Category: Blog

Don’t Ask, Don’t Tell

Posted on by Psychotherapy.net Team

Last Sunday night I dropped a pot of boiling water on my hand. My quick thinking teen aged son who was standing near by promptly grabbed me, led me to the sink and held my burned wrist under perfectly tepid running water. Shortly there after we took a quick trip to the ER where they wrapped me up and sent me back home.

I’m healing nicely. But the white bandage around my left hand has been good fodder all week in my office. There’s been an interesting hodgepodge of reactions from my clients, from not noticing at all to “Wow! What happened to you?”

It’s brought me back to the several pregnancies I’ve had while in private practice when my body was inflating in front of me, and in front of my clients. Some noticed early on, and others were shocked when – toward the end of the pregnancy – I said I would be out of the office for a bit. Some wanted to know why, others just wanted to know when I’d be back. It was indeed an interesting study in narcissistic transferences, object relations, relationships and character.

So here I am with white gauze wrapped around my literal wound debating about which figurative hat to wear in session. My own analyst, if wounded, (would I want her wounded? If so, why?) would most likely nod slightly and say something like “What do you think happened?” And then we might spend the session in some sort of fantasy exploration of my ideas, associations or feelings about what may have happened, about knowing or not knowing, and what that would or would not mean to me. Depending on my mood I would find this either interesting and helpful or downright annoying and useless. Probably some of both. But I would tell her that too.

That’s part of the freedom of being able to say everything and anything in therapy. It includes saying whatever you feel about the therapy and the therapist, which does often lead to better feeling states and more insight. So what’s better for my clients? To know? To guess? To talk and see what comes up? Or to satisfy the question if asked? Feed the desire, gratify the need? Or perhaps just to engage in the righteous social norm of polite dialogue? After all if I tell too soon, are we missing out on a memory of a mother being hauled off in an ambulance, or the time they cut their own finger? Maybe if I don’t answer too quickly I will find out that they feel concerned about me, that I mean a lot to them, or the opposite. Some folks just want to know that I am able to do my job or continue to take care of them or both. With some, the exchange has been sweetly and simplistically human, a currency of concern and connection that flows naturally through both the therapeutic and real relationship that exists between us.

Perhaps too, my injury offers an opportunity to explore empathy and to learn more about how aware we are of each other, of others, of ourselves. And for some, my injury means that I must know now, for sure, what it feels like to be hurt.

Mostly, my clients have been satisfied to know that my attention to them has not been affected by whatever has happened to my wrist, even though it does bring home, on some conscious or unconscious level the registration that I exist outside of the office and am susceptible to the perils of life just as they are. And that I too might benefit from an analysis of why I hurt myself, unconscious though it was.

Not mistreating the treatment seems to be the most important thing. That and taking very good care of the relationship. So, to satisfy or to analyze? It’s hard to know exactly all the time, but it seems to me that a little bit of both usually goes a long way toward healing and avoiding burns.

Who Else Wants To Know Why Americans Spell Counseling With A Single “L”?

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A while back, when I opened my afternoon snail mail I received a card from Dr. Thomas W. Clawson, CEO of the National Board for Certified Counselors (NBCC). Dr. Clawson asked in his correspondence if I knew why the words counseling and counselor are spelled with a single "L" in the U.S., while in England and Canada the words are correctly spelled with two "L's” (i.e., counselling or counsellor).

He then went on to answer his own question. The mystery, he noted, could be traced back to Frank Parsons, the so-called father of guidance and vocational counseling. It seems that the multi-talented Parsons was also trained as an attorney. To avoid confusion he would spell counseling or counselor with two "L's" when working in the legal profession (e.g., counsellor- at-law), but he used a single "L" spelling (i.e., counselor) to distinguish his work as a helper.

Clawson shared with me that his source for this information was none other than Dr. Joseph W. Hollis, a prominent figure in the counseling arena. Joe had been the Chairman of the Department of Psychology and Guidance Services at Ball State University in Muncie, Indiana. After thirty years of dedication to the university, he retired in 1984. But retirement for Dr. Hollis turned out to be the beginning of a new venture. He founded a publishing company, Accelerated Development (later purchased by Brunner Routledge, a division of Taylor & Francis), that he initially ran out of his garage. But the company blossomed and Joe brought a lot of the seminal titles to our field in the 80's and 90's. In addition, he was known for undertaking the first major study of counselor preparation programs. He also helped found and served as president of C-AHEAD, the Counselors Association for Humanistic Education and Development. I had the pleasure of coauthoring a book with Joe in 1994.

I emailed Dr. Clawson back to report that I had not only been privy to the story about Parsons, but my source was precisely the same as his: Joe Hollis.

At that point in time I became very curious and wanted to verify our hypothesis in a scholarly source. I searched near and far and was assisted by several talented college research librarians. I perused ancient tomes that had accumulated over nearly a century of dust (now I know why some books have dust jackets!) to no avail.

Since I came up empty handed, I thus contacted the one individual who I knew had publicly broached this subject, Dr. Samuel T. Gladding. Gladding is a noted counseling textbook author and a former president of the American Counseling Association (ACA) and the Association for Specialists in Group Work (ASGW). Indeed Dr. Gladding was espousing the identical explanation concerning Parsons. His source: None other than—you guessed it—Dr. Joseph W. Hollis.

For now, I'm sticking with the story because Joe never told me anything that wasn't the truth, the whole truth, and nothing but the truth! Sadly, Joe passed away at the age of 80 on November 23, 2002, so we can't ask him where he acquired his information.

But hey, if you uncover something in the literature that proves we are wrong, just give me a holler. I'm all ears.

Albert Ellis and the Traveling Road Show

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As a master's level graduate student at the University of Missouri, St. Louis, I was very fortunate to have Dr. Patricia Jakubowski as my advisor. Pat was not only a recognized behaviorist, but she was also a pioneer in the assertiveness training movement. Best of all, she had befriended a psychotherapist who was very close to Dr. Albert Ellis. That's right the Dr. Albert Ellis.

At the time, it was virtually impossible for a student such as myself who didn't own a master's degree sheepskin to attend an ongoing training session with Dr. Ellis, but Pat worked her magic (can you say used her connection?) and there I was at the Institute for Rational Emotive Therapy in New York City. Although Ellis came across as dynamic in his writings, he was ten times as colorful and entertaining in person. During the training Ellis cast many gems of wisdom related to his baby, RET, which stood for rational emotive therapy. In his mind it was the ultimate form of counseling and psychotherapy. Later, with a little coaxing from psychologist extraordinaire Raymond Corsini, Ellis renamed the modality rational emotive behavior therapy or REBT in 1993. Thus REBT is the name which lives on in the pages today's textbooks and counseling classes.

But the one thing that stands out in my mind after all these years was a remarkable story he shared that transcended the boundaries of his own theory. Ellis mentioned that during the early 1970s he was conducting a presentation at a major national conference. After his speech another presenter demonstrated a new form of therapy. Suffice it to say that this other treatment modality was everything RET wasn't. This novel approach stressed intense catharsis, abreaction, and focused heavily on one's childhood experiences. Convinced of the superiority of RET over any other form of helping Ellis was ready to dismiss the whole idea until he watched a demonstration of the new system in which an acutely disturbed client was cured of what ailed her in less than sixty minutes.

Even the great Dr. Albert Ellis was amazed and could not believe his eyes. Could this innovative form of therapy be that effective? But make no mistake about it—Ellis had an open mind and decided he would investigate the new paradigm. His investigation came to a surprising and screeching halt in less than 30 days. You see, not long after the first conference, Dr. Ellis was scheduled to present at still another national conference. At the second conference he spied the same psychotherapy expert, curing the same client, of exactly the same problem, in precisely the same period of time.

So the moral of the story is that if some new, improved form of psychotherapy makes a giant splash onto the helping scene that just seems too good to be true . . . just use a little creative visualization and think of Albert Ellis and the dreadful deception of the traveling road show.
 

The Joy of Small Miracles in Psychotherapy

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I confess that sometimes in the course of my work sadness overwhelms me. I am not talking about compassion fatigue, burnout or a concoction of transferences and inductions. I’ve been listening to folks talk for almost two decades now, but sad narratives still affect me, as well they should.

Sometimes the healer in me dips under the radar and I feel only like I am standing at the station watching a train wreck happen, or so I think. Faith and that good old fashioned “patience for the process” that I learned back in social work school get eclipsed by the urgency and impulsiveness that often walks through my office door. Even though I know that we do not control outcomes (and as my career ages into its mid life, I am finding this truism to be a relief), I do sometimes wish for miraculous epiphanies and prescient strides forward.

Not too long ago, I got my miracle.

A couple I’ve been seeing was in therapy to discern whether or not they were going to stay together. He wanted to stay married and she was, she said, not sure. She did not feel loved. He did not feel supported. When she felt angry or hurt, she threatened divorce, or told him what she hated about him. When she did this, he became more frustrated, backed away further, and so went the dance.

We’d been unpacking things for a while—the dialogue between them, her history, his. But still she maintained that he was a louse. (He had never impressed me as such.) There’s more to their story, but over the course of the therapy, I began to feel utter sadness. I found myself wondering why I was such an advocate for their marriage. Was I thinking of their four kids? Was I feeling his sadness? Or hers? Was I feeling my own sadness? How do I know what’s best for them? Or their kids? Was I lapsing into judgment? And if so, why?

My sadness in this case was this too: This guy really did step up. And this woman kept knocking him down at every turn. She seemed to be deeply, wholly cathected to killing him, the marriage and love itself.

As a defense against my sadness, I began to diagnosis her in my head. “She is borderline,” I’d tell myself. Or, “She is a typical ACOA.” And then, “She suffered too much trauma to be able to sustain a mature relationship.” Silently I found myself begging her not to destroy her home. She did love this man, she claimed. And she fessed up to his good fathering. But for session after session she wept about how her husband was not her hero, and how out there somewhere her real love awaited.

And then one day, out of the blue, she came into session and said that she had prayed. And that she had made a decision. She said that she had been behaving terribly and it was going to stop. She said that her husband was a good man and deserved her respect and support. She said that she sees that he is not her father who disappointed her, that she is loved and loveable and that her relationship with her husband and her self fair much better when she acts reasonably and kindly, and handles her feelings better. She told me that she understands that when she feels vulnerable and afraid she threatens instead of saying a feeling or expressing a need. She understands that words can build or break, and that she wants to build. That she is now fully aware of this and can and will do it differently.

Her husband was right on board, appreciating her openness and her effort, restating his love for her and his willingness to keep working on himself and on their emotional connection.

Perhaps all those elements of EFT, IFS, CBT, DBT, Imago, Attachment and good old psychoanalysis that I’d been pulling from did their job. Or maybe it was my attentiveness or occasional loving looks, or as of late, my restraint from saying very much at all. In my mind, as I listened to her I would visualize writer Ann Lamott’s acronym for WAIT – Why Am I Talking? Perhaps in my silence she felt understood, and that her profound longing and sadness could breathe.

I admit that I really do like to see breakthroughs now and again. I suppose they help me hang in better when all those feelings come through my door, whipping up my own like a wind gust on dry leaves. With all my ideas about what really happened swirling about, I’m settling on the miracle. I’m giving myself the gift of joy, of seeing the train wreck derailed and not the train. I know that in this business some miracles are temporary—sometimes it seems like character, relationship and repetition difficulties are more resilient than their resolutions—so I’ll take the miracles when they come.

The Miraculous (or not) Efficacy of Solution-Focused Therapy

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For years solution-focused therapy approaches have been all the rage; the popularity of this distinctively brief therapy method is unarguable. Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. If you recall, that was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Nevertheless, as much as I’d like to ignore all evidence contrary to my own beliefs, I also find myself attracted to old-fashioned modernist reality—especially that scientific research sort of reality. Consequently, over the years I’ve often wondered: “What the heck does the scientific research say about the efficacy of solution-focused therapy anyway?”

Well, here’s a quick historical tour of scientific reality.

• In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”

• In 2000, Gingerich & Eisengart identified 15 studies and considered only five of these as relatively well-controlled. After analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”

• In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies–a fairly small effect size.

• In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted. But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is only modestly effective.
 

Psychotherapy: Terminal or Interminable

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“I was okay until I met you!” she said and slammed the door of my office as she left. I have never forgotten that moment. I was shocked, not just by the vehemence, her incandescent anger, but by my complete failure to anticipate her reaction. I thought I was a good judge of character and I had got this woman badly wrong. I had invited her husband to attend the previous session and, instead of supporting her jibes and scarcely veiled attacks on him, I had taken a neutral stance. In her eyes, I had let her down. The one certainty was that the therapy had ended. Abruptly, unilaterally, angrily, admittedly, but it had the virtue of being unambiguous. I never saw my client again. 

During my long career as a psychotherapist I rarely experienced such a definitive ending. Fortunately, one might think, but was it? Looking back, I wonder whether I missed a trick, that, basking in my role as the Good Therapist, I colluded with my clients’ fantasies that therapy might go on forever. I would always be there, willing to see them again if they wished, for a few more sessions or a resumption of therapy. There were many clients who returned to me after an apparent ending. Smugly, I thought of myself as good at this job. I was not taken in by the idea that CBT or any other set of techniques was what determined outcome. It was the therapeutic relationship that mattered most and, for many clients, that relationship was the gossamer thread that linked us together. It might be scarcely visible but it was always there in the background even after therapy had ended. Now I wonder if something else was going on and the reason I was prepared to let people return, encouraged it even, was a fantasy of my own. Was it that I thought I was truly important to my clients, indispensable even, and that each time I received a phone call or a letter asking for more help, I felt the warm glow of satisfaction at the confirmation of my self-worth? 

This is not a comfortable thought. It would be easy to dispel it. I could tell myself that therapy rarely works in a straightforward way at first, people need more than one bite at the cherry, and those who returned to me did so because they trusted me and valued what they had received. And they benefited. All that may be true. But perhaps it is not the whole truth. Sometimes, therapist and client are dazzled by the therapy. It becomes a unique, special relationship. They have fallen in love. I do not mean that romantically or sexually but that something of the same specialness delusion operates. Good sense goes by the board and the relationship seems timeless. Until at some point it has to end.

“I have something to tell you,” I say. I am apprehensive, hesitant.

Patricia gives me a hard look. “That’s what people say when they want to end a relationship.”

“Well, that’s partly what I mean.”

Suddenly, her eyes fill with tears.

“In a year’s time I am stopping being a psychotherapist. I thought I should give you a year’s notice.”

She looks down. Tears are falling freely now. “Do you think that makes it any easier?”

I had thought exactly that but I don’t say it. I had wound down most of my clients. And earlier, I had thought that I might just keep Patricia on, to keep my hand in so to speak. When I mentioned this possibility to my supervisor, she looked me straight in the eye and said: “Why would you do that, John?” And I knew immediately that it would be wrong. 

“I’m sorry,” I say, inadequately, deflatedly, although what I am apologising for is only clear to me much later. 
All therapies have to end. When a therapist loses sight of the ending, it is no longer therapy but something very different.

Ethics of Treating Two Psychotherapy Clients who Know Each Other

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A question was recently posed to us about what to do when you discover in an early session with a new client that they are the former partner of another well-established client. Well, for those of you who actually stopped to think, “Oh, this may be a problem,” then you are certainly one step further away from sliding down the slippery slope of unethical behavior than those who did not recognize that this situation may pose a potential ethical dilemma. Professional codes of ethics (e.g. APA 3.06, NASW 1.06) ask us to be mindful of conflicts of interest that arise and to take steps to resolve them. The best resolution is to refer the new client to another therapist (if possible).

For those of you who can refer this new client to another therapist, then the question arises as to how to do so in an ethical manner. First, remember that you cannot ask permission to disclose your relationship with the other client because this will breach patient confidentiality. You can, however, simply express that in reviewing this new client’s case you believe he/she would be better served by a different therapist who is more closely matched or specialized with his/her needs. Remember, you are not mandated to treat every client who seeks treatment from you. Second, provide the names of two or three therapists who currently have openings for new clients in their practice. It is important that these referral therapists have the capability to accept new clients at the time so that continuity of treatment is maintained and the client’s (potential) feelings of abandonment are diminished. Third, if you terminate in a responsible clinical manner then you will likely be terminating in a responsible ethical manner. Thus, if you terminate in accord with the standard of care for your theoretical orientation, using good clinical skills to transition the new client and allowing them to feel heard about your decision, then you again decrease the probability of the client feeling abandoned which often leads to board complaints. Last, provide a written termination letter confirming the termination of treatment and the referral therapists contact information. Keep a letter in your file as part of the clinical record.

Earlier I mentioned that this situation “may” pose a dilemma because if you practice in a small or rural town then you may encounter this situation frequently since you are one of the few practitioners available. In those situations, if you cannot refer out then it is best to have a clear plan as to how you will keep from falling down that slippery slope of potentially unprofessional conduct. For example, how will you handle information you learn from your well established client from seeping into your sessions with your new client, and vice versa? How will you identify and handle information learned from one client inadvertently influencing how you think about the other client? Consultation, and of course subsequent documentation of decisions and rationale, is a good way to keep your own personal biases and such influences in check.

As a general rule of thumb remember that our professional codes of ethics require us to be mindful of conflicts of interest that arise and to take steps to resolve them. While the best resolution (especially in this scenario) is to refer the new client to another therapist, if this course of action is not possible, and refusing service to a client is clearly detrimental to the client’s welfare, then chart and note the steps taken to minimize potential conflicts and difficulties that arise in the course of treatment. Such documentation is part of good (and mandated) record keeping procedures but also demonstrates your contemporaneous judgment, which is always your best proactive defense.
 

First Impressions in Psychotherapy

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A woman wrote to me, having heard me on a radio programme. She had picked up my concern that not enough attention was being paid to the quality of the therapeutic relationship (as opposed to techniques) and wondered how her 25 year-old son, who was seeking a psychotherapist, could assess that in advance of therapy when neither of them knew any therapists where they lived. The obvious answer is that he should wait until he and the therapist meet. Therapy is after all a personal relationship and only by knowing the person could there be a real alliance. If on meeting the therapist for the first time, he felt uneasy or badgered or misunderstood or puzzled or demotivated, then perhaps the therapist was not the right person and he should find someone else. But is that right?

First impressions are important. Think of meeting someone for the first time and how even after the end of a brief exchange, you have already formed an opinion of them. I met a neighbour at a party my wife and I gave, someone I was prepared to like having already met his charming wife. To my surprise, I disliked him. What was it about him that provoked this strong reaction? Thinking back, I realised it was that he had shown not the slightest interest in me and my attempts to engage him in conversation had been met with distracted inattention. I even resented the fact that, when I moved past him to get someone a glass of wine, he made no effort move aside! (This says as much about me as him, I realise). A prospective client could do something like this, evaluating the therapist by how he or she responded and how the client felt in the session.

But therapy is not the same as a conversation. Most therapists are good at putting clients at ease, asking questions sensitively, listening attentively and making the client feel safe and understood. For most clients the experience of the initial session is likely to be positive, allaying anxiety, reinforcing the hopeful expectation that at last help is at hand. Unless the therapist is distracted or disturbed, the first session will generally pass well. That does not mean the therapy will always be bathed in this arm glow of positivity and, if it were, we might wonder whether the therapy was really that helpful. As Patrick Casement points out in his autobiographical memoir, Learning from Life, good therapists must learn they should not always be nice to their clients.

In the first session unconscious processes in both therapist and client will be at play. I recall reading about a client who knew from the therapist’s name alone that he would be the right one for her. Once I heard a client’s hesitant and garbled message on my answering machine and that made me reverse my just made policy of not taking on any new clients. And on another occasion, opening the door to a new client I took fervently against her and, to my shame, manoeuvred the session so that I could refuse her help. For all these factors, conscious and unconscious, the first session may not be the best place to judge the therapeutic relationship, although of course a judgment will inevitably be made. The truth is that the success of the relationship can be judged only in the experience of it.

Perhaps I should be a bit more psychological in my response to this woman’s question. Why was she contacting me, not her son? Was she just an over-protective mum, simply anxious that her son should find the ‘right’ therapist? Or was she anxious that he would find such a therapist who would replace her? Was she seeking help for herself? I don’t know and, no longer being in practice, means I will never know. My first impressions therapeutically occur now only in the virtual world and that is altogether different.
 

Videotaping Therapy

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Therapists have been using videotape to enhance psychotherapy training and supervision for decades. Recent technological advances have allowed for a range of creative new affordable ways to record “picture-in-picture”, so the video shows both the client and therapist. These setups do not require any video editing. Below is a list of instructions for picture-in-picture video setups, with links for more information. If you know of another recording setup, please email me, and I’ll add you to the list.  

(Updates to this list are available here:  http://istdpinstitute.com/resources/)

1. I use Wirecast software to combine two digital webcams, connected to my computer, into one picture-in-picture therapy video. Psychotherapy videos are stored on the computer and can be burned onto DVDs. No editing is required.

2. Nat Kuhn developed a system to video therapy sessions that uses two digital cameras, two DVD recorders and a Picture-in-picture (PIP) video mixer. Therapy videos are stored on DVDs and no computer editing is required. He provides very detailed equipment and setup instructions here: http://natkuhn.com/equipment/equipment.pdf.

3. Arno Goudsmit in the Netherlands has developed a psychotherapy recording tool for a 2-camera and computer setup (also adaptable for 1 camera), which gives a picture-in-picture effect on an mpg-file. He uses memory sticks which the patient can take home; and they keep a copy of the psychotherapy video for study purposes. (You could also burn the therapy video onto a DVD.) You can find his software at: http://www.edtmaastricht.nl/2cameras. His software is free and no video editing afterwards required.

4. Rick Savage is a producer in New York City who has experience helping setup therapy videotaping systems using Apple computers and digital cameras. He can be reached at 917-364-1866 and
www.savagetunes.com.

Also:  Jon Frederickson and I have been experimenting with the use of Skype for one-way-mirror supervision. Jon provided live, one-way-mirror supervision for me from Washington, DC, while I was working with clients in San Francisco. We have had very positive clinical and training outcomes with this new technology. If you would like setup instructions, email me.

Clinicians and supervisors may also find the following articles of interest:

1. Allan Abbass, a psychiatrist in Halifax, published “Small-Group Videotape Training for Psychotherapy Skills Development”, as well as “Web-Conference Supervision for Advanced Psychotherapy Training: A Practical Guide”

2. Peter Costello, a media ecologist and clinical psychologist at Adelphi University, wrote “The Influence of Videotaping on Theory and Technique in Psychotherapy: A Chapter in the Epistemology of Media”
 

Is Self-Regulation or Co-Regulation Better for Couples?

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Should couples in distress attempt to change their partner or themselves? Recent research discusses concerns about both of these strategies, and raises an interesting third option. Shreena Hira and Nickola Overall examined 160 couples attempting to change their partner or themselves. As they expected, attempts to change their partner didn’t make either their partner or themselves feel better. Surprisingly, however, a focus on self-change did not consistently help the relationship either. Instead, the researchers discovered that the most beneficial change occurred when one or both partners in the relationship perceived the other as changing themselves (self-regulating.)

This poses an interesting challenge for couples therapists, as partners don’t always perceive the change (or effort) made by their partners, and rarely does either partner want to “go first”.  One idea to address this dilemma, proposed by Victor Yalom, is for the therapist to help clients  tune into the changes and effort made by their partner, even if the change or effort is very small.  This can help build trust, morale and set the stage for greater changes later.  Likewise, therapists could use recognition of small-item effort or change as an assessment tool for determining when the couple is ready to work on more challenging change goals.

There is currently a hot debate in the field between therapists who promote self-regulation (differentiation) and therapists who promote co-regulation (attachment). This research suggests that couples may in fact improve co-regulation capacity by witnessing self-regulation efforts by their partner. 

From: Shreena N. Hira & Nickola C. Overall. (2010). Improving intimate relationships: Targeting the partner versus changing the self. Journal of Social and Personal Relationships 28, 610-633.