A friend of mine (let's call him Kurt to preserve confidentiality and perhaps more importantly not to embarrass him) told me was gearing up to take his state licensing exam. Had he prepared for the exam?
"Come on Rosenthal, I just spent two of the best years of life in grad school and another three or so in supervision. I think I know this stuff by now."
"Really," I remarked. "Who is the father of rational emotive behavior therapy?"
"Come on dude, that's easy, "Glasser is the father of REBT."
"Sorry, my friend, but that distinction, belongs to Albert Ellis. Glasser created reality therapy with choice theory."
"Hey, look, I said I was prepared, I never said I was a psychotherapy savant."
I continued, "What was REBT called before it was REBT?"
"Alright Rosenthal, so I would have missed two questions on the exam. Big deal."
I challenged him once more. "Who was the father of guidance?"
"Duh, it's Freud, any first year psychology student has committed that one to memory."
"Sorry, but Freud was the father of psychoanalysis. The name they will be looking for on your exam would be Frank Parsons."
"Say what? Frank who?"
As the author of licensing and certification exam preparation materials I am often asked why therapists don't pass their tests. Here, on the head of a pin, are the top reasons.
1. A little bit of knowledge is a dangerous thing. Hmm? Somehow the name Kurt is ringing a bell. Thinking Ellis is Glasser or Glasser is Ellis . . . well you get the point.
2. Waiting until the eleventh hour to crack a book or a study guide. "Can you send the material overnight Dr. R., I'll be taking the test in 48 hours?" Oh sure, maybe the Air Force would let us borrow an F-15 fighter plane to make certain you receive your materials at Mach speed. Is this insane or what? Imagine if this therapist had a client who was taking the Bar Exam. Would he or she advise the client to wait two days before the test to begin preparation? I'd say six months or more would be a tad more realistic.
3. Believing in the psychotherapeutic exam prep tooth fairy. You scan the Internet and discover a card deck which takes just 15 minutes to read for just $29.95 or whatever. Most serious complete exam prep packages will set you back a bare minimum of $150 or $200. Sorry, but that's the truth, the whole truth, and nothing but the truth. In fact, in some disciplines like psychology the price tag can soar over the $1000 mark. Just for the record, I speak with thousands of folks who have taken these exams and have never conversed with a single individual who only used a bargain basement card deck as his or her sole method of preparation. If you do use one and pass then you are probably the one person in 500 who didn't need a study guide anyway.
4. Relying on marathon study sessions. These folks boast that they plan to lock themselves in a vault with a seven foot stack of text books, enough exam prep guides to capsize a small battleship, and a case of diet soda. Moreover, folks of this ilk won't come out until they study all areas on the exam. To be sure, they may come out bloated due to the excessive diet soda intake, but there is little, if any, chance they will remember much of anything. Keep your study sessions short. Twenty minute study sessions are good, but fifteen minutes is even better.
5. Failing to use simple memory devices. How do you remember that stationery is spelled "ery" and not "ary" when it means a letterhead? Simple. The word letter has an "e" and so does stationery when it means letterhead. How do you remember that in Pavlov's famous experiments with dogs that the conditioned stimulus (CS) comes before the unconditioned stimulus (US)? Simple: C comes before U in the alphabet. How can you recall what the meat was in the experiment? That's easy, because in the US we eat a lot of meat. When you see the meat in the experiment in will be the US. Memory devices only need to make sense to you and sometimes the crazier they are, the better they work.
6. Giving up during the actual exam. You wouldn't believe some of the horror stories I have heard. I remember a woman who told me she bolted out of the exam site because just before she finished. Why? Simply put, because she was certain she had already missed 40 or more questions and failed the test. The amazing thing is that on her particular exam, 40 items were not being graded. These questions were used to test their suitability on future exams. Thus, instead of telling herself she was failing, she should have told herself that if she really only missed 40 or so items, she might be flirting with a perfect score.
7. Cheating We all know that cheating is morally and ethically wrong, but did there is another reason not to cheat that never occurs to most people. At most test sites you can't see the paper or computer screen next to you, so that's not an issue. But let's say you've been struggling with question 143 dealing with Wolpe's systematic desensitization. You don't have a clue what the answer is. Nevertheless, as you stroll over to the drinking fountain your eyes accidentally glance at another test taker's computer screen and you see "d" as the answer. Now, needless to say, you would never do this, but our hypothetical examinee goes back to his computer terminal and clicks "d" as his answer. There is just one problem. The person he copied off of was taking the cosmetology exam and was answering a question on administering a permanent wave!
I rest my case.
Category: Blog
Training in Microexpressions
There is a growing movement in psychotherapy towards reading clients’ facial microexpressions and body “tells”. One of the leaders in this movement is Stan Tatkin, PsyD, who teaches a Psychobiological Approach to Couples Therapy (PACT). I recently talked with Dr. Tatkin about how he uses microexpressions to enhance couples therapy.
Dr. Tatkin uses microexpressions to read subtle shifts in his clients’ moment-to-moment autonomic nervous system arousal. Using visual cues in the eyes, nostrils, mouth/lips and skin tone, he can tell whether a person is open and receptive (“regulated”) or in a threat-response (“dis-regulated”). He points out that people often aren’t aware when or why they shift into a threat-response in relation to their partner, because it happens so quickly, and involves parts of the brain that don’t give explicit thoughts as explanations.
Dr. Tatkin notes that people will unconsciously make up (“confabulate”) reasons for their sudden anger or fear of their partner, based on old stories about themselves and their partner. He calls this “dirty data." His therapy down-plays the importance of sorting through narrative in favor of helping couples attend to each other's moment-to-moment physiological arousal level.
Most therapists focus on narrative content in therapy. Dr. Tatkin notes that therapy training focuses on narrative, and the human brain tends to get caught up in language, as a function of the left hemisphere. In contrast, he trains his students to pay close attention to their own bodies and self-regulation; to use themselves as a “tuning fork” to help their clients learn to self-regulate.
Dr. Tatkin uses an innovative teaching approach: he sits perpendicular to a trainee in a therapy role-play. This lets him give moment-to-moment instructions on reading and adjusting autonomic nervous system arousal levels. He calls this “regulating the regulator."
How can therapists learn to read microexpressions? Dr. Tatkin recommends the training programs by Paul Eckman. Advanced training can be found from Erika Rosenberg.
Dr. Tatkin also suggests that training in drama or psychodrama can be helpful to learn how to read movements from the whole body, and how voice prosody can affect emotions. Pat Ogden and Peter Levine do body-oriented psychotherapy training.
Additionally, Dr. Tatkin also recommends reading the work of Steven Porges regarding polyvagal theory.
Dr. Tatkin points out that it is important to remember that all microexpressions are idiosyncratic to the individual, and thus we need to know each individual’s “baseline” in order to know what a specific microexpression means to that person.
Treating Special Clients in Psychotherapy
In the film, The King’s Speech, George VI seeks treatment for his stammer from a maverick Australian speech therapist, Lionel Logue, played brilliantly by Geoffrey Rush. “My patch, my rules,” is what Logue tells the King when he insists on being given special treatment. He is, after all, the King of England, used to deference and privilege. Logue accords him neither, treating him just like any other client. Or so we are led to believe. As a therapist I applaud Logue’s resolution but how realistic is it? Are there not always "special" clients, people who demand and get special attention? It is hard to believe that the feminist therapist, Susie Orbach, whose most famous client was Princess Di, treated her as simply another disturbed, bulimic woman. How could she ignore all the razzmatazz that surrounded Diana for was that not a large part of the problem? It would be difficult, impossible I believe, to pretend that she was anything but a special case.
During my psychotherapy career I treated only a handful of well-known people and most were well-known only in their own communities. In Oxford where I had my private practice, I treated a fair number of academics, dons as they are called here, a few of whom were part of the media circuit, appearing on TV or writing in the newspapers. I never felt they demanded or needed any special privileges other than for me to take particular care not disclose who they were. Oxford is a small place. But then I was an academic myself and when you have worked in a University, you are soon disabused of the notion that academics are in any way special. I did, however, treat someone who was internationally renowned. I recall his all too brief foray into therapy with a mixture of chagrin and regret as I realised, too late in the day, that his specialness had undermined what good therapeutic sense I had.
The man had come to me for stress management. It was not surprising that he was stressed given the huge demands placed upon him by his work and his fame, not to mention those he placed upon himself. He had had a string of difficult personal relationships, one of which had just come to a messy end. I told him about anxiety management and he was very keen to try it even at one point stretching out on the floor while I instructed him in how to relax. We fell into this practical, problem-solving therapy before I had taken stock of the man partly because I felt pressurised to deliver something useful. It was an ill-considered decision and it set up a particular type of relationship in which I responded to what he felt he needed or, in truth, believed he was entitled to. The crunch came when he told me about an employee of his who, while brilliant in many ways, had problems with anger management. Would I see him too? I agreed and, a couple of weeks later, my famous client had gone. How I wish I had refused or at the very least queried why he was in effect palming me off on to someone junior to him. Was this his way of reasserting control? That he could "employ" me like he employed others to do his bidding? I sensed something was not quite right and perhaps with another, less special, client, I would have brought my unease into the open, or simply refused outright. I did neither and have regretted it ever since.
Free Psychotherapy Training
As a psychotherapy training nerd, I’m always looking for good training opportunities. What’s the most training one can find on a limited time and budget? I recently talked about this with Carol Odsess, PhD. Dr. Odsess is a psychotherapy trainer in Albany, California who specializes in EMDR and Energy Psychology.
What trainings have the best cost/benefit ratio? A good place to start are the many excellent articles and interviews with master therapists available at psychotherapy.net, which are free to read. (You only have to pay if you want the CEs.) In addition, Dr. Odsess offered a few recommendations to stretch your training dollars.
- Instead of going to a conference, consider buying the audio recording of the conference instead. You save the costs of airfare and hotel, and keep your weekend! Additionally, you get to experience every training at the conference, which is more than you would get if you went in person. Dr. Odsess recommends listening to audios of conferences while commuting (which has the side benefit of reducing road-rage.) I’ve been working my way through 200 hours of the 2009 Evolution of Psychotherapy Conference during my commute for the past year. She also pointed out that having the trainings on audio makes it easier to refer to them when writing or teaching.
- A free way to enhance your training is to videotape your own therapy sessions and review them later. There’s nothing like getting an un-edited view of your work to improve effectiveness. Likewise, many consultation groups are free to join, or you can start your own.
- Dr. David Nuys produces two excellent podcasts on psychology: Shrink Rap Radio and Wise Counsel. All past talks on both podcasts are available for download.
- Check with your local library to see if they can order psychotherapy books or videos through their national link system.
- Join a listserv related to your specialties. Many listservs have fascinating ongoing discussions about psychotherapy theory and technique.
- Check out the great psychology blog mindhacks.
- A few other websites offer free trainings via the internet or teleseminars, including traumasoma, wisebrain, and dharmaseat.
Collaborative Couple Therapy With High Conflict Couples
What’s hard, when dealing with high conflict couples, is getting their attention. If they do register your presence, it is to recruit you to their cause, confiding in you conspiratorily, “Look what I have to put up with.” And if they do acknowledge what you say, it is to turn your comments into ammunition against their partners, assuring you, “I do what you’re saying, but he never does.” High-conflict couples attack each other at such high velocity that you don’t have time to think. And you may not get much chance to talk, either, if, as sometimes happens, they keep interrupting you. Here are various methods I have heard therapists use to deal with these couples:
1. Take control from the beginning by doing individual therapy with each in turn in the presence of the other or taking them through a structured sequence.
2. Separate the partners. See each individually for a session and then bring them together. Taking it a step further, some therapists tell certain high-conflict couples that they each need a course of individual therapy before even considering couple therapy.
3. Ask them how they met and what originally attracted them to each other. In so doing, you distract them from their fight and introduce something positive.
4. Establish and enforce ground rules such as “no name-calling.” In a videotape of her work with a high-conflict couple, Susan Heitler gave the couple two rules: 1) stop talking when I say to and 2) don’t interrupt when I’m talking to your partner.
5. Tell the partners “hold it” or “stop” or wave you hands between them. Forcefully take command, as does Terrence Real. Or wave off the interrupting partner (Robert-Jay Green does this, but then later adds the wonderful touch of apologizing to the partner he waved off).
6. Confront the partners with the counterproductive nature of their behavior, saying, for example, “Listen to yourself!” or “Blaming doesn’t help” or “Talk about yourself rather than about her” or “Do you want to be right or do you want to be married” or “You’re acting like a couple of three-year olds in a sandbox fighting over a pail and shovel.”
7. Hook them up to a heart-rate monitor and when either partner’s heart rate exceeds one hundred, get them to take a time out. John Gottman came up with this.
8. Interrupt a fight to play back the video of it. John Gottman and Stan Tatkin do this.
9. Pick up a book and tell them you’ll stop reading when they stop fighting and get down to business.
10. Tell them that things are going too fast for you to think. Rather than blame them for doing something wrong, you take responsibility for the need to slow things down.
11. Move in quickly when things suddenly erupt and say “What just happened?” Susan Johnson does this.
You have to be forceful when dealing with high-conflict couples who interrupt each other and interrupt you and thus make therapy difficult. My way is forcefully to enter on the side of both partners and develop what they are trying say rather than to confront them with the counterproductive nature of their behavior and urge them to restrain themselves.
Why do I want to develop what the partners are trying to say? Because anger is typically a fallback measure, in EFT terms a secondary emotion. It’s what you’re often left feeling when you can’t express what you need to say—you lose your voice—or when you can express it, but you can’t get your partner to listen. In a couple fight—and this is the definition of such a fight—there are two people who feel too unheard to listen.
So I try to get the partners to listen to each other. I try to show them how it would sound if they were to express what they needed to say and take in what the other is trying to say. I move over and speak for them, in a method similar to doubling in psychodrama. I try to turn their fight into an intimate conversation.
And I do something else. I try to shift the partners to the meta-level—what I call the platform—and get them talking collaboratively about their fight. I want to get them commiserating with each other about it.
So these are the things I try to do with high conflict couples (and, actually, with any couple):
- Help them express what they need to say,
- Help them take in what the other is trying to say
- Create this platform.
There is a natural sequence of things I do in my effort to accomplish these purposes.
The first is to catch the fight in its early stages before it builds up steam. If I see the emotional temperature rising or if one of the partners lets loose a zinger, I jump in. If George says something angry to Rose, I move next to him and, doubling for him, that is, speaking as if I were he talking to Rose, I say, “As you can tell, I’m angry and that’s because I felt hurt by what you just said.” I turn his angry comment into a confiding one. If I can’t think of how to do this, I repeat some version of what he said but in a nonangry tone. Alternatively, I might help Rose deal with what George has said by asking her, “How much does what George just said seem an accusation and how much an understandable concern?”
If I’m unable to catch the fight before it starts and it really gets going, I try to translate the fight into a conversation—that’s number 2. I go back and forth between the partners, doubling for each in turn, trying to detoxify each person’s comments. This can go on for some time. Sometimes the fight goes too fast for me to keep up with. When that happens, I wait until I regain my bearings and then go back over what they just said, but detoxifying it (“first you said…, then you said…., then you said….”). I bring out the conversation hidden in their fight.
Third, if I am unable to translate the fight into a conversation, I make a statement for each showing how each partner’s position makes sense. “Jim, it’s understandable that you don’t like Brenda’s bringing up something you did 20 years ago. It makes you feel she’ll never let you live anything down. And Brenda, it’s understandable that you’re bringing it up because it’s the clearest example of what you feel Jim continues to do in more subtle ways today.”
If I fail to get the partners to appreciate how each of their positions make sense, I try to get the partners up on a platform—a meta-level—talking collaboratively about how they are being adversarial. That’s number four: talk about the fight:
- I ask, “Are you getting something from this fight, a chance to say a few things or hear a few things? Or is this fight discouraging, what happens at home, and what you came to therapy to stop?”
- Or I ask, “In what ways is this fight useful and in what ways is it not so useful?”
- Or I ask, “You came in today feeling relatively good about each other, but little by little the good will disappeared and now you’re quite upset with each other. Do either of you have any idea of what brought about this shift?”
- Or I ask, “What should we do about this fighting? Should I step in more quickly to stop it?”
- Or I ask, “Am I doing my job in keeping things safe? Or am I allowing too much fighting.”
While I am doing all these other things, I look out for and focus on conciliatory moments. That’s number five. I say, “Hey, I want to go back to what happened just a minute ago. You made that sweet comment (or you had that sweet exchange). What allowed that to happen? What were you thinking and feeling just before you said it that led to it?” And to the other partner I say, “How did you feel hearing it?” I’m looking for moments when these fighting partners aren’t fighting—much like a narrative therapist or solution-focused therapist looking for an exception. At other times I try to create a conciliatory moment. When one of the partners says he or she feels lonely or disappointed, I harken back to earlier in the session, or earlier in the therapy, when the other partner expressed such a feeling. I jump at the chance to show that they share a particular reaction.
Turning now to the situation in which one (or both) partners makes long provocative statements, either repeating (belaboring) a complaint or stacking complaints one upon the other, I try to find a collaborative way to interrupt them. That’s number six: “interrupt tirades in a collaborative manner.”
- I say, “I’d like to interrupt you here because I’m afraid that we’re losing Linda; she seems to be sinking deeper and deeper into the couch”
- Or “Let me interrupt you here to find out how Linda is doing hearing this”
- Or “I’d like to interrupt you here because you’re making some important points but I’m concerned that they are getting lost; I’d like to repeat them and then get a response to each from Lois.”
- Or, “In the last couple of sessions things got pretty intense when one of you laid out a number of complaints in a row, so I think when that happens this session that I’ll move in and interrupt so we can have more of a conversation. What do you think about my doing that?”
- Or I move in after a partner has made one or two points (or has made one point but has repeated it several times) and before he or she can repeat it again or go on to make the next point and I say, “Let me work with that; you’re saying that…” Or, more simply, “Okay, so you’re saying…” or “Let me interrupt here.”
If all these various efforts fail to rein in the fight, and I feel overwhelmed and powerless and don’t know what to do, I give myself a little pep talk—that’s number seven: “Console myself.”
- I remind myself that although I don’t know what to do at the moment, I’ve always in the past been able to come up with something a little later.
- Or I remind myself that partners who appear to ignore or reject everything that I and their partners say, often come to the next session having made changes that show that they had heard, but just weren’t in a position at the time to acknowledge it.
- Or I remind myself that partners who fight the whole session sometimes come to the next session saying, “We needed that—a chance to let off steam. We feel better now.”
If it looks like the session is going to end with the partners angry at and alienated from each other, I talk with them about that. That’s number eight: appealing to the partners as consultants in evaluating and dealing with the situation.
- I say, “Given what’s happened here today are you sorry you came?”
- Or “What does a session like this leave you feeling about what we are doing here and whether these sessions are helping or just making things worse?”
- Or “It looks like you’re going to end the session feeling angry and alienated. Is there anything either of you can think to do in this last couple of minutes to change that, or is it something that we shouldn’t even try to change?”
Another thing I do if it looks like the session is going to end with the partners angry at and alienated from each other is to ask what is going to happen after the session. That’s number nine. I try to create a platform—a vantage point above the fray—from which to speculate about what is going to happen.
- I say, “Given how upset you are with each other, what is it going to be like driving home together, and tonight, and the next couple of days?”
- “How are you going to get over this and how long is it going to take?
- “Who’s the one more likely to reach out to the other?”
By anticipating with them what is likely to happen, I am trying to keep the aftermath of the fight from being the lonely, alienating experience it usually is. The three of us would be talking about it ahead of time. I follow up the next session by asking what did happen—what evolved from last session?
In this next session, I might ask whether they want to return to the issue they were fighting over the previous session? Or do they think that’s a bad idea because doing so will just get them back into the fight? That’s number ten: attempting a recovery conversation—revisiting the issue when they are not upset. If they want to make such an attempt, I guide them through it. And I jump in quickly if it does begin to turn back into the fight. Developing an ability to have recovery conversations is a premier goal of Collaborative Couple Therapy. In a successful recovery conversation, both partner come away feeling that the positions of each made sense.
To put all this together, I move in to keep the fight from happening. If it does happen, I try to turn the fight into an intimate conversation. If I’m unable to do that, I make an elegant statement for each partner showing how his or her position makes sense. If that doesn’t turn the session around, I try to get the partners on the meta-level talking collaborative about their fight. All the while, I draw attention to collaborative moments and interrupt partners (in a collaborative way) when they belabor or amass complaints. At various points in difficult sessions, I console myself. If it looks like the session is going to end with the partners angry at and alienated from each other, I appeal to them as consultants in dealing with this problem and ask what is going to happen after the session. In the next session, and if it is possible to do so without rekindling the fight, I conduct a recovery conversation. A major goal of Collaborative Couple Therapy is to enable partners to have recovery conversations in which they turn fights, problems, misunderstandings, and glitches into opportunities for intimacy.
Fact and Fiction in Psychology
In 1992 I was a Visiting Fellow in the Psychology Department at the University of Western Australia in Perth. For two months nothing was demanded of me other than to talk to the staff and students of the Department in a learned and wise manner, which is easy to do even if you are neither. I was asked one favour which was to give a lecture to the whole department on a subject of my choosing. Can it be any subject, I recall asking the Chairman? Yes, he said, what did you have in mind? An exploration of the psychoanalytic theories of narcissism as illustrated in Oscar Wilde’s novel, The Picture of Dorian Gray, I replied. At that time the UWA Psychology Department was staffed by hard core scientists whose idea of psychology was to do controlled laboratory experiments and high-powered statistical testing. That sounds fascinating, said the Chairman. Too optimistically as it turned out for fascination was not quite the word to describe the stunned and horrified silence that met the end of my eloquent, literary disquisition. I remember one questioner spluttering angrily that psychology was about data, about hard facts in the real world, and I was talking about a work of fiction, the last word spoken with contemptuous disdain. But why have psychologists ignored fiction? What is wrong with studying the works of good novelists and poets for the illumination they provide about the human condition?
Psychoanalysts have long recognised the value of fiction. Freud delved into Greek mythology to explicate analytical theory, the Oedipus complex being the most famous example. Narcissism, the subject I was studying at the time, is founded, as its name indicates, on the myth of Narcissus who was transfixed by the beauty of his own image in a pool, and, depending on which version of the myth you follow, faded away or was transformed into the narcissus flower. Dorian Gray’s intense fascination with his own portrait is an echo of that story. His self-obsession and relentless pleasure-seeking lead to his gruesome death, exemplifying how narcissism is, in the final analysis, self-destructive.
Like many psychotherapists I would pepper my words of wisdom with extracts from favourite novels and stories. I was fond of an episode from Lewis Carroll’s Alice Through the Looking Glass though I now think that my recollection of it may not be totally accurate. Alice is in a garden with paths leading in all directions. Her earnest wish is to get to a house she can see in the distance. She takes a path that apparently goes towards the house but inexplicably it vanishes and reappears to her right. She then takes that path but again the house vanishes and appears elsewhere. After a few more futile attempts like this she says ‘Oh blow,’ for she is a well brought up girl, ‘I shall not bother with the house.’ She turns and walks off in the opposite direction only to run straight into it. It is a good metaphor and the great value of metaphors is that they enable us to see the world differently. However, for academic psychologists seeing the world differently was not at all what they wanted. In fact, they wanted to see the world as it is. That is, they would claim, what psychological science is about. But that too is an illusion for we can never see the world as it is. We are always looking through the prism of our ideas. Facts do not exist in isolation from our interpretations as all good scientists should know.
It can be said of a novel or story that it is not true by which is meant that someone has created it from their imagination. This is why my talk angered the UWA psychologists; the subject matter was not observable reality, the world of facts, but a story, a fiction. But truth has many forms; it is not always literal. There is truth in fiction; you only have to make sure you look at it in a certain way. In the story of Anna Karenina, for example, Tolstoy shows us how an intelligent and beautiful woman can lose everything for the sake of love that is at heart narcissistic. Towards the end of the novel, Anna is in deep despair. In a remarkable passage, Tolstoy enters her self-consciousness as she is driven to the station by her coachman, Pyotr. It is the best account of depressive, self-destructive thinking I have come across. Anna throws herself under a train. It was reading about just such an incident, of a young upper class woman killing herself in that way, that prompted Tolstoy to write the novel. A fact led to fiction which in turn illuminates the truth about certain types of relationships.
I have just finished reading Jonathon Franzen’s novel, Freedom. One its strengths is how real the characters feel; I am sorry that I shall not be there with them anymore. If I look at the novel from a psychotherapist’s perspective, I see how well Franzen has captured the way people unconsciously replay the scripts of their childhood. For example, Patty’s overweening love of her son, Joey, derives from the casual indifference of her parents to her own achievements. But just as she was driven away from her family by that neglect, so Joey is driven away by the intense scrutiny of his mother’s love. I think anyone reading this novel would learn more about the psychology of family life that they would from reading any psychology textbook. It is fiction of course but it tells a certain truth.
Interacting Sensitivities in Couples Therapy
It is a typical night at Tom and Betsy's house. Tom has his nose in a newspaper. Betsy is leaning in the door of his study trying to talk to him, getting more and more frustrated at his periodic, vague “Uh huh.” After a few minutes of trying to entice him into a conversation, Betsy starts complaining, and then criticizing him for being cold. Tom snaps, “Can't you just once leave me alone?” Betsy yells, he withdraws further, and Betsy stalks out, thinking, “I'll give him all the alone time he wants!”
Tom and Betsy are caught in “interlocking vulnerabilities” (Carol Jenkin’s term) or “interacting (or reciprocal) sensitivities” (my term). Each partner responds to having his or her sensitivity inflamed in a way that inflames that of the other. Tom is sensitive to criticism and responds by disengaging; Betsy is sensitive to disengagement and responds by criticizing. Michele Scheinkman and Mona Fishbane call this pattern “the vulnerability cycle.” Scott Woolley calls it “the EFT (Emotionally Focused Therapy) Cycle.” Robert-Jay Green calls it the “problematic couple interaction cycle.” “Pursuer-distancer” (coined by Thomas Fogarty) and “demanding-withdrawn” (researched by Andrew Christensen) are earlier ideas out of which the notion of interacting sensitivities developed.
My purpose here is to distinguish two major subtypes of interacting sensitivities—“pursue-withdraw” and “attack-withdraw”—and to describe how the pattern of interacting sensitivities plays out in the couple relationship. Awareness of this pattern will help the therapist follow the flow of the session and enable the partners to appreciate what they are caught in.
In “pursue-withdraw,” one partner is sensitive to the other’s withdrawal (feels ignored, shut out, abandoned, rejected, lonely, uncared for, unloved, unlovable, or just not as close and connected as he or she wants) and responds by pressing for connection (time together, intimate talking, affection, sex), and the other partner is sensitive to pressing (feels engulfed, smothered, suffocated, bombarded, besieged, flooded, controlled) and responds by withdrawing (disengaging, abandoning, shutting down, closing off). The self-reinforcing nature of this exchange is clear. The more Bob disengages, the more Gloria needs reassuring contact. The more Gloria presses, the more Bob needs to disengage.
In “attack-withdraw,” the other major form of interacting sensitivities, one partner is sensitive to attack (complaint, blame, criticism, anger, reproach, scolding, demands, sarcasm, rejection, disapproval, humiliation, exposure) and responds by withdrawing; the other partner is sensitive to withdrawal and responds by attacking. Again, the self-propelling nature is clear. The angrier Ben gets, the more Alan withdraws. The more Alan withdraws, the angrier Ben gets.
In a fight, the withdrawn partner typically seeks to end the fight or, at least, take a time out. He or she is the one more aware of the destructive and stalemated quality of the fight. The pursuing partner typically wants to keep talking. He or she dreads ending the exchange without a resolution and on bad terms.
In practice, “pursue-withdraw” typically morphs into “attack-withdraw.” At some point, and in some cases very soon, the pursuing partner becomes frustrated and shifts from pressing for connection to reproaching for failing to connect: “Why are you so defended?” “How come you never talk to me?” “Living with you is like living alone,” “Hello, are you alive over there?” Such reproach creates an “attack-withdraw” pattern (unless, of course, the other partner responds with anger rather than with withdrawal, which would then trigger an “attack-attack” pattern. I’ll get to that in a moment). Here is an example of the shiftfrom “pursue-withdraw” to “attack-withdraw”.
Sally (inviting): What do you say we go for a walk?
Tom (vaguely): Maybe later.
Sally (encouraging): Come on. Let’s go now, while it’s still sunny out.
Tom: I want to read this book.
Sally (pressing): You can do that when we get home. Come on. You’ll feel different once we’re out there.
Tom: I’m really into this book.
Sally: (pressing): Well, okay, we don’t have to walk. Why don’t we just hang out and talk for a while?
Tom: I’m not in the mood.
Sally (shifting to attack): You’re never in the mood.
Tom (shrugs)
Sally (blurting out a hidden fear): Admit it—you just don’t want to do things with me anymore; that’s it, isn’t it…
Tom (looks up for a second): That’s not true.
Sally: Well, it is true. You’re like your father—the way he treats your mother. You’re getting to be more like him all the time.
Tom (Looks down at his book)
Sally: Aren’t you going to say anything?
Tom: I don’t know what I can say.
Sally (sarcastically): You could say, “Sure, let’s go for a walk. What a great idea! Thanks for suggesting it. You always make things such fun.”
Tom (looks unhappy)
Such “attack-withdraw” can go on for some time. At some point, and with some couples very soon, the attacking partner thinks, “I’m tired of being angry,” or “Oh my god, I’m sounding like my father,” or “This is starting to go nowhere fast,” or “I hate how whiny and needy I sound, even to myself,” or “You can’t change people, especially some people” or “You can’t get all your needs satisfied by just one person; I’ll call my sister,” Thinking such thoughts, the attacking person joins the withdrawn partner in disengaging. The result is a “withdraw-withdraw” pattern.
At times, the pursuing partner purposely withdraws, creating what looks like a “withdraw-withdraw” pattern. He or she secretly hopes that the withdrawn partner will miss the engagement and start pursuing. But the withdrawn partner is usually just relieved by the decrease of pressure and doesn’t pursue.
While one partner has remained withdrawn, the other partner has shifted from “pursue” to “attack” to “withdraw.” At some point, and in some cases very soon, the latter partner again becomes distressed by the lack of emotional connection and again starts pursuing, which triggers a repeat of the three-part sequence. Couples can go on for years repeating the sequence of “pursue-withdraw,” “attack-withdraw,” and “withdraw-withdraw.”
At some point in this repetition, the pursuing partner may become so resentful about the withdrawn partner’s lack of engagement that he or she bypasses the “pursue” and goes directly to the “attack.” From then on, the partners shuttle between “attack-withdraw” and “withdraw-withdraw.” The “pursue-withdraw” has dropped out. At yet a later point, the “attack-withdraw” may drop out, too. The attacking partner becomes so discouraged that he or she gives up, and the couple slips into a chronic “withdraw-withdraw” devitalized state.
The discussion so far portrays one partner as remaining in the withdrawn state even when the other gets angry. In some cases, however, the withdrawn partner responds with anger of his or her own: “Why do you always have to get so angry about every little thing?” “Don’t yell at me!” “You could use a crash course in anger management—my treat.” In some cases, the withdrawn rather than the pursuing partner is the first toburst into anger: “Stop trying to control me,” “Get off my back!” “Give me room to breathe,” “Back off,” “You never let up, do you?” “Can’t you do anything by yourself?” “You’re the neediest person I’ve ever known.” When the withdrawn partner attacks, the result is the pattern of “attack-attack” (if the other partner fights back), “attack-pursue” (if the other partner continues pursuing), or “withdraw-attack” (if the pursuing partner is now the one to withdraw).
Withdrawal and attack are not always clearly distinguishable. When you give your partner the silent treatment, you appear to withdraw. You relate to your partner in a grim, wooden, disengaged, monosyllabic way. But all the time, you are communicating anger. You are simultaneously withdrawing and attacking.
In summary, interacting sensitivities (the vulnerability cycle, interlocking vulnerabilities) has two main forms: “pursue-withdraw” and “attack-withdraw.” If the withdrawn partner remains withdrawn, the couple repeatedly passes through “pursue-withdraw” “attack-withdraw,” and “withdraw-withdraw.” As time goes on, the “pursue-withdraw” may drop out as may also the “attack-withdraw.” If the withdrawn partner doesn’t remain withdrawn, but instead attacks, the couple shifts into “attack-attack,” “pursue-attack,” or “withdraw-attack.”
We customarily think of a couple as being a particular type—for example, volatile, withdrawn, or pursuer-distancer. But if we look at what actually happens moment-to-moment, we see that couples often shift among several phases.
Knowledge of this shifting helps a therapist follow the flow of what is happening in the couple and understand how the partners are triggering each other—how, for example, Alex pursues because he feels abandoned and Judy withdraws because she feels cornered, which leads to mutual accusation, and, in an effort to avoid further damage, to mutual withdrawal. The therapeutic goal is to enable the partners themselves to observe their relationship in this way: to give them a compassionate vantage point above the fray—a platform—from which to monitor and manage their relationship. Such a vantage point is created by developing the couple’s ability to hold recovery conversations in which they go over their alienating interactions and appreciate how the position of each made sense.
The Lake Wobegon Effect
How good a therapist are you?
Odds are, you think you’re pretty good. A recent study[i] of 129 therapists found that over 90% self-rated their psychotherapy skills at the 75th percentile or greater. All of the therapists rated themselves above the 50th percentile.
In his fascinating new book on therapy outcome, Michael Lambert calls this positive self-assessment bias the “Lake Wobegon effect”. While it is true that the overall industry-wide effectiveness rates for psychotherapy are very good, our blindness to our weaknesses is dangerous.
Lambert points out that 30% to 50% of our clients don’t improve in treatment. Even more alarming, roughly 8% of clients get worse in treatment. (Deterioration rates of children and adolescents may be as high as 12% to 24%.)
If all of us are above average, then who is causing the problems?
Lambert cites a study in which 20 experienced therapists and 20 therapist trainees were asked to predict the progress of current clients in their caseloads. Of the 550 total clients, the therapists in the study predicted that only three were deteriorating. The actual number of clients who got worse was 40.
Notably, none of the experienced therapists predicted any of the clients in their caseload getting worse, even though they were reminded at the beginning of the study that the industry-wide average deterioration rate is 8%.
How can we fix our blindness towards our weaknesses? The traditional method of addressing therapist deficits is supervision and consultation, but those only work when we can correctly identify which clients in our caseload are deteriorating.
Lambert proposes using an intriguing actuarial model, in which the clients’ session-by-session data on outcome measures is entered into a computer program. Using a large database of client outcome data, the program is able to alert the therapist when the probability of client deterioration is high. In his book, Lambert cites a few studies that indicate promise with this method.
Understandably, many therapists will be loath to make clinical decisions based on a computer’s calculations. But then how else do we overcome our self-assessment bias and seriously deal with the risk of client deterioration? Whatever tool we choose, this is an important question for our field to address.
[i] Walfish, S., McAlister, B., O’Donnell, P. & Lambert, M. Are all psychotherapists from Lake Wobegon?: An investigation of self-assessment bias in mental health providers. Submitted for publication.
Eysenck, Rogers and Psychotherapy Effectiveness
In the 1970s I worked as a psychology lecturer in Hans Eysenck’s department at the Institute of Psychiatry, London. He was a controversial figure, quiet and introverted when met face to face, but on the academic stage a formidable and ruthless opponent. Rod Buchanan’s recent biography, Playing with Fire:The Controversial Career of Hans J Eysenck, nicely captures the complexity of the man, part prolific scientist, and part inveterate showman. Whether it was race and IQ, cancer and smoking or the effectiveness of psychotherapy, Eysenck did not hold back from taking the unpopular position. His 1952 paper challenging the effectiveness of psychotherapy triggered off a fierce debate that resonates today. How do we determine that psychotherapy works? Many therapists believe the question is either meaningless – like asking if medicine works – or has been loudly answered in the affirmative following thousands upon thousands of research trials. But the question is not as simple as it sounds.
In the 1970s I recall researching into Encounter groups that were all the rage then and coming across a statement by Carl Rogers. He claimed that a positive consequence of a successful Encounter group was for the members to become aware of their psychological problems and go on to have individual therapy for them. So the measure of success in Rogers’ terms was (a) having a problem and (b) going into therapy, the opposite of what most people see as psychotherapy’s goals! What Rogers claim illustrates is that any notion of outcome is based upon a set of values. For him authenticity was paramount and therapy was not a means of getting rid of symptoms but a chance to explore oneself, a process of self actualisation that was the key to the well-lived life. To be happy was not to be free of problems but to feel comfortable in oneself and to relate to others in a genuine and empathic way. Attractive as this philosophy may be, it is not one that the researchers into the effectiveness of psychotherapy have adopted. On the contrary, a quasi-medical model has been all powerful. Researchers have sought to prove that any specific therapy works in terms of making people feel better and enabling them to get rid of depression, anxiety, addictions or whatever ‘illness’ they are deemed to have. The problem I have with that it does not describe psychotherapy as I know it. Most psychotherapists realise that these simplicities mask the truly interesting part of therapy which is determining what the client’s problem actually is.
In my memoir, The Gossamer Thread. My Life as a Psychotherapist, I describe my first therapy case whom I call Peter. Peter’s problem was a phobia about using public toilets. His anxiety would rise exponentially when any men came in so he avoided public toilets altogether and led a restricted social life. I took over the therapy from another clinical psychologist (who went on to become a distinguished researcher into psychotherapy) and plugged away at Wolpe’s systematic desensitisation, first in imagination then in reality. The reality I chose was to see Peter in a bar where we would chat and drink beer in a way that is unthinkable today. In the course of these conversations I got to know him well, and he me, since I had no idea about boundaries being young and totally inexperienced. The result was a great success but it was in Rogerian not quasi-medical terms. When by chance two years later I met Peter again, he was a changed man, relaxed, happy in himself, content in his career. When I asked him about the original problem, at first he looked puzzled and then said, ‘Oh, that. I still have it but it doesn’t bother me anymore.’ There was a lesson to be learned about what psychotherapy outcome really means but it took me many years to learn it.
Psychotherapy outcomes: The best therapy or the best therapist?
I’m often asked, “What’s the best therapy for anxiety/depression/trauma/etc?” CBT, EMDR, ISTDP, ACT, DBT – the alphabet soup of therapies – how do we (and our clients) choose? Research shows that psychotherapy outcomes often vary more between therapists than therapies, suggesting that picking the right therapy may actually be the wrong approach. In other words, choosing the most effective psychotherapist is more important than choosing the most effective therapy.
How can our clients pick the most effective therapist? They can’t. There is no industry standard for tracking and reporting psychotherapy outcomes. This won’t last. Regulators and consumers are going to demand public accounting of treatment effectiveness. If I have the right to ask my surgeon for their success rate, then why can’t my clients ask for mine?
In a recent panel, the eminent psychotherapy researcher David Barlow noted the “inexorable trend” toward outcomes measurement. He believes it will bring “enormous benefit for all of us,” by improving the connection between clinical research and the effectiveness of actual clinical practice.
Many therapists, however, dread the movement towards measuring outcomes. They raise important concerns about the ability of outcome measures to assess subtle nuances of psychotherapy in long-term treatment. Other concerns include paperwork hassles, and the danger of “therapist profiling” by outcome. (You can join a lively discussion of these concerns in the forums here.)
However, the benefits of embracing outcomes far outweigh the concerns. I’d like to suggest four major benefits to tracking psychotherapy outcome:
- Measuring outcomes will help us become better therapists. How else can we know if all the workshops, trainings and supervision we do are actually helping?
- If we get out in front of this movement then we will have a stronger hand in designing it. If we resist the push towards accountability, it will be forced upon us. (For example, the Los Angeles Times recently published a report outcomes of public school teachers in Los Angeles county, by teacher name.)
- Online therapist-review websites (such as yelp.com or healthgrades.com) lets one or two disgruntled clients hurt your reputation. A public system for reporting outcomes gives a fair perspective of your work.
- Most importantly, our clients deserve to know about the treatment they are getting. Research consistently shows that most therapy is very successful. Dodging accountability can foster the impression that our failures are more common than our successes.
How can a therapist start tracking their outcomes? I use the Outcome Rating Scale, which takes about one minute at the beginning of each therapy session. The free scale and instructions can be downloaded here and here. There are also three online services that help therapists track their outcomes: myoutcomes, oqmeasures, and core-net.
[This blog is dedicated to exploring training tools and techniques that help us become better therapists. Please email me at trousmaniere@yahoo.com if you have any feedback or new psychotherapy training techniques you would like to share.]