Category: Advanced Clinical Skills

Sometimes I Also Feel Lazy: A Clinician Reflects on Self-Disclosure

Posted on by Psychotherapy.net Team

“Sometimes I also feel lazy,” I calmly mentioned to Chris. I noticed his chest instantly decompress with a sigh, as a slight smile took shape at the corner of his mouth. As a clinician, I make calculated decisions about how and when to disclose to my clients.

Chris is a Black man in his early 20s who struggles with symptoms associated with anxiety and persistent depressive disorder. He is currently living with his parents and saving to purchase a condominium. He works in the highly competitive industry of data analysis and takes an interest in both playing the guitar and learning new languages. However, Chris has ongoing thoughts and concerns associated with where he “should” be in life compared to his peers.

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My self-disclosure came after multiple sessions of hearing Chris berate himself, thinking he is not “doing anything with my life.” According to Chris, he should be earning more money and proactively searching out new places to live. We have all dealt with clients who appear to be doing better than most but seem to treat themselves as if they are the worst.

At the moment and in looking back, I felt conflicted. Should I have revealed how proud I was of him? No, that might be taken as gratuitous praise that he believes I “say to everyone.” Or should I have simply sat back and normalized his thoughts and concerns? Well, I tried that in previous sessions. This time I had a different idea.

I recalled how Chris had seemingly put me on a pedestal in the past. He had sometimes made remarks about how “you own your own business” and had “written books.” Now was a moment that I could come across as more relatable. I have noticed that power differentials present significant challenges when working with male clients.

Chris mentioned feeling “lazy” due to his perceived lack of initiative. I responded briefly with, “Sometimes I also feel lazy.” I aimed to be succinct so that my intervention was not taken as an attempt to monopolize his session.

Self-disclosure is not without controversy. Some colleagues argue that it helps, while others suggest that it may be harmful. With Chris, I wanted to convey that I go through periods of indolence as well. As it turned out, this led to a rich discussion about how routines might work better for him than relying on motivation.

One of my concerns prior to disclosing was my experience that mental health disorders are often associated with stigma, and this may delay clients from entering therapy. Chris could have suggested that it was “easy” for me to say that I go through periods of inactivity, as I don’t struggle with anxiety and depression (though inaccurate, I was not willing to take up his session with my issues).

I have found that self-disclosure —when used appropriately—has been a powerful tool in my practice to reduce some of the stigma associated with mental health issues and their treatment, normalize my client’s experience, offer different ways of thinking and behaving, and deepen the connection between me and them.

Below are some considerations for the appropriate use of self-disclosure that I have found in my clinical work:

Cultural Sensitivity

The use of self-disclosure can be problematic if I make assumptions about my clients based upon a real or perceived similarity with them. Culture goes beyond race and ethnicity. Chris and I are of the same race, but that does not mean we have the same worldview, so I must be careful to disclose only after having a thorough understanding of the cultural factors that impact his worldview.

Authenticity

My clients appreciate me when I am real, which is also when I think I am doing my best work. I fear that my professional licensure and other symbols of my presumptive clinical expertise sometimes create distance as opposed to allowing clients to connect with me. Sharing something about myself—when relevant—can help minimize this barrier. My clients come for the clinical interventions but stay for the relationship.
Client-Focus

My goal is always to help my clients meet their needs, as opposed to having my own needs met. The above-mentioned session could have easily become a discussion about me. However, this is not what Chris was there for.

Brevity

It is their session, not mine. I do not want to elicit a caretaking response from my clients. I have written elsewhere that good therapists are in therapy themselves. Another point is that disclosure should not happen frequently, for the same reason mentioned above.

Eliciting feedback

I have found it to be important to carefully observe my client’s reactions (facial expressions, tone of voice, and body language) in order to obtain a sense of how my self-disclosure affects them. It helps when I ask clients directly how they perceive my disclosure. I was able to pay close attention to Chris’ bodily response and noticed that he found comfort in my disclosure. Further, my observation was validated by asking him what the disclosure was like for him.

Some questions that I have found helpful prior to self-disclosing include:

  • What need is driving me to share this information (is it for me, or is it for the client)?
  • How might this information be helpful?
  • Is this helpful to share now (perhaps the disclosure may be better suited for a later time)?

I have also discovered that my use of self-disclosure has not always been as helpful as I had intended. One example stems from a time when I tried to normalize medication compliance with one of my clients who was diagnosed with schizophrenia. I mentioned the fact that I have asthma and am required to take my inhaler regularly in order to maintain optimal health. The client responded by saying that he would much “prefer asthma over schizophrenia.” I attempted to salvage the moment by admitting that it was not appropriate for me to compare asthma to his lived experience. I also allowed the client to give me feedback on how the disclosure made him feel (I learned that it came across as slightly dismissive). I have found that these lapses in clinical judgment have actually strengthened my alliance with clients when I am willing to admit them. Through self-awareness and honesty, these moments have become opportunities for a deepening in my therapeutic relationships and for my client’s self-awareness and growth.

***

In my clinical experience, carefully planned self-disclosure has been a transformative tool in the relationships with several of my clients. Chris viewed my personal revelation as a breath of fresh air, and it made our work together more effective. He respected and appreciated my authentic humanity—even if it meant I was sometimes lazy.
 

The Four Brahmaviharas and the Quiet Inner Voice

Posted on by Psychotherapy.net Team

My patient, whom I’ll call Andrea, is a lovely woman in her 60s. She wakes at 4 am each night, stomach clenched with worry about her adult son, who just left his job without a clear plan for his next move and appears quite depressed. My patient leans her head against her hand, and through the video screen, I can see the worry lines tight across her face. She is terrified that he has made a terrible mistake in leaving his job, and she is fighting the urge to micromanage his every decision. “Feeling his pain is so much worse than feeling my own. I just want to make it stop,” she tells me. She and her husband have been at odds about the situation—he tells her she worries too much, and she thinks he isn’t worried enough. “I am all alone in this.”

We explore her good reasons for feeling anxious through a “Positive Reframe” exercise, which comes from TEAM therapy, developed by David Burns. In this exercise, we explore how painful negative symptoms can be useful and can reflect our most deeply held values. “It shows I’m paying attention, it keeps me vigilant about the situation,” she reflects. Indeed, she has been very proactive about helping her son find a good therapist and has been brainstorming with him about leads for a new job. She identifies the values that underlie her worry—“Seeing his pain hurts so much because I care so much about him. But I know my reaction pressures him, and that’s not helpful. I just want him to be happy!”

Most recently, Andrea and I discussed the Buddhist concept of the Four Bramaviharas or the “divine abodes.” They are 1) Metta—loving-kindness or goodwill, 2) Karuna—compassion, the awareness of the suffering of others and the desire for it to stop, 3) Mudita—sympathetic joy in the happiness of others, and 4) Upekkha—equanimity.

When she examines her underlying motivations, it is clear that Andrea is manifesting Metta for her son. She wants him to be happy. She is also demonstrating Karuna, compassionate awareness of his suffering and desire for it to stop. And by coming to see me, she demonstrates both Metta and Karuna for herself: she recognizes a need to bring things into balance and bring down the level of her suffering, which she can see does not help either of them.

She finds this part of our conversation helpful: “It’s a good reminder that I don't need to believe all the things my mind tells me, like that I’m not a good mom. I’m feeling pain because I care about him, not because I’m doing something wrong.”

“And what about the thought, ‘I’m all alone?’” I ask her. “Could there be a kinder way to speak to yourself?”
“What do you mean?”

“Well, what if instead of saying ‘I’m all alone,’ you said, ‘I’m with myself’?” Changing the words we use is an example of one of Burns’ cognitive methods, the “Semantic Technique.”

She looks up thoughtfully as she tries that on. “My first response is that I don’t really want to be with myself. No wonder I feel lonely! It’s interesting to imagine being ‘with’ myself.”

“Are you willing to try that right now?”

She nods.

“Go ahead and turn your attention inward. When you think about your son’s suffering, what comes up for you?”

Her face tightens into a grimace. “I feel a strong tightness in my chest—right here,” she gasps. I feel a swell of admiration for her as she stays with the difficult sensations.

“That’s great, keep going. What else do you notice?”

She falls silent. “Yes,” she says finally. “I have a teacher who says, ‘the wise voice is quiet.’ When I listen more carefully, I hear a voice that says that what my son needs is this, what’s happening right now, this kind of being-with. I can’t fix his depression or make him find a job. But I can be with him. And I can be with myself.” She smiles. “If I’m listening to a wise voice, I’m not all alone, am I?”

We sit together in silence. Then she continues, “I feel less helpless and desperate. His depression, my anxiety, they are part of being human. It’s okay.”

She has hit upon the fourth Bramavihara—equanimity. The willingness to be fully present with things as they are. Equanimity acts as a natural brake on compassion and our tendency to become preoccupied with the feelings of others.

“My teacher has taught me an equanimity prayer,” I offer. “I call it ‘a mother’s prayer’. I’ve found it helpful in parenting, if you’d like to hear it.”

“Sure,” she replies.

“It goes like this: ‘Things are just as they are. Joy and sorrow arise and pass away. Your happiness depends upon your intentions and your actions, not upon my wishes for you. I love you, but I cannot prevent your suffering.”

“That’s nice, I like that.”

“I added a line: ‘I delight in your capacity to make your own decisions, even if I don’t agree with them.”

She laughs. “Oy. That’s a tough one. What if his decisions are making us both miserable?!” She pauses and answers her own question. “I understand. I want him to be his own person, and he has to figure out his life from his own experience.”

Mudita, the third Bramavihara, fills us with sympathetic joy in the happiness of others, even if we did nothing to create it.

“I’m grateful for all the times my parents let me make my own mistakes, I suppose I can take pleasure in his being able to do the same. I guess I know what I’ll be practicing this week.”

***
 

And so, by sitting with herself, Andrea weaves together the message of the four Bramaviharas, guided by the wisdom of her quiet inner voice.
 

The Queen’s Gambit and Me: The Surprising Similarity Between Therapy and Chess

Posted on by Psychotherapy.net Team

I was mesmerized from the first frame of The Queen’s Gambit, a Netflix mini-series about a Kentucky orphan girl in the 1960s and her passion for chess. Thoughts of the show colonized my thinking for the three days it took me to get through its seven episodes. I loved it, it intrigued me, and I cared deeply about the characters. It was a perfect jewel. But little did I know how those seven hours would change my life.

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I don’t remember how it happened, but a week or so after the final credits rolled, I started to research chess. I’d never played before and didn’t even know how the pieces moved, so I typed “chess for beginners” into YouTube and curiously, like Alice, fell down the rabbit hole.

I find that I’m dreaming about chess these days and have started to see chess tactics and strategy in everything. I’ve been a psychotherapist for thirty-five years and it's become clear to me since I started playing how a course of therapy conforms, in many ways, to a chess game, with its well-defined opening, middlegame, and endgame.

The first few therapy sessions, when you’re learning about your new client, are like the opening. You start slowly and respectfully, using moves that you’ve used many times before to get a feel for the person sitting across from you. You’re getting situated, knowing that you’re at the very beginning of an important relationship.

For example, I start the first session with my new client, Isabelle, with the opening move I’ve used so many times before—a variation of the question “What brings you here today?” Everything is possible at this point, and I have no idea where this exchange will take us.

During this opening phase, I’m getting a sense of the pacing. Will she jump right in with a cascade of emotion (making dizzyingly fast moves) or sit quietly waiting for me to ask questions (establishing a pensive introspective pace to the “game”)? In this case, holding back and very reserved (not making risky moves), 28-year-old Isabelle explains that she wants to improve her relationships. She’s on pause with her boyfriend, who has not treated her well, and is wracked with indecision about whether to go back to him. She doesn’t trust herself. But when asked her biggest goal in life, she says she wants to meet the love of her life.

A session later, in a latter part of the opening, Isabelle tells me about the struggles she faced in childhood. I learn that her much-loved mother, whom she describes as an angel on earth, suffered mental health problems that were so severe that when she was eight and her parents divorced, she was sent to live with her father’s parents. They were very strict remote old-fashioned immigrants who did not speak English, and she did not speak Italian. She rarely saw her mother and felt alone and abandoned.

More complexity is introduced in a later session as Isabelle reveals that no matter what has happened in her childhood, she’s determined to build a wonderful future and has enrolled in a course to become a life coach. With this goal in mind, at the turn of new year, she’s started to eat more healthily, is trying to exercise, and has incorporated a meditation practice into her day.

In this part of the therapy, the middlegame, I’m searching for patterns. It’s both a science and an art. Isabelle relaxes, and story after story comes spilling out. I’m receiving reams of information and have to make continuous decisions about which pieces are vital to attend to and which not to “take.” I could focus on a tantalizing piece of information that Isabelle shares (capture a knight that’s available to take but which won’t advance my position), but I have to make sure not to make a move unless it contributes value. There’s no doubt that I could chase the pieces all over the board, but I need to develop a plan that will guide my choices.

Over time, the essential issues are brought into focus and, in the endgame, many of the peripheral bits have been eliminated so that only the primary core issues remain. There are fewer pieces on the board, but every one is vitally important. We’re narrowing our focus on the need for Isabelle to forgive herself for having left her mother, who later died of cancer, and working on helping her develop a deep well of self-compassion. The search for the love of her life will have to wait until she’s very comfortable with the love of herself.

Isabelle is not, of course, my opponent, and a course of therapy is certainly not a process of win or lose, but I like to think of strategizing how to help my client in her struggle (our chess game) as the mutual challenge for both of us. The pleasure of checkmate comes from feeling that we’ve shared a profound experience together resolving something important, and that now Isabelle and I can celebrate that positive change has happened in her life.

I've found that there have been many surprisingly meaningful aspects about life during the pandemic, and discovering chess is certainly high up on my list. I smile when I think about it and look forward with anticipation to the next game. Where it’s going to fit into my uber busy life, I’m not sure. But for the moment, hey, set up the board and let’s play!

Snatching Defeat from the Jaws of Victory

Posted on by Psychotherapy.net Team

After several tries, Jim, age twenty-five, was finally accepted into a prestigious bank management program. Once in the program, however, Jim found it difficult to make time to study. Assignments were handed in late, if even completed at all, and Jim developed severe headaches, all of which eventually led to his being the only trainee to leave the program, just days before he would have been forced to withdraw.

Alice, a first-year student in the Ph.D. program in psychology at a northern university had a similar experience. An otherwise unusually hard working and effective person, she found it easier to help others than to help herself. A cherished friend, colleague, and fellow student, Alice consistently failed to handle the demands of the graduate program, despite a well-demonstrated ability for academic work. While ably helping fellow students with their work, she neglected or mishandled her own papers, and her presentations were neglected to the point where her status in the program became jeopardized.

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Both Jim and Alice exhibit a pattern of self-defeating behaviors—clusters of thoughts, ideas and actions that sabotage success at work and in relationships. Self-defeating behaviors include a broad spectrum of self-imposed handicaps and other ploys and tactics that may suggest emotional trouble. Simply stated, a self-defeating behavior is any behavior that keeps someone from reaching their goals or sabotages their ability to be successful in ways that matter to them.

The obvious questions that arise in situations like these are “Why exactly do these people become their own worst enemies?” and “What would make bright, upwardly mobile, and ambitious individuals self-sabotage?”

Many explanations have been proposed for these behaviors. The most traditional analysis claims that people who repeatedly “shoot themselves in the foot” fear success, feel guilty about their behavior, or simply suffer from low self-esteem. Other explanations include the possibility that self-defeatists have inflated opinions of themselves, and that they use self-defeat to take control of a fear of failure. Perhaps Jim had serious doubts about his ability to successfully make it through the bank management program, so his being “too busy” to find the time to study, as well as his headaches, provided excuses that justified his exit without having to risk failing in the actual program.

Alice might have been handling her anxieties about the graduate program by developing a praiseworthy excuse for her own self-doubts and conflicts about her performance. If her sacrifices on behalf of her fellow students led to her inability to successfully complete the program, she could take comfort in the belief that she would have succeeded if only she would have finished. Her self-defeating handicap protected her from the risk of failure.

I have had success working with self-defeating individuals like Jim and Alice by helping them to learn to reflect rather than react and by identifying the negative self-beliefs that were partly responsible for their propensity to self-sabotage. With Alice, these beliefs caused low expectations for success and, hence, little motivation to try for better performance in future endeavors. This precipitated additional failure and helped to create a cycle of self-defeating behaviors for which she constructed defenses (e.g. rationalization) as her only means of coping. Therapy consisted of eliminating the irrational negative beliefs associated with self-defeat and replacing them with positive and rational alternative ones that she could gradually accept as valid. In addition, Alice was encouraged to consider alternative explanations for her failures. This was accomplished by considering hypothetical explanations for various events in which she was unable to succeed. With Jim, we were able to shift his attribution for failure from his claim that he lacked the ability to succeed to the realization that his failure in the bank management program had more to do with his insufficient effort. This enabled him to develop an expectation of possible success and helped him to imagine that he could, in fact, succeed if he was willing to try, and try differently, a second time.

A question that has had a great deal of traction with clients like Alice and Jim has been, “If you could do this over again, what would you do differently?” This helps them to begin a conversation that allows them to consider a different pathway, one that takes them to success rather than defeat.The satisfaction I was able to enjoy with both Jim and Alice had a great deal to do with their ability to tolerate the insights that illuminated their histories of self-defeat.

Gradually, they were able to relinquish the distorted beliefs and rationalizations that camouflaged and perpetuated their self-sabotage. Both of them were good examples of how insights become a blueprint for change in the course of a psychotherapeutic experience. Too often, the people I work with become "insight rich and change poor," which is why, for some, therapy feels moderately helpful, but not sufficiently productive and fulfilling. Good therapy has both therapist and client keeping a careful eye on the extent to which insights are implemented and identifiable and measurable change is able to occur.
 

Healing the Authoritarian Wound Through Writing: 8 Writing Exercises to Share with Clients

Posted on by Psychotherapy.net Team

A Therapeutic Place for Writing

Therapists endeavor to help clients handle life’s problems and their particular difficulties, including those that have come about because of the way they were treated as children, adolescents, and adults. We deal with people, and we need tools that actually help people grow, heal, and change. One great tool at our disposal is inviting clients to write.

One of the areas that interests me is the consequences of authoritarian wounding, those wounds created by prolonged contact with a family bully, like a father, mother, or sibling, with a bullying mate, authoritarian mentor, teacher, clergyman, boss, or co-worker, or with any other authoritarian who is operating in one’s sphere. I’ve written extensively on this in Helping Survivors of Authoritarian Parents, Siblings and Partners (Maisel, 2018) and in scores of blog posts for Psychology Today and The Good Men Project.

A second area that interests me is the value of writing as a useful tool that therapists and coaches can use with their clients and offer to their clients. I’ve advocated for the wisdom of inviting clients to write, most recently in Transformational Journaling for Coaches, Therapists, and Clients (Maisel, in press). In this piece, I’d like to share with you eight writing exercises that I use in my work with survivors of authoritarian wounding.

I think you’ll see how these exercises can also be used with all clients, either as is or with some tweaking. I hope that your main takeaway from this piece will be that clients can make tremendous strides in self-awareness and in healing when they write in a focused way about what matters to them. These aren’t the “describe a tree” or “describe a sunset” writing exercises that you might encounter in a writing workshop. These are therapeutic exercises that invite clients to face their experiences, learn from their experiences, and move past their experiences.

Maybe you don’t currently invite clients to write between sessions or assign any homework. You might want to rethink that a bit. Many psychotherapy clients are smart, articulate, sensitive folks who may well already keep a journal or engage in some other reflective writing or who, even if they aren’t journal-keepers, are likely to be receptive to the idea of doing some writing. If you do decide that providing writing exercises might prove a valuable therapeutic tool, here are a few points to consider:

  • I let clients know that if a given exercise doesn’t speak to them, they can write on a prompt of their own choosing or, of course, not write at all. It’s wise to give clients who’ve been wounded by an authoritarian this sort of instruction and permission, since they will have had a long, difficult history with rules and especially with the consequences of violating or ignoring rules.

  • I explain to clients that perfect knowing isn’t the goal. If they increase their awareness a little bit or heal a little bit, that is a victory and a blessing. We all have the wishful hope that we can get from a muddy understanding of something to a crystal-clear understanding of it, but perfect understanding is more than elusive, it is unattainable. I remind clients that if they get even just a little something of benefit from the exercise, that is a welcome outcome.

  • I warn clients that the exercises may well prove provocative and emotionally difficult, and I give them real permission to stop if the going gets too hard or painful. You can tie this instruction to several of the tips in the tip box provided below, for instance to the ideas of creating a support system and staying alert for triggers. Clients should be helped to understand that this work is not easy and that stopping should be viewed as a self-care strategy and not a defeat.

Before I describe exercises I have found useful with clients who have been impacted by authoritarian relationships, I would first like to describe some of the long- and short-term impacts of authoritarianism on the individual. These include (but are certainly not limited to) lifelong relationship difficulties (including serially choosing authoritarian mates); existential despair rooted in feelings of worthlessness; a pessimistic, critical attitude that makes it hard to give life a thumbs up or people the benefit of the doubt; an anxious nature that plays itself out as indecision, confusion, and an inability to make clear or strong choices; a felt lack of safety, including in the therapy session; obsessive worrying and powerful feelings of overwhelm; and a pull toward addictive behaviors.
 

Eight Writing Exercises

Here are the eight writing exercises. Each comes with three prompts, as I find it useful to provide clients with choices.

Exercise 1. This really went on (you weren’t crazy)

We can almost believe that what happened to us didn’t happen to us, maybe because we did a lot of dissociating, because other people saw the authoritarian in a different light, because we wished so hard that it wasn’t true or that bad, or for some other reason. But it did happen. Please pick one of the following three prompts to write on (they are written from your point of view):
 

1. What exactly went on? Let me pick one experience that still deeply affects me and try to describe it as carefully as I can. I do want to know for certain that what I believe went on actually did go on!

2. I want to think a little bit about how it might be to remember some of those terrible experiences without having to re-experience them and without having to be flooded with bad feelings. Can I see a way to do that?

3. I have long thought that I must be a little crazy to believe that such awful things could possibly have gone on. But they did go on. So how can I completely let go of that feeling that I was “a little crazy” for believing what, it turns out, was completely appropriate to believe?

Exercise 2. You didn’t have a choice (you didn’t choose it)
 

If your experience of dealing with an authoritarian happened in childhood, it should be clear to you that you didn’t choose to experience that wounding. But as clear as that truth may be, it’s still easy to feel complicit or as if you deserved what happened to you, maybe because you weren’t “perfect.” Now is a good moment to get clear on the fact that you didn’t choose to be abused by that authoritarian. Please pick one of the following prompts to write on: 
 

1. Is there some part of me that still thinks that I did choose my situation? How can I still be thinking that? And what can I do to stop thinking that?

2. If I’m still dealing with an authoritarian today, do I have new choices to make? Different choices to make? After all, I’m not that child any longer!

3. Because I didn’t really have a choice in the matter, I think I may have gotten it into my head that I’m not entitled to make strong choices or maybe that I’m not equal to choosing. I think I’d like to do some reflecting on that possibility.

Exercise 3. You didn’t have allies (you had to go it alone)

It is hard to overestimate the extent to which you had to go it alone. Authoritarians can’t function if everyone around them says “No!” For the authoritarian to bully others, those others must be staying silent, not fighting back, tacitly accepting the situation, or even defending the authoritarian. Maybe you were lucky to have an ally in an aunt, a sibling, or someone else, but basically you had to go it alone—the proof is that no one ever successfully stopped the bully’s behavior. Please pick one of the following prompts to write on:


1. Did I or didn’t I have any real allies during those bad times? What was the exact nature of my situation with respect to allies and/or a lack of allies?

2. If I did have a real ally during those times and he or she is still living, do I want to reach out and say something to him or her? Or maybe say something to him or her even if he or she is deceased?

3. I wonder, what are the consequences of having had to go it alone? Did that make me independent or dependent? Did it make me love solitude or recoil from solitude? Let me do a little writing and tease out those consequences.

Exercise 4. You didn’t have power (you couldn’t fight back)

Grown-ups possess all the power. Children can dream about being powerful, fantasize about being powerful, and engage in small acts of strength, but they are essentially powerless in the face of adult abuse. This true powerlessness can produce lifelong feelings of powerlessness, even though you are now an adult with all the powers of an adult. Please pick one of the following prompts to write on:

1. I want to think clearly about the ways in which I was powerless in those terrible times, primarily for the sake of making absolutely certain that I do not blame myself for not taking actions that were just not available to me.

2. How would I describe the power I now possess? Surely, I do possess some adult powers! How would I describe them? And how do I use them?

3. What would it take to transform myself into a “real life superhero?” And what would I be able to accomplish then?

Exercise 5. You couldn’t possibly understand (how could you?)

You may blame yourself for not understanding what was going on, for being too innocent, for missing what was right in front of your nose. But how could you possibly have understood? Feeling that something was seriously wrong and fully understanding the complicated dynamics of the authoritarian personality are two different things. Really, how could you have understood? Please pick one of the following prompts to write on:

1. What do I understand now that I couldn’t possibly have understood back then?

2. What intuitions that I had back then about my situation and about what was going were actually accurate? Did I maybe have some understanding of the situation that I couldn’t quite access then?

3. What additional understanding is available to me now? Is there more for me to understand?


Exercise 6. You were genuinely afraid (of course you felt scared)

Authoritarians scare us. You may have spent much of your childhood terrified. Of course you were afraid. The question to grapple with now is, do you still have to be afraid today? Please pick one of the following three prompts to write on:
 

1. I want to remember what it was like to be frightened as a child, to validate that experience. I am going to go back in memory, remember what I felt, and honor that I had those terrible experiences. But I am going to go back very carefully.

2. I know that I’ve lived in a fearful way and that I’ve been scared a lot in life. What can I do to feel safer now?

3. I want to live differently. How can I live more bravely? What would such a life look like?


Exercise 7. You were truly harmed (there were real consequences)
 

To say that you were wounded isn’t to speak metaphorically. Something in you got seriously injured. Maybe it was your willingness or your ability to deal with conflict. Maybe it was your self-image, your self-esteem, or your self-trust. Maybe it was your ability to trust others or to deeply care about others. The list of possible injuries is long. Please pick one of the following three prompts to write on:
 

1. I want to calmly and patiently identify the consequences of that wounding. That’s the important writing I’m going to undertake.

2. I think it might pay off to describe some of the ways that those consequences played themselves out. This won’t be easy, but I think that drawing a direct line between the wounding and the things I’ve done in life might prove eye-opening—and maybe I can forgive myself a little in the process.

3. I want to write about my strengths, too. I think it might be a good idea to spend as much time writing about my strengths as my injuries.


Exercise 8. Healing is possible (in part, through writing)

You may have gotten into the habit of thinking that nothing can really change in life, including, and maybe especially, your own personality. But healing, change, and growth are possible. Use your reflective writing practice to help you make the changes you identify ought to be made. Please pick one of the following three prompts to write on:
 

1. I think I’d like to describe some daily practice that will serve me as I try to shed the psychological and emotional baggage of the past.

2. I want to create some firm-but-gentle action plans that support my intention to heal, grow, and live well.

3. I want to write about a better, brighter future, one where I feel less burdened by the past and more optimistic and passionate about the future. Let me write about that.


Eight Helping Strategies

In addition to inviting clients to write, you can also make the following suggestions and work with clients on the following issues:

1. Creating physical separation

Survivors of authoritarian wounding regularly report that only physical separation between them and the authoritarian in question allowed them to feel safe and provided them with the opportunity to heal. And the wider the separation, the better! You can have very productive conversations about the need for physical separation and the practical details of such separation.

2. Creating psychological separation

Survivors are likely to still love, or feel that they ought to love, their parents; be pressured by other family members to continue to deal, psychologically and emotionally, with their parents; and never quite be able to get their parents out of their head. You might try a guided visualization where your client is invited to escort the perpetrator out of her head once and for all.

3. Ventilating and eliminating feelings of guilt

Survivors typically experience guilt. Some feel guilty about not protecting their younger siblings from the family dictator. Some feel guilty about having failed themselves or not having lived up to their potential. Some feel guilty about physically or emotionally separating from their authoritarian parent. You can help your client ventilate these feelings and begin to think thoughts that serve them better, thoughts like, “This guilt isn’t serving me.”

4. Creating a support system

My client Maria explained, “I have to be able to handle things on my own because, growing up, I lost so much power and so much self-confidence that my goal for myself is to be powerful and self-confident. However, that doesn’t mean that I have to handle every single thing alone. So I’ve created a kind of informal support team. I don’t turn to them first thing—first, I want to trust my own resources. But I’m not stubborn, and I do turn to them just as soon as I understand that I could use some help!”

5. Staying alert for triggers

In the language of the 12-step recovery movement, a trigger is an internal or external cue that is likely to cause a person in recovery to relapse and resume the addictive behavior. A trigger might be the appearance of a certain feeling, like feeling overwhelmed, seeing someone in a film or a television show in a similar situation, relationship events that mimic family-of-origin events, or encountering a certain smell (like an aftershave lotion) or a certain sound (like a door slamming). You can help your clients identify their triggers and create a plan of action to deal with those triggers.

6. Communicating with and enlisting “healthy” family members

Survivors often express that maintaining contact with family members who saw the situation the same way that they did was their number one healing and survival strategy. A client and her sisters might support one another in validating their memories (“Yes, Anna, it was that bad!”) and standing together in mutual defense and in ongoing defiance of the authoritarian parent. You can help your client identify allies and begin the process of reaching out to allies.

7. Not accepting the vision of family members who do not see the situation as your client sees it

Other family members may have had a very different experience of Mom and Dad from your client’s experience. They may have entered the family later than your client did; maybe the authoritarian had mellowed by that time, and the younger sisters and brothers did not receive the same authoritarian wounding as your client did. Maybe her siblings were in fact just as abused and traumatized as she was, but they are currently in denial about their experiences or have followed in the authoritarian’s footsteps. You can help your client deal with her siblings’ demands that she be “nicer” to the authoritarian parent and with their accusations that your client is being disloyal or ungrateful.

8. Limiting contact

Your client may still be living with the family tyrant or may have returned to live with that parent, perhaps because the parent has become infirm. If complete physical separation is out of the question and complete psychological separation is unlikely, the questions you can pose to your client are “What’s the least amount of contact that you can have with your mom?” or “How can you stay out of your dad’s way most of the time?” You can help your client think through the practical details of limiting contact and the emotional consequences of remaining in contact.

Clinical Case Applications

Let me briefly describe two client situations where reflective writing helped my clients grow in awareness and make important life changes.

One client, John, a British professor of history, had never finished writing any of the many books that he’d begun. I invited him to get some thoughts down on paper about why this might have been the case. He shared the following journal entries with me:
 

I grew up with mean parents. After years of therapy, I think I’ve come to identify a kind of demon who comes into my consciousness and does not want me to be productive or successful. That demon was born in childhood. It somehow has to do with safety. It did not feel safe living with my parents, plus they told us that the world wasn’t a safe place. They filled our lives with continual anxiety and catastrophizing.

Here’s how that all plays out now. My creativity starts to flow and then anxiety floods in. I tear up the work, I tear myself down, and I abandon the project as no good. I’m also flooded with feelings of intense dread all the time, especially at night; and during the day, I’m always finding ways of avoiding entering my writing space. And my writing space is easy enough to avoid, as I have classes to teach, committee meetings, a bit of a commute, and all the rest. It’s supremely easy to avoid my study. And my study is so lovely. I wanted to write, ‘lovely and inviting,’ but it never does invite me.


In another session, he shared the following journal entries:
 

Those demons. The demons have made it harder for me to keep meaning afloat in my life, they’ve made it harder for me to keep despair at bay, they’ve made it harder for me to live my life purposes, and they’ve contributed to my anxiety and depression diagnoses. It’s all a piece. I’ve come a certain distance in all this and I can function, but I’m still searching for answers and I’m still wanting to finish some damned book.

I think that the bottom line for me is that the demon just won’t budge, because it is about core safety. Maybe I have to celebrate lesser forms of creativity where the emotional stakes and pressures are lower. An article, maybe, though articles aren’t easy either! I haven’t found ways to conquer the demons of darkness, but I do intend to continue to work on this block through some kind of inner demon work. I haven’t quite given up. Not quite!


John and I worked together for the next three years, chatting via Skype once a month. There were many downs, but also enough ups that John did manage to finish a draft of a book, deal with its several revisions, send it on its journey into the world of academic presses, tolerate the criticisms and rejections his book initially received, enjoy the moment when it was accepted for publication, and so on. I kept reminding him, “This is the process,” and at some point, he began to laughingly beat me to the punch and become the first to announce, “I know, this is the process!” And throughout the process, he used reflective journaling and writing prompts to hold important conversations with himself and deal with the demons that were never going to fully go away.

A second client was a Parisian painter, Anne. At the time we began working together, Anne was hiding out in Provence, licking her wounds after an unsuccessful show of her paintings at a prestigious Parisian gallery. She was barely communicating with the world and painfully wondering if she should continue as an artist. The fact that she has sold paintings previously, that she had had successful shows previously, and that she was still something of a darling of the art world seemed to amount to nothing. Not in the aftermath of what she dubbed “that monumental disaster.”

We chatted over Zoom. One of my goals was to help her change her perspective. Her career certainly had taken a hit. But for her to dwell on that “disaster” amounted to a serious mistake and a recipe for despair. Focusing on that event was only one lens through which to look at her career. I quietly and carefully explained to her that she was fortunate to have had the successes she had had, that this one event might or might not signal anything in particular or auger anything in particular, and that her best path was to get on with her life and get on with her art-making—the act of which, fortunately, had lost none of its luster for her.

I asked Anne to detach from the show results. I also asked her to invite a postmortem from the gallery owner. How brave that would be, to ask him why he thought the show had produced no sales! She wasn’t sure if she was equal to that. I explained that she might get “more equal” to that bit of bravery by doing some reflective writing, maybe on her turbulent childhood, maybe on her bullying father, a famous painter who always belittled and minimized her efforts, or maybe in a more “in the moment” way by writing about her feelings about communicating with Claude, the Parisian gallery owner.

We chatted a week later. It turned out that she had journaled every day that week using the prompt: “Do I dare write to Marcel?” She explained that she had learned a lot about herself in the process, especially about her habit of fleeing at the drop of a hat. In childhood, she hadn’t been able to flee. She had been watched, controlled, commanded, and punished for taking even the smallest step out of bounds. Now, as an adult, because she could physically flee situations, that’s what she did—and far too quickly, she now understood.

Indeed, she returned to Paris, bravely met with Claude, and had that painful conversation. It turned out that Claude had very little to offer by way of explanation. People “loved the paintings.” People were “wild for the paintings.” Many expressed what Claude felt was a completely genuine desire to make a purchase. Yes, nothing had sold. But, Anne explained to me with relief, Claude was not down on her, had no intention of reducing her presence in his gallery, and in fact expressed his intention to redouble his efforts on behalf of her and her paintings.

Over the months, I learned that several paintings from the show had sold for fancy prices and that her new suite of paintings were progressing nicely. She still had to endure all the challenges that creatives must regularly endure; but her “monumental disaster” seemed clearly behind her. “And I now have a sturdy tool in my tool kit,” she explained. “I now have conversations with myself in writing where the part of me that wants a good outcome can coax my wounded self in the right direction. I now have a friend who is nicer to me than I usually am. And that friend knows all about my tendency to flee! She knows all about it—and she knows how to talk me out of running away.”
 

***


It’s likely that many of your clients have been adversely affected by an authoritarian: by a close family member like a father, mother, sibling, or mate, by someone else close, like a mentor, teacher, clergyman, or boss, or by authoritarian leaders and others in high places.

What ought you try if your client is suffering from an unhealed authoritarian wound that has produced adverse consequences? You can try any of the tips I’ve provided, any of the tactics and strategies you routinely use, and the writing exercises I’ve described. By working in this way, you will help increase your clients’ personal power, aim them in the direction of useful daily practice, help them envision and plan for the future they want, and, in the process, help them upgrade their personality, heal, and grow.


References:

Maisel, E. (2018). Helping Survivors of Authoritarian Parents, Siblings, and Partners. New York: Routledge
 

When a Client Resists, I Persist

Posted on by Psychotherapy.net Team

When it comes to client resistance, I should know better than to blame the client. The burden is on me, the clinician, to adjust my approach, search for my hidden personal biases, repair a therapeutic breach, and empathize more effectively with the client. It is my job to remedy clinical stuckness, to take that responsibility head on, and for good reason. I am the service provider. I am in the position to help. It is not the client’s job to transform my deficiency or blind spot into effective help. I get this on an intuitive level. So why do I get stuck personalizing resistance and harboring secret negative judgements of my clients? Psychiatrist David Burns, author of Feeling Good, suggests that counselors struggle with client resistance because their egos get in the way. He says we are too fragile, therefore strive to protect our pride and identity, forcing us to match the client’s resistance with our own. Thus, to help the client and enhance the clinical work by taking their critical feedback, we must, according to Burns, “put our egos to death.” What he means by this is that I, as a clinician, need to drop my defensiveness so I can truly hear what the client is trying to communicate. Once I am no longer defensive, I am then free to see the client’s resistance for what it really is—information, rather than a personal attack, although it may feel like one. And I can use that information to adjust my approach and hopefully enhance the overall clinical work. In my experience, ego doesn’t go down without a fight; it doesn’t even like surrendering. When I have felt slighted or diminished by a client, my first impulse is to prove them wrong; I want to show them I’m right or that I’m superior, or smarter. This is the dark side of my clinical self. I find it far more clinically useful to expose this darkness to the light. This is no easy task, but the pain of putting my ego to death is worth it. A dead ego means I can engage with the client’s criticism and defensiveness without taking it personally, without being threatened, without having to argue back. The client can no longer offend or wound me. I can harness their criticism and use it as information that changes the therapeutic work. That’s empowering! But this is easier said than done, so below I provide 5 suggestions from my own clinical experience on how to do this: Reframe the client’s criticism/resistance: It is my work to reframe the client’s resistance and criticism as information. They aren’t resisting me; they are, in fact, communicating with me. And what they are saying is valuable information uttered in the hopes of making the relationship better. I try never to ignore this useful information because of my ego. The stakes are too high. Take responsibility: I am the service provider. If the client is resisting, the responsibility falls on me, not them, to remedy the situation. I will not become a defeatist or a helpless blamer of the client. I can make things better. I can directly change the situation. I am not powerless. In order to serve the client, I will own the situation and take concrete steps to address the client’s resistance. The client is a person: The client is in a vulnerable position. They aren’t trained mental health professionals with high-powered degrees, certifications, and letters after their names. How are they supposed to tell me that counseling isn’t working? Their main vehicle for feedback is resistance. Therefore, I strive for compassion for my client and for their need to resist. The client could be teaching me something: It is possible that resistance is the result of venturing into an area of my weakness or ignorance, which is not the client’s fault. I am not all-knowing and comprehensively skilled—becoming a competent clinician is a life-long endeavor. I learn just as much from my clients as they learn from me. Counseling offers me the potential to expose my ignorance. And the possibility of that shouldn’t threaten me; rather, it should excite me. Exposure of ignorance can be gentle; it can also be harsh; but within are lessons that can be used for my growth and the client’s benefit. Modeling: I can demonstrate health to my clients by receiving their resistance in a respectful manner. My goal is leading my clients and modeling healthy give-and-take. The client’s resistance can be a teaching moment where I show them how to offer feedback in a more kind and respectful manner. I recall working with a young man who taught me how to see the benefit of resistance. I remember that anytime we tried to discuss the content of his assigned workbook exercises, he would do everything in his power to change the subject, to mock the content of the workbook, to say it was boring or that it didn’t matter. He would say the exercises were “stupid.” And when he did complete the assigned work, he would write down one-word answers. This always came as a surprise to me, because our conversations at the beginning of sessions were usually engaging and positive. At the beginning of our relationship, we could spend an entire session hour talking about why he didn’t do the homework. I grew tired of the run-around and finally asked if he thought the homework was helpful. He answered honestly. He said doing the homework felt like school. And when it came time to discuss it in session, it ended our positive conversation. He added that I was the only positive male figure in his life. When he was young, his father had abandoned his family, and his mother dated a series of angry and controlling men. All of his teachers at school saw him as the “problem kid.” So it was a huge relief and comfort to be with a man whom he liked and with whom he could have fun, lighthearted conversations. In that moment, I realized that working through the content of a workbook was secondary, and what this young man really needed was a caring relationship from a man with whom he felt safe. I thanked him for his honesty and feedback and adjusted my approach. I focused more on relationship building and made the workbook exercises completely optional. I would only discuss them if he brought it up. From then on, the young man’s resistance was gone, and he voluntarily put more effort into the workbook. Understanding my client’s resistance helped me understand him at a deeper level and, in turn, improved our therapeutic relationship and its outcome. His resistance offered us both the opportunity to grow in our respective roles.

The Double Standard

Posted on by Psychotherapy.net Team

“Of course, I wouldn’t say that to a friend!” My patient, Alice, has come to me for help with depression and procrastination, and we’ve identified her long-standing habit of calling herself “a lazy fuckup” when she gets stuck on an assignment. We’ve been using David Burns’ version of the “Double Standard” method of challenging this harsh negative self-talk. In this role-play method, I play an imaginary best friend who is a clone of her – with her same genetics, childhood background and adult circumstances – who has turned to her for help with her negative thoughts. She’s given me the name “Gina.”

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 “Alice,” I say as Gina, “I’ve been feeling so stuck on this work project and feeling down on myself about it. I’ve been telling myself that I’m a lazy fuckup. Isn’t it true, that I’m a lazy fuckup?”

 “Of course, that isn’t true!” Alice rises out of her slumped position and leans forward, almost as if she were going to lay a hand on ‘Gina’s’ knee. “You aren’t a lazy fuckup. That is such an unkind thing to say.”

“So, it’s not true? Are you just being nice to me because I’m your friend?”

Absorbed in the role play, Alice shakes her head without flinching. “Of course, it’s not true.”

I had a feeling this method would be helpful to Alice, as she has demonstrated plenty of compassion for the others in her life, reserving her harshness for herself, and she had already made progress identifying the distortions in her thoughts. But despite seeing that her thoughts were distorted, she wasn’t quite connecting with her positive, encouraging thoughts. Roleplay methods are often a powerful way to bring home a change at the gut level. I continue with the role play, encouraging her to get specific.
“But Alice, I’m so stuck on this project. What makes you think I’m not a lazy fuckup?”

This takes her a bit more time, and I can see her brain shifting gears, as she starts to engage the work of compassion, work that involves seeing what is there rather than reaching for a label.

“Well, it’s true that you haven’t gotten as far in on the email copy as you would like. And you spent most of the morning doing the New York Times crossword puzzle. It sounds like you are feeling pretty stuck,”

I nod along in character, encouraging her.

“But you did finally sit down to work on it. You haven’t given up,” she continues, “and that is important.”

We both smile.

Why are we kinder to our friends than we are to ourselves? Why do we poke at ourselves with hurtful labels and lash ourselves with should statements, those whips of the mind that create anxiety, guilt and shame? In TEAM therapy, “A” stands for “Agenda Setting,” or “Analysis of Resistance.” In this step, we walk with a patient to see what is positive about negative self-talk and the painful feelings it generates. Alice has come to see that the anxiety, guilt and shame that rise up when she starts to criticize herself for procrastinating, stem from deep-seated values to be productive, to move forward on projects she cares about, to engage instead of to withdraw. Telling herself she is a lazy fuckup is a way to keep herself from enjoying her procrastination too much, a kind of guard rail that protects her from the consequences of not getting her work done.

So, knowing that there are good reasons for her to stay stern with herself, I test her again, giving another one of her harsh thoughts, in my role as Gina. “But Alice, shouldn’t I just get over myself?”

“No, no,” Alice’s eyes are warm. “You want to move past this, I can see that. But name-calling and pressuring yourself won’t be helpful. You can get past this place where you are stuck. It’s going to be hard, and scary, and you might be tempted to believe you can’t do it. But I believe in you, and you can always call me for encouragement.”

“Wow,” I say, wanting to linger as ‘Gina,’ and bask in her kind encouragement, “that feels incredibly good hearing you say that. I feel so seen and supported and encouraged.” Reluctantly, I add, “can we hit the pause button?” She nods and sits back. She is calmer, sadder, tears in her eyes. She seems fuller.

“Wow, indeed,” she says. “I know where you are going with this. Can I talk to myself that way?” She considers this. “It should be a no-brainer. I mean, right now at this moment I feel so connected to you as Gina – it seems easy to want to stay present with her and encourage her. But somehow, when it comes to me, I feel hesitant.”

“Yeah, go on. There is something important in your hesitation. Why would you be hesitant to stay encouraging instead of punitive with yourself.”

“I really, really love to procrastinate. If I’m kind to myself the way I am with Gina, I will feel better, and then how do I know that I won't just get soothed and feel better and jump on the couch with another crossword puzzle? Being strict with myself is the only way I can stay on task.”

“So, your worry is that if you let up on yourself, that you’ll become self-indulgent?”

“Yes, exactly,” she nods.

“And what would your self-indulgent voice be telling you. What are the thoughts that tempt you to the couch?”

“Oh, I’d tell myself that I can totally do this tomorrow and that I deserve a break.”

“Can we go back into the role play?” She nods, and I resume again as Gina, “Alice, thanks so much for those kind words about my project. I feel so much better that I’m going to grab that crossword and go sit on the couch. I deserve this break.”

Alice starts to crack up.

“Oh no, you don’t my friend! I love you too much to let you do that. This project is really important to you! You won’t have time later, now is the time to do it! You can do that crossword after you finish this email copy and after you confirm your plans with Diana.” She breaks from the role play, “I get it now, kindness and accountability are all wrapped up together.” She sees me open my mouth, and beats me to it, “Now that’s something I would say that to a dear friend, and to myself.” 

Tools to Help My Patients

Posted on by Psychotherapy.net Team

Coping Strategies and the Paradox of Change

When patients come to me, they are already using various coping strategies to regulate their emotions, improve their mood and deal with challenges. Their strategies—such as drinking, withdrawing, gambling, eating, or hoarding, as maladaptive as they might be—are seemingly essential to their survival. And they are effective… until they aren’t, which is generally the point at which I meet many of my patients for the first time. In fact, their coping strategies can and often do become the major source of their adjustment problems.

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The paradox of change—“Doc. Please help me to change, but change is scary so I’m going to stay put. Accept me as I am.”—can be more readily seen when viewed in this context. It is vital for the therapeutic relationship to recognize that I am essentially asking my patients to strip away the very things that they have been clinging to for survival.

Among other goals for therapy, such as learning to manage emotions, making sense of their past, and assisting with the other changes they desire, therapy is also about “tool replacement”: I’m helping people replace harmful coping strategies with new, healthier ones.

However, if patients have experienced a great deal of trauma, I must sometimes collude with my patients’ denial to maintain their existing coping strategies before beginning to help dismantle them. To illustrate, I must first work with a patient who has experienced complex trauma to resolve some of the trauma while they continue to drink. Otherwise, a premature referral to AA could be a set-up for therapeutic failure.

Reducing the Layer of Judgment

Not only do my patients have various coping strategies, but they often judge themselves harshly for having to rely upon them. A way of explaining the layer of judgment is to use the metaphor of the panopticon, Jeremy Bentham’s 18th century semicircular prison design that allowed one guard to simultaneously watch all prisoners without their awareness of being watched. In the case of therapy, the all-seeing guard is also the patient. The layer of judgment that patients see as they look down on themselves from the guard tower includes:

“What’s wrong with me?”

“Why can’t I be like other people?”

“Why can’t I just get over it?”

There is a common emotional thread woven through these self-statements, and it is often shame. Therefore, I have to help them identify how they feel. Also, I try to help them understand what shame feels like and what it is. I tell patients that shame feels like “embarrassment times 10.” I also distinguish guilt from shame: “Guilt is feeling bad for what you do. Shame is feeling bad for who you are.”

These self-statements, along with embarrassment, remorse, and shame, create the layer of judgment that can make their difficult situations worse. This layer is like a lid on a pressure cooker: it keeps the entire mechanism in place.

To illustrate, I often use the example of obesity. Obese people generally know about the mechanics of weight loss better than people who have never struggled with weight gain. But if weight loss were about simple mechanics, no one would be obese. For that matter, no one would engage in any unhealthy activity.

But obese people often use food as a coping strategy to regulate their emotions. When they subsequently tell themselves how awful they are, it generates more emotions that they have to manage. And how do they best know to do it? By consuming more comfort. The next day they are filled with remorse and shame—which then needs managing. The result is a vicious cycle: the very coping strategy they feel ashamed of is prolonged.

So, for change to occur, this layer of judgment must be challenged with as much compassion I can offer and self-compassion they can muster. Change comes not from self-condemnation, but from greater acceptance and higher self-regard.

Achieving the “No Wonder” Goal

To achieve greater acceptance while reducing self-condemnation, my role is to help patients find healthier coping strategies both through the process and from the material. One way to ease the layer of judgment and reduce the concomitant shame is to propose working toward what I call the No Wonder Goal.

The aim of the No Wonder Goal is to have an emotional understanding of how and why their coping strategies picked them. Please note the specificity of the language. I often tell my patients, “You didn’t pick your coping strategies. They picked you.” In other words, no one starts out drinking to become an alcoholic or begins collecting to become a hoarder. Rather, the psyche says, “Aha—relief! I found what I need to calm down.” What starts out as a social activity, a hobby, or an adventurous undertaking can turn into a destructive addiction, compulsive activity, or manic behavior.

The purpose of working toward this emotional understanding is to thin the layer of judgment and to soften their self-condemnation. I recently had a patient who developed a driving phobia who was condemning herself for her irrationality. I said to her, “It makes no sense that you’re afraid to drive. It used to be no problem. However, these days, just going to the store can be scary! Your psyche is trying to protect you from harm, perhaps even trying to save your life from COVID. What a better way than to stop going places. Your home is where you are safe, so it’s no wonder that this particular coping strategy picked you.”

I also try to transform what has been concretized back into a metaphor. As an example, a porn actor with severe OCD went through an entire bottle of hand soap daily and washed his face at least 25 times per day. During one session, I said, “Could it be that you wash so much because you feel ‘dirty’ being a porn actor?” Through the No Wonder Goal process, he realized that he felt dirty inside, and no amount of washing would make him clean. He was then able to transform the concretized activity back into a metaphor, and as a result, became less judgmental about his OCD.

Of course, it takes months and possibly longer for this idea to sink in (to be an emotional understanding). But many patients have mentioned without solicitation that in the one session when I introduced the No Wonder Goal, they felt a sense of relief and a little less shame.

For greater acceptance, I can also ask, “Does this self-condemnation sound like someone from your past?” Most of the time, patients will tell us that it sounds like their mother or father. Let’s say the patient’s mother’s name is Katie. I will say something like, “OK, so this is your Katie-brain talking to you. Katie was trying to protect you, but in a misguided way.”

The other intervention is to call the self-condemner a committee member (with a caveat for dissociative patients). “What is this committee member saying to you? Can you let the committee member know that you appreciate the protection but that you don’t need it right now?”

Over time, patients realize that this part of their psyche serves a very important function, and its purpose is to protect them against a real or perceived threat. And how can they hate themselves for that?

Tool Replacement

I’m not going to elaborate on the actual tools, since they are generally known—avoiding withdrawal or being controlling, asserting themselves more, connecting with others, expressing emotions, just to name a few. However, it would not be therapeutic nor practical to try to dismantle patients’ coping strategies without helping them build healthier ones or build onto the ones they already have in place. Sometimes I provide them with new tools while their old coping mechanisms are still in place. At other times, as they use their new tools more, the older ones organically diminish.

One tool that I value is to ask patients to use their feelings. Frustration and anger can be transformed into determination, jealousy can produce striving, and sadness can be used to find acceptance. The example I like to give is MADD, Mothers Against Drunk Driving. They gathered their anger, pain, and despair to become the most effective group to educate others and strengthen drunk driving laws.

Recall that tool replacement exists in the process as well as in the material. The process of opening up about their shameful coping strategies, crying over them, and acknowledging missed opportunities and lost relationships is a form of grieving. Grief must happen for greater acceptance. This process, plus exposing their vulnerability as we accept them as they are, can lead them to feel better about themselves, have greater peace of mind, and enjoy more satisfying relationships.

Reducing harsh self-judgment, knowing how they got to the place where they were when they walked through my door for the first time, and managing their emotions with new coping strategies can truly be transformational.  

Barry Duncan on The Heart and Soul of Change

Posted on by rezendevknowfully.com

Routine Outcome Monitoring

Lawrence Rubin: You’ve dedicated your professional career to improving clinical outcomes and effectiveness at the individual and organization level with the Partners for Change Outcome Management System (PCOMS). Can you tell us what this is and why you think it’s so important for optimizing clinical outcome?
Barry Duncan: It’s really a very simple idea that fortunately has had a great return on investment. The idea is simply that you monitor outcome with clients and you identify those consumers who are benefiting from whatever treatment or service that you’re providing to them. You then put your heads together with those clients that aren’t benefiting, collaboratively deciding what to do next and based on the information of their lack of benefit, create a new treatment plan. Try a different venue of service.
Try everything at your disposal that meets the client’s resources and needs and your own areas of expertise and limitations
Try everything at your disposal that meets the client’s resources and needs and your own areas of expertise and limitations. And ultimately, maybe give them to a different provider if you’re not able to get things back on track. So, it is a process of monitoring clients’ response to treatment, and then using that feedback to determine the way the treatment is delivered. So, if it’s working, you rock and roll, keep doing what you’re doing. If it’s not, then you figure out what else to do. That prevents dropouts, and by recapturing those clients who would otherwise not have benefited, you can improve your outcomes quite substantially.
LR: In the truest sense of the word, and perhaps invoking Carl Rogers, it is truly client centered, for together with them we become partners for change.
BD: That’s exactly it. And that’s the part that the field is a little slower to come around on. The idea of routine outcome monitoring is generally thought of as a therapist-driven process. You know, we monitor outcome and then we get our expert information, we figure out what else to do with people. PCOMS is client directed. We get the information collaboratively from clients and then together, we figure out what to do next based on their reaction to the treatment being administered, their reaction to the services, their experience of the alliance. From there, we can formulate a better path for them if they’re not benefiting from our therapeutic business as usual.
LR: So, your approach to working with clients is really trans-theoretical and trans-methodological. A clinician can bring in their own pet therapy as long as they listen to the client as to how that therapy is working.
BD: That’s exactly it. So, do what you do that works best for you and your clients until you have direct evidence from the client that they’re not responding to that, your business as usual, and then, with that, you can move on and try other things. This also happens to be a great way to grow as a therapist in that you don’t always do what you’ve always done, you step outside your comfort zone and do things you’ve never done with people before, and therefore grow and expand your own repertoire of interpersonal relationship and technical therapy skills.
LR: Didn’t Einstein have something to say about doing the same thing over and over again and expecting different results?
BD: It doesn’t make sense to continue doing the same thing in the absence of response from the client. And we only know if our treatment is working if the client says so, if they are monitoring their benefit and reporting that on outcome measures. We haven’t been very good in our field at changing tracks. When treatment fails, therapists are quick to attribute it to client pathology or resistance. Only later do they consider perhaps that “I’m not competent enough to deal with this person.” So, first, we shoot the client, and then the therapist, right? But we don’t want to shoot anybody actually; we just want to alter the treatment to better fit what the client will respond to.

For the Love of Model

LR: Why are therapists so entrenched or in love with their models and techniques? What makes it so difficult for them to say, “This isn’t working. I need to change?”
BD: Our field has had a long love affair with models and techniques. I mean, we’re really enamored of them.
We begin to believe that our models represent truths about human beings, rather than being metaphorical representations of how people can change
We begin to believe that our models represent truths about human beings, rather than being metaphorical representations of how people can change. We just over-attributed the truth value to all these different ways of thinking about things, and some fit our own view of how people really are, our own view of ourselves, and we hold those close and dear.

That makes it very difficult to say that it’s not the client, it’s actually the method that I’m using, and can we find another thing that’s a better fit? It is very hard to let that sense of certainty go, leaving us with the existential angst. It’s like, “Well, if I don’t have these certainties to hold onto, I’m in the abyss of uncertainty when I’m with clients and I won’t know what to do next.” So, the models give structure and focus to the work, and help us manage our own anxiety when we’re in the room with somebody in a lot of distress.

We also have to acknowledge that there’s no conceivable way that every client will respond to a model and technique that we’re using. If that were the case, we’d all use the same one with everybody that walked in the door. In reality, it’s a far more interactive and changing process that we engage in with clients as we try to figure out what will work best with them. 

The Rating Scales (ORS/SRS)

LR: Ironic isn’t it, that on top of this inflexibility, your research strongly suggests that therapeutic technique accounts for only a very minor portion of treatment outcome. Yet still we cleave! May we shift here to a discussion of your remedy for this dilemma which is routine outcome monitoring and use of rating scales like the ORS and SRS?
BD: I’ll start with the Outcome Rating Scale (ORS). It is a four-item analog scale that asks the client how they’re doing in the major areas or domains of their life: individually, their personal wellbeing; interpersonally, how things are going in their close family relationships; socially, how things are going with them outside of the family in the social world at work, school and with friendships; and finally how they are doing overall in their life. The client puts a mark on each of the four 10-centimeter scales. This results in four individual scores and a total score between zero and 40. It takes about 20 seconds to do.

What clients do, amazingly, is that they imbue their life and their life experience on those four little lines of the scale
What clients do, amazingly, is that they imbue their life and their life experience on those four little lines of the scale, and whatever presenting concern they have, they represent that by the scale they mark the lowest. So, if they’re struggling with anxiety or depression, they’ll usually reflect that on the individual scale. If they’re having a relational problem with a kid or a partner, they’ll reflect that, and so on. And so, it goes from this general view of how life is going to a specific representation of what they’re doing in therapy. And at that point, then, it becomes a valid measure of therapy’s progress.

The Session Rating Scale (SRS) is a classic alliance scale built on the major ways of looking at the therapeutic alliance. In fact, it’s built on Borden’s classic view of the alliance, which is the relational bond, the Rogerian triad variables, the degree of agreement with the client about the goals of therapy and then how you’re going to accomplish the goals of therapy. So, it’s a quick check with that. We do the ORS at the beginning of the session. We do the SRS with about five minutes to go in the session to check with them. In essence, we are asking the client, “how is this for you here today?” This way, we can alter our approach if it didn’t go well or there’s something else they want to make sure that we do.

My own style is to do a wrap-up of the session and a take-home message. I ask the client if they have a take home message from the session, and then I give the SRS to check in with them about their experience of the session, with the idea being that
I’m building the alliance, not just giving lip service to it. I am very interested in their experience
I’m building the alliance, not just giving lip service to it. I am very interested in their experience. 
LR: Are these measures a hard sell to clients?
BD: It is not a hard sell at all. First of all, they only take about 20 seconds to fill out, and so it’s not a big investment of time or energy. And it’s all in how you present it to clients. If you’re flicking forms and not using the information, clients are going to get tired of it in a hurry, but if it’s integrated into the therapy that you’re doing, and it makes some sense and they see the benefit of it, then it’s not a hard sell at all. I simply say, “Look, I like to work and use these two very brief forms. The first one is the ORS, and this is a way to ensure that your voice remains central to everything that we do here, that your view of whether your benefiting is going to actually direct what we do in our sessions. And second, it’s going to be the way that you and I can collaboratively look at whether you’re benefiting, and if you’re not, you and I will put our heads together and figure out what else to do.”
LR: I would imagine most good therapists implicitly incorporate some sort of client feedback into therapy. Is there a real difference between those who implicitly check in with their client and those who use standardized measures such as these?
BD: The other advantage is that you have this incredible data that lets you know your effectiveness, so you can then strive to get better and do things to improve yourself over time. You can actually monitor your career development as a therapist and know whether the strategies that you are implementing, the new things you’re learning, are actually improving outcomes. Also, when you have data, then you have your client list, you can look at your client list, and of course, that’s what software does for you. You know, you have a client list and you can look at a glance and see who the clients are who aren’t benefiting so that you can reflect more about them, talk to a colleague, talk to a supervisor before you see them again. And we found just that process alone, to be more reflective about what you’re doing, improves outcomes, improves effectiveness.

PCOMS-The Heart and Soul of Change

LR: And that’s really where psychology is attempting to go; in the direction of a science-based and empirical-based foundation for what some have otherwise called soft science or an art. I’d be remiss if I didn’t ask you to tell us what PCOMS is. We’ve been talking around it?
BD: PCOMS is the Partners for Change Outcome Management System, the title for which came from the book, Heroic Clients, Heroic Agencies: Partners for Change that Jacqueline Sparks and I wrote. We conceptualized the whole therapy process as working together with clients as partners for change. PCOMS brings this partnership process to routine outcome monitoring using the SRS and ORS to solicit the client’s response to therapy and their experience of therapy through the alliance measure. I co-developed the measures with Scott Miller and then developed the process of using them clinically in what would become the EBP of PCOMS. Jackie and I wrote the first PCOMS manual.

I thought it was a great idea to check in with clients more formally, and I wanted to get therapists to talk to clients about outcome and the alliance. Then, we started doing the research to validate the measures and not only were these short, feasible and easy to do, but they were also reliable and valid when compared against much longer measures like the OQ45, Michael Lambert’s gold standard outcome questionnaire. And then, finally, I was able to say, “Well, gosh, I think this really works. Let’s do the language of science. Let’s do a randomized clinical trial.” And
with my colleagues, Morten Anker and Jacqueline Sparks, we did the first RCT of PCOMS. And since then, we’ve done seven more that have shown the increase in benefit
with my colleagues, Morten Anker and Jacqueline Sparks, we did the first RCT of PCOMS. And since then, we’ve done seven more that have shown the increase in benefit.

We next expanded our research populations and implemented the PCOMS in many large organizations. My own main work has been in public behavioral health, so I really wanted to apply it to clients who are often get the short end of the stick. We’ve shown that use of the system improves outcomes in real-world settings where we can achieve outcomes comparable to those achieved in randomized clinical trials. The final step in the evolution of these ideas is performing RCT’s in integrative care, and then making it even easier through technology. We launched a web version of PCOMS called Better Outcomes Now, which allows the whole process to be automated, easy and very visually appealing to clients. 
LR: Because I’m a child clinician, I wonder what challenges you’ve had using your system with kids, considering their developmental differences.
BD: Great question. There are, obviously, developmental differences, and we have implemented with kids since the very beginning. You know, I did family therapy and seeing children has been a part of my own development as a clinician, and so I wanted to develop measures right away that would apply to kids. Soon after the ORS and SRS were developed, Jacqueline Sparks and I applied these measures to children ages six to twelve. In fact,
the child outcome rating scale is the first self-rated outcome measure for children six to twelve in the world
the child outcome rating scale is the first self-rated outcome measure for children six to twelve in the world, because previously, only parents were rating children that young. When you have a child in therapy, it’s always a good idea to get a parent view or an adult view of how the child is doing, as well, just for the reasons that you speak to. While we validated the measure for six-year-olds, that doesn’t necessarily mean they all get it. They have difficulty connecting the dots between what is talked about and what happens in therapy, and what’s going on in their life from session to session.

By the time a child is nine, they pretty much can make that connection, so you have to use your own judgment. That’s why we always also want to have the parents’ view of how the child is doing. On the research side, we just published an RCT that we did in the UK with Mick Cooper with children under 11 years of age, which demonstrated a very similar feedback effect using the Strength and Difficulties Questionnaire, which is a mandatory measure in the UK.
LR: Am I correct in assuming that with kids, you would use pictures on the SRS rather than words, per se?
BD: First of all, the child versions of these measures are in eight-year-old language, and there are faces. There are happy faces and frowns that give an orientation to the child. It’s basically, “How did it go for you today? Did you like what we did? How are things in your family? How are things at school?” So, it really puts it in a way that children can understand. I think it’s been very nice to do with kids, because kids can be very lost in the shuffle and not have a voice.
I think a good therapist will make sure that children have a voice in therapy, but this systematizes the process
I think a good therapist will make sure that children have a voice in therapy, but this systematizes the process. And whether the measures are valid, I’m still going to use it to check in with the kid.
LR: For the connection.
BD: Yes.
LR: I’m wondering if the PCOMS has been effectively used with families? Are you actually going to give out the SRS and the ORS to six family members in the room, or is that sort of an insurmountable challenge?
BD: It’s not an insurmountable challenge. Actually, it works quite well with families. The more people you get in the room, the greater the logistical challenge, so you’ve got to use it wisely. For example, if I have five people in the room, and the kid is presented as a problem, I’m going to do only the key people. I’ll have everybody do it, but the only data I’ll record will probably be the kid or the main parent that’s there, or both parents, if they’re there. If I also have grandma and a pastor, I’m certainly going to include them in the conversation and get their viewpoints, but the data points will be the parent(s) and the kid.

And you know, in this day and age you can have two iPads in the room for filling out the scales. Twenty seconds each and I’m rocking and rolling. I can put all their scores on the same graph and talk about it in that way. It quickly cuts to the chase with families. I really like that about it, so I’ve used it with families since the very beginning. I know who is seeing the problem the most, who is seeing it the least, what the differences are, and I have them explain those differences to me right at the top of the hour.
LR: I can see therapists believing that they can easily use the PCOMS measures without training. What do you say to them?
BD: I would encourage them by saying, “I’m glad you’re really interested in this and you’re seeing the benefit this could bring to your practice. So, I would just ask you to invest a very small amount of time. For example, you know, on our website, betteroutcomesnow.com, there are 250 free resources. There are 20-minute webinars about every aspect of doing PCOM, so with very little time investment you can access a whole curriculum of reading and watching free videos about how you might do this.” So, I think it’s quite possible for a thoughtful therapist to implement this just with the available resources.
LR: You’ve mentioned, and I’ve read in your work, that you’ve applied the PCOMS at the institutional level in community mental health centers and hospital settings. And I know documentation is critically important on that end of it. What challenges and benefits have you seen in this facet of your work?
BD: There’s almost always, at the very least, institutional apathy, if not resistance. Because the way therapists are in institutions tends to be “Oh, now, gosh, here’s the new paradigm shift. The next one will be five days from now. Let me just hunker down, the storm will pass, and we’ll go back to business as usual here.” One thing that’s helped is that the three main accrediting bodies now require client generated outcome data.
LR: Yours or just in general?
BD: In general. We’re one of the approved ones, but nevertheless, it’s required now, and people are coming to grips. If they’re going to be re-accredited or accredited by COA (Council on Accreditation) or JCAHO (Joint Commission on Accreditation of Healthcare Organizations), they’re going to have to face this. So, that’s the wakeup call to a lot of places which is making them move. However,
if an organization’s mission is to put consumers first, outcome monitoring allows for an operationalization of that mission in a very real way
if an organization’s mission is to put consumers first, outcome monitoring allows for an operationalization of that mission in a very real way. That’s an institutional benefit. As a quality improvement or quality assurance initiative, this allows the organization to know whether any of their initiatives are actually working—the beauty of data. You can know at the individual provider level, you can know at the program level, you can know at the location level.

Let’s say you implemented another evidence-based practice like functional family therapy for your kids who have been adjudicated. So, you spend the money, you get the training, you implement it. You’ll know whether that was or wasn’t money well spent because you’re collecting data on every client that comes in the system. So, besides the benefit of looking at your supervisory practice, identifying at-risk clients and looking at programs to address the needs of people who aren’t benefiting, you can track each program to see which ones are really doing the job for you and which ones are not. And again, not to be punitive about that, but to learn from that data what else you can do to improve your outcomes. The largest public behavioral health venue in Arizona, Southwest Behavioral Health, was an early adapter of PCOMS. By collecting and analyzing data, they have been able to raise the bar of their performance in all their programs, including their inpatient units. So, there are institutional benefits, but it’s not for the faint of heart to implement this. You’ve got to be in it for the long haul. You’ve got to think this whole process through.

The Heroic Client

LR: We began by discussing the PCOMS, its use in the individual consulting room and then its use at the institutional level. I’d like to drop back to the level of the client/therapist relationship and ask about the so-called “heroic client” you discussed in your book of the same title.
BD: I coined the name of that book, like I did The Heart and Soul of Change. Titles are important and in guiding readers. For too long, we’ve thought of the client as this helpless victim of their own psychopathology. But what if we think about clients in terms of what they’ve endured, what they’ve accomplished, what they’ve overcome.
The metaphor of the heroic client was a way of shifting our thinking about therapists riding in on this white horse of theoretical purity and brandishing the sword of evidence-based treatment to slay those psychic dragons that terrorize them
The metaphor of the heroic client was a way of shifting our thinking about therapists riding in on this white horse of theoretical purity and brandishing the sword of evidence-based treatment to slay those psychic dragons that terrorize them. It’s their story of transformation, not ours.

We’re a useful component of change in that story, but it’s not us making those changes, so I just wanted to shift that. The notion of the heroic client is really borne out by the literature which says that the client and their life factors account for the majority of the variance of change in psychotherapy. If look at how change happens—at meta-analytic views of psychotherapy change, about 86% of it is due to the client. If we discard them in the process, or only see the more negative sides of who they are, we are really starting out with two strikes against us in terms of how change happens. In fact, we are embarking on a new, edited book process about the common factors, and one of the themes of the book is that you should spend your time in therapy commensurate to the amount of variance that the different factors account for.

Since client variables account for 86% of outcome, you probably ought to be spending most of your time harvesting, recruiting, activating clients’ resources, strengths and resiliencies. You’ve got to spend a fair amount of time doing that because clients walk in with a lot already to contribute to the process of change.
I call it soliciting these heroic stories, because where there’s pain, there’s endurance; where there’s suffering, there’s coping and where there’s destitution, there’s desire for something different
I call it soliciting these heroic stories, because where there’s pain, there’s endurance; where there’s suffering, there’s coping and where there’s destitution, there’s desire for something different. Those are the sides of the story I want to come out in my interview with a client, these more heroic aspects of who they are. Doing this doesn’t invalidate the struggles that they’re having, but it also puts it next to the other things about them that could be utilized to deal with the struggles they’re having, if that makes sense.
LR: It reminds me very much of some of the basic tenets of narrative therapy and solution focused brief therapy in that it’s really the therapist’s obligation to dig into the life of their clients to find evidence of strength and resilience. You know, it’s interesting. Patch Adams said that if you treat a disease, you win or you lose, but if you treat a patient, you win, regardless of outcome.
BD: It is a real shift, and as you mentioned, there are approaches that line themselves up with that shift, like narrative and solution focused views, and positive psychology as well. The Heart and Soul of Change books have been best sellers because people like the idea. I wrote an article in 1994, published in Psychotherapy and with Dorothy Monaghan, who was a student of mine at the time, about the clients’ frame of reference guiding psychotherapy.

I had been publishing for almost 10 years at that time, but I got more requests for reprints from that article than all the other articles I’d written. I got almost 1,400 of them for that article. So, the idea of the common factors and actually operationalizing them, what that actually means in therapy, really resonated with a lot of people. So, of course, then that led into “The Heart and Soul” and all that business, so I think there are a lot of people out there that these ideas resonate with, and that speaks to this shift and the way that psychotherapy is thought of as a far more collaborative, client-directed process.
LR: In therapy, we try to teach clients, if i may evoke John Bradshaw, how to move from the perspective of human doings to human beings. In your model, we’re asking therapists to do the same, “Don’t be a therapist, don’t be someone doing therapy. Be someone in a caring, monitored relationship with a client, with whom you’re not central, but influential.” It’s almost liberating for the therapist.
BD: I think that is liberating, for sure, and I think that in the course of training, younger clinicians really get that. They like the liberation that flows from the idea that “we’re in this thing together. It’s not solely my responsibility. I don’t want to have to figure everything out, we can come to some terms about what change means.” The measure then provides some structure to that process about how you know whether the client is benefiting and how is the client experiencing their time with me so that I can alter that. So, in that way it does free you from having to know the right way to be a therapist, as if there is some golden right way to be or right method to use. We’ve been in search of that holy grail throughout our history as a field, but it’s not been very fruitful considering all the different models and techniques.
At last “count”, I think it was up around 400 different models and techniques, and still no holy grail yet
At last “count”, I think it was up around 400 different models and techniques, and still no holy grail yet.

In Search of the Grail

LR: Why do you think the field is so hell-bent on finding the holy grail? Is that taking us away from the true holy grail, which is the relationship with the client?
BD: People are so dismissive of the relationship, it drives me crazy. It’s my biggest irk with the field, that people think that, “Oh, you form a relationship and then you do the real treatment.” It’s like it’s anesthesia before surgery, right? We dumb the client down with our Rogerian reflections until they’re asleep, and then we kind of on the sly stick it to them, right? It’s crazy, because you could make a much stronger empirical case that the relationship alliance is the therapy, right? That’s the continuum for everything to happen, all the exploration, and it’s not easy to experience with everybody that you see. You have to work at it. I used to love it when someone would come in and we’d hit it off great, we got down to what we needed to be doing really quickly, but then there’s everybody else. It’s the same with those people who are not so sure about therapy or they don’t want to invest, or they’re mandated, or they haven’t ever been in a good relationship, or they’ve been screwed over so many times. My job is still the same. I’ve got to form a relationship with that person, and it’s not easy. It’s a daunting task. It’s not something I do just because I’m a nice guy. So, it’s those things that are real misconceptions about the change process and the skill it takes to form strong alliances with the varied amount of people that we see.
LR: I can’t tell you how many times I hear from interns, “Okay, I built rapport. Now what do I do?” It’s just amazing.
BD: It’s such a simple idea of just asking the client, what do you think, do you have any ideas? A lot of people have ideas about how things started with their struggles, and perhaps even ideas about what would make it any better? You know, I call it the client’s theory of change, and it’s a great alliance building tool, and a way to dig into their own viewpoint. And you know, what I find is clients have very good ideas. Not all the time, but most of the time. These are worthwhile questions to ask. And you know, what do I do next? Well, what does the client think about that? That’s my broken record in the situation. What does the client say? Then you talk to them about them not benefiting. What are their ideas about that? That’s what you’ve got to do, have a dialogue about this.
LR: What would you offer to the readers who are not really tuned into this whole evidence-based relationship gig yet, or who are not even aware of the value of client-driven informed therapy. What would you offer as closing words?
BD: My closing words to them would be, take a step back and think about the way that they are a therapist, and what their identity is as a therapist, and who they aspire to be as a therapist. And that it is a relational process more so than any other way that you can describe it.
Therapy is not a biomedical process, it’s not diagnosis plus prescription equals cure
Therapy is not a biomedical process, it’s not diagnosis plus prescription equals cure. That’s not what we do. It’s a relational process. The main things that account for outcome in psychotherapy are the people involved, the client, the therapist and their relationship. These account for the overwhelming majority of outcome variance, so they should focus on those aspects, harvesting the client, you know, monitoring their own outcomes and improving themselves in that way, and then putting their efforts into getting better at their relational repertoire.

That would be the way they can improve. In fact, my recipe for improvement is to focus on harvesting client resources, abilities, and the therapist’s alliance and relational abilities. And the way that you can get at both of those things is to monitor outcomes in the alliance with clients. It’s long-winded advice, but nevertheless, that’s how people can get going. And there’s lots of free stuff to help them do that. Very brief videos to help getting their thinking process going about all those things on the website I mentioned.
LR: As you make these concluding comments, I think of medical practice, and it seems that doctors have this built in magic by virtue of their tools, medicines, techniques and machines. I wonder if medicine could be better oriented if it moved in the direction of outcome monitoring, patient collaboration and relationship building.
BD: I think this would be a very nice fit into the primary care world, and in fact, a colleague and I, Bob Bohanske, developed and validated primary care measures analogous to the PCOMS. The next step will be an RCT, and so they’re patient-guided quality of life measures. We believe that if patients improve the quality of their life with treatment, then that will translate to biomedical markers. The physician checking in to ensure that their intervention is what the patient is looking for—the part of their life they’re most distressed about, and then checking in with them that it was indeed a collaborative process, we think will have an impact on chronic illness outcomes.
LR: This seems to be a necessary next step; taking all that you’ve learned from psychotherapeutic relationships to medical relationships and treatment.
BD: Absolutely.
LR: I want to thank you Barry, for the voluminous amount of time and research you put into developing PCOMS, the contributions you have made to the field and for sharing your time today.
BD: Great, great. No, Larry, thanks very much. I enjoyed it. My pleasure, totally.

Listening Up and Leaning In: Active Listening in Therapeutic Relationships

Posted on by Psychotherapy.net Team

As a brand new, inexperienced first year medical student, I took the required patient interview course. Actors were hired to portray patients with a variety of medical conditions. On my first day, dressed in my short white coat, notebook in hand, I entered the exam room. “Hi, my name is Dr. Anthony (I was a young, single student at the time),” I began. “What brings you into the office today?” As soon as my patient began her story, I started to formulate my next question while anticipating her possible responses. I heard everything she said, evidenced from the copious notes inked in black on the pages in my hands. But, I really didn’t listen to a word she said. Over the years, I have learned the importance of active listening. As a student, I focused on hearing my patient’s account of her illness, allowing me to gather pertinent details. Now, as an experienced clinician, I have come to appreciate how active listening serves the additional goal of helping the listener gain understanding and trust. I have also come to realize that in most circumstances, how the patient experiences our interaction is as important as what he or she tells me. While my training taught me how to gather details, it did not teach me the practice of active listening. Studies suggest that the brain’s reward system is triggered during active listening. In a 2015 study published in the journal Social Neuroscience¹, researchers selected 22 participants who were video recorded while reading essays they wrote about a variety of their life experiences. Evaluators (actors hired for the study) were instructed to view these videos and demonstrate either active or non-active listening behavior. Researchers then conducted functional magnetic resonance imaging (fMRI) on participants while they viewed the evaluators assessing their video clips. Participants rated both the evaluators who showed active listening and the episodes where there was active listening more positively. The results also showed enhanced neural activation in both the ventral striatum and the right anterior insula when active listening was perceived. These brain areas are associated with motivation and reward. Both results suggested that the active listening process was rewarding in the truest sense of the word. Active listening allows us to gain a deeper understanding of our patients. When we understand our patients, we gain insight into their complex lives. We begin to see beneath the layers of their narrative to the “real” story. When we give our full attention to a person, we are able to maximally receive his or her message while decreasing the interfering “noise” of our own thoughts. The noise is all those activities our brains engage in when we are not listening to the person who is speaking. With active listening, our focus centers on truly and deeply knowing the other, instead of being known. A patient labeled as ‘non-compliant’ for not taking their medication becomes a patient who, after losing his job, is too depressed to get out of bed in the morning and muster the energy to take their medication. When we build trust with our patients, they find comfort and safety as they reveal their concerns. We trust that what they are telling us is their best understanding of what they are experiencing. We are not imposing our agenda on them and are able to receive what they have to share with us. Of course, there are times when our agendas are important as certain details must be clarified and understood in order to allow us to do our jobs. However, active listening helps us forge more holistic relationships with our patients, giving us a clearer picture of the individual sitting across from us. With intention and practice, active listening helps us become attentive and receptive to what another has to say. Your own emotions might shift in response to what is being shared. You will know another person in a way that you didn’t previously, increasing your capacity for sitting in his or her experience or emotions. Active listening engages empathy, also housed within the brain. How good of a job are you doing at bringing active listening into your conversations? The International Listening Association suggests asking yourself these questions to understand whether you are engaging in active listening: Are you giving the speaker 100% of your attention? Are you listening to understand, rather than listening to respond? Have you opened your mind to receive what is being said? Have you rejected the temptation to prepare your response while the other person is speaking? Are you open to changing your mind? Are you aware of what is not being said as well as what is being said? Are you taking account of the degree of emotion attached to the words? Are you aware of any differences, and similarities (such as culture, age, gender) between you and the speaker which may influence how you listen? Are you giving signals to the speaker that you are listening? Are you valuing the speaker and the experience they have gathered in their life so far? Active listening is an important tool in every doctor and therapist’s toolbox. It can help facilitate more trusting and deeper therapeutic relationships. In our professional and personal lives, active listening can lead to more connected and rewarding interpersonal interactions allowing us to experience even greater fulfillment. Resources

  1. Perceiving active listening activates the reward system and improves the impression of relevant experiences. (2015). Kawamichi, H., Yoshihara, K., Sasaki, A T., et al. Social Neuroscience.