Category: Blog

Techniques, Therapeutic Relationship and the Importance of the Body

Posted on by Psychotherapy.net Team

Throughout my career as a psychotherapist I struggled to find the right balance between using specific techniques and the importance of establishing a safe therapeutic relationship. Toward the end I veered more to the latter as I realised, rather belatedly I admit, that people sought therapy not necessarily to get better but often just to be heard. A safe haven and a sensitive, empathic and caring individual can be enough; specific techniques can get in the way. Of course this is hard to square with the demand for evidence-based psychotherapy where therapy is defined as applying identifiable techniques and improvement seen in terms of symptom reduction. This quasi-medical model is rightly seen as simplistic, ignoring both individual meaning and the influence of socio-economic factors on mental health. Nevertheless, it has certain virtues. It enables those who know very little about psychotherapy to grasp what is supposed to be happening, something that both clients and commissioners of psychotherapy legitimately wish to know. Seeing a CBT therapist, for example, means that the approach is likely be collaborative, problem-focussed and address the client’s thoughts, feelings and behaviour in an open, adult and rational way. Seeing a psychodynamic therapist, on the other hand, means the therapist is likely to be passive, say relatively little, attend to underlying meanings and dynamics and use the therapeutic relationship as the main vehicle of gaining understanding from which change may or may not happen. Neither of these descriptions captures the subtlety and complexity of psychotherapy, nor the uncertainty that is part of all therapies. But they are not unimportant especially when it comes to making useful distinctions to those who know very little about what goes on behind the therapist’s closed doors.

In researching a book about peoples’ response to major traumas, I discovered some interesting and new (to me) therapies, ones that worked primarily through the body. I watched a DVD in which therapists trained in Emotional Freedom Techniques worked with highly disturbed combat veterans with strikingly positive results. I read up on the many and varied somatic therapies and began to understand how therapists who attend to the physical body gained much from not having to work verbally or at least not as the primary means of intervention.

Peter Levine is one of the best known exponents of “somato-sensory psychotherapy,” an approach that sees traumatic reactions as largely due to undischarged energy. Therapy is geared to enabling the person to discharge energy through more sensitive and balanced physical actions. Levine is adept at seeing the embodied person in a way that most psychotherapists are not. It is easy to equate the somatic therapies with their striking physical techniques. Tapping pre-defined meridian points in a particular sequence and in relation to a particular phrase or thought is clearly one such technique. But it also reflects a general therapeutic approach, one that conceptualises the psychological impact of trauma not in terms of trauma narratives or past history but in terms of physical experience. If, as seems to be the case, people can recover remarkably quickly, sometimes in a single session, then this different approach deserves to be taken seriously.

EMDR, essentially the precursor of the somatic therapies, was very critically received precisely because it seemed too good to be true. But it has proved its worth since. Similarly, it is easy to dismiss therapies as ‘wacky’ if they draw on traditional Chinese Medicine, focus on acupressor points, use an uncertain and vague term like “energy,” and involve rather simple physical actions like tapping. Beware of not seeing the wood for the trees. Energy psychology and somatic therapies offer something radical and different. Traditional (verbal) therapists would be well advised to keep an open mind. Seduced by our Freudian heritage, we plunged into the complexities of the mind and, with some notable exceptions, forgot the body. Isn’t it about time we brought the body back?

Nordstrom: Psychotherapy Lessons From The Cathedral Of Commerce

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Let's get something straight right from the get-go. I don't work for Nordstrom, nor am I am affiliated with them in any way, shape, or form. I've never spent a dime there. Truth be told, the only time I ever set foot in a Nordstrom was to walk from the mall to the parking lot. (Elapsed time: one minute and forty-five seconds.)

But I do know this. Nordstrom has become the darling of the customer service movement. If you are searching for the prime example of the customer-is-always-right philosophy, trust me when I say, you just found it. The stories are legendary, such as the time during the mid-1970's when a customer returned a set of snows tire to Nordstrom. Yes, the customer received a cheerful refund. The only wrinkle was that Nordstrom didn't sell snow tires. Then there's the saga in which an unhappy customer returned a set of ice skates. Here again, Nordstrom took them back. Never mind that Nordstrom didn't carry ice skates.

Historians and business scholars who have investigated these transactions are still debating how much is myth and how much is fact. I don't pretend to have the answer and indeed will let the MBA's battle it out on their own turf. Nevertheless, there is no doubt that Nordstrom is the poster child for the customer is always right, even when the customer is wrong philosophy.

But do we, as helpers, always abide by this stance or do we hide behind our favorite technique, what helped us when we were wounded warriors, or what the latest evidence based practice literature tells us?
A well-known dyed-in-the-wool behaviorist once gave me an excellent clue. The therapist noted that he was seeing a client whom he was treating with behavior therapy and behavior modification techniques. But there were two problems with this approach. First, was simply that the behavioristic modalities did not seem to be working. Second, was that the client kept insisting he wanted classical psychoanalysis. This went on for a significant period of time until one day when the therapist was so frustrated he threw in towel and agreed to provide classical analysis.

The situation became a tad more bizarre when the therapist explained to the client that he was sure psychoanalysis would not work. He thus created a behavioral contract stating if the analysis didn't work in six weeks, the client (excuse me, I mean the analysand), would agree to give behavior therapy another whirl. Since a course of analysis usually runs approximately three to five years this contract was about as paradoxical, if not downright silly, as it gets! Moreover, the use of a behavioral contract in psychoanalysis is little like trying to mix purified water and used motor oil!

For the next six weeks the client made the couch his new psychotherapeutic home as he babbled on about his childhood and his dreams, while the his behavior therapist, turned Freudian analyst, sat out of his sight and took copious notes.

In less than six weeks the client reported that he had overcome his symptoms and was feeling well enough to terminate treatment. No doubt somebody had to pinch the therapist to make sure he wasn't dreaming.
So, the next time your client makes a treatment suggestion, my advice is to listen very carefully. You might just catch a rare glimpse of the path less traveled from the annals of Nordstrom.

Conduct Therapy Sessions Like Ellis Or Rogers In 7 Days Or Your Money Back!

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Okay Rosenthal, tell me something about psychotherapy I don't know. Fine: I will! If you've read all the textbooks, analyzed the classics, and been to enough workshops to receive frequent flyer miles, I've got something new to teach you so put down the managed care forms, and pay attention.

My secret weapon for improving your psychotherapy sessions comes from the field of copywriting. That's correct, I said copywriting. Copywriting is the act of creating written documents that persuade customers to reach into their wallet or your purse, and hand over some greenbacks, a plastic card, or simply click that familiar Paypal button.

When you receive a letter trying to sell you Ginsu knives or the latest Ab blasting exerciser, that's copywriting. Ditto for those letters begging for a contribution for your Alma Mater. According to many experts, the greatest copywriter of our time was an upbeat fellow named Gary Halbert. Now according to Gary Halbert (aka "the Prince of Print"), one of the fastest ways to become a master copywriter is to take samples of the best ads ever written and simply copy them in your own handwriting. Rumor has it that Gary did this himself for hours, if not days on end, when he first entered the business. The result was that he transformed himself (and later many of his students) into consummate professionals in weeks, rather than years, using this paradigm.

Along those same lines, I would urge you to select a well-known therapist you believe in and copy their therapy dialogues in your own handwriting. Better yet, since psychotherapy is a verbal pursuit, read the helping sessions aloud. In fact read the session (or portions of the session) again and again. Notice, I said "believe in" inasmuch as Rogers would certainly conduct a therapy session with a given client in a different manner than Ellis. O'Hanlon would no doubt rely on an intervention that bears little or no resemblance to either of the aforementioned luminaries.

When you get to the point that you can guess with a high degree of certainty what the world class therapist will say next you are well on your way to becoming an accomplished practitioner in that particular psychotherapeutic modality.

Will I really give you your money back if this strategy doesn't transform you into a world-class therapist in 7 days? Hey, I'll let you know. I'm still copying a master's ad and I haven't reached the small print section yet.
 

Ethical Guidelines: Do We Really Want What Is Best For Our Clients?

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Most therapists are familiar with the affliction of Seasonal Affective Disorder (SAD). SAD impacts approximately seven million people each year in America, mainly women.

At one point in my career I shared a private practice office with a psychiatrist. She would use the office on some days and I would use it on others. When I entered the office for the first time I was struck by the fact that she had a phototherapy apparatus in the room. It was physically huge and was much larger than any commercial unit I had ever seen. Many experts believe that SAD is caused (or at least intensified) by a lack of sunlight. Hence, when the sun is not shining very often or the days get shorter depression sets in. Phototherapy devices fight the depression and emit massive amounts of full spectrum light. The phototherapy simulates or mimics the sunlight you would receive if you more spent time outdoors.
My initial reaction to this situation was beyond positive. I was elated that this psychiatrist was utilizing cutting edge technology. I thus decided to praise her and let her know in no uncertain terms that I was impressed.

The good doctor's reaction, nevertheless, was hardly what I expected. "Oh my gosh, no, I don't use it for my clients. That's fringe psychiatry. Somebody might think it was unethical. I might even be sued or reported to the Board of Healing Arts. I might be branded as a quack."

"Well what in the world is a light therapy lamp doing in your office?" I asked inquisitively.

"In the dreary short days of winter I am stuck in this office all day and I generally become extremely depressed, so I had an engineer build me a phototherapy unit that is stronger than anything you can purchase. As soon as my current patient exits the treatment room I flip on my phototherapy device. I then turn it off before the next patient enters the office."

Oh, so now I get it: It's good enough for you, but not for your patients. Go figure.

In one of my recent books, Favorite Counseling and Therapy Techniques, I share a fascinating story about a young man I treated who had such low self-esteem that he walked bent over like an ape. The kids at school thought it was hilarious and made the situation worse by calling him the Ape Man.

One reason for the young man's Ape Man posture was that he believed he was extremely ugly and could never date a nice young woman. To counter his feelings I set up a contrived situation in which a female colleague walked in the room and said, "Gosh, is that your client, he's really cute." He seemed shocked (exactly the reaction I wanted). I told him we weren't going to discuss his looks because we both knew he was an exceptionally good looking guy and there were serious issues of his we needed to work on. He walked out with the finest posture he had displayed in years. Cured, no. Improved, yes.

Unfortunately, I also point out in my book that today's ethics which stress informed consent would not permit an intervention of this ilk. The female colleague who gave him the compliment would need to be identified as part of the treatment or therapy team up front and there is a 99% chance he would have totally discounted her remarks as being staged. (The young man's mother had repeatedly told him he was a good looking guy many times to no avail.)

Along these same lines a client I shall call John came to see me who severely depressed. John's brother was a very well-known psychiatrist. Now I was aware of the fact that ethical codes frown on (or downright prohibit) dual or multiple relationships, but certainly John's brother knew another top notch psychiatrist who could help. Why was John seeking my little old services?

When I asked John why his brother did not provide a psychiatric referral John quoted his brother verbatim. "Look I give those dangerous psychiatric medicines to my patients, but I'm not going to let my family take them. You need psychotherapy."

I so I get it. It's not good enough for your family, but it's okay for your patients. Oh sorry, I think I said something similar to that that before.

I remember hearing a presentation given by Jay Haley once. He told a powerful story regarding a difficult client he had successfully treated. I raised my hand and asked if his psychotherapeutic intervention was in violation of the ethical principle of informed consent. It certainly seemed like that was the case.

Haley was silent for a moment and then grinned. "I never let ethics get in the way of good treatment."

The problem for those of us who are mere mortals is that Haley's philosophy might leave us without a therapist's license and standing in a long unemployment line.
 

How One Desperate St. Louis Psychotherapist Cured A Schizophrenic

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Maggie began the session by telling me that she had been diagnosed by three different psychiatrists. The good news was that all three agreed on the diagnosis. The bad news was that each psychiatrist told her she was schizophrenic.

"So, what brings you here today?" I asked.

"Well, I saw something in the newspaper and it said you wrote some books on mental health and teach in the field so I thought you might know something these psychiatrists don't."

(Wow. How refreshing. A client who actually thought that a nonmedical mental health professional such as myself would know more than a bona fide MD psychiatrist. Perhaps this was my lucky day. Maybe I should purchase a lottery ticket or search Google for the nearest horse race track.)

As Maggie began talking my elevated mood and optimism began dropping like a thermometer placed in an overactive refrigerator freezer. In short order I was convinced that the psychiatrists were wrong — dead wrong. This lady wasn't just schizophrenic. Maggie displayed more hallucinations, delusions, and thought disorders, than ten schizophrenics combined. As I listened I couldn't help thinking that the folks who penned the DSM needed a new category. What? Oh heck, I didn't know, perhaps mega-psychotic or super-schizophrenic or something. Now I realize that doesn't sound nice and isn't very high on the Carkhuff Scales, but at least I was facing reality: something Maggie clearly was not doing.

The session went on for what seemed like eternity. At the end of our meeting I was faced with a dilemma. If I diagnosed Maggie as schizophrenic for the fourth time she would be devastated. I scribbled something on her insurance super bill and scheduled her for another appointment.

I continued to see Maggie weekly for approximately one year. To say that she made monumental progress would be an understatement. I thus terminated her.

About a year later I saw an article about her in the neighborhood newspaper. Maggie was being honored by her college for being the only student in her program to snare a perfect 4.0 straight A average as a chemistry major. The article also boasted that she landed a pristine job in her chosen field.

Just days after I read the article Maggie dropped in not for a therapy session (because she was doing very well), but just to say "hello."

"You are doing fantastic," I said. "Listen, I just have to know. What I'm about to ask you will help me with all the clients I will be seeing in the future. Why do you think you made such good progress in therapy? Was it because we explored the abuse in your childhood? Was it the relaxation techniques? Perhaps it was the dream work. Maybe it was the focus on your self-talk."

"Oh no," she replied. "I'm sure those things were helpful, but none of them cured me. No, not a single one of them. I can tell you precisely what it was.

Do you remember when you saw me for the first time and I mentioned that three psychiatrists had diagnosed me as schizophrenic? Well we decided right then and there that because you had written some books and taught in a college you knew a lot more than those psychiatrists. And when I left your office after my first session I felt terrific because I glanced at the insurance bill you gave me and you said I was an undifferentiated type. And that was wonderful news because schizophrenia is caused by chemical imbalances and genetics and it can't be cured. You know that.

But, I wasn't schizophrenic. I was just a normal person who was an undifferentiated type. And that meant I could be cured."

Thus, if you happen to be an advisor in a graduate program and an upbeat perky chemistry major named Maggie comes strolling in, please, pretty please with sugar on top, promise me you won't even think about letting her enroll in an abnormal psychology class.

Supervision of Executive Coaching

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Last year I was tempted out of my retirement as a psychotherapist to provide supervision to a group of colleagues working with business executives. This was not psychotherapy but coaching, and my protests that I had never done any coaching or even read very much about it were overruled: they wanted me and they had every confidence that I would do a good job. I was flattered of course, intrigued too, and the extra money was welcome. So I began. Sessions were individual and scheduled to last an hour and a half, not the usual fifty minute hour. I met my supervisees just once a month. These parameters took some getting used to and I found myself having to take detailed notes in the session, something I had not done for years, simply in order to keep in mind who people were, what their place was in a particular firm, what work they were doing and who they related to. It was a steep learning curve and, more than once, I wondered whether I had taken on something of a monster. But I got used to it and developed a way of working that suited me. Interestingly, only one person out of the six I was supervising asked me at the outset what my model of supervision was. I was not expecting the question and answered without preparatory thought. I listen to what you tell me, I said, and, where appropriate, I shall say something. I admit that this is terribly vague but it is nevertheless accurate. I could have said something about attending to the currents and undercurrents in the material, or about the dynamics of relationships, or about the transactional nature of coaching. But I felt that that was too prescriptive and even, to some degree, false. I would do what I was good at and what I had done as a therapist, which was work out what I thought might be going on and seek out the best moment to make an intervention. This is not as straightforward as it sounds.

In supervision there are three levels of ‘what might be going on.’ What the coach/therapist and client are doing in the world outside, what material the coach/therapist chooses to bring to the session, and what is happening there and then in the supervisory relationship. The last is particularly important. One of the supervisees was someone I had met 20 years ago when we were both involved in training clinical psychologists but I had not seen since. He is a likable and charismatic person with an unusual background. At our first supervisory meeting, he said that, when he had heard I was to be their supervisor, he had told his colleagues how great I was and how he had known me for 20 years. My ears pricked up not just at the effusive compliment but the claim to have known me for 20 years when the truth was he had known me briefly 20 years ago, an important difference. I said nothing. Time would reveal whether his desire for special recognition would be important in the work as indeed it has proved to be.

The man who asked me what my model of supervision was suddenly quit. He came to one session and bluntly told me that he had decided to stop. It was not adding enough value and he was a busy man. I was filled with overwhelming anger. I felt the narcissistic wounding and I knew this was in part counter-transference, how I hated to be wrong-footed and made to seem a worthless minion. I waited a while for my feelings to lessen and then formulated my response. “You have sacked me,” I said, deliberately using that dismissive word, “and I am feeling quite angry at that.” Immediately, he acknowledged the peremptory way he had done this, apologising for it. The anger, which had been felt by both of us, was transformed and even though, he stuck to his decision to quit, we could spend the last session in productive work.

There are some who argue that supervisors have a responsibility to tell their supervisees what they are doing wrong or to suggest particular techniques to use. While there is a place for this, it is far less important that understanding and reflecting back. It is better for supervisees to find things out for themselves and unless something very bad is going on, the supervisor should not be directive. In a heated debate on supervision in the late 1970s, I vividly recall a distinguished psychoanalyst quietly saying, “Those who tell their supervisees what to do end up telling their clients what do.” He did not mean it as a compliment.
 

Training for the Treatment of Eating Disorders

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Eating disorders are widely recognized as some of the most challenging psychological diagnoses. I was surprised to learn that they are also the most dangerous: eating disorders have the highest mortality rate of any diagnosis. Many clinicians assume that eating disorders only occur in young women. However, research has shown that the frequency of eating disorders is rising across a wide range of client populations, including men, middle-aged, and the elderly. Regardless of the population you work with, sooner or later you will encounter clients with eating disorders.

How can a clinician get training to help clients with eating disorders? I recently discussed this with Deborah Brenner-Liss, PhD, the director of the Association of Professionals Treating Eating Disorders (APTED). APTED is an affiliation of eating disorder specialists based in the San Francisco Bay Area. APTED provides support and training for clinicians, and referrals and direct service for clients.

APTED emphasizes a multi-modal method of treating eating disorders, including trauma, attachment-focused, somatic, experiential and affect-focused treatments. Given the complexity of eating disorder ontology and treatment, Dr. Brenner-Liss encourages students to “enlarge the depth of their conceptualizations”. APTED treatment includes a wide range of providers in the treatment team, including therapists, social workers, physicians, psychiatrists, nutritionists, body workers and coaches. (I personally find this to be a welcome relief from the all-too-common clinical turf battles!)

For clients with sub-clinical eating disorders, Dr. Brenner-Liss recommends consulting with an eating disorder specialist. Like other addictions, eating disorders are behaviors that build over time, and can sometimes be arrested in the early stages if they are addressed early with serious treatment.

For clinicians who want to work with clinical-level eating disorders, Dr. Brenner-Liss recommends getting formal training. In the San Francisco Bay Area, both UC Berkeley extension and JFK University provide eating disorder certificates. For those in other areas, the International Association of Eating Disorders Professionals Foundation (IAEDP) provides an online training and certification course (http://www.iaedp.com/). The IAEDP course includes readings, audio records from IADEP conferences, and writing assignments. I am currently taking this course myself, and have found it very rich.

Dr. Brenner-Liss also recommends joining a eating disorder-focused consultation in order to get exposure to a wide range of case material. Likewise, attending a weekly 12-step eating disorder group for a few months can provide valuable insight into the nature and course of eating disorders. Most ED groups are “open” so clinicians can be a “fly on the wall.”

For those in the SF Bay Area, APTED is hosting a two-day conference, “Re-Finding Our Way to Wholeness: What heals? Eating Disorders and Trauma,” September 24-25th, 2011, in Berkeley.  Registration required by September 10th. For more info, call 415-608-6307, or e-mail AptedSF@aol.com.  Notably, the conference is open to both clinicians and individuals in recovery.  I am personally encouraged by the growing movement in the psychotherapy community to break down the barriers between providers and clients.  (Another notable recent example is the Marsha Linehan's courageous self-disclosure about her struggle with mental illness.)

Listening versus Hearing in Psychotherapy

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In my memoir, The Gossamer Thread: My Life as a Psychotherapist, I describe my treatment of ‘Angie’, a young mother with horrific fantasies of killing her two young children by stabbing them through the heart with a kitchen knife. It was back in the 1980s and I was in the process of shedding my old behaviour therapy skin, realising I needed to listen to the client more carefully before embarking on any specific intervention. My therapy was a success, or so it seemed at the time. I even wrote her case up for a behaviour therapy journal under the grandiose title, Verbal methods of behaviour change. I had confidently formulated her fantasies as extreme anxiety since there was no evidence of her ever harming her children. I discovered that they had begun after she had read a newspaper account of a couple’s murder of their children in a Satanic ritual. She worried that, however much she loved her children, that she too could be taken over by the Devil and do things she would never normally do. I saw this as vicarious traumatisation and her anxiety stemmed from her ruminations about this. I was able to help her, getting her to monitor the fantasies, reframing them as anxious thoughts, and substituting more positive ones, until the fantasies declined significantly in both intensity and frequency. This was my pre-cognitive therapy days and Angie was to lead me into training as a cognitive therapist. But that is another story.

I revisited the case in my book and, looking back, I realised that, while I had listened to Angie, I had not really heard her. Or rather I had heard what I had wanted to hear. She was a young mother, looking after two very young children while her husband was away working on the North Sea oil rigs. She was living hundreds of miles from her home town and the family she had grown up with. She had relatively little money and had given up her job. She was trapped like many young mothers are. Was that perhaps what this was all about? After all, what trapped her most were her children as they needed her constant care and attention. Could her fantasies be an unconscious expression of her resentment of them? If I had trained in systemic therapies, I might have heard a different story to the one I had carefully elicited with my prototype cognitive therapy hat on. I might have heard how unhappy she was, perhaps heard her fear that her marriage was a mistake and that she no longer loved her husband. Or had I been more analytically inclined, I might have wondered about the aggression in the fantasies and perhaps linked that to infantile aggression or sibling rivalry or other possible unconscious conflicts from her past. I did none of these things because I had heard what I had wanted to hear. I prided myself on attentive listening, on my sensitivity and creativity as a therapist. I had done a really good job. But had I? Listening is not a passive matter. It always reflects what we expect to hear. Hearing, on the other hand, is something else altogether as I later went on to learn. To hear properly one has to suspend one’s preconceptions and be prepared to question one’s own thoughts and beliefs. It is important to give a space to the client and not fill it with one’s artful questions, ideas or interpretations. It is to take a step back for a moment and wonder. We all listen but how much do we actually hear?

Turning Blaming into Confiding in Couples Therapy

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The defining task in a Collaborative Couple Therapy session is to create an intimate conversation out of whatever is happening—frequently a fight. Sometimes that means helping the partner who has just been accused deal with the accusation. Sometimes, and this is my focus in this write-up, that means reshaping the accusing partner’s angry statement. I speak as if I were that partner, translating his/her blaming statement into a confiding one, in a method similar to doubling in psychodrama. I show what this partner might be saying if the couple was having a conversation rather than this fight. Here are the principles I use for making these translations.

• Change the tone of voice
• Omit the blaming
• Report the blaming
• Add or substitute heartfelt feelings
• Append a question that turns the monologue into a dialogue
• Acknowledge

1. CHANGE THE TONE OF VOICE. If I can’t immediately think of ways to modify a partner’s angry comment, I repeat or paraphrase it, but now in a nonprovocative, nonaccusing, nondefensive, warm, intimate tone. Of course, if I can think of how to modify what was said, I still change the tone. None of the changes listed below would do much good if they were stated in the partner’s original angry, defensive, arrogant, sarcastic, contemptuous, or distant tone.

2. OMIT THE BLAMING. An important way to turn a partner’s fight-fostering comment into a conversation-fostering one is, of course, to omit (or at least reduce) the blaming, accusations, anger, attack. Lynn says to Fred, “You’re selfish, immature, and totally irresponsible to go out to a bar with your office pals after work, and come home late for dinner. You’re probably flirting with what’s-her-name in the next cubicle.” Moving in and speaking for Lynn, I say, “I’m going to restate what you just said but change the tone in order to help you get your message across to Fred. In my version, Lynn, you’d say, ‘I hope you can understand why I might be upset about your going to a bar and coming home late and why, given the situation, I might be imagining all kinds of things like your flirting with other women’.”

3. REPORT THE BLAMING. Another way to eliminate (or at least reduce) the toxic fight-fostering effect of blaming is to report the anger rather than unload it. Bob says angrily to George, “You’re nasty and mean-spirited and never think of anybody but yourself!” I move over and speak for Bob in an effort to show him what it would sound like if he were to talk about the anger rather than from within it. I say for Bob, “I can’t remember when I’ve felt as angry at you as I do now” or “As you can see, I’m still furious about that comment you made this morning” or “At times like this when I’m really angry at you, I forget all that I like about you and just see you in a super negative way.”

The effect of such reporting is to create a platform, a perch, a meta-level, a vantage point above the fray from which Bob confides being angry. Most of the other interventions on this list create such a platform or vantage point.

4. ADD OR SUBSTITUTE HEARTFELT FEELINGS. In a fight, people lose the ability to make “I” statements. They lose contact with their vulnerable, heartfelt feelings and become “you” statement generating machines. In speaking for a partner, I uncover these vulnerable feelings: the wishes, fears, worries, longings, disappointments, self-reproaches, shame, guilt, self-hate, loneliness, and so on. I reveal the “I” statement hidden in the “you” statement. Here, as in other instances in which I guess what the partner might be thinking or feeling, I use information gleaned from earlier in the therapy, label my comments as speculations (saying, for example, “I give myself about a 30% chance of being right”), and check back to see if my guess was correct (“Where was I right and where was I wrong?”). At times I recast much of the partner’s original statement, changing “you” statements to “I” statements. Sometimes, as in the following examples, I append a vulnerable feeling (an “I” statement) to the partner’s attack.

John snaps at Judy, “You’re being selfish thinking of going back to school when you’ve got our kids to take care of, and in this rotten economy. Don’t you ever think of anybody but yourself?” Moving in and speaking for John to Judy, I append “… and I worry that your going to school might be the first step toward your leaving me.”

Sylvia says to Bob angrily, “I’m tired of always being the one who has to manage the family: schedule everything, make all the phone calls, assign all the chores.” In saying “I’m tired,” her comment appears to be an “I” statement. But implied is: “You don’t do your part,” “You take me for granted,” and “You’re selfish and irresponsible.” Moving over and speaking for her to Bob, I add the following clearer underlying “I” statement to what she just said: “I feel lonely” or “I don’t like the kind of person I’ve become in this relationship.”

5. APPEND A QUESTION THAT TURNS THE PARTNER’S MONOLOGUE INTO A DIALOGUE In an effort to make their cases, partners often give little lectures presenting their evidence, making speeches, pronouncements, or indictments. They deliver monologues. I try to turn these monologues into dialogues by appending a dialogue-creating question. Sue expounds on her knowledge of interior decorating and denigrates Phil’s taste in an attempt to prove to him that she should have the larger say in what furniture to buy. Moving over and speaking for her to Phil, I append to what she just said, “What do you think about what I’m saying?” or “Am I convincing you?” or “You probably disagree with most of what I just said. Am I right?” or “Is there any part of what I’m saying that you agree with?”

6. ACKNOWLEDGE. In a fight, each partner argues his/her case and either ignores or refutes that of the other. Neither acknowledges the validity of any of the other’s points or admits weaknesses in his/her own case. In speaking for partners, I do this acknowledging and admitting for them by doing one or more of the following:

• Acknowledge what the other partner has been trying to say
• Agree with parts of it
• Recognize the other partner’s efforts or achievements
• Appreciate the difficult position the other partner is in
• Admit his/her (the person on whose behalf I’m speaking) own role in the problem
• Confide doubts about the validity or fairness of what he/she is saying
• Express concern about how the other partner might hear what he/she is saying

Acknowledge what the other partner has been trying to say. In a fight, each partner feels too unheard to listen, which is what keeps the fight going. In speaking for a partner, I do the listening for him/her. I demonstrate how it would sound if this person were to do a bit of active listening and acknowledge what the other partner has been trying to say.

Judy complains to Bill, “Are you at all aware that you hardly ever talk to me except to complain about things I haven’t done right.” Bill pays no attention to this and, instead, tells her what is on his mind: “You forgot to lock the front door again.” Judy pays no attention to this and, instead, repeats her concern: “That’s all you care about—the front door. What about the fact that we never talk about anything important, like about us?” Bill says, “Keeping the door locked is important. We’ve got a lot of valuable stuff in here. You’ve got to think about that.” Judy says, “I’ll tell you what you’ve got to think about, and it’s that I’m starting to feel closer to my friends than I do to you.” Bill says, “But this is serious. Half the time you don’t lock the door; it’s just luck that we haven’t been robbed.” Judy says, “Speaking of robbed, I feel totally alone in this relationship.” Bill says, “All I’m asking is for you to be a little more careful when you leave the house.” The partners go back and forth repeating their point (because the other appears not to have heard it), paying little attention to what the other is saying.

Moving over and speaking for Judy, I say, “I know you’re worried about my not locking the door, but I can’t listen to that right now because I’m so frustrated that you won’t listen to my concern, which is that we never have intimate conversations.” I could just as easily have moved over and spoken for Bill, saying: “I know you’re saying that I don’t talk enough, but I can’t listen to that right now because I’m so frustrated that you won’t listen to my concern about locking the door.”

Agree with parts of what the other partner has been trying to say. In a fight, neither partner gets the satisfaction of having the other agree with anything. Each partner rebuts or ignores what the other says. In speaking for a partner, I do the agreeing for him/her. “You have a good point that I…and I have a good point that….” Or, “If we weren’t in the middle of a fight, I’d admit to you that you are making some good points.”

Often I turn to one partner and say, “I’m going to repeat what you just said, but begin by agreeing, which would then put you in a better position to make your point.”

Gloria criticizes Ed for being too harsh with the kids. Ed criticizes Gloria for being too lenient. The argument goes back and forth in this way for some time. Moving over and speaking for Gloria, remembering what she had said in a previous session, I say, “You’re right that I can be too soft with the kids. I need to work on that. My concern right now is to get you to consider that maybe you’re too hard on them.”

Paul criticizes Cheryl for something she did. Cheryl’s justification seems to convince Paul, but instead of acknowledging that, he goes on to make another complaint. I say, “Paul, were you feeling at that moment, ‘Okay Cheryl, you convinced me. But it just reminds me of something else I’m upset about, which is that…’”

Recognize (at times even celebrate) the other partner’s efforts or achievements. Sam proudly describes doing what Ann had asked him to do—pay the bills and clean the bathrooms. Ann replies, “Yes, that’s good. It’s about time. You act like you’re still single. You don’t take responsibility.” Moving over and speaking for her talking to Sam, I say, “You obviously paid attention to what I asked for last time. That’s wonderful! I really appreciate it. I hadn’t thought you would. But—and I’ll make this a multiple-choice question, Ann—A, I don’t want to get too excited about it and get my hopes up that the change is permanent, or, B, it’s too small a part of what I want to be really excited about. Ann, is it A or B. Or is it C, something else entirely?” (When I am uncertain what the person is feeling, I often ask such a multiple choice question.)

In her original statement, Ann skipped over Sam’s achievement. I try to show how it might make sense that she did so and how it would sound if she hadn’t done so.

Appreciate the difficult position the other partner is in. In a fight, each partner feels too unempathized with to empathize, too worn down by his/her own struggle to notice that the partner is caught in one, too. In speaking for partners, I do the appreciating, empathizing, and noticing for them.

Sara says to Ralph, “You never stand up for me when your mother pulls one of her numbers.” Ralph says, “Can’t you just do what everyone else in the family does—just accept that that’s how Mom has always been and realize there’s no way to change her.” Hearing this argument, I look for the right time and moment to say for Ralph, “I feel bad that I haven’t protected you from my mother” and for Sara, “I see how you’re caught in the middle.”

Admit his/her own role in the problem. In a fight, each partner blames the other partner for the problem and denies or minimizes his/her part in it. In speaking for a partner, I do the admitting for him/her. “I came home frustrated and took it out on you.” Or, “I overreacted.” Or “I know it didn’t help that I…” Or, “I’m suddenly seeing you as my father, which I know isn’t fair” Or, “I’m feeling hurt, but you have no way of knowing that, because my hurt is coming out as anger.”

Express concern about how the other partner might hear what he/she is saying. In a fight, partners lower their heads and bull ahead without acknowledging that what they are saying is provocative. In speaking for a partner, I do the acknowledging for him/her, often as a kind of prefacing statement. I say, “I know you never like it when I bring this up, and that’s why I mostly keep it to myself, but it’s been really bothering me lately so I need to say something…” or “I know this is a criticism, but I need to say it anyway” or “I’m angry, so I’m probably not saying this in the best possible way” or “I hope you see my distress peering through my anger,” or “This could get us into trouble, but I want to talk about it anyway” or “I wish I could find a way to say it that wasn’t a criticism because there’s something important here that I want to get you to see.”

Admit doubts about the validity or fairness of what he/she is saying. In a fight, partners focus on making their case. They put aside (and often lose awareness of) any doubts or reservations they might have about what they are saying. In speaking for a partner, I reintroduce these doubts or reservations. I say, “I know this isn’t fair, but it’s on my mind so I want to say it anyway and it’s that…” or “I know I’m on shaky ground here because I do the same thing myself, but…” or “I go back and forth between blaming myself for this problem and blaming you and, as you can see, at the moment, I’m deeply into blaming you” or “For a fraction of a second I was pleased by the lovely thing you did—and began to hope that it meant that you’ve really changed—but then I thought, ‘Wait a minute. I’m not going to get my hopes up just to be disappointed again’” or “I know I’m difficult to live with, so I probably don’t have a right to complain about something you do that’s so minor, but here it is…”

In speaking for partners, I try to make their case more effectively than they had been able to do so themselves. I repeat what they had just said but now in a more disarming, engaging, and heartfelt way. At times, I shorten what they have said and at times lengthen it. At times I reformulate what they have said and at other times append something to it. My effort in each case is to restate what the partners have just said in a way that will give them greater satisfaction and that their partner will be better able to hear.

My purpose here was to list the principles I use for arriving at my statements for partners in an effort to turn their blaming statements into intimate ones.
 

Training in Couples Therapy

Posted on by Psychotherapy.net Team

Why might a therapist who works primarily with individuals consider studying couples’ therapy? If you work from an attachment perspective, as an increasing number of therapists do, then training in couples therapy may greatly inform and improve your work.

Many clients present to therapy for “relationship problems.” I’m sure all therapists who treat individuals have had the same experience I have of clients who want to spend their therapy hour talking about their spouse. Why do therapy on a relationship without both people present? Our training generally states that individual therapy will build resources in the individual, which they will then use to improve their relationships. But might an individual build resources faster and stronger with their partner present? Is working with the attachment dyad more efficient and powerful than working with the individual?

This hypothesis was presented at a recent training on Emotionally Focused Therapy for couples (EFT), an attachment-based approach developed by Sue Johnson, EdD . The presenters, Scott Woolley, PhD, and Rebecca Jorgenson , PhD, framed this question from an attachment perspective. They suggested that a client’s attachment system is more activated by and responsive to the client’s actual attachment figures than the therapist. Dr. Woolley quoted Dr. Johnson as saying, “As therapists we have 60 watt light bulb to bring light and healing to someone’s life, but the partner has a thousand watt search light!”

Attachment theory proposes that evolution has programmed us to be highly reactive to our partners, positively and negatively. “Relationship skills” learned in the presence of a soothing therapist might be no match for the tinderbox of a primary relationship. Likewise, there are risks in doing individual therapy. John Gottman, PhD, has found that people in individual therapy are much more likely to get divorced.

I emailed Dr. Johnson regarding this question. She replied, “A therapist’s empathy and validation are very useful — but to be really seen and accepted by the most important person in your life — that is transformational. The therapist is at best a surrogate attachment figure who validates.”

Victor Yalom points out that even if you plan to work individually, bringing the partner in for a single session provides invaluable data into the actual (versus reported) nature of your client's primary relationship and their interpersonal functioning, and can help broaden the frame of therapy. (Likewise with bringing in family members.)

Over time I have transitioned an increasing amount of my individual clients who present with relationship problems into couples therapy. Although the work is often harder, the results can come quicker, and I usually feel more confident that the results are lasting and durable.