members. Therefore, with my own therapy groups I used Becca’s agreement that it was okay to socialize outside of the group. Within a few years of conducting and supervising groups, I saw that permission to socialize was detrimental for some groups. For example, some socializing leads to major enactments outside the group which are never discussed in the group because of such reasons as shame, wanting to keep a secret relationship or fear of retaliation from group members or therapists. Gradually, I developed my own way of structuring outside group contact, which fit me and my patient populations better.

In more formal psychoanalytic terms, I had initially introjected David and Becca whole, but gradually was able to differentiate from them, keeping the good part objects (that which fit me) and eliminating that which did not fit me or my patients. “In everyday terms, I became truer to the way I work best and to the unique needs of my patients and groups.” I learned some extremely valuable lessons from my two analysts. However, as I developed more confidence in myself I was able to let go of the idealized internalization of my analysts and start to become the analyst and therapist who fit my character and my patients.

Collaboration with Other Analysts Treating the Same Patient

Much to my surprise, Oscar’s individual analyst said to me, “You group therapists are strange ducks. . . . you don’t understand that such talk between us will interfere with the treatment. Only if there is a suicidal or homicidal emergency should we contact each other.” Unfortunately, I agreed to treat Oscar under this restriction. The group, a good composition for Oscar, enabled him to play out a central dynamic underlying his chronic friction with men and his inability to sustain a meaningful relationship with a woman. He frequently attacked me and two of the other three men in the group, while placating and sweet-talking the three women in the group. Then one of those felicitous accidents happened. One session, all three women were absent, leaving Oscar alone with me and the three other male group members. Oscar’s behavior changed dramatically in this session. He not only did not attack us but became friendly to me and the other men. All of us, including Oscar, noticed this marked change. The following week when two of the women returned, Oscar reverted to his typical attack on men and his seduction of the women. When this remarkable behavioral change was brought to his attention, he strongly denied it. Group members suggested that Oscar talk to his individual analyst about the discrepancy between the group’s and his perception of his behavior when the women were and were not present in the group, but he refused, insisting that there was nothing different to talk about.

Oscar had enacted a salient dynamic—a dynamic that was hidden from his awareness because it was too threatening to be known. Yet this enactment was ripe with wonderful therapeutic possibilities. With Oscar unwilling to discuss this with his individual analyst, I told him that I would alert his analyst that something crucial was happening with Oscar in the group making it vital for us to talk. Oscar said, “Go ahead. My analyst will never believe this group bullshit anyway!” However, since Oscar was neither suicidal nor homicidal, his analyst refused to talk with me. Not surprisingly Oscar dropped out of the group within a short time. I believe that had his individual analyst been willing to talk with me, we would have had a good opportunity to cooperatively work with Oscar in depth on this crucial dynamic.

Sheila, a psychiatric resident in individual analysis, wanted group treatment because she was starting to recognize that she was rejecting decent eligible men as lovers and potential mates. Within a couple of months the group and I realized that Sheila was looking down upon the group members, especially the men, from an “I-am-superior-to-you” position. Believing this was salient to her reason for group treatment and being concerned that she might flee from this group of “inferiors,” I told Sheila that with her permission, I was going to talk to her individual analyst. After her analyst did not return several of my calls, I informed Sheila, and she responded that her analyst must have had a good reason, but she refused to elaborate. Shortly thereafter Sheila dropped out of the group.

What lessons did I learn from the two frustrating experiences cited above? Over the last decades I have made it my practice not to accept any referral for group or individual therapy when there is another therapist treating the same patient, unless there is agreement from the other therapist that we can collaborate if and when needed. In my experience our collaborative contacts are usually few and far between, but occasionally crucial. It is the trust between the two professionals that is vital. I have found almost all patients agreeable to therapist collaboration, and in fact are often pleased with this arrangement. Many patients experience this as genuine interest in them. In the rare case when the patient is reluctant for me to speak with their other therapist, I try to understand what this means for the patient. Typically our work on understanding the patient’s reluctance has led to a solution that benefits the therapy and the patient. In one situation with a suspicious patient who protested, I told him I would be willing to talk with his therapist on the phone while the patent was present—thus allowing him to hear every word and tone that I expressed. Hearing this willingness on my part, the patient said that he did not need to be present, but he wanted me to tell him what I said and what was said to me, which I was quite willing to do. In another unusual situation where the other therapist said communication between us would damage therapy, the patient insisted that we two therapists cooperate. She said that she would never go to a second physician if he would not collaborate with her present doctor.

Becoming Wiser

What does this mean to me? “I believe that mistakes and solutions are unique to each practitioner and interact uniquely with each particular patient.”

Over the years I have come to know myself better both as a human being and as a therapist, and what works better for my patients with our intersubjective uniqueness. With experience, analysts and therapists are ideally true to our own uniqueness and our particular interersubjective fit with individuals, couples or groups that we are trying to help. This to me is a vital component of clinical wisdom. I know of a few analysts of varying theoretical perspectives who adhere so closely to their cherished theoretical and technical ideas that they miss what I would consider crucial aspects of their relationships with their patients. These analysts may need such adherence to theory and practice for them to feel coherent, secure and competent. Another type of wisdom would be for those therapists and analysts to understand how this view affects their practice and work.

Dogen and Michelangelo

Dogen, considered one of the greatest Buddhist teachers, stated in the thirteenth century, “My life has been a continuous series of mistakes.” After decades of experience, I continue to make mistakes and try to learn from them. As Michelangelo said at the age 87, “I am still learning.” I certainly am too.

Notes

1 A briefer version of this paper was originally presented by Dr. Rabin at the Annual Colloquium of the Group Department of the Postgraduate Center for Mental Health, New York City on December 7, 2006.

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