Category: Advanced Clinical Skills

From Darkness to Hope: Using Compassion-Focused Therapy

Posted on by Psychotherapy.net Team

The most authentic thing about us is our capacity to create, to overcome, to transform, to love and to be greater than our suffering – Ben Okri

“It’s a head-heart disconnect,” were the words of my supervisor when I asked her why my client, who seemed to ‘know’ or agree with our cognitive reframe of their traumatic experience, didn’t feel it. I’ve repeated those words countless times since—to clients, to colleagues, even to myself when reflecting on my own processes. The head-heart disconnect, when we know something intellectually, but don’t feel it emotionally.

As a newly qualified cognitive behavioural therapist at the time, I was still grappling with the difference between cognitive change at the head level versus the deeper, felt shift that happens when change touches the heart. When I encountered that disconnect in sessions, I felt helpless and confused.

Sarah: Freedom from Shame and Guilt through Self-Compassion

Many clients stand out in my memory. This is a fictional account inspired by them, but not representing any particular person in order to protect their privacy. Sarah was in her late twenties and had been grappling with intense self-blame following a traumatic online sexual experience. She would nod in agreement when we explored the lack of control she had over the situation and when we challenged the beliefs she held about herself as “naive and pathetic.” Yet, despite these rational shifts, her emotional reality remained unchanged. “I know you’re right,” she’d say, “but I still blame myself for what happened.” It was difficult to witness how much guilt Sarah carried, as though she were the perpetrator.

In supervision, I shared my helplessness, feeling as though I were missing something essential. It seemed like no matter what we did—whether we used Socratic questions, conducted an anonymous survey of other people’s opinions, or used thought experiments about whether she would judge anyone else who had been in the situation as harshly—Sarah’s guilt persisted.

My supervisor, with the same gentle wisdom she’d shown me before, said, “is it guilt or is it also shame? I think it is shame you are dealing with, and what do we do with shame? We bring compassion to shame.”

That statement, and what it helped me to learn, changed my practice and my future research interests all at once. Up until then, I’d understood compassion as an element of the therapeutic relationship, but I had not yet worked with it as a core intervention. I began to understand how emotional change requires more than cognitive insight; it requires an internal felt sense of warmth, safety, and connection.

Shame relates to how we see ourselves through others’ eyes, or a lens through which we view ourselves. It can create a powerful urge to hide, even when there’s nothing to hide from. Compassion helps counteract this by fostering a body-mind sense of safeness, belonging, and acceptance.

In the following sessions, I introduced Sarah to the concept of her compassionate self. We practiced guided imagery, inviting her to imagine a nurturing, wise, and courageous part of herself—a part that could hold her pain without judgment. At first, she resisted. “This feels silly,” she said. “Why would I give myself compassion when I caused this?”

Together, we explored that resistance, gently uncovering her fears about compassion: that it might let her ‘off the hook’ or make her weak. Over time, she began to understand that self-compassion wasn’t about denying responsibility or making excuses. It was about recognising her suffering and meeting it with wisdom and strength.

Compassion-Focused Therapy in Action

The shift didn’t happen overnight, but gradually, Sarah started to replace feelings of numbness and the extreme discomfort of shame with the underlying pain and the caring feelings she needed to heal. As part of this process, we introduced soothing rhythm breathing—a core Compassion Focused Therapy practice that activates the parasympathetic nervous system and fosters a sense of inner safety. Sarah practiced breathing slowly, finding her own soothing rhythm that settled and calmed her. This simple, embodied exercise became an anchor for her, helping her regulate overwhelming emotions and connect to a felt sense of stability.

One day, during an imagery exercise, we identified what fuelled Sarah’s shame was the isolation she had experienced at the time of the trauma. She had hidden what had happened to her from everyone close to her, while knowing that hundreds of people, possibly more, online, were aware and might be judging her. This isolation was, in part, the source of the intense shame she carried.

Together, we created a new image. Drawing on her knowledge that her close-knit group of friends did not blame her and would have surrounded her with solidarity and love if they had been there years ago, Sarah allowed herself to develop a felt sense of protection and connection instead of ostracisation and stigma. As she did so, the head-heart disconnect dissolved.

By shifting our attention away from guilt and blame toward shame and acceptance, Sarah was able to acknowledge that she had felt tricked and that it had been a painful experience. She learned to relate to her past self with wisdom, gentleness, and acceptance, replacing the internalised feelings of social danger and the urge to hide with an internalised feeling of social safeness and being deserving of care.

This experience profoundly shaped my clinical practice and research interests. I realised that, like Sarah, there may be more people who carry shame and hide because of online sexual experiences. I dedicated my doctoral research to developing a compassionate self-help programme and testing whether it might help individuals become more open to seeking support and relating to themselves in a kinder way.

There is still much work to be done in this area, but this experience taught me an essential lesson: the head-heart disconnect is not a sign of resistance or failure in therapy—it’s a sign that the heart hasn’t yet felt what the logical brain understands. Compassion is the bridge. And sometimes, we may find the work stems from the question “What would it take to feel safe enough to receive compassion?”

Transformation, creativity, love and the overcoming of suffering through compassion. This is what gives me hope in the darkness in my work at the Oak Tree Practice.

Questions for Thought and Discussion

  • Have you encountered a ‘head-heart disconnect’ with your clients? What interventions helped bridge this gap?
  • How do you distinguish between guilt and shame in your clinical work, and how might compassion help address each?
  • How might incorporating embodied practices, like soothing rhythm breathing, support clients in connecting with a felt sense of compassion?
  • Are you able to find compassion for yourself when you feel helpless at times? What helps you to do so?

Psychotherapy Status Report: Past Achievements/Current Failures/Future Disruptions

Posted on by Psychotherapy.net Team

A Very Brief History of Psychotherapy

Depending upon how you look at it, psychotherapy is among the oldest of professions — or one of the newest. Lacking effective active treatments, doctors always got by with some combination of supportive psychotherapy, magic, and placebo effect.

The Shaman in prehistoric times was the first psychotherapist — diagnosing and treating the mental and physical ills of tribal members by negotiating with the spirits on their behalf. In settled agricultural societies, priests assumed the same role, though the negotiation was with gods, not spirits. Then came the philosophers.

All the basic principles of CBT were laid out by the Epicurean and Stoic philosophers in ancient Greece and Rome. The Arab world, one thousand years ago, was the first to have a separate profession of psychiatry, whose practitioners developed techniques of psychotherapy quite similar to how we practice today. And Pinel substituted psychotherapy for chains in caring for the mentally ill in Paris 225 years ago.

Modern psychotherapy began with the few practitioners of psychoanalysis in Vienna 140 years ago — but psychotherapy quickly became a growth industry, both in the number of practitioners and in the wide variety of techniques they used in their practice.

One hundred years ago, there were very few people who would label themselves psychotherapists; now there are almost 200,000 in the US. About 60% hold a master’s degree, 40% are PhD’s; 70% are female; and average age is 45. Seventy percent of therapists provide mostly individual therapy; 30% also work with couples and/or families. Therapists in private practice usually see 20-25 patients a week; charge anywhere between $75-$200 for sessions that last 50 minutes; and on average, see patients for anywhere between1 and 12 sessions. The average wait time for a first appointment is several weeks.   

CBT is the most popular form of treatment followed by psychodynamic approaches. Two thirds of therapists feel deep satisfaction in their work, but half report having felt burned out at times during their careers. The US Bureau of Labor Statistics estimates that the number of therapists will increase by about 20% by 2030. You can find many more interesting statistics characterizing therapists and therapies here: 

My purpose in writing this piece is to provide my personal, and admittedly biased, view of the major achievements and major failures of our psychotherapy enterprise — and to provide some guesses of what likely future directions will be.

Five Major Achievements in Psychotherapy

The Therapeutic Relationship

The greatest paper in the history of psychotherapy was among the first — Saul Rosenzweig’s 1936 “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” Rosenzweig correctly predicted that the most robust finding in all the later extensive psychotherapy research would be that “everybody has won, and all must have prizes.” His “Dodo Bird verdict” (borrowed from Carroll’s “Alice in Wonderland”) asserted that most comparisons of the efficacy of various forms of psychotherapy result in tie scores. Although therapies may differ greatly in theory and technique, the greatest contributors to good outcomes are the factors all have in common; the therapeutic relationship, patient and therapist positive expectations, healing rituals, catharsis, and regression to the mean with the passage of time. The success of any given form of therapy is not proof of its specific theories or practice, because so much of the variance comes from what is shared across therapies, not what is particular to each. This is not to deny that specific techniques have specific value for specific indications, but it does focus therapist attention on getting right the more general factors that cut across therapies. Rosenzweig guessed the Dodo Verdict without the benefit of any controlled studies, but many thousands of subsequent well-controlled, randomized comparison studies have proven him remarkably prescient.

Documenting The Efficacy of Psychotherapy

The most important thing I’ve ever done in my career was serving on the NIMH committee that funded the early studies of CBT and DBT during the 1980s. These were the early days in systematic psychotherapy research applying the model of clinical trials — the controlled, randomized comparison method that had already revolutionized medical research and efficacy studies of psychiatric medications. 

The few million dollars that supported research documenting the efficacy of CBT and DBT have since benefited millions of patients worldwide. In contrast, NIMH has since spent many tens of billions of dollars on brain and gene research that has provided little to no benefit to patients. The research success of CBT and DBT legitimized psychotherapy and led to their widespread acceptance as reimbursable treatments worldwide. Tens of thousands of therapists have subsequently received systematic training in CBT and DBT — and both have generated extensive professional literatures and also books aimed at patient education and self-help materials, virtual and written. Psychotherapy would not be nearly so widely accepted today if it lacked this demonstration of efficacy.

Expanding The Scope of Psychotherapy and Its Specificity

Modern psychotherapy began with Freudian psychoanalysis, usually conducted several times a week, with the patient lying on a couch and free associating. Within decades, innovative pioneers developed less regressive short and long-term psychodynamically-based therapies that eventually largely replaced the original model. Almost simultaneously, behavior therapy had its origin in Pavlov’s dog conditioning experiments and was brought into clinical practice through innovations introduced by John Watson, B. F. Skinner, and Joseph Wolpe.

Cognitive therapies developed independently by Albert Ellis and Aaron Beck became popular in the 1970s and dialectical behavior therapy was developed at about the same time. In subsequent decades, at least 50 different psychotherapies have been named and defined. This profusion of different therapies is not an unmixed blessing (as we shall soon see), but it has vastly augmented the toolkit of modern therapists and increased the specificity of psychotherapy techniques for depression, panic attacks, generalized anxiety, phobias, anorexia, bulimia, addictions, sexual, and many other disorders. 

Research Comparing Psychotherapy with Psychiatric Medications

The ultimate test of psychotherapies is not how they do against one another (because such comparisons routinely result in tie scores (actually, CBT is usually found to be more effective than others), but rather how they do against medications (when either might be indicated) and how they do against no specific treatment (when meds are not indicated). The evidence of hundreds of studies across different therapies, different medications, and different disorders is that psychotherapy and meds are about equally effective when both might be indicated and that the combination of both may be more effective than either alone. Meds work quicker (not entirely true); psychotherapy has more enduring effects. 
A useful rule of thumb is that psychotherapy alone may be indicated for most milder psychiatric problems; psychotherapy or meds, alone or in combination for moderately severe symptoms, and meds plus supportive therapy for more severe and enduring symptoms. Very mild and transient symptoms do well with watchful waiting (or, as prescribed in the UK, self-help materials or self-help groups).

Reducing Stigma

Mental illness had been more easily accepted before the urbanization that followed the industrial revolution. And in some cultures, the mentally ill had even been revered as a source of spiritual power and insight. But stigma increased dramatically when individuals with mental illness became inconvenient denizens of crowded cities. The typical expectation was that the mentally ill were all badly out of touch with reality; useless; in the way; untreatable; likely to deteriorate and become dangerous; and worthy only of warehousing in badly overcrowded, dingy, smelly, neglectful inpatient snake pits. This stigmatization of mental illness has been much dissipated with the expansion of disorder definitions according to the DSM; the inclusion in the DSM of much less severely impaired individuals; and the widespread experience of psychotherapy in the general population. Many people, especially in cities, have been in therapy or know someone who has.   

Five Major Failures

Lack Of Access

In the US, most people needing psychotherapy can’t get it or wait months on waiting lists. Some of this is due to a shortage of trained therapists. Some is due to lack of parity in insurance coverage and tricky ways insurance companies have of avoiding responsibility for reimbursement. Some is due to geographical distribution of therapists — people with psychiatric symptoms live everywhere, but almost all psychotherapists live in cities.

But economic inequality is by far the greatest culprit in depriving needed psychotherapy for the very people who are experiencing the greatest psychosocial stresses. Add to this that most therapists are white, come from middle class backgrounds, and have little experience with or empathy for (or deep understanding of) people of color, with diverse cultural experiences and values, and with the economically disadvantaged. It is a great failure of public funding in rich nations that the needs of the vulnerable, most in need, are so often neglected. 

Lack of access is exacerbated by the fact that most psychotherapists focus on doing the most possible for each individual patient, rather than having the public health ethos of striving to do the greatest good for the greatest number. Many psychotherapists exclusively conduct long term therapies with very ambitious goals, resulting in long waiting lists or no treatment at all for those frozen out of the system. Most patients want and need only brief treatments aimed at symptom relief. Long term therapy is valuable, but it should be the exception, not the usual first reflex.

Community mental health centers, often vastly understaffed and with therapists with less training, are expected to treat a crushing number of patients per week. And then there has been the emptying of psychiatric hospitals without needed therapeutic services, housing, and vocational support

Lack of Integration

There has been a tension during the past 50 years between the psychotherapy splitters (those who create an ever-expanding list of new psychotherapies) and the psychotherapy lumpers (those seeking to integrate psychotherapy into one coherent whole). Despite the best efforts of the lumpers (count me in here), the splitters are winning out. At last count, there are more than 50 named psychotherapies — a veritable alphabet soup. Most therapists are narrowly trained in one type of therapy and remain tribally loyal to it — applying the same techniques to all their patients rather than developing sound conceptualizations and treatment plans for each individual, integrating and flexibly applying the specific techniques most appropriate for that individual.

Most training programs are narrow in focus — locked into the techniques developed and taught by their founders, rather than teaching a wide array of the best techniques from across all models. Cognitive therapies are now by far the most prominent in the world because they have been by far the most flexible — over the past 40 years incorporating behavioral, psychodynamic, experiential, and recovery techniques and applying them flexibly to a widening range of symptoms within their theoretical framework

Losing The Battle with Drug Companies

Psych meds are essential for those with severe psych symptoms, and often necessary for those with moderate symptoms. Even though most people with milder symptoms would do better with psychotherapy or watchful waiting, a startling 20% of the general population are instead regularly taking a very often unnecessary psych medication.  

There are three causes of this overuse of psych meds and accompanying/underuse of psychotherapy; 1) drug companies spent billions of dollars promoting meds; virtually nothing has been spent promoting psychotherapy; 2) 80% of psych meds are prescribed by primary care doctors with little training and great eagerness to get a satisfied patient quickly out of the office; and 3) psychotherapists are so hard to access in most communities. This overuse of meds and underuse of therapy is bad for patients, bad for therapists, bad for society — it is good only for drug companies.

Underemphasizing Supportive Therapy

The flourishing of specific techniques of therapy has obscured the fact that supportive psychotherapy is valuable and should be part of every patient encounter, whether in a medical or a psych setting. With the exception of some psychiatric residency programs, there are few training programs teaching how to do supportive therapy, and few books and papers describing it. This, despite the facts that supportive therapy is the only helpful tool most doctors have had during most of the history of medicine, that psychotherapeutic support creates hope, reverses demoralization, and counters isolation, and that supportive psychotherapy requires more skill and empathy than the use of specific techniques.  

Failing To Include Evolutionary Perspectives

Darwin was the greatest psychologist who ever lived. He had three seminal insights that should vitally inform modern psychotherapy: 1) we have inherited many of our emotions and behaviors from our animal ancestors in the same way we inherited our bodily morphology; 2) we are unaware of the underlying motivations of our behaviors; and 3) many of our now maladaptive behaviors are relics of a time when they were much more adaptive.

An evolutionary perspective helps patients normalize their symptoms by better understanding where they come from and why they have them. It is normal to grieve as the price of love. It is normal to feel sad when we fail as a motivator to do better in the future. It is normal to have anxiety and phobias in response to dangers, to feel paranoid when confronted by potential enemies, to be dependent when in need of help, to overeat when delicious food is available, and so on.

Normal feelings and behaviors become problematic symptoms only when they are severe, prolonged, stereotyped, and not adapted to the current environmental contingencies. Understanding the normal roots of symptoms reduces the patient’s feeling of being uniquely damned and points the way to more adaptive responses. The valuable application of an evolutionary perspective toward psych symptoms has been described for 30 years — but most psychotherapists are woefully ignorant about it. Notably, one of Aaron Beck’s last papers did include an evolutionary perspective on depression. 

Five Future Trends

Teletherapy

Telemedicine has been around for 60 years, particularly for providing services in rural areas and particularly in psychiatry. But all this was on a small scale until Covid isolation protocols temporarily made telethetherapy the predominant way for psychotherapists and patients to communicate and for young psychotherapists to be trained. States temporarily relaxed licensing restrictions that had prevented therapists from extending their reach across state jurisdictions. The results were remarkable — many therapists (and patients) preferred zoom to in-person sessions because they afforded greater scheduling convenience, eliminated travel, allowed access to a greater range of therapists, reduced waiting time for first sessions, reduced therapist overhead, and achieved surprisingly high rates of patient and therapist satisfaction.

The lifting of Covid restrictions has made teletherapy something of a geographical jumble. Different states now have very different licensing requirements, some welcoming teletherapists from other states, some tightly restricting, and many in between. But the trend is clear — more and more, psychotherapy (like so many other aspects of life) will be done remotely via screens, rather than in person.

Text Therapy

Covid isolation also resulted in the explosive growth, increasing acceptance, and commercialization of text-based therapy. The convenience and advantages of easy and expanded access, flexible scheduling, efficiency, and low cost are clear. But texting as a psychotherapy modality also has some real advantages over in-person meetings. Patients are often more open in texts than face to face, and less likely to ignore or reject therapist’s comments. Writing gives them the opportunity to think through their problems, and texts can be read and reread and considered in a way not possible with fleeting verbal communication. One exception may be CBT, where clients are encouraged to take good notes of the most important points of the session.

The disadvantages of texting are also obvious — the lack of visual appraisal and non-verbal cues can lead to incomplete evaluations and miscommunication. We can’t really trust the few generally positive studies on texting as they may be biased, but my guess is that it will play an increasing role with the advent of a new generation of patients and therapists, who have grown up using texting as one of their major forms of relatedness.

Competition From Coaching

Life coaching is a fast-growing profession with over 70,000 coaches practicing worldwide. Theoretically, coaching and psychotherapy have different goals, practitioners, and consumers. Therapists receive more extensive training, require more formal licensure, and treat psychological symptoms that are diagnosed, coded, and compensated as “mental illness.” Coaches receive much less training, have much looser licensure requirements, and provide wellness training to improve business, interpersonal, organizational, or sports performance and to enhance life satisfaction. People with more severe problems need psychotherapists; those who are generally doing well but want to do better may seek coaching. Coaching has the advantage of less stigma (no DSM disorder required); but the disadvantage of not being reimbursed by medical insurance. As coaching becomes more available and well known, it will doubtless draw many people who would otherwise have seen therapists.

Corporatization

Psychotherapy began as mostly an individual endeavor — one practitioner contracting with one patient who paid out of pocket. Soon however, and particularly after World War II, psychotherapists increasingly began working in institutional settings — hospitals, outpatient departments, community mental health clinics, the military, and VA facilities. Especially beginning with managed care in the 1990s, psychotherapists have increasingly worked as employees of increasingly larger and larger private, for-profit groups.

Teletherapy has recently exponentially speeded up the concentration of psychotherapist — one company has accumulated a network including tens of thousands. This has the possible advantages of improving patient access and quality control but drains money from the system and risks creating inappropriate uniformity and decreased quality.  

Artificial Intelligence

I have previously written on the very real risk that computers will replace psychotherapists.  

Conclusion

It is the best of times and the worst of times for psychotherapy. Best because we have so many therapists and effective therapies. We can help most patients more than medication can and no profession is more interesting or fulfilling. I am a much better person than I otherwise would have been because my patients taught me so much. Worst because the field is so unnecessarily fragmented, so poorly compensated, and so at risk of being controlled by corporate interests and/or reduced by coaching or replaced by artificial intelligence.  

The best hope for the future, both for patients and practitioners, is to do our job well. We must integrate the hodgepodge alphabet soup of existing therapies by combining what works best from each within the context of a sound conceptualization. Therapists should no longer be trained in, and express fealty to, just one school of therapy. We should discuss, but rather feel comfortable applying techniques across all relevant schools, flexibly meeting the specific needs of each patient.

Psychotherapists have, since the dawn of time, provided comfort and solace to mankind. Labels change — shaman, priest, minister, doctor, psychiatrist, psychologist, social worker, counselor, nurse, occupational therapist, coach, and many more. But the essential function of explaining and healing human suffering has always, and likely always will be part of the human condition.  

The Wisdom of Therapist Uncertainty

Posted on by Psychotherapy.net Team

“Uncertainty is your space for growth.” – Angela, psychologist

Work hours for many are unpredictable. Political divisions, pandemics, and extreme weather add further unknowns to daily life. In an era that challenges mental health, it’s easy to assume that therapists should be pillars of all-knowing sureness.   

One Fear to Rule them All

But growing evidence suggests that practitioners can benefit from leaning into their uncertainty in times of flux. Skillfully accepting and even embracing not-knowing is linked to better mental well-being and improved decision-making in both clinicians and their patients. “We need to help psychologists view uncertainty not as a horrible thing you need to minimize, but as an opportunity to learn and grow,” says Elly Quinlan, a senior lecturer in psychology at the University of Tasmania and a leader in the study of uncertainty in clinical practice.

How humans contend with the unknown is a topic attracting attention in clinical psychology. This critical capacity is measured by gauging people’s “intolerance for uncertainty,” or the degree to which they view unknowns and the unsureness they spark as threatening or merely challenging. (Sample assessment component: “Unforeseen events upset me greatly.”) (1) Importantly, being intolerant of uncertainty is now recognized as a transdiagnostic vulnerability factor for a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. (2) As Canadian researcher Nicholas Carleton writes, this trait (and state) may be the “one fear to rule them all.” (3)

As a result, leading psychologists are targeting uncertainty intolerance as a promising new way to treat many mental disorders. By taking on more unknowns in daily life, patients gain skill at meeting life’s twists with a curious, open mind, rather than fearfully racing to eliminate uncertainty through denial or snap judgment. During one intervention, young adults tried answering their phones without caller ID. (4) An adult learning uncertainty tolerance in therapy challenged himself to delegate more at work. (5) Results are encouraging: in one recent study focused on bolstering uncertainty tolerance, worry and anxiety in people with generalized anxiety disorder fell after treatment to levels experienced by the general population. (6)

Now Quinlan and others increasingly see uncertainty tolerance as a needed skill for psychologists themselves to practice. Psychologists interviewed for a small quantitative study led by Quinlan reported primarily negative responses to situations filled with unknowns, such as an ethical dilemma or the challenge of selecting treatment for a high-risk patient. (7) The psychologists, who had diverse levels of experience, reported anxiety, feeling inadequate, frustration, and anger. Some avoided complex, ambiguous cases or left a client in order to escape uncertainty. “I actually could not resolve that uncertainty, so I shifted the client to another clinician,” said one.  

Such markers of an inability to manage uncertainty are associated with both anxiety and with burnout, conditions that undermine well-being and decision-making skill. In one study of 252 psychologists, their uncertainty intolerance in client care and in daily life predicted burnout (8), a form of exhaustion that up to 40 percent of mental health providers experience today. (9) Uncertainty intolerance is also linked to overtesting, according to studies in primary care medicine. (10)

The Importance of Uncertainty Tolerance

In contrast, psychologists who accept the intrinsic uncertainty of their work and see not-knowing as an opportunity for learning, as discomfiting as that may be, tend to have higher mental well-being. Angela, a psychologist who participated in another of Quinlan’s qualitative studies, advises younger peers to “treasure the darkness a bit. Uncertainty is your space for growth.” (11) Uncertainty-agile clinicians ask, “What is this ambiguity or my uncertainty telling me?” instead of rushing to bury or eradicate the unknown, says Quinlan, whose research has inspired her to assure her trainees that it's okay, and even helpful, to not know.

By recognizing uncertainty as a path to wisdom, providers gain time and space to consider nuance and alternative perspectives. In a speed-driven world where experts are expected to be all-knowing and ultra-decisive, psychologists often “long for the magic wand” of the quick, clear answers, observes educational psychologist Daniela Mercieca of the University of Dundee. But “it is only by allowing ourselves to be uncertain that we are open to shock and surprise … and complexity.” (12)

How can psychologists learn to recognize unsureness as an opportunity? Efforts to map uncertainty tolerance are so new that interventions to teach this skill set to practitioners are sparse in both psychology and in general medicine. One intervention found that training in non-judgmental mindfulness helped trainee psychologists become less stressed by uncertainty. (13) Other studies have shown that exposure to the visual arts or the humanities can boost uncertainty tolerance in medical students. (14) Quinlan plans to begin formally testing uncertainty-tolerance strategies for trainee psychologists in a few years. 

There may come a day when healthcare practitioners will be routinely taught to manage uncertainty as a way to improve their well-being and their efficacy. But until that time, perhaps clinicians can learn from the peers and patients around them who find wisdom in accepting life’s inherent unpredictability and in realizing that at any one moment they might not know.

Recently, two young practitioners found that openly admitting uncertainty in their practice felt unexpectedly liberating. The opportunity arose in 2020 as cognitive behavioral therapist Layla Mofrad and psychologist Ashley Tiplady worked with Mark Freeston of the University of Newcastle to develop a group intervention to teach uncertainty tolerance to patients just starting to receive care for a range of disorders. (15) To model the intervention’s content, they explicitly talked to one another and to patients about the program’s unknowns, ranging from outcomes of this novel treatment to how a tech outage might affect the day’s schedule.   

Most patients who completed the “Making Friends with Uncertainty” intervention showed significant improvements in their anxiety and depression and nearly half became more tolerant of uncertainty. Moreover, the facilitators themselves found that working with, not hiding from, uncertainty improved group solidarity and their own ability to be partners in care. “It’s easy as a therapist to jump into trying to make things feel more certain … we tried to hold back from that,” says Mofrad, adding that this approach returns therapy to its ideals. “The best therapy will always have an uncertain element, and the best therapists are those who will ask questions, be curious, and not stick to a rigid framework.”

Note: All quotes are from interviews with the author unless otherwise noted. Due to an editing error the references below have been updated as of 4/24/2024


Questions for Thought and Discussion

1. What were your impressions of the author’s premise about certainty and uncertainty?
2. How comfortable are you with uncertainty both professionally and personally?
3. In what ways might you carry forward the author’s research in your own clinical work?  


References

(1) Carleton, R. N.; Norton, P. J., & Asmundson, G. J. G. Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.

(2, 15) Mofrad, L., Tiplady, A., Payne, D., & Freeston, M. (2020). Making friends with uncertainty: Experiences of developing a transdiagnostic group intervention targeting intolerance of uncertainty in IAPT: Feasibility, acceptability, and implications. The Cognitive Behaviour Therapist, 13 (49), 1-14.

(3) Carleton, R. N. (2016). Fear of the unknown: One fear to rule them all. Journal of Anxiety Disorders, 41, 5-21.  

(4) Unpublished material shared with the author by Stephanie Gorka and Nicholas Allan of Ohio State University’s College of Medicine.

(5) Keith Bredemeier Assistant Professor at the University of Pennsylvania Perelman School of Medicine Center for the Treatment and Study of Anxiety, in discussion with the author, September, 2023.

(6) Michel Dugas et al. (2022). Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults with Generalized Anxiety Disorder. Behavior Therapy, 53 (6), 1147-1160.

(7) Quinlan, E., Schilder, S., & Deane, F. P. (2021). `This wasn’t in the manual’: A qualitative exploration of tolerance of uncertainty in the practicing psychology context. Australian Psychologist, 56 (2), 154-167.

(8) Malouf, P., Quinlan, P., & Mohi, S. Predicting burnout in Australian mental health professionals: Uncertainty tolerance, impostorism, and psychological inflexibility. Clinical Psychologist, 27 (2), 186-195.

(9) O’Connor, K., Muller Neff, D., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74-99.

(10) Korenstein, D., Scherer, L. D., Foy, A…Morgan, D. J. (2022). Clinician attitudes and beliefs associated with more aggressive diagnostic testing. American Journal of Medicine, 135 (7); also Lam, J. H., Pickles, K., Stanaway, F. F., & Bell, K. J. L. (2020). Why clinicians overtest: development of a thematic framework. BMC Health Services Research, 20 (1011),

(11) Fewings, E., & Quinlan, E. (2023). ‘It hasn’t gone away after 30 years.’: Late-career Australian psychologists’ experience of uncertainty throughout their career. Professional Psychology: Research and Practice, 54 (3), 221-230.

(12) Mercieca, D. (2009). Working with uncertainty: Reflections of an educational psychologist on working with children. Ethics and Social Welfare, 3 (2), 170-180.

(13) Pickard, J. A., Deane, F. P., & Gonsalvez, C. J. (2024). Effects of a brief mindfulness intervention program: Changes in mindfulness and self-compassion predict increased tolerance of uncertainty in trainee psychologists. Training and Education in Professional Psychology, 18 (1), 69-77.

(14) Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56 (12), 1163-1173.   

How to Use Structured Writing to Help Clients Unclutter

Posted on by Psychotherapy.net Team

The clock struck three and Mary was calling me on Zoom. Before I could say “Hi,” she was reading from a crumpled paper held in clenched fists. This was her weekly list of the topics that she wanted to bring to therapy. Her timing gained momentum until her words reached a breakneck pace. It seemed that I was witnessing a contest. Mary was like a game show contestant, reaching for the top prize that came with climbing to the top of her list of priorities.

Mary: The Gravitational Pull of Lifelong Habits

I waited until Mary finished reading, and then after taking a few deep breaths, began the arduous task of adding some modicum of structure to her list — rating the topics, determining their priority, and then talking out the prioritized topics in a bit more detail than she originally planned. Mary dutifully and enthusiastically jotted down notes corresponding to the topic at hand.

While rapport came easy with Mary and our conversations typically flowed, a seemingly interminable pause — you know, those that are unique to online therapy — Mary proclaimed, “I know, I know. I’m not ready to give up being the rescuer.”

“You think?!”

Before continuing, she gave me her usual comedic smirk and said, “But this is all real. I have a vitamin company that I’m running solo because…Um, well. It just happened. Sort of. Slowly.”

Knowing the answer, I asked in jest if Mary was still office manager at the commercial real estate company where she began working 15 years ago. Mary nodded. We turned back to her list. There were a few items that Mary also described as having “just happened.” These included volunteering to cook Thanksgiving dinner for her husband’s family and letting her sister-in-law stay with them for a long visit with an end date that was “to be determined.”  

Prior to that session, Mary had been angry that her daughter had forgotten to place an order for groceries, making it necessary for Mary to stop and bring home dinner for the family on a very cold night after leaving the office. Initially, Mary regarded her anger as a simple and logical reaction to her daughter’s forgetfulness, but because there was already a template in place from an earlier clustering of items on her list, she finally seemed ready to identify another significant pattern of behavior she very much wanted to address, and hopefully change.

“My mother was always angry. She was the Lone Ranger, always putting out fires that we all set. My siblings and father, that is; not me! I did what I was supposed to. At some point, I became everyone’s helper. I guess I learned to do this when my mother became depressed.”

We eventually got to a point in Mary’s processing where she saw that there was a historical satisfaction she received from maintaining order by handling everything around her, instead of accepting the risks that came with engaging, or directly asking for the help of others. When others failed, as they invariably did, Mary felt anger. It wasn’t anger; however, at the perpetrator, but at herself because of her intractable belief that she had to then pick up the slack and failed to do so — and instead, outsourced. This rescue theme permeated all facets of her life.

Mary was circling items on her list that felt optional when she put her face in her hands. After some minimal silence, Mary described how she felt the first time she noticed her mother’s depression. “The sadder she looked, the busier I became. The busier I became, the less my brothers and father were doing. No chores or help around the house in any way.”

Through writing lists and seeing reality in print, right in front of her, Mary was able to appreciate the wide scope of her expectations of herself, and her role in continuing to be the rescuer to prevent the potential for disappointment from others.

Terry: Therapeutic Lessons in Self-Advocacy through Writing

Terry, aged 35, presented in a very warm wool blazer over a buttoned-up Oxford shirt that looked uncomfortable. His mannerisms seemed almost choregraphed corporate professional in such a way that made me think that he was working too hard at appearing polished. I believed that still waters ran deep with Terry, but I delayed my full impressions.

“I just can’t take my life anymore! Oh, no, not like that. I mean, I’m fine. Well, no, thanks to them, I am not fine. Or thanks to me, maybe. I could just leave, but then they need me, and I’m committed to seeing these changes through. I made a commitment. And I need the money. This is a huge opportunity. And, at the same time, this is no way to run a company and no way to treat a human being.”

Terry paused, looking at me almost apologetically. Wanting to normalize his expressive shouting, I nodded as if we were already in a working alliance and immediately went into establishing the presenting problem, before moving carefully into recent history. Terry’s upbringing seemed complex, and his expanded HR role at work which included dispute resolutions and public relations, seemed to mirror those early-life experiences.  

In describing his days, Terry painted a picture that felt very much like a Pollock painting — taking meetings, picking up prescriptions for his uncle, being too tired to enjoy a weekend party, listening to a manipulative employee with a treacherous track record fabricate a story about discrimination, and finally, feeling financially burdened, depressed, alone, and coping with “a heart that feels like it’s doing summersaults inside my chest.”

As he frenetically laid out the complex intertwining of work and family-of-origin demands, once again, I had trouble catching my breath. Like a sports referee, I motioned for time-out, nodding slightly to offer Terry assurance that I wanted to understand everything, and to do so, I needed separation and space between each different subject. Granted, that’s not the effect that Pollock was aiming for, nor would we want to break down and bring order to his works, as chaos seemed to be the goal. But I explained to Terry that while the head-spinning menagerie of topics he was tossing onto the canvas of our session gave us a lot to work with, it would otherwise be helpful if we could indeed structure his topics and disassemble the inner chaos.

I’ve found that one of the many ironies in therapy is that the more issues are linked together, the more important it is to first separate them out. I’ve had good clinical luck by establishing traction with one issue at a time, usually the most current “hot topic.” The high voltage of that topic usually complicates and obscures other issues, regardless of when they arose in the client’s life. Without separating, wires cross, and I have frequently sat in an electrical storm of past and current issues as they collided in a dazzling and confusing Pollock-ian explosion.

Terry’s past did clearly contain some currency. He described being alone most of the time as a child, until his parents rented their basement apartment to his aunt and uncle. His uncle became his mentor. Terry emulated his uncle and grew up having two role models — his father and his uncle. Terry empathically described the contrast between his parents’ old fashioned work ethic of long hours and constant worry about the business, and his uncle’s more creative and impulsive risk taking. His uncle had a wild ride of achieving financial success after living for a time in the basement apartment, moving out and buying an enormous house on a fancy street in Brooklyn, only to lose everything 10 years later and wind up back in the basement, divorced, and working for Terry’s brother.   

Terry’s formative years were spent being caught in a tug-of-war between his father and his uncle. His father wanted to hand the restaurant over to his son and his uncle wanted Terry to go to college. Terry did both, but through the years, he became the go-between for the two men. Unconsciously, he feared rejection from his father and carried this with a constant state of nervous energy and anxiety attacks, somatic digestive symptoms, and an obsessive monitoring of his health. His present work environment had some shared features of his family of origin homelife and ongoing sense of family-based obligations.

Terry was getting visibly angry within three minutes of our second session. He wanted to alleviate the sting from his recent reprimand at work, yet at the same time, he knew that he was in the right, and that his supervisor’s issues of paperwork falling through the cracks was 90 percent due to lack of administrative support and maybe 10 percent human error. Terry needed to fight back with professional decorum, but first, he needed to calm down. My suggestion was to disentangle the different items and then respond to each one — to himself — on paper, as preparation for communicating with his supervisor.  

At first, Terry was irked, reluctantly pulling his laptop open and making a few nominal clicks. As we talked and Terry clicked, we created separate headings for each action item that was part of his entire merging of multiple job receptibilities. This master list with heading included multiple separate jobs that he had been unofficially asked to cover, without any new prospects for hire. Terry was pleased, and I was proud of him. As he gained clarity in the organization of his responsibilities, he also increased his personal conviction — his inner authority. Eventually, through his writing, Terry became fully prepared to meet with his supervisor. The meeting was without the previous subject of Terry being a remedial employee and failing to live up to expectations. Rather, this meeting was direct, goal-oriented, and successful.

The Positive Impact of Therapeutic Writing

In my experience with clients like Mary and Terry, I’ve found that when a client states facts on paper, they are also asserting the following:

1. They have the authority to interpret and define the facts
2. This authority is not subject to permission or approval from another
3. They have custody over the facts, as they are
4. They have the right to communicate these facts to another person, and doing so is not a betrayal or violation

Writing as a means of expressing feelings is well known, but the use of technical, terse writing can also be a valuable therapeutic tool. The tracking done in REBT and CBT therapy fits with clients when they are at a point of delving into activating events, beliefs, and consequences, but so often they also want to fully describe all the different scenarios they live out week to week. They want to take their therapist through a deep dive into the details of what transpired. This can often result in a confusion of ideas, goals, and plans, much like Mary and Terry initially experienced.

Technical writing can also be an effective means of helping a client work through the struggles of day-to-day life, including communication with others. Writing between sessions gives a client the opportunity for greater insight while deciding in advance of session time what is important to focus on. Sometimes, clients uncover a theme for the week as a direct result of writing. Whether a laundry list format or paragraphs, writing can fit easily within sessions on an impromptu basis. While the undesired feelings (dissatisfaction, grief or anger, or irritating tasks such as administrative responsibilities) do not get resolved through pen to paper or typing in a device, there is clarity through organization. This is similar to how balancing books doesn't make the red go to black, but often results in a feeling of ease.

Getting Organized: The Pre-Therapy Phase

After getting a baseline history and general understanding of the client’s concerns, there is a pre-therapy phase, akin to treatment planning. This phase begins by sifting through past and present to hit on the main problem of this moment. What is being experienced now that is problematic? Why is this problematic? What are the consequences? Is any of this problem optional? Could there be any benefits — even the kind of benefits that have more consequences later, such as avoidance? At about this point, I ask my clients to write down the words “Secondary Gains.” Some immediately Google it and some tell me the definition, as if on cue.

Once the main problem is identified, then the work of uncovering the various aspects within the problem becomes the next step. Technical writing is an ideal tool for this phase and can be a useful complement for therapy throughout the process.

The Top Card

My clients are accustomed to me saying that there is only one card at the top of each deck. Before selecting the top problem, it often helps to sort out problems into two basic categories.

In therapy, a problem is not always a separate entity, such as struggling with a recent promotion at work or difficulty adjusting to a new city. Rather, problems are sometimes complex and long standing, such as pervasive anxiety or depression or life patterns stemming from a background of trauma.

Often this pattern results in multiple struggles, where each struggle may seem like an independent problem, but each problem is part of a cluster of circumstances spurred on by the damaging pattern. In session, we take a sheet of paper and draw a line down the center. At the top of the page, we write a title on each side. On the left side is Problem Group A — Discrete Problems, and on the right side is Problem Group B — Overarching Patterns.

Problem Group A, for example, may be difficulty accepting a recent job loss, and Problem Group B typically shows up as a cluster of events or consequences linked to a combination of undesired habits, such as isolation, anxiety, and an endless state of resentment.

Problems from either category require teasing out and separating the different aspects. Aspects often include finding meaning in the problem and uncovering the types of environments and circumstances when the problem feels more present. There is often overlap between the discrete situation problems and the overarching pattern problems. But, even with this overlap, there is ultimately one card at the top of the deck and one situation or state of mind to home in on before delving into the others.

While this strategy may seem formulaic and concrete, I have found it very useful for clients like Mary and Terry, as they have tried, and successfully disentangled, prioritized, and addressed the problems that have plagued them. Doing so has also helped me to breathe a bit easier with clients who might otherwise pull me in the Pollock-like paintings of their lives. 

Dialogue 1: How Do We Define Collaborative Writing?

Posted on by Psychotherapy.net Team

Editor's Note: In this “dialogue” between client (Daniel X. Harris) and therapist (Trish Thompson), the co-authors explore how collaborative writing that focuses on the therapeutic relationship can be a powerful tool for building trust, multiple dimensions, and humor. They also explore some of the ethical questions surrounding this kind of work and note that the entries do not always run sequentially, “as the themes they explore circle back and around, more like circuits of curiosity than a linear journal.”

Defining Collaborative Writing

Trish Thompson: Dan, so what do we mean when we say collaborative writing? Does it have to be writing with each other, or can it be writing to each other? Or can it be considered more broadly, including things like one-way writing about collaborative sessions?

Daniel X. Harris: This is an interesting question, Trish, and one (in my view) that is framed by disciplinary considerations. There are different ways of responding to it, whether you are coming from psychotherapeutic, autoethnographic, narrative writing or creative writing perspectives. One entry point might be the work of Jane Speedy, who is both an academic and narrative therapist. Her 2017 book, Narrative Inquiry and Psychotherapy, offers many responses to your questions. For example, Speedy offers, “My own interest in narrative research is very much as a collaborative co-inquirer, first in relation to the problems that have come to overshadow and shape peoples’ lives, and secondly in terms of re-telling these stories in writing” (1). Further, she defines “meaning-making as collaborative activities and “reality” as the space between people engaged in conversation.”

There is no hard and fast rule. It can mean a wide range of things, but if it is “collaborative,” I think there has to be that element of working together, not just reporting to each other what we have done individually or independently. For example, you have described using writing with other clients in which they write to you things between sessions. If you read those works and then you work on the content in their session, I would not consider that collaborative writing. If you both read your writings to each other, and change each other in that exchange, then for me that’s moving into the realm of collaborative. Or maybe, more accurately, that would be considered “interdependent” writing! Yalom (2) falls somewhere in there, I think. While I appreciate the efficacy of those approaches, and the many diverse ways in which writing is used in art therapy, I’m more interested in the mutuality of what we have done together. That to me is the “radical” bit: how can one part of a pair (the client) be helped by the therapist’s trained knowledge, through a multi- directional exchange that requires vulnerability and sharing from both sides? That’s truly collaboration.  

Thompson: Ah yes, I like what you are saying here. It makes me think about our writing process, particularly for this book, and the different ways we worked together. What about when we recorded a Zoom chat and then converted the conversation to text? Didn’t seem to make a heap of sense on the page. Technology at fault, surely! Our writing sessions were more productive — 45 mins of writing, screens off (I wonder if your dogs are at your feet?), and then sharing what we had written after. You had always written about three times as much as me, the words pouring out of you, capturing your experience so evocatively. But for me, it is slow work, as if I have to coax out reluctant words that are not sure whether they should show up in case they don’t get along together when they arrive on the page, despite my pleading! I remember telling you about my writing imposter syndrome, saying that there are so many great (much better) writers out there, what do I think I’m doing? And you said something like, “here is room for lots of writers to be out there.” That was so helpful to me.

Harris: Trish, what difference does it make to co-write for publication, rather than just as a therapeutic tool (and does that mean they have to be good writers)? 

Thompson: The first question I ask myself whenever I write something is, “who is the audience?”

This to me is fundamental in shaping the purpose of the words. Using writing as a therapeutic tool has its focus in deepening the shared understanding of the issues being explored in sessions. It is endlessly provoking in the material it continues to throw up. I am writing with a client at the moment, and the face-to-face sessions are so enlivened by the picking up of the threads of the email exchange, once they have also been through the reflective cycle. This client uses visual imagery to great effect in her writing, which I love and respond to. She says she loves how I capture and summarise her therapeutic journey so clearly. But this co-creation is done with little thought to skill or form, it is just about an illustration of our process that continues to build connection. But if a client/therapist pair are writing for publication, they are allowing others into the intimate space of therapy because they believe that what they have to say will be of benefit to others. It could raise feelings of vulnerability when imagining what are usually confidential words reaching the eyes of an unknown audience. I think if therapy writing is to be published, it would be important that the client and therapist can write well enough to convey meaning, create interest and inspire the audience (gulp!). The ethics of this issue are also touched on in Dialogue 3.

When Narratives Meet

We wonder how therapist narratives and different parts of them might enter the space and connect with the narratives/parts of the client? We argue that the meeting point/s of these narratives can be a catalyst for change in both the client and therapist. As Speedy states, collaborative writing between therapist and client, researcher and researched, can “take issue with the low- and high- ground positions in relation to “writing” and “research”… and to promote and encourage ideas of scholarship (alongside research) within the therapeutic domain as collaborative …” This problematisation of the unequal power dynamic that typically haunts both kinds of engagement is at the heart of this book.      

Harris: Collaborative writing doesn’t have to be of equal investment. Clients are looking for witnessing more than a therapist would. They don’t need the writing to witness/reflect them. It’s okay that what the client gets out of it is different from what the therapist gets out of it. Narrative therapy tells us that what a lot of the therapeutic work does, written or not, is bearing witness to someone’s pain or joy or hardship. Validating. It takes the experience from being in one’s psyche to being made real in “real life.” Validating the difficulty of an experience.

But what allowed Trish to accept that invitation? What allowed her to become playful in ways that I experienced as deeper, more or different than in the room? We agree there is something alchemical in the movement of being in, stepping out, looking. This is both a feeling and also is materially and spatially shown by the text and the comments down the side. We were doing that together. It wasn’t just Trish going to supervision and thinking about the therapeutic work.

It felt like there was a collaboration going on around what was going on. There was a shared analysis of what we were doing. Some therapeutic models absolutely flatten the hierarchy: the therapist is not there to tell the client what it “means,” or what to do.

What did it feel like for Trish? You don’t often get a client doing that. Reflecting on the last session, or the work, or where this was helpful – you invite it, but it doesn’t happen a lot. Therapists spend a lot of time wondering if techniques work or not. We have talked a lot about the tendency of therapists to workshop these questions with one another, but less so with clients. How would you know if something worked, if you didn’t ask the client?

This collaborative process speaks to something deeper in Trish, rather than therapist Trish. She doesn’t want to assume or believe things if they’re wrong. She wants to know. This kind of dynamic has been a long-term struggle for her, so the explicit-ness of the conversation in the writing (of the first article) really jazzed her because “the dialogue is open.” You get to know, understand, no matter how hard it is; so much better than wondering. We think that’s why Yalom did that exchange of, “I’ll write my version and you write yours.” He talks about how there are some moments he thinks are pivotal successes, but then the clients debunk that.  

Thompson: What I have particularly enjoyed in the collaborative writing with you, Dan, is the energy I felt when reading something you had written. I would then have a rush of ideas and start making connections – with things we had talked about in the past, with things that were happening in my life, or questions I wanted to ask you or other clients. And then in writing a response, something would click in me about my own journey in finding myself. The writing constantly challenged my self-perceptions.

May 2023: I have been reading your chapter Unstable Sense of Self. So many emotions came up for me. And then the anger came. People don’t see. People think they know better. And because of this you have to endure the experience of the deep knowing that comes from a life’s work of amazing “you-ness” being minimised, whether it is by psychiatrists or dramaturgs. God, who doesn’t want a play that makes you laugh and scares you shitless at the same time?  

“Taking Charge” as Collaborators and as Client/Therapist (29 November, 2020)

Thompson: I’m interested in the idea that as a therapist, I might have personal motives, desires and preferences. When I was studying for my counselling qualification we were drilled with the maxims of “do no harm” and “the clients’ needs are paramount” and that there in fact can be no personal gain for therapists. It is easy to understand this in the context of, say, not allowing a client to arrange to get you the best table at the restaurant they happen to work at, or free tickets to a concert through their connections. So, what about our writing together? You are right about a long-held desire coming to fruition. Not that I haven’t already written, having had three other articles published and many letters to The Age newspaper! The fact that the experience of writing our article has been so positive for both of us equally has felt like a relief. I have been thinking about how it might be for you to feel like my desire to write creates an obligation for you to meet this need. So, it seems like the arrangement is that I can meet your needs, but if you meet mine, there is an ethical problem. And yet you say that to see my excitement and investment is gratifying for you, and you don’t resent it. Not yet anyway. I wonder what might happen to make you resent it?

Harris: I can’t imagine that. I feel that we entered into this mutually – in fact, I suggested it.

Thompson: Dan, I knew you wrote for a living, and I remember when your email came through, suggesting we co-author an article about the process of arriving at the diagnosis of Borderline personality disorder (or BPD). A light inside me flicked on. Can this be something clients and therapists do together? Something about our therapeutic relationship suggested that it could work. Those many hours of therapy-built trust, and this would allow for a story to be told – not just from one perspective (be that client or therapist), but from both. We did due diligence around ethics (spoke to the editor of the PACFA journal, my supervisor and even the CEO of PACFA). Green light given. The writing allowed for a stretching, bending, flexing, and reworking of traditional client/counsellor dynamics and enhanced the work in possibly unexpected ways.

Harris: We tried writing separately, as Yalom and his client “Ginny” do in his book Everyday Gets a Little Closer (1974/1991). But eventually we returned to co-authoring in a shared Google doc that has satisfying interactivity and vibrancy. The fluidity of being able to write into the same document, and comment on each other’s and our own writing as we go, seems to form a big part of the “energy” of this new kind of shared work. (3). It also calls to mind the important work done by Wyatt et al. (4), who have offered an overview and history of collaborative writing (CW) in general, one that might be helpful to readers who are wondering how collaborative writing might be distinct from collaborative autoethnography, for example, or from narrative therapy, as we’ve discussed elsewhere in this book.

Thompson: I often think that the client-therapist relationship resists a definition that truly lands, no matter how hard we might try. An intimate partnership that grows and deepens over time, though it does not find representation in photo albums, social media posts, or at family dinners. But this relationship can be in existence one day, and not the next. When the therapy ends, chances are the client and therapist will not ever meet again. All that sharing, all that caring comes to an end when the decision is made that the work has been completed. The relationship is very contextual though; I know that people want to experience their therapist in a different way, whether that be as a person who will ultimately tell them what to do, or as someone who will help them feel differently about themselves. As a person-centred therapist, I know I resist taking on the role of the “expert.” Clients are experts of their own lives and I am there to hold the torch in a good spot so they can see more clearly what’s up ahead and choose the path.

Harris: I’m interested in what “expert” means to you. I love your ethos, but I also want to challenge you on your unwillingness to hold a position of power or expertness in the room or in this relationship. For example, when I was a teacher, I tried to do the same thing, but the students resisted it. They WANTED a parent/expert/person in charge. We were taught that it makes them feel safe. Maybe this is the same for the client in your rooms. Inviting clients into agency and power and self-determination and collaboration is one thing, but eschewing power or control altogether may be a bit disingenuous? I’m interested in what kinds of feelings it gives you to be “in charge,” and how you relate to those feelings and where they come from.

30 November 2020

Thompson: I have to respond to some pressing client issues in the next few days, so may not get back to writing till Wednesday, but I wanted to respond to this comment, as it is wonderfully provoking. I did not say I was unwilling to hold a position of power in the room, just unwilling to label myself “the expert.” I am very aware of holding power and in fact, recognise it goes with the territory. We are trained to understand this, and I think it is only in recognising it that you can be mindful of not abusing it. There are times I will be directive with clients, and even strongly suggest what should happen next. I agree that so often clients want to sink into the feeling of being held and directed by someone more powerful than them. I have also had the experience of wanting that myself as a client, from my own therapist. I am very interested in the power dynamics between client and therapist and think there is much we can write about and explore here. I note that you feel rebellious when Yalom uses his power in a paternalistic way, and it makes me wonder if that has anything to do with him inhabiting the role of “expert” to the extent that it takes the client into an infantile space. I know he doesn’t want to do that, but maybe that also goes with the territory of being a white male of his time and circumstance.

So, for me, what I reject about the expert stance is creating a vibe that puts me in a position of being “all knowing” and bestowing the answers from a superior position, creating some idea of the client having a deficit that I will “fix.” I have training, experience and skill which allows me the authority to occupy this role and do the work. I love the question around what “being in charge” means to me. I have often thought I am more comfortable with a second in charge role. I know I have leadership skills, have often been told that, and have also been in a number of leadership positions over my career. But as the youngest of four siblings (by a long shot) and older parents, I could never have been the “expert,” or “in charge” in a million years!

Thompson: You said to me that as a result of our writing the article together, you felt you trusted me more. Initially, I think I assumed that the trusting me more was about the fact that the writing went smoothly, and that nothing went wrong. Then I wondered about what it might have been like for you to read about my experiences of you as a client and to see my care in the words I offered. Not only that I wanted so much for you to be happy and fulfilled in your life, but that I saw you as vital and full of life. But now I am wondering more about the process we engaged in to produce the article. There was a spark that was ignited as we poured what was in our minds and hearts into the document. You would write something and it would create a flash of an idea in me, and then a rush of energy in trying to capture it in words. I think the same might have happened for you. There was a synergy that I don’t know we could have predicted, but maybe it was not so surprising, given the successful therapeutic space that we have created. We have been exploring the issue of the power dynamic in the client-therapist relationship. It is a strange beast because it seems like it is both needed and rebelled against simultaneously. Sometimes as a client you want me to take the reins and show you the way, and at other times you are aware that as you bare your life to me, I keep mine under wraps. You step into a vulnerable space, and I have a boundary that keeps me safe. And I want to offer sup- port and guidance but reject labels like “expert” and get cozy with terms like “fellow travellers.” Did our writing together even the score? For in that space, I saw you as the authority and looked to you to have the answers on how the work would come together. I completely trusted that you would take us to where we needed to be with this piece. Did you know that I trusted you result in you trusting me even more? 

Harris: Trish, I’m feeling the resonances of this co-authoring work with you in other places in my life. At the time of this writing, I’m also co-writing a chapter with one of my doctoral students, and co- supervisor, Julia and Elise. The chapter uses autoethnography to explore how our relationship changed during lockdown. Julia, the student, is talking about how previously she was trapped in a perfectionist student persona that didn’t allow her to share her mental health challenges, but through COVID, widespread attention to each other’s mental health in general, and us as supervisors sharing our own mental health challenges (to a degree), she has been freed to be “imperfect” and more open, thereby allowing a richer supervisory relationship. Sound familiar? In a material way, we even saw into each other’s homes through our online video sessions. A snippet, reminiscent of our conversations here:

Importantly, this turn to the personal and emotional in the context of the pandemic and consequent reduced hierarchies does not undermine Dan and Elise’s roles as supervisors, including as intellectual guides, advisors, and supporters; on the contrary, it creates a culture of care that enables Julia to further develop as a researcher by generating an ecology of empathic collaboration which fosters curiosity, connection, understandings, confidence, risk-taking, and expressivity. I love the resonances of this work we are doing as it truly does echo out into the other parts of my life. 

What Happens Underneath “What Happens”?

Thompson and Harris: Yalom and many others teach some foundational tenets: that the therapeutic relationship is a microcosm of out- side life. That whatever occurs between them, the focus and benefit must always be on the client, not the therapist. Yet Yalom also says therapists should let clients affect them, challenge them, even change them. For him, therapists must honestly and rigorously examine what it is they are bringing to this. So here we ask ourselves from both the client and therapist perspectives: Can/should we go beyond the Yalom client-centred writing, and if so, for what purpose? These questions are informed by our enquiry into the potential risks and ethical considerations identified in our creative collaboration, a challenge we have continuously held at the forefront throughout our practice together and throughout this book. Our boundaries required constant negotiation and adjustment. The foundations of our current questions in this section are underpinned by our discussions of how those risks were processed, and resolved. For example, sometimes our writing in our shared documents veered toward the therapeutic. In one case, Dan wrote about a dream they had had about Trish, and once we started to discuss it, we both realised it felt like it had crossed a line into the “therapy” space. We acknowledged it and moved back into a more shared enquiry.

Always in relation to these questions, we wonder together about the mystery of the therapeutic encounter. What hap-pens, and what happens underneath “what happens”? Common factors theory (5) suggests that the most important influence on therapeutic change is the strength of the alliance between therapist and client. Looking beyond technique and intervention (the old-school referents of mechanistic schools of psychotherapy), we instead look at what happened in the room with the two of us, and what has changed during and after the process of our collaborative experience as client and therapist.

The Power of Dialogue

 Harris: Hey Trish, what do you call a homeless horse with borderline personality disorder?

Thompson: Unstable.

We both love to laugh, and humour was there in the room but burst out even more unrestrained once we were “on the page.” It opened up new areas of exploration and trust, and helped us both relax a little as well, while we explored this new relationship. We started co-writing online during the 2020 Melbourne lockdown, while maintaining fortnightly therapy sessions, as face-to-face sessions had been prohibited by home isolation, and the humour was there from the beginning.

Thompson: Yalom (2002) talks about the therapeutic relationship between client and counsellor as being one of “fellow travellers,” So when you share your life with me, in all of its realness, I want you to experience the humanity that connects us to one another. And so, over the years, we’ve built a strong alliance, one in which talking about disorders hasn’t really figured (6). Hey Dan! How many psychotherapists does it take to change a light bulb?

Harris: Probably just one, as long as they take responsibility for their own change. This could be called having “a light bulb moment.” (3).

“We wonder together: what if we were writing a novel instead, or painting a picture? We’re writing about our therapy, not something else, so it reinforces the therapeutic relationship. We reflect on the fact that Trish is also a teacher and practice supervisor, and in those roles she encourages her students to be prepared to walk the talk, to consider the ethics of asking clients to go further than they’ll go themselves. 

We use many of the suggestions Yalom offers for calling attention to the bond between client and therapist including: doing process checks, inquiring about the state of the encounter during the session, me asking if Dan has questions for me. Through creative collaboration, the trusting here and now becomes multi-modal and multi-directional in ways that can offer new forms of corrective emotional experience.

Collaboration Extends to Co-Presenting

Harris: In May 2021, we were invited to co-present on our collaborative creative work at an art therapists conference near Melbourne, on the beautiful Morning Peninsula. We were well-prepared, drawing on our three already-published articles together, and having rehearsed. We were excited for the day. But the night before, I had this dream:

Dan’s dream:

So, we show up at Inverloch but arrive late for some reason – just before our session.

We are getting ready, and I have to go to the bathroom, and we are both fussing around and Carla is getting impatient.

All the participants are sitting at their tables, waiting for our “performance” to begin.

I take out my script but it’s not the right one – a previous draft. I ask you if you have yours and basically, we just spend a lot of time fussing around and you tell me I can read off yours, and then you say I can use your computer, etc., but all these versions of the script are wrong. Things are getting tense. The audience is impatient.

Finally, I say to you to just follow me. I start improvising, narrating that I don’t have the right script and narrating what we are going through out loud. Then I start blaming you – your script isn’t right either. Why don’t you know your script isn’t right? What are we going to do? You start laughing. I say, “don’t laugh out of nervousness, we need to do our show for these people.” It’s funnier than it sounds here.

The audience is not sure what to think. Eventually we do a series of audible asides and morph into a full blown “fight,” where we move around the room and then up to a semi-private space still in view of the participants. By now, we are arguing about the performance, and you are telling me I’m projecting and that this is the problem with doing standup with your client! The audience start to wander away, into the dining room for their meal, and we realise we need to re-engage them by asking for their help. I woke up and realised that we could perform therapist-client and that it might be funny but also instructive in a “‘show-not-tell” kind of way. I also remembered that I had done this with a student teacher in one of my first university classes. We pulled a prank where I went into class first and started complaining loudly about the teacher not being there, being late and getting the students kind of riled up, and then when Nick arrived, we were all difficult to control. He did some expert redirecting, and when it was finally calm, I would go up to the front of the room and say I was the lecturer and they always loved it.   

Thompson: I remember you telling me about this dream on the drive to Inver- loch. I thought it was hilarious and it got me imagining what we could do after we do the collaborative writing gig. We should so do stand-up comedy! I mean, how great would that be, telling insider therapy jokes and making people laugh and cry? Did I tell you that on the drive? I can’t remember if I said it or just thought it. And we had a great experience presenting to this gathering of art therapists, who were familiar and comfortable with our methods but also affirmed the radicalness of the reciprocity of our approach.

Harris: It’s challenging and at times risky work. Work that’s asked us both in different ways to re-examine the power of letting go: letting go of what we thought we were good at, who we thought we were … but the rewards are a powerful experience that is changing our self-awareness as both client and therapist.

Thompson: We have used a number of other writers in our shared work, including the meditation master and psychologist Tara Brach, and one of her favourite poets, yoga practitioner Danna Faulds. We ended our workshop with the arts therapists with the following poem by Faulds, called LET IT GO:

Harris: “Let go of the ways you thought life would unfold,
the holding of plans or dreams or expectations, let it all go.
Save your strength
to swim with the tide.  

Thompson: The choice to fight what is here before you now will only result in struggle, fear, and desperate attempts to flee from the very energy you long for.

Harris: Let go.
Let it all go and flow with the grace that washes through your days whether you received it gently or with all your quills raised to defend against invaders. 

Thompson: Take this on faith:
the mind may never find the explanations that it seeks, but you will move forward nonetheless.  

Harris: Let go,
and the wave’s crest will carry you to unknown shores, beyond your wildest dreams or destinations.

Thompson: Let it all go and find the place of rest and peace

Harris: and certain transformation.

 *** 

This material is taken from Collaborative Writing and Psychotherapy: Flattening the Hierarchy Between Therapist and Client (2024), by Trish Thompson and Daniel X. Harris, published by, and with the consent of Routledge. Buy the book with a 20% discount using code CWP23 here (discount valid from 1st December to 31st January): https://www.routledge.com/Collaborative-Writing-and-Psychotherapy-Flattening-the-Hierarchy-Between/Thompson-Harris/p/bo

Deploying Therapeutic Airbags to Enhance Clinical Outcome

Posted on by Psychotherapy.net Team

“Angels can fly because they take themselves lightly.” -C.K. Chesterton

Jessica

Jessica (an amalgam) was 30 years old when she came to our clinical team. Her health was complicated and so I attended a consultation to discuss the details. This meant another meeting sitting around a round blonde table that looked like it was donated by a local elementary school. If you’ve ever worked in an institution, you know the table I’m talking about. I was told that Jessica had a brain tumor that would periodically swell with blood, and it was hypothesized that this tumor was the reason she would become aggressive. The theory was that when the tumor would expand, it placed pressure on the parts of her brain that stimulated survival reactions, and this is what led to her violent outbursts. This caught my attention. I was astounded, really. These were the early years in my practice, and this case formulation was bringing all the pieces together. It made sense of what I learned in graduate school about the fight-or-flight response, and it demonstrated the mistake of thinking that aggressive behavior was simply a result of poor character. It opened the door for compassion, and it humanized Jessica. I left the meeting with a bit of a brain buzz. It’s that feeling you get when you come across a new idea that you can chew on for a couple of days. It’s like a runner’s high, but for therapists.

Eager to meet Jessica, I walked down the hallway enjoying my high. I eventually found the right room, stepped in, and we made small talk for a bit. The discussion was off to a smooth start, and with my compelling conceptualization in hand, I decided to jump in.

“If you’re comfortable, tell me about the brain tumor. I’ve heard it plays a role in the aggressive times.”

With the appearance of deep reflection, Jessica looked down, paused, and then looked back at me. Then she gave me something to think about.

“I’m 30 years old, and somehow, I’ve got a brain tumor. Has it occurred to you over-educated and stubbornly inept shrinks that this is the reason that I’m angry?”

I felt the capillaries in my cheeks begin to swell, and I knew my skin was glowing red. It seemed there was nothing left to do, and so I just sat there, draped in embarrassment’s ridiculous costume.

Clinical Creeds

When we’re in graduate school, we learn about the maxim, “First, do no harm.” The adage comes from the ancient Greek physician Hippocrates, but we talk about what this motto might mean for a therapist. No dual relationships. No receiving large gifts. Keep your clothes on.

We learn that therapy can be dangerous in its most negligent manifestations. What makes it powerful is also what makes it dangerous. Therapy is like a flame; it can warm you or it can burn you.

While the cardinal sins seem easy enough to avoid, once we move deeper into our work, we discover how difficult it really is to do no harm. No harm? Really? Zero? Well, what about the time I was caught checking the clock only five minutes after I started the session? Or the time I made theatrical eye contact and then confidently called my client the wrong name? Masterstroke! And what about the time I immediately damaged my rapport with Jessica because it was more important that I be entertained by an interesting idea than to discover who she really was? Some amount of harm was done in each of those instances, and for the record, I’ve made much bigger mistakes.

I understand the intent behind the axiom, but I think, “First, do no harm,” is a puritanical expression. I don’t like that third word. No mistakes allowed. Be perfect. You’re only one fumble away from doing serious damage. That’s a lot of pressure, and so I’m going to try to convince you to gently set this motto aside.

Like many creeds, “do no harm” is a noble abstraction, and when we try to pull abstractions down from the ethereal world of ideas and place them into the corporeal world in which we live, we discover their limitations. We find out that what makes sense in our head doesn’t always translate into our hands. It’s like when an inspirational speaker tells you to “Carpe Diem” or “Do what you love, and the money will come.” These diet Deepak Chopra-isms seem to know more about lofty slogans than implementable methods; more about the sky than the soil.

Why does this matter? It matters because something happens when our eventual mistakes collide with this puritanical mandate to do no harm. It creates fear, and it’s a fear that lives in the heart of every therapist I’ve ever met.

Mistakes are Mentors

Fear runs deep in the heart of this profession. We fear being sued, we fear being interrogated by the regulatory board like we’re testifying before congress, and ultimately, we fear losing our careers.

But maybe this climate of fear shouldn’t surprise us. While in school, we watch video clips of awe-inspiring clinical moments. We read transcriptions of perfectly executed interventions. How many of these moments are helped along by editors? We can’t be sure. My hunch is these videos clips are often highlight reels, and the perfect dialogue transcriptions are like glossy grocery store magazines — air brushed to remove blemishes. It’s tabloid therapy.

Tabloid therapy is any presentation of the therapeutic process that’s absent of imperfection, and unfortunately, it saturates the university and post graduate training environments. But where are the blooper reels, the blunders, the awkward moments, and the misunderstandings? Where is the throat clearing, the sneezing, the spilled coffee on the shirt? I never saw myself in any of those videos or books. The unpolished learning process wasn’t role modeled, and because we’re only introduced to perfect therapy, it makes sense why we treat our blemishes like pathologies.

Problems begin to emerge when we’re too afraid of our mistakes, because this makes it difficult to learn from the valuable information held within them. When making mistakes becomes forbidden, our mistakes create fear, and then the adjustment signals are more difficult to discern. But when we relate to mistakes effectively, they signal to us where to adjust. They mentor us. This means that to grow as a therapist, the great majority of our mistakes must be taken lightly. We must sit safely with our mentors and listen for their guidance.

While I wish that all harm could be entirely avoided, I don’t see a way around it. This isn’t an invitation into clinical recklessness, but the reality is that some of our clients will experience our growing pains, while others will benefit from what we’ve learned. So go ahead, stumble over your words, double-book an appointment, botch a reflection, catch yourself zoning out, violate HIPAA, and commit insurance fraud. Okay, don’t do the last two things, but because “do no harm” interferes with the learning process, we should sweep it into the dustpan with the other noble abstractions. Carpe Diem could use the company.

First, Reduce Harm

Instead of developing an adversarial relationship with our mistakes, what if we thought about learning therapy in the same way we think about learning to drive? I didn’t want to make mistakes when I first got in a car, but despite wanting to drive perfectly, it wasn’t meant to be. The speeding tickets and fender benders were part of the learning process.

As I learned to drive, the car had safety features to reduce the risks. I did my best to drive safely, but just in case, I could rely on the airbags. What if we approached therapy this way? We don’t want to make mistakes when we’re practicing therapy, but mistakes will invariably occur. Therapy carries inherent risk, and eventually we’ll get into accidents, but what if we built strategies into therapy for damage-reduction? “First, do no harm” is unrealistic, but “First, reduce harm” might work. We could create therapeutic airbags.

The types of mistakes that can occur within therapy are limitless, and so it’s natural to wonder where we should begin with trying to reduce the risk of harm. Which mistakes should we build these airbags around? Let’s start by exploring where the accidents are the most dangerous.

Over many decades, a slow consensus began to emerge about why therapy works. Instead of believing that the correct therapeutic method was necessary for the client’s improvement, researchers noticed that there were common factors across different types of therapies that ultimately made the difference.

There were many people involved in this emerging consensus, but it was Michael Lambert who suggested that the single variable that influenced client improvement more than any other had little to do with the therapist. Instead, the client improved because of their personal qualities and environmental resources. When the client improved, about 55% of the reason had nothing to do with the therapist (1).

Up until this point, therapists were taking credit for improvements they had no part in influencing. As the saying goes, we were roosters taking credit for the sunrise. This didn’t mean that therapy wasn’t effective, but it did mean that the single most influential part of what made a person feel better was not within the therapist’s control. In hindsight, it was hubris to think we could take most of the credit for a client’s improvement.

The area where the therapist had the most influence was the quality of the therapeutic relationship. Lambert concluded that the relationship between the therapist and the client accounted for 30% of why the client improved. It mattered if empathy and warmth were characteristic of the relationship. It mattered if there was a sense of personal closeness. So, there it is. If the relationship with the client is where we can make the biggest difference, then damage to the relationship with the client is where our accidents are the most dangerous. This is where we should install the therapeutic airbags.

What does damage to the therapeutic relationship really mean? It seems to depend on who you ask. If you talk with a client-centered therapist, they’ll warn you about directing the client too much. They’ll remind you about the problems with giving advice. Directive therapy can create an aura of expertise that makes it harder for our clients to disagree with us. If it’s difficult for the client to disagree with us, they will express agreement even when they privately disagree. Then the client can’t be themselves, even with their therapist. Giving advice can lead to client hiddenness. That’s one way we can do damage to the relationship.

If you talk to a therapist that’s directive in their style, they’ll tell you about how nondirective therapy becomes aimless, and for that reason, frustrating for the client. They’ll tell you about how cognitive behavioral therapy, dialectical behavioral therapy, and acceptance and commitment therapy are each directive treatments protocols, and they work just fine. They’ll tell you about how expecting people to come up with their own answers is a form of withholding help. Clients will think you’re too removed, they’ll say. That’s another way to damage the relationship. I think they both have a point.

I once had a well-meaning directive therapist say to me, “You know when you have to tell your client that it’s time to leave their marriage?”

Nope, I really don’t. Point for non-directive therapy.

I’ve also heard something like this said multiple times, “My problem with therapy is that eventually, I need someone to tell me what they think. Some therapists just want to listen. I start to wonder if they don’t know what to do with me.”

I get that, too. Point for directive therapy.

Both directive and non-directive therapies have important critiques about each other. They’re a divorced couple that has a refined sense of the other’s shortcomings. Fortunately, the truth is that our choice is not between directive or non-directive therapy. We don’t have to pick a parent. Instead, there’s a long green field between these two positions, and how much we engage with the client should be a matter of degree. When we decide to engage with our clients more directly, we can incorporate strategies that address the concerns of the non-directive therapists, but we can proceed with our work, nonetheless.

Using Therapeutic Airbags

If we decide that we’re going to be directive to some degree with a client, then we should use a strategy that helps reduce the risk of potential harm to the therapeutic relationship. As Lambert demonstrated, the relationship that we have with our client is the single greatest factor where we have influence, and so it’s where we should be the most careful. This is where we should use the therapeutic airbags. The nondirective therapists are correct that our clients might be uncomfortable disagreeing with us, and so the purpose of a therapeutic airbag is to incentivize client disagreement. This way we can be confident that our clients aren’t overtly agreeing with us even when they privately don’t. We can work to prevent hiding, and here’s how we can do it.

Step 1: “This simply crossed my mind…”

Before we’re directive to any degree, it’s important to signal to the client how seriously we’re taking our own thoughts. If we present our impressions as authoritative theories, then the client will feel more pressure to agree with us. For many clients, it will be difficult to disagree with the theory of a professional. But if we use the opening, “This simply crossed my mind,” then we can signal something quite different. This phrase seems uninteresting on its face, but when we look closer, the words “simply” and “crossed” are doing some heavy lifting.

The word “simply” suggests that we aren’t taking ourselves too seriously. It diminishes the authority of what we think. It’s casual. There’s no grand theory about the client’s life that’s about to be introduced, because the thought just simply came to mind.

The word “crossed” also communicates our own lack of commitment to what we’re about to share. The thought passed through our mind. It came, and it went. We haven’t spent excessive amounts of time thinking about what we’re about to say. We’re signaling that we’re not personally committed to the ideas that they’re about to hear. We’re keeping things relaxed.

Step 2: “…and so tell me if this doesn’t fit.”

This is an invitation for disagreement, but it’s also more than that. Notice what word isn’t being said. We aren’t saying, “…and so tell me if this is wrong.” If we were to use the word “wrong” it would make the disagreement overt. This would make it harder for the client to disagree with us. For some people it will be hard to explicitly say to a therapist, “No, that’s wrong.”

Instead, we can use language that invites more subtle disagreement. “Tell me if this doesn’t fit,” sounds more like we’re in the changing room of a department store. Yes, there would be ethical issues with that, but you know what I mean.

Step 3: “but I found myself wondering.”

This is where we share our impressions about the client or their situation. It’s where we’re the most directive. In this step we aren’t conveying conviction, but it’s opposite — we communicate wonder.

Wonder is an essential quality in a therapist. Wonder is the combination of imagination, openness, and awe. It helps us to travel into the experience of another, and for this reason, wonder is a relative of empathy. Expressing wonder might sound like this:

“This simply crossed my mind, and so tell me if this doesn’t fit, but I found myself wondering…”

Notice the difference between, “I found myself,” and “I find myself.” The first one is past tense and the second one is present tense. When we say, “I found myself” then we are sharing a memory. When we say, “I find myself,” then we’re talking about right now. The present tense creates immediacy, and immediacy can create intensity in the conversation. There’s a place for immediacy in therapy, but this isn’t one of them. Instead, if we express what we found ourselves wondering about in a previous moment, then we can continue to keep the pressure on the client low.

Step 4: “But tell me where this misses the mark.”

This is the closing phrase. It’s useful because, “tell me where” assumes that we made a mistake. If we were to finish the skill with, “Did I miss the mark?” then for many agreeable clients, this would elicit a reassurance reaction, “No, you got it right.”

Instead, the client must correct us if they want to express agreement. Here’s how this might look:

Therapist: “But tell me where this misses that mark.”

Client: “Well, I’m not sure it does miss the mark.”

If the client wants to agree with us, then they must be disagreeable. They must jump a hurdle to correct our assumption that we made a mistake. When we set things up this way, we can have more confidence that the client is being sincere in their agreement because we’ve made the agreement harder. We’ve also made disagreement easier, because conveying the assumption that we’ve made a mistake makes it easier for the client to follow our lead.

Here’s a fictional example of the skill in its entirety. This is how things often transpire when we successfully get our client to correct us:

Therapist: “This simply crossed my mind (step 1), and so tell me if it doesn’t fit (step 2), but I found myself wondering (step 3) if part of the difficulty is that you’ve thought that setting boundaries is selfish. Setting boundaries seems to chafe against your values. But tell me where this misses the mark (step 4).”

Client: “Well, I don’t really believe that having boundaries is selfish, so I’m not sure.”

Therapist: “Okay, I gotcha. You don’t take issue with boundaries. Can you help me understand what I’m missing?”

Client: “Well, I think it’s okay to have boundaries, but I just don’t do it for some reason.”

Therapist: “I think I’m getting it now. You don’t have anything against having boundaries, but putting them into action doesn’t happen, and you’re not sure why. Tell where this missed the mark.”

In the last exchange, the therapist can return to the assumption that a mistake was made by repeating step 4 (“tell me where this missed the mark”). This way the therapist can gain confirmation from the client, or elicit a second correction.

***

This strategy is built to constantly elicit feedback from the client. It’s a feedback machine. If we use the strategy effectively, then we’ll be corrected more often. When I first started using therapeutic airbags, I thought I was getting worse at my job. The truth is that I was previously unaware of how many mistakes I was making, and this strategy was bringing my mistakes forward.

Let’s learn to view our mistakes differently. Rather than be afraid of them, we should actively work to hear about them, and then we can protect our relationship with each client. Mistakes don’t have to be blemishes, and they don’t have to be threatening. A client who talks about our mistakes is a client who feels safe enough to share them. This is not a sign of damage to the therapeutic rapport, but a sign of investment in the relationship — the client has decided not to hide. When we use these therapeutic airbags, our mistakes will come forward, and when they do, so will our clients.

Editor’s Note: This is the first in a series of five articles by David Prucha. While initially intended for beginning therapist based on his own clinical evolution, you will see that there is certainly something in each of these essays for clinicians at all levels. In the next installment of this five-part series, the author will address the challenges and benefits of working effectively with client dependence.

Reference (1) Lambert, M.J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J.C. Norcross & M.R. Goldfried (eds.), Handbook of psychotherapy integration (pp.94-129). Basic Books.

My Romance with Narrative Letters: Counter-Storying Through Letter Writing

Posted on by Psychotherapy.net Team

How My Romance with Narrative Letters Began

From the second time I met with David Epston for supervision in December of 2003, learning to craft narrative letters became almost as important to me for learning to devise counter-stories as studying the verbatim transcriptions of my therapy conversations, which David had amended with his own questions. When I arrived at the door of David’s practice in Auckland on that December afternoon, he met me with these words:

“Kay, as chance would have it, Wally has just been meeting with me, and I wondered whether you would mind if he joined us for our supervision session today.”  

Before I had had time to find out who on earth Wally was or why David might consider it a good idea for him to join us, “Yes of course,” popped out of my mouth. Despite my consent, I wasn’t at all sure about the idea, especially as this was the first transcript of one of the therapy sessions I had brought to my supervision with David. I was more than a little nervous and already the paper I clutched in my hand was somewhat damp with perspiration.

As if it were not enough to be presenting my first transcript, my anxiety was heightened because I had “failed” my first supervision session a month earlier. I had made the grave assumption that our inaugural meeting would be given over to an introductory chat, preparing a supervision contract which we would sign, after which away I would run until we met for supervision properly. Surely this is how my experience told me supervision was always done? I should have known that just as David’s approach to therapy is uniquely his, so too would be his approach to supervision. At that fateful first session, when David realized that I had arrived empty-handed, he almost threw me out on my ear, but thankfully relented, settling for a firm reprimand and gifting me two more sessions in which to prove myself as a worthy supervisee. This second session had to go well, so the surprise presence of Wally was something of a curveball.

The warmth of David’s greeting slightly thawed the edges of my anxiety, and when Wally rose to greet me with his broad smile, generous handshake, and cozy, bear-like presence, I was somewhat soothed. Wally turned out to be Wally McKenzie, a veteran narrative therapist, famous for his practice in Hamilton, and for his narrative teaching on the Waikato University Masters Programme in Narrative Therapy.

“Hey, Kay,” David said as he caught sight of the pages of transcript in my slightly sweaty palms. “I can see you have brought a transcript!” David, overcome with what I soon came to know as his irrepressible and indefatigable excitement, slapped me on the back and before I knew it, he was reading the transcript aloud whilst Wally, chin in hand, listened with the ears of a seasoned therapist.

The transcript was of the second session with Wiremu and Mere, M?ori couple whose fourteen-year-old son, Edward, had found himself on the “wrong side of the tracks,” and had taken to joyriding with his mates. Rather than see his son risking the wilds of the “West Auckland hood” on his own, Wiremu had begun to join his son in his drinking and driving escapades, much to the distress of his wife.

When David had finished reading, a fevered discussion followed. Alternative questions zoomed around like silver balls on a table — first one from David, then one from Wally, rapidly followed by another from David and so it went on. Feeling that I was on something of a joyride myself, I held onto my seat and observed the narrative spectacle unfolding before me. With his usual aplomb, David then announced that he thought a letter was in order. “A letter,” I thought “What does he mean?” I soon found out. I left that day holding in my hand the gift of a two-page letter, feverishly crafted by David and Wally for this beleaguered couple and for their son, Edward.

The letter spoke of how the couple had stuck together through hard times. It acknowledged the injustices and struggles that their son had experienced, and spoke of how, despite his understandable anger, his attributes shine through in his care of his siblings and in other ways. The letter went on to invite Edward to join his parents in their commitment to put the hard times, together with mistakes they had all made, behind them. It spoke to his parents’ conviction that life could get better for them all and that they all deserved a break. It ended with an invitation to “stick together as a family,” and for their son to join them at the next session. Edward did not come with them when we next met. I began our session by reading the letter out loud to Mere and Wiremu.

Here is the beginning of my email to David written straight after my next session with Wiremu and Mere:

“When I read the letter to Wiremu and Mere, it was emotional for them both. Mere cried quietly. Wiremu began to talk about wanting his place back in the family and declared to Mere that he was no longer going to try to be a ‘mate’ to his son and instead would learn to be a father.”

And so that was how my relationship with narrative letters began, even if it might have been better described as an arranged marriage.  

Narrative letters have come to serve as extensions of sessions in my practice. Initially, they became the way in which I made up for what I judged to be mistakes in my conversations with people, or when I deemed that there was something missing from a conversation. As David once said to me with humility, “Kay, whenever I have messed up, I have always known that I could write a letter by way of apology.” While I am not immune from the need to write letters for such a reason, and I doubt if I ever will be, nowadays the purpose of my letters is almost entirely to add momentum to counter-storying. Sometimes they serve as counter-story “bombs” designed to explode the “Problem Story” between sessions.

Over the years, I have learnt how to write various types of narrative letters to serve different purposes. There are letters which act as a reminder of ideas discussed in a session; there are letters which serve to “keep the problem at bay;” letters which help to forge understandings and solidarity between the person, family members and friends; letters which recruit communities into a person’s life; letters which are written with a person to send to “a community of concern;” letters to respond to emergencies including life-saving letters; letters that I write with someone to another person or persons in their life to bring about changes in a relationship, and more. The letters that David has schooled me to write over many years have included all these intentions at times. However, despite the form of the letter, their purpose is always to give traction to an emerging counter-story. 

How My Romance with Narrative Letters Evolved

For many years (roughly between 2004-2010), I would submit draft letters to David’s “narrative eye” as regularly as I would submit transcripts. Letter writing became my way of wrestling with intransigent problems in the hopes that doing so would aid me and the people with whom I worked to find quicker and more clever ways to evade the Problem. Along with “mind maps” of possible questions, they were also my “drawing board” for my practice.

For some time, my letters would be impossibly long. I would go through reams of notes to find ideas and the germs of counter-stories themes that I wished to include. Mind-mapping of conversations would give me a picture of the story so far. The maps would lay out the different threads of possible counter-stories before me and make visible possible lines of enquiry to form the backbone of the letter. Sometimes lengthy letters were invaluable with complex problems such as anorexia/bulimia and attempted suicide, as they pulled together vital counter-story threads from sessions and juxtaposed the problem’s story and the emerging counter-story, laying each of them bare for all to see. Over the years my letters have tended to become a great deal shorter as experience has enabled me to glimpse the counter-story more keenly and resolutely. 

How I Compose Narrative Letters Today

Whenever possible, I write the letters immediately after a session. Letters written straight away have more effect because the conversation is still fresh in our minds (mine and my client’s) and in a manner of speaking, the Problem has less opportunity to displace the Counter-story. I put a limit on the time I will spend. Otherwise, I can become intoxicated with the emerging counter-story and a fifteen-minute letter can turn into a three-hour blockbuster. Rather than beginning by reading through my notes, I draft the key ideas of the letter in mind map form or by writing them down. I tend to find this easier to do on paper. Once I have a skeleton plan, I read through my notes from my sessions and circle or highlight key phrases. I then type my client’s words into the plan for the letter. As David has suggested, I aim for 40% of the letter to be in a client’s words, although sometimes this is too difficult or doesn’t ideally serve the purposes of the letter. The client’s words become the structure for the letter, arranged in a form that best “tells” the Counter-story. I then ruthlessly edit out whatever does not “move the action of the story forwards.” I then re-read and edit as I go.

Examples of Three Narrative Letters

I thought I would end with some examples of very different letters from my recent practice. The letters speak for themselves. In each letter you will see counter-stories unfolding.

This first letter is to “Leni,” a twelve-year-old girl who was referred to me through the Youth Health Hub, the community wing of the Child and Adolescent Mental Health Services here in Auckland. The letter was written after the second session. This is what her parents wrote on the referral form:

“As a family, we are struggling with Leni’s anxiety issues which have worsened since starting Intermediate School. It is getting increasingly difficult to get her to school as she worries about having to go to the toilet during class time, etc. We have talked to the school, and they are trying to work around the anxiety, but Leni gets extremely anxious when her school days involve any activities outside of her normal class (sport, drama, etc.). Normally, Leni becomes emotional during these mornings and refuses to go to school. We have managed to keep her attendance quite high, but we are usually emotionally drained each morning.

The anxiety over needing to go to the toilet so often is now affecting her out-of-school activities, and she is now refusing to go to her dance classes in case she needs to go to the toilet whilst she is at the class.   

Leni has always been an anxious girl, worrying about issues she has no control over. We are looking for strategies to help manage her anxiety. The whole family is struggling because of Leni’s emotional outbursts which seem to be increasing. We feel we need to help her before her next transition to high school.”

Dear Leni

“Dear Leni,

I looked at the date before I started writing to you and realized you had been 12 for a whole week! Do you think that you are noticing being 12 at all? Even though some people might only think of 12 as just being the number after 11, are you noticing that you are a little wiser and more mature than you were this time last year? If you are, are you noticing that you are more worry-wise this year than last? If you agree that you are becoming more worry-wise, do you think it is most unlikely that as you continue to mature and grow in your wisdom that the worries will ever worry you as much as they did when you were 11 or 10, or 9 or 8?

Anyway, I said I would write to you because I thought it would be good to collect up on paper all I have learnt from you about how you have been distracting and calming down the tiger worries. Leni, would you mind letting me know when we next meet if I have got anything wrong in my letter? Can I rely on you to let me know?

I am thinking that perhaps you haven’t realized how much worry-wisdom you have now. Do you think there might be some truth in that? I ask this because when we first met, I was expecting to find that the worries had really got the better of you. Instead, I discovered that you had been using your ability to ‘pick up on stuff,’ that your Mum told me about, and had already worked out that the best way of calming the worries down was to distract them. You told me about how you worked out that distraction was your best anti-worry tactic on your own and that compared to before, you were doing ‘quite good.’

Between you and me, I had to wonder whether I would be needed at all, and I got worried I might be out of a job. I thought to myself that if you just kept distracting the worries, there was a good chance that your strategy would pay off completely. I decided to hang on in there though just in case. I’ve noticed that worries can get pretty tricky so hoped I might still be of help in a backup kind of a way. After the first time we met, you told me that you had shrunk the worries down to about twenty centimetres from thirty centimetres and then the next time you shrunk them down to ten centimetres. I have to say that this made me think even more that you had become worry-wise and it might just be a matter of time before you got the better of them completely.

That first day we met, you also told me that you had worked out that talking about the worries made them stronger, and so you had stopped telling your Mum about them.

Keeping quiet about the worries had worked so well that your Mum even wondered if they had gone! You also told me about another anti-worry tactic you had devised — you had decided to go to a different toilet at school. I didn’t ask you why you did this and now I am wondering if you decided that this would confuse the worries because they were used to you going to another toilet? Is this why you decided to do this or was there another reason?

That first day we also talked about the worries as being ‘tiger worries’ because I got to wondering about whether the worries that have been bothering you come from the same place that lots of other people have told me that the worries that bother them come from. And truth be told, the worries that bother me come from. Do you think its possible, as we talked about, that they come from that old cave girl part of you which kind of got left behind and had not grown up over the centuries like most of the other parts of us have? People say this old, cave girl, cave boy, or cave man or cave woman part is a part we needed centuries ago in case there were dangers around like tigers because it helped us to run away from them or to fight them.

Some people also say that although the tiger worries are trying to protect us, they cause trouble and instead are ‘killjoys’ because there are no real tigers. So, there is nothing to get you to run from or fight and they end up running around in circles in people’s heads instead. Do you think that the tiger worries that have bothered you are like this? Do you think they might have been frozen in time and don’t realize that there are no tigers in Te Atatu (western suburb in Auckland)? Considering you are a very caring person, I am wondering if rather than being scared of the worries as much as you were, you have started to feel a bit sorry for them because they don’t know there are no tigers in Te Atatu and don’t know what to do except run around and around?  

Do you know the phrase ‘why re-invent the wheel?’ Well, I thought to myself ‘why re-invent the wheel’ because you had already found out that distracting the tiger worries worked. Do you remember how we thought that you might have a go at distracting the worries with fun and how last time we met you told me how you and your Mum had been spending time being silly and entertaining each other (and perhaps the tiger worries too) whilst you were waiting to go to school?

Do you remember that we talked about your dog Henry when he first came to live with you, and how he was scared and cried in the kitchen the first night? Do you remember your Mum telling me about how your brother had to sleep with him to stop him crying because maybe he thought he was all alone? Do you also remember how we talked about how your whole family went with Henry to dog training to teach him how to be calm and to behave?

When we talked about Henry, I got to thinking about how it might be a bit the same for the tiger worries. You agreed that maybe they needed training, so they understood that there are no tigers in Te Atatu. We then had a bit of a problem though because the problem with these tiger worries is that you can’t see them, so how do you go about training them and calming them? We thought about you getting a little furry tiger keyring to put on your school bag to remind you to calm and train the tiger worries. We agreed that maybe you could stroke the little furry tiger on your bag when you sensed that the tiger worries might be about to come along so that you could calm them down. Do you think that this is maybe where your caring nature comes in so handy?

I am so looking forward to finding out how you have been getting on with this new anti-tiger worry tactic.

Yours in anti-tiger-worrydom,
Kay

P.S. Did I spell Henry’s name right? I don’t want to offend him or you, so please would you let me know? Thanks.” 

After the letter, Leni continued to grow her anti-worry wisdom. We had two more sessions. She is now happily settled at high school. 

Dear Jasmin

The next letter was written to “Jasmin,” a 20-year-old Egyptian, Muslim, young woman after our third session. She had also been referred by the Youth Health Hub. This is what she had written on her referral form.

“I am a 20-year-old girl who is dealing with homophobic parents. They have disowned me, and I have been living all over the country for the last year. My mood is so low that I have been in hospital four times this year and the police have been involved in helping me as well. I’m currently unsure if I should accept my parent’s support and ‘be straight,’ or live with my girlfriend… and be sad? I don’t know.”

“Dear Jasmin,

Here is your letter! We agreed I would write to you about some of what we have talked about in the hope that this gathering up of the very different strands of our conversation might help you to see them more clearly, and to support you in your attempts to ‘anchor myself inside of the two worlds I am struggling to live in.’

I have been sitting here today, reading through the notes from all our conversations, pondering the ideas, thoughts, and feelings that we have talked about and wondering what to include and what to leave out for now. Would you please let me know if you think I have not made mention of something that is important to you or if I have got anything wrong?

Jasmin, when I think of you, I think of that first day we met and how we likened your being shunned and cast out by your beloved family to being a refugee. Jasmin, would you say that for as long as you can remember you have tried to live with a foot in New Zealand and a foot in the miniature Egypt of your family home?

When you were cast out because you were in a relationship with Anna, do you ever suspect that although this casting out was more dramatic that you could ever have anticipated, that sooner or later the tensions between being ‘a Kiwi’(colloquial term for a New Zealander) and being Egyptian, would have caused a rift between you and your family as you attempted to navigate the territories of both worlds at the same time? Has your love of Anna and your parent's refusal to ‘accept me being with a woman’ intensified and perhaps hastened the tensions that might well have burst through, and perhaps forced you and your parents apart at some point or another?

As you wrestled with the heartbreak and feeling ‘so very lost,’ you also wrestled with seemingly impossible dilemmas: ‘My parents say come home, but what is home? Is it worth choosing my family over my partner or my partner over my family? If they love me, why do they not accept me?’ We talked about how perhaps your parents’ love for you and Anna’s love for you are not loves that can be compared; how your parents’ love for you is not less than Anna’s love for you and Anna’s love for you is not less than theirs.  

We discussed how every culture has blind spots which render some other ways of living so alien that they either are not seen at all or are seen very differently from the inside than from the outside. Jasmin, do you think that same-sex love is so unfamiliar to your parents as an expression of love that, in fact, it does not appear to be love to them? Do you think that perhaps your love for Anna appears only to be a threat to the life that they believe will bring you happiness? If this is true, then is their casting out of you a misguided attempt to force you to choose the only way of life that they believe will bring you and your family happiness? Is it, in fact, a very awkward and confused expression of love?

Even though these are probably not dilemmas that can be resolved, we talked at our second meeting about ‘can I find a way of living in both worlds that is not a lie?’ Do you think it is possible, Jasmin, that this question may have come to seem unanswerable to you because you have been very understandably assured that there is a true way of living? If your love for your parents and their love for you is true, and your love for Anna and her love for you is true, then could looking through the lens of a ‘one truth’ be unhelpful? Would you be interested in playing with the idea of many truths? If so, then do you think it is possible that what is said or done in one world may possibly not belie what is said or done in another world even if they seem opposed at face value? 

Jasmin, what do you think of extricating yourself from ideas of ‘truth’ and asking instead different questions? For instance, what if you were to ask yourself: ‘If my family’s love for me and my love for them is true, then is it a lie to express my love to them in a way that makes sense within that world?’ ‘In their world, can I speak my love for them “in Egyptian ways” without pretending to love in the same ways as they do?’ ‘If my love for Anna and her love for me is true, then when walking in Anna’s world, can I “speak love” as a modern, gay, Kiwi?’

Although speaking more than one language of love could be nigh impossible if these worlds collide, do you wonder whether sometime in the future, it may be possible to traverse these two worlds even if it remains hazardous and delicate? If this means agreeing to the pact that your parent’s proposed: ‘To never speak of this again,’ do you think that they and you could find some kind of unspoken understanding that, just as you will not speak of your love for women, that they will not push you towards heterosexual love? Jasmin, would you forgive me if these ideas seem impossible to you? Do they seem impossible, or do you think that there may be some virtue in considering them?

Warm regards,

Kay”

I met with Jasmin for three more sessions. She went back to work full-time, and she began to find ways to navigate ways of seeing her parents and her sister whilst remaining with her partner. Previously, her parents had refused to see her, and they had no contact for a year. When I called her recently to talk to her about publishing her letter, she was going through a tricky time after a whole year of doing very well. She is seeing a counsellor at her university. 

Recent Developments

A recent development in my letter-writing has been my “four-letter-series" for young people, an idea invented from necessity when the mental health agency, which refers to me most of the young people with whom I work, recently had their funding reduced and consequently the entitlement of sessions was reduced from a possible five to eight to a maximum of four. As a way of reconciling this, I decided to shorten the sessions to 45 minutes and spend the fifteen minutes remaining crafting short counter-story letters.   

Dear Lucy

Here is an example of a letter quartet which shows the development of the counter-story between sessions. The letters are to “Lucy,” a 14-year-old young woman. Here is what Lucy’s General Practitioner wrote on her referral from:

“Lucy presents with low mood and social anxiety worsening over the last few months. She would really benefit from some counselling.”

Again, I will let the letters speak for themselves and tell you the story of our four sessions. The letters are each written one week apart: 

Letter after Session One

"Dear Lucy,

It was a real pleasure to meet you today! Here is the letter I promised. If there is anything that you think I have misunderstood or that I have missed out, would you please let me know when we meet? Would you also mind letting me know if there is anything in this letter which particularly interests you?

Lucy, we mostly talked about ‘the glass wall’ that seems to have appeared, separating you from others and the dreadful loneliness of life behind the wall. You told me how much you would like to be able to reach through the wall, and even that you might consider ‘letting people in more.’ As we talked, it was no surprise to me to find out that you have had your trust most hurtfully broken in the past, not only by other young people but by a teacher, an adult in authority, who should have known better. I suggested to you that just maybe the reason the wall suddenly appeared in high school might have been because your body remembered how badly and shockingly hurt you were in 5th form and leapt in to protect you with the wall. If this is indeed what has happened, then do you think that your body overdid it? In its attempts to protect you, has it left you out in the cold, and you have become a little rusty in the friendship-making department? Do you think that we might be able to teach your body that, slowly but surely it can allow you to risk getting a bit closer to people again?

At the same time as you have the gift of being able to enjoy your own company, do you think that you could give yourself permission to retreat into your own world whenever you need and want to?  

As you taught me more about your experiences, it became apparent that you have learnt a great deal from these past hurts. You have learnt to speak out and to stand up to authority. Would you say that the suffering has not all been in vain because by un-suffering yourself, you have learnt to look after yourself better?

Lucy, next time we meet, how about we start to talk about what it is that you would look for in a friend and then we can start ‘testing’ people around you (even if they are only people who would be lesser friends or acquaintances), to slowly find out if they are worthy of your time, attention, and friendship?

Warm regards,

Kay”    

Letter after Session Two

“Hi Lucy,

Good to see you today. So, here is a little account of what we spoke about today and some questions that we might both like to think about.

We began our chat today by reading the letter that I wrote to you after our first session. You looked very thoughtful as you told me that you agreed that the ‘wall had come up when I went to high school because I was going through puberty, and it made me more self-conscious.’

Lucy, if self-consciousness has grown with puberty, do you think it might also be possible that you might be able to shrink it back down again as you mature more?

Do you think that the difference between now and when you were little might just be that when you were little you didn’t need to learn how to be un-self-conscious (or out-going), it just kind of happened, but now as a young person, you have to learn how to do it?

We talked a little about how you made and kept friendships before the wall went up. You told me about a whole group of friends. Melinda was the person that you felt closest to. When I asked you what it would be like if the wall isolated you from others for the rest of your life, you told me that it was if you were ‘in a bubble,’ and if you remained in the bubble you would become ‘a hermit.’ You admitted that you really don’t want this life for yourself and if you did, you wouldn’t have come for counselling. Then, you told me something I found very interesting. You likened your friendships to an egg, telling me that ‘I only need one yolk and the others are acquaintances — they are

The CORE Approach to Therapy: Helping Jennie Find Resilience

Posted on by Psychotherapy.net Team

A 58-year-old CT scan technician at a local hospital, the youngest of three sisters, and a recovering alcoholic, Jennie came to therapy four months after healing from surgery to repair an atrial septic defect, one of two major congenital holes in her heart. The repair of one of the major defects, and other secondary repairs had been done during Jennie’s childhood. When we began her treatment, Jennie was about three months into a second episode of sobriety after a relapse prior to heart surgery.

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As Scott Miller’s research into therapeutic effectiveness has taught us, the relationship is the key variable in virtually any modality. With this in mind, I decided to utilize the CORE method with Jennie to develop a safe, trusting context in which a strong therapeutic alliance could develop. The method offers a schematic guideline for the utilization of intuition as a curative dimension, particularly in the treatment of trauma. The model is comprised of four components.

Connecting in a caring climate of calm and comfort

Orienting toward strengths, including inner wisdom

Resourcing resilience, evoking awareness of capacity

Establishing strengths that endure, including symbols and metaphors

Connection

When Jennie first came to therapy, my intent was to attune to her and to her story in a way that would communicate a sense of being heard and clinically “held.” My intention was to create an atmosphere of positive regard in which Jennie would experience acceptance and, with her nervous system sufficiently regulated, feel safe enough to address past painful memories and traumatic events of the past. My strategy was to build a connection with attunement to Jennie’s frame of reference, her beliefs, and her presentation and language, to create a context in which Jennie might better understand events of the present.

As our alliance flourished, I would look for opportunities to offer trance, possibly with a lengthier induction, but maybe a short absorption, in which Jennie might find latent or cut-off resources she could apply in future situations. In this way, I was able to help her to identify and integrate new resources in the service of managing her emotions and behavior in future situations.

For the first two sessions, I mostly listened to Jennie’s story, affirming the trials and problems she revealed. In doing so, I gently guided Jennie to express as clearly as she could what she hoped to get from her therapy. Although I didn’t know at first, or even at the start of any particular session how exactly I might utilize methods of hypnosis and trance in combination with ideas arising from my intuition, I hoped that the strength of our connection, characterized by validation of both Jennie’s struggles and her strengths, would ultimately lead her to recognize and absorb a belief in her own resilience and achieve her clinical goals.

I trusted that as I listened to Jennie’s story with compassion, attuned with an empathic gaze, and validating responses, that I would pick up both overt and minimal cues of what was most important for her. I also believed that as I scanned the impressions arising from my clinical observations, I would recognize cues for what might be needed to help her learn to recognize and shift into a state of calm when sympathetic arousal overwhelmed her emotional boundaries, and what points would stand out for me for utilization of trance.

It did not take long for Jennie to come to her goals. She wanted to deal with cumulative stress that would “pile up” and lead to “rage that can get out of control.” During exploration of her major life stressors, Jennie reported a difficult under-staffed work setting as well as on-going communication problems in the family of origin which included at the time a terminally ill brother-in-law and misunderstandings between herself and her two older sisters, Naida and Meg, that often involved the oldest sister’s daughter, Marcia, a niece who was close to Jennie in age and whom Jennie considered a close friend.

Although Jennie’s life partner, Tony, was dealing with a terminally ill mother, this added stress in Tony’s life was not causing conflict in their life together. From all reports, this primary relationship appeared to be a stable area and an island of support for Jennie. Clearly, she was more likely to be triggered into anger by relationship disturbances with her siblings or with coworkers when differences of opinion resulted in disagreements and distorted perceptions.

Such interpersonal static would cause Jennie to question her understanding of a situation, trying often with difficulty to determine her part in the problem. Often, the aftermath would be distance from her niece or from a sister or might form resentments toward a co-worker that could affect her morale and threaten her sense of competent efficiency at her job.

While Jennie reported no incidents of physical violence toward anyone with whom she would get angry, she expressed high motivation to learn to refrain from lashing out and making disagreements into larger issues that would disrupt contact with her sisters and leave her feeling bereft and disappointed in herself.

These types of painful emotional episodes reminded Jennie of the dysfunction and traumatic chaos caused by alcoholism in her family of origin. She wanted to understand how the old images, left-over impressions, and painful memories of the past affected her in her relationships now.

In the service of self-differentiation, Jennie longed to understand her personal role in these painful experiences. As therapy progressed, Jennie became even more consciously motivated to find strategies for reducing the emotional/somatic arousal that would break through her conscious intent to refrain from lashing out.

Orientation: Toward Strength and Inner Wisdom

My realization was that an inner wise intelligence was available for utilization as part of problem solving, and in this case, specifically for healing trauma via re-association of cut-off strengths and resources.

It seemed both clinically and intuitively advisable to consider orienting Jennie toward her strength and helping her to access via her intuitive, inner wisdom. Jennie, I intuitively hypothesized, would benefit from an approach that would utilize trance and also provide some solid stress management skills. Both the intuitive and the practical would serve to guide Jennie toward the resources she wanted for managing both her emotions and her behaviors, particularly during interpersonal stress and conflict. Like every feature of CORE, intuition would be best accomplished with the CORE features of an approach that would access the non-conscious processes of the intuitive dimension of mind to remind Jennie of strengths she had already used in her life, and access dormant and latent strengths that were, for the moment, dissociated from a consciousness plagued by conscious as well as subliminal memories from her past.

First Intuitive Impressions

As therapy began, so did both overt and minimal cues as well as intuitive impressions. My first initial postulation, based on Jennies wide, welcoming smile, was that she had relational resources she was evidencing, but not fully aware of. I sensed based on the way she connected on screen, face-to-face, eagerly listening to what I chose to say, that Jennie might be open to the focused attention of hypnotic trance, with or without eyes open. While later this proved to be true, at first it was more of a hunch as she was readily beginning to let me know her by revealing a background history of emotional neglect, family conflict, and multiple complex losses, as well as the recent operation to correct a congenital heart defect.

It did not take long for a certain current situation in Jennie’s work life to give me a chance to test out my hypothesis. The idea for the experiential moment came intuitively in the third session. I was working on two channels, the intuitive and the clinical, listening to Jennie, and paying attention to her non-verbals. I was also scanning my own hypotheses. As I was also sorting out clinically what direction I might go in next, Jennie’s narrative gave me the inspiration, an intuitive idea.

Resourcing Resilience

I was able to guide Jennie toward the realization that inner strengths existed and could be available — in this instance, using a brief trance and metaphor, as well as a dissociative moment in the service of integration of strengths.

Jennie revealed that in the imaging department, a complaining and underperforming co-worker was “driving me crazy!” (I was now in intuitive territory). Extremely conscientious in her work, Jennie could feel her anger brewing and escalating as the co-worker’s poor work ethic and performance was leaving her overwhelmed and frustrated. Jennie was adamant that she did not want to lash out or do anything to cause problems for herself at the job, as had happened in other situations in the past. She wanted some help to calm herself so she could cope in a different way.

“Just ignore this person and go about your business,” might have worked for some people, but Jennie’s anger was deeply embedded in her emotional and operational self. I intuited that reaching her non-conscious intuitive mind was the way to go.

“I am so angry when I go in and I see her! I feel like I am just a bitch!”

In that moment, I remembered her history of conflict with two older sisters who had blamed Jennie and called her a bitch! I also knew Jennie had not just a broad smile, but a way of seeing the world with humor. How to externalize this self-denigrating sense of herself was the intuitive question — the answer came quickly and surprised me with its humor and potential to utilize Jennie’s sense of humor — without formal trance. I also knew that I was going to trade in what had felt like a positive alliance.

“Jennie, I have this idea and you can tell me if it seems too odd. (She agreed to hear the idea) Have you ever seen a spray perfume bottle?”

“I just happen to have a very fancy one,” Jennie replied.

“What if you imagine that it is filled with a perfume called “Eau de Bitch?” And you can imagine that you can spray it all around when you go into work, so you know it’s just in the air and it’s not in you!”

Now chuckling, she said; “I love that idea!” I’m going to do it!

Evoking Endurance

“Well, let’s take it one step further, okay? You could also have another imaginary bottle that could be for you. This one could be sprayed in the air like an air cleaner, or on you like perfume. This one could be called “Eau de Calm.”

Now fully belly-laughing, Jennie reported that she was actually going to use the real spray bottle for “Eau-de-Bitch.” She later sent me a picture of the bottle and reported at the next session that not only did she no longer feel bothered by the co-worker, but Eau-de-Bitch could also be a go-to when she was upset by her sisters.

***

Over time, using intuition in my work, and teaching others how to use this psychic dimension of mind, I have learned that although people might understand the concept of what intuition is or can be, may clinicians want something more concrete about how to utilize intuition in the clinical setting — or in life.

[Editor Note: “Jennie” has given the author permission to share her story on psychology platforms for teaching purposes.]    

Cognitive Reframing is the Key to Counselling High-Conflict Couples

Posted on by Psychotherapy.net Team

It’s been my clinical experience that a majority of emotionally unravelled, destabilized couples present to treatment hamstrung by chronic, unresolved conflict. Some teeter precariously on the cusp of separation and/or divorce. In one recent case, the couple confessed to me, unsurprisingly, that “Our decision to come to therapy is a desperate, last-ditch effort to salvage our ‘war-torn’ relationship.” Sorrowfully, I’ve observed similar privations hovering menacingly over too many couples who come to treatment.

Being a Clinical First Responder in Couples Therapy

Often, in my efforts to help prevent the worst from unfolding, I’ve found it helpful to shoulder the exigencies of a first responder and lift the couple’s weighty emotional load by reassigning new meaning to their suffering. To do this, I’ll first administer a double dose of empathy, couched in caring authority, while delivering what I hope is a consolatory, reassuring, and reality-based perspective on the rigorous nature of the intimate relationship.

Then, if the couple appears amenable, I’ll gingerly introduce this complementary tongue-in-cheek, but important, cognitive reframe: “As painful as your emotional upheavals are, they reflect the steep price of admission to ‘intimacy land’s’ unsurpassed rewards and fulfilments, despite its topsy-turvy, rugged ride through what can sometimes be treacherous emotional terrain.”

As you might expect, my preliminary biddings at cognitive reframing often require me to periodically double back and re-apply a salve of empathy to obviate any appearance of downplaying or minimizing the couple’s suffering. Then, I’ll again underscore intimacy’s unrivalled complexities and the towering challenges that the couple surely must have wrestled with for so long and with so much accumulated frustration, dismay, confusion, and hurt.

Once the empathy appears sufficiently attuned and absorbed, I’ll ask the couple something akin to this: “Do you suspect, as I do, that your lamentable turmoil and the profound emotional pain that saturates it, are the hugely troublesome but expected outcroppings of these problematic complexities and challenges that commonly plague intimate relationships? However, notwithstanding these forbidding hurdles, here you are, willing to try to rehabilitate your relationship — I commend you!”

While the couple digests my efforts to impose new meaning on their grapples, I’ll ask them to carefully consider what they think stokes their fiery conflicts. As I weigh their responses, I’ll gently elbow them down another cognitive path by suggesting this: “Thoughtfully unpacked, your impassioned, outsized emotions can provide valuable ‘grist for the therapeutic mill’ because they expose a nexus of fundamentally valid personal needs and feelings, and importantly, your abilities to manage both.” I’ll stress, “It’s even intimacy’s ‘job,’ so to speak, to continuously unearth — throughout the countless interactions you have with one another — what your individual need management patterns or styles are like, revealing those that are well-developed, or functional and those that require further development.”

Pushing on, I’ll carefully warn the couple that despite intimacy’s tall promises of unequalled, incomparable personal fulfilments, one of its conundrums consists of a subtle but sinister “dark passenger” that is notoriously commonplace for weakening, even dismantling the individual identities of its constituents. This erosion of partner identity can easily be viewed as the direct, insidious consequence of the non or mismanagement of individual partner needs. Uncorrected, this loss of identity can gouge deeply at the core quality of the relationship.

When Couples Clients Dodge Conflicts

In many of my cases, I’ve witnessed the biting irony of partners who’ll myopically dodge even the slightest prospect of conflict and thus sacrifice themselves by under-managing or not managing their individual needs. Done with “golden intentions,” partners ofttimes deploy this misguided, potentially debilitating tactic for seemingly the “right” reasons: To be considerate of their partner’s differing needs, or to keep from rocking the interpersonal boat by avoiding the risk of conflict sparked by disparate individual needs and the regrettable upshot of painful emotional fallout.

However, I’ll point out that partners who attempt to duck, dance around, or otherwise evade their potentially conflict-generating differences — especially those who do so chronically — risk a nasty, backfiring accrual of metastasizing self and partner resentment.

I often have observed that when conflict-diffident partners opt to use this quick and easy out of conflict for the short-term gain of reducing tension, they paradoxically — and most often unwittingly — induce a downstream, longer-term escalation of couple tension. This proverbial “kick-the-can-down-the-road” pattern of conflict avoidance can diminish partner affection because it most often magnifies rather than lessens couple animosities, making them more pernicious and thus significantly harder to manage. Left untreated, unresolved conflicts create a fecund spawning ground of couple-crippling antipathy.

Conversely, well-managed needs can reduce, even eliminate long-term tensions, even though partners are often called upon to move toward rather than away from potential conflict. Further, well-managed personal needs can cleanse the emotional atmosphere of tension-preserving, lingering feeling debris by prophylactically applying the brakes to self and partner resentment that might otherwise ooze toxically into the partnership.

However, what happens when partners trend in the opposite direction and mismanage their needs by force-feeding their partners non-negotiated demands, manipulations, cajolery, or in some other manner, coerce, blame, or pressure their partners into gratifying their needs? For example, commonly, I hear partners grumble that they don’t feel heard or understood, often voiced as, “We don’t communicate,” or, “He/she never listens to me,” or some fault-finding variant on this complaint-driven, non-constructive relationship critique.

While the need to have one’s partner’s sensitive, respectful understanding is indisputably valid, when frustrated, it’s easily mismanaged with angry accusations and demands which then pulls the targeted partner’s attention away from the need’s legitimacy. Or very often because of a need’s fundamental validity, its gratification can be perilously taken for granted, meaning it’s not actively or effectively managed at all. Partners merely expect, often flutily, that their need for understanding will be met, especially when it’s perceived to be most needed.

I’ll reiterate that poorly managed or non-managed personal needs often become a couple flashpoint. For instance, a partner’s exasperated accusation, “You never listen to me!” most often immediately deploys the accused or “non-listening” partner’s defenses which can then lead to a galling and fruitless spinout in an emotional cul-de-sac of counter-attacking allegations.

Effective Need Management in Couples Counseling

By clear contrast, effective need management can look like this: “Your efforts to listen and understand me leave me feeling respected and cared for…thank you…this means so much to me…and I could sure use a dosing of it now…that is, if you have a moment.” Here, both partners are dealt an equal measure of respect. And while far less economic for time and/or energy, this investment in good need management can pay off in big emotional dividends, since it tends to pull partners toward one another.

Happily, neither partner is likely to be defensive. Instead, good need managers deliver a respectful compliment to their partners which, in turn, helps create a savory atmosphere of mutual respect. Surely, partners who respect one another are more likely to gratify each other’s needs.

Now moving ahead in a decidedly concrete fashion, I’ll encourage the couple to survey their shared history for “healthy exceptions,” that is, to search for instances when they may have effectively managed their personal needs and the feelings orbiting them. I’ll instruct the couple to meticulously and sensitively reference these noteworthy times, calling their attention to how they felt during this all-important personal obligation to themselves and the quality of their relationship, especially when it was done with little or no feather-ruffling.

I’ll encourage the couple to take a moment to reflect and comment on any residual or lasting glow of relational health they may now feel while recalling those moments of good personal need management. Equally important, I’ll ask the couple to try and identify the specific conditions which may have made these propitious partner exchanges possible for the clear therapeutic advantages of reinforcing, burnishing, or otherwise embellishing them.

Moreover, my hope is that this type of positive intervention will resuscitate at least a momentary tincture, if not more, of optimism in the couple. I’ve also discovered that periodic, well-timed infusions of hope can be an especially beneficial mode of intervention.

I’ve also found it helpful to dole out frequent reminders that effectively managing some individual needs may pose a temporary threat to the equanimity and stability of their relationship. I’ll frequently coach the couple to practice in session, with follow-ups at home, the calculated risks associated with the effective management of their needs. This entails summoning the courage to vulnerably enter the “emotional lion’s den.” I’ll promote this important step as key to effective personal need management, highlighting that it’s intimacy’s lifeblood — I risk therefore I am intimate.

Nonetheless, I’ll repeat, seemingly ad nauseam, that intimacy’s matchless portfolio of far-reaching, personally fulfilling enrichments are achieved in proportion to the couple’s efforts to acquire greater “intimacy intelligence” by intrepidly sharpening their skills of effective need management. Specifically, I’ll point out that these highly enviable rewards take their form in a gratifying uptick of self-esteem. Moreover, this uptick in self-esteem is usually accompanied by a flattering bonus — a commensurate boost in their partner’s esteem.

I’ll encouragingly describe how applying the orthodoxy of effective personal need management deepens the connection, or the integration, partners have within themselves, which is arguably a necessary precursor to a deep, meaningful connection between relating partners. I’ll be no closer to my partner than I am first close to myself. Again, I’ll stress that personal needs and feelings that are effectively managed ensure that partner identities are well-embroidered in a need-by-need, feeling-by-feeling fashion, a well-knit fabric of the self. I like to emphasize that the quality of the intimate relationship is a function of the quality of the partners who inhabit it.

As each session draws to its end, I’ll send the couple home with a small buffet of helpful maxims, like those just mentioned, “clinical love notes,” as it were. I’ll often remind the couple that the art of loving is rarely, if ever, perfected but it can be improved upon by taking on the lifelong prescription to hone the personal skills of effective need management. My intent here is to keep the work done in treatment fresh, alive, and well-practiced at home where it counts the most.

Breaking the Rules: When Parroting is the Best Approach in Therapy

Posted on by Psychotherapy.net Team

A Non-Directive Approach

Carmen is your new ten o’clock client. You are excited to be of assistance but you will soon discover that this enthusiasm is short-lived. You have decided to begin with a Rogerian person-centered approach since this is your typical modus operandi and is generally very effective in most instances.

The first rule that runs through your mind is that like virtually every other non-directive therapist, you were trained to employ paraphrasing and not parroting when responding to the client. Parroting refers to repeating back the exact words that the client has said, without any interpretation of evaluation.

After Carmen utters a few sentences, you respond. Secretly you feel greatly convinced you were hitting all the desirable keys on the Carkhuff Empathy Scale. But Carmen’s response was not even close to what you expected.

Her reply, “No that’s not what I’m saying, not at all. I believe you are missing the entire point of what I am attempting to convey.”

Okay, let’s try it again. Carmen tells you more and once again you paraphrase using fresh words only to hear, “Seriously! Are you listening to anything I am saying or am I just paying you to talk to the wall?” (Your thought, not verbalized, of course, is: Um, no, your insurance company is just paying me to talk to the wall.)

Focusing on the positive, I was convinced I would not need to spend a lot of time making Carmen more assertive.

This is déjà vu therapeutics. It immediately occurs to most helpers that on rare occasions, we have all experienced this dynamic with other clients. The dilemma is always the same: Is it truly the fact that your responses are pathetic or is Carmen (and similar clients) just the difficult, resistant clients from Hell?

Unfortunately, without running a complete battery of tests, consulting a string of experts, perusing a host of journal articles, and watching a video of the session again, it is next to impossible to know for sure. And yes, your own negative self-talk haunts you as you recall the sage advice of your uncle George who often quipped during your grueling time in graduate school, “Forget about this counseling and therapy graduate school stuff. Become a plumber like me.”

In essence, you really have no way to be 100% certain whether your therapy skills are a bit rusty, your uncle George was on to something, or if Carmen is just the resistant client your professors warned you about.

And surely you would never turn to parroting since your graduate faculty depicted the horrors of this evil technique. Moreover, every book, article, and mentor in the field insisted parroting was negative as well. In fact, it had to be true, since I have mentioned the dangers of parroting in my own books.

Even the ultimate expert Chat GPT AI says, “Parroting can be seen as invalidating and unhelpful for clients. Chat continues, “Parroting is condescending and dismissive to the client and does not allow the helper to add interpretation or elaboration.”

Does Therapeutic Parroting Work?

Having said that, ironically, I am going to suggest that the solution to your predicament with clients like Carmen lies in using a fool-proof intervention that can help you diagnose the situation virtually every time: parroting. Yes, parroting, the concept your professors warned you to avoid like the plague.

Your answer will become crystal clear when the client responds to your intentional parroting. Hence, if Carmen says, “I hate my mother,” and you violate the advice of your graduate faculty, and virtually all texts on the subject and say, “You hate your mother,” and Carmen replies, “No you really aren’t getting this, are you?” We can begin to suspect that her combative or perhaps clueless behavior is fueling the discord.

Assume Carmen’s next response was, “I had a terrible childhood,” and you come back without a shred of creativity with, “So you had a terrible childhood” only to see Carmen roll her eyes and say, “Where did that come from? I mean, really. No, I never said that. Are you really trained to perform therapy?”

Now you know Carmen has some issues and most likely your psychotherapeutic skills, although they may not be ideal, do not need a complete overhaul.

At this point, you can choose to confront Carmen either now or later or implement whatever strategy you deem appropriate, but at least you will have convinced yourself the issue is within the client and not you.

You may be asking if I have just invalidated a long-standing tradition in treatment. Well, not really. My guess is that in perhaps 99% of your interactions with clients, your graduate faculty got it oh-so-right when they recommended you refrain from parroting. Parroting is used for the 1% when a client has put your paraphrasing, summarizing, and reflective listening skills in a double bind.

I must disclose that I have a slight advantage over most therapists. On rare occasions when I need a little encouragement, I have my two pet African Grey parrots in the next room ready to help if I can provide a small treat.

Questions for Thought and Discussion

How effective has parroting been in your own therapeutic work?

What techniques do you find most effective in demonstrating that you are listening?

Are there particular clients with whom parroting is more effective? Less effective?