Category: Advanced Clinical Skills

Gary Greenberg on the DSM and Its Woes

Posted on by rezendevknowfully.com

The Book of Constructs

Deb Kory: Gary Greenberg, you are a psychotherapist and a writer, author of Manufacturing Depression: The Secret History of a Modern Disease and, most recently, The Book of Woe: The DSM and the Unmaking of Psychiatry, from which we’re featuring an excerpt to go along with this interview. You’ve written for Mother Jones, Harper's, Rolling Stone, The New Yorker, The Nation, and McSweeney's to name a few. In these books you've taken on the mental health industry, psychiatry, pharmaceutical companies, and the culture they have created. Let's start with your most recent book, The Book of Woe. Why did you decide take on the DSM?
Gary Greenberg: Well, I actually didn't decide. I was happily ignoring the whole thing and knew what any person scanning The New York Times would have known until I got a phone call from Wired magazine asking me if there was something about the DSM that might be worth their while. At the time I was sort of aware that there was this rebellion at the top within the American Psychiatric Association—that the guys who had done the DSM-III and the DSM-IV were really unhappy about the DSM 5—and so I started looking into it and realized that their complaints were really about the nature of psychiatric diagnosis. That interested me and I told the magazine I would write the article. I've been thinking and living in this whole set of questions for many years, and it didn't seem all that remarkable to me, but the reaction I got from people who I thought would have also seen it as old hat was pretty strong, so the decision that I made wasn't to go out after the story, but having gone after the story I decided to feed the curiosity of the people who responded to it. In particular because everybody grouches about the DSM.
DK: It’s kind of a monstrosity. Unwieldy on so many levels.
GG: Nobody likes the DSM, including, for the most part, the psychiatrists who author it—but also therapists, clinicians, researchers and academics too.
Nobody likes the DSM, including the psychiatrists who author it.
And when you look into what people object to, a lot of their objections are—I don't want to sound haughty—but they're uninformed. There's an understandable, and for the most part accurate, instinctual objection to the whole idea of it. So I thought it would be interesting to do with the DSM something like what I did with Manufacturing Depression, which was to explore it as an instance of a problematic mental health culture.
DK: It seems like sort of the same book written from a different angle, where you're deconstructing the way that we think about mental health and disease, and taking on two of its principle constructs: depression and diagnosis. One of the things I've heard you say is that the DSM is a book of constructs, not of real entities. Can you explain what you mean by that?
GG: Whether it’s correct or not, in medicine real entities are those that have a biological basis, where you can find the causes and the boundaries of a disease through biochemical means, whether that's by culturing tissue, or looking under a microscope, or doing a blood test, or whatever it is you do. The problem with mental illness, or with psychological suffering in general, is that it's very difficult to come up with those biochemical assays. In fact, I shouldn't say, “very difficult,” but rather, “at this point, impossible.”
DK: Because?
GG: Mostly because the brain is so seemingly infinitely complex and the tools that we have for understanding it are comparatively crude. And if you pay attention to neuroscience, the field changes dramatically all the time. It's a moving target.

So you don't really have the basis for understanding mental illness in terms of real entities in that respect. On the other hand, for many different reasons, there is a strong need to have those entities. From the political and ideological having to do with the authority of medicine, right to the most practical having to do with how society decides to ration its health care resources, and everything in between. The way that psychiatry has bridged that gap is by using the rhetoric of science to create a DSM without ever being able to say that those scientific sounding categories are truly scientific. In other words, you can create the construct and then build all sorts of science around it.
DK: From inside it makes perfect sense.
GG: Right. But so does schizophrenia. And this is a problem with all ideologies. If you accept their basic premise, then everything else makes sense. In scientific methodology this is known as the validity problem. None of the categories in the DSM are valid, and that becomes a problem particularly because once you use that rhetoric it is inevitable, inescapable, that the categories will become reified, meaning that people will take them as real, and they'll use them as real, and they will become the basis for all sorts of political, economic, and individual decisions based on their reality.

One of the things that you find when you talk to the people who make the DSM is they're all really smart—well most of them are really smart people—and they're quite capable of understanding and appreciating the problem that we're talking about. But they have trouble taking account of the fact that the reification is a problem for everyone, not just for the professionals.
DK: Say more about that.
GG: In other words, they're happy to say to you, “Yeah, I understand that. We all know these are just constructs,” as if their knowing it is enough. But what that really means is that they don't want everybody else to know.
DK: Because it confers power on them?
GG: Right. It's the problem of the noble lie. Actually, I think that the best example isn't really the noble lie as Plato saw it, because that's a more complex topic. It’s more like what the Grand Inquisitor presents to Ivan Karamazov [from Dostoevsky's The Brothers Karamozov], which is that, “We in the Grand Inquisitors coterie, we know this stuff and nobody else needs to know, and in fact we're using our knowledge to help people.” That's exactly the pitch that the Grand Inquisitor uses to justify what he's doing to Ivan Karamazov.
DK: That power dynamic does a lot of harm.
GG: Of course. Power unquestioned is always a problem, and the problem is always damaging to the people that don't have it.
DK: If I were to draw your work together thematically, it seems to be challenging power in its various manifestations. You’re also a journalist and have obviously written widely on a variety of topics, but because you're a psychotherapist, you’ve taken on its institutions of power.
GG:
Power unquestioned is always a problem, and the problem is always damaging to the people who don't have it.
I think that's an interesting point. I think that's true. I don't think any of that is particularly conscious. I imagine that’s why I chose these professions—they both try to unearth power relations in one way or another, and claim, anyway, that that's the truth that they're uncovering.
DK: But they reify that power at the same time that they are claiming to unearth it.
GG: In what way?
DK: I'm thinking more of psychologists and psychotherapists than journalists, though the claim could be made for them too. There is a power dynamic in the therapy relationship that I think we are often unwilling to recognize. They come to us, they pay us, they have all kinds of transference reactions to us that we help them “work through” while we choose to reveal those aspects of our internal experience we think might be helpful to them. Having gone through the medical system I think psychiatrists are much more clear about their power in relationship to “patients,” whereas many psychotherapists are not. You take on psychiatry a fair amount but haven’t necessarily gone after psychotherapists.
GG: Well, the only direct approach I make to that question is my critique of cognitive-behavioral therapy.
DK: Talk about that.
GG: Do I have to?

The Problem of Piety

DK: Well, you don’t have to but I think it might be interesting to our audience.
GG: Cognitive-behavioral therapy is an ideology of optimism that is used by therapists to induct people into a more genial understanding of their lives and their circumstances. It's in some ways the diabolical twin brother of Freudian psychoanalysis, in that it trades on optimism rather than pessimism. CBT believes in the perfectibility of the human as opposed to the depravity of the human. It posits, without saying so, a benevolent universe, which is the opposite of what Freud thought.
DK: Is it their certainty that you have a problem with? You seem to wrestle with the notion of certainty a fair amount in your writing.
GG: Well, piety is a problem. Ask the people at Charlie Hebdo. If power is the general preoccupation of my books, piousness is the specific preoccupation. Unquestioned belief. For all of his problems at the granular level, at the macro level Freud was the master of ambivalence and uncertainty, and I think that there is a connection to be drawn between understanding life as infinitely uncertain—at least mental life—and the tragic sensibility.
I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life.
I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life. So, to get back to your original question, why do I go easy on psychotherapy? Well, this is one way that I don’t go easy on it and, as you and I both know, CBT is the dominant theme of psychotherapy in this country right now.
DK: Along with “evidence-based” therapies.
GG: It links in with the evidence based therapy thing, which bleeds over into my second criticism of psychotherapy, which is that we're way too tied in to medicine. Regardless of what we individually, or even as institutions, believe about psychiatric drugs, that's not the issue. The issue is how do we get paid and how do we get our status and authority in society? When I pick up the phone and I call somebody and then say, “Hey, this is Dr. Greenberg,” I get a different response than I would if I called up and said, “Hey, this is Gary Greenberg.” I'm not averse to using that power, but I'm implicated in a whole web that I shouldn't be. That critique shows up in both of my books, where I repeatedly question the whole business of psychotherapy.
DK: These days almost everyone talks about therapy as a business.
GG: Well, you've got to make a living.
DK: True enough. But it’s disheartening to me, nonetheless.
GG: We're all doing it. You make your accommodation with it however you can. The problem, when it comes to the DSM and to the medical-model aspect of our practice is that it is so at odds with what we purport to do. If you start your therapy by giving a person a diagnosis that you don't believe in, there's no way that you can't see that as a contradiction of the terms of psychotherapy, because it's dishonest.

The Rhetoric of Disease

DK: That’s interesting. I recently had someone come in claiming to be bipolar, and I pulled out my DSM for the first time in quite awhile because, in my mind, bipolar is not something to dawdle around. It has a high suicide rate, and is one of those diagnoses we are taught is genetic and kind of untreatable without medication. How do you deal with something like schizophrenia or bipolar or autism where there's clearly a mental disorder of some sort happening, there’s a pretty compelling case for genetic transmission, etc. Is there some utility in using the DSM for something like bipolar disorder?
GG: Well, I don't know about the DSM, but I do know about the larger rhetoric of mental illness. The DSM is just the most obvious example. I believe that as symptoms get more severe, and as impairments get more severe, the justification for using the rhetoric becomes greater, because it is a rhetoric that is quite effective. For instance, the rhetoric would say, “Schizophrenia is a biological brain-based illness that is just the luck of the draw. Maybe you had some stressors, but you definitely had this serious predisposition and your brain's all fucked up and now you're going to have to manage this all your life. And the best way to manage it is with Geodon.” Or you can go farther with that. You can say to somebody, “You have to take responsibility for you who you are, just like I do. And who you are happens to be somebody with this vulnerability, and that means keeping yourself in situations that aren't likely to kindle your psychosis. It means recognizing the prodromal nature of it. It means taking medications when it seems to be necessary to keep you and the people around you safe.”

That whole rhetoric is very helpful. I believe at some point it makes sense. And I even would go farther and say that there are some psychiatric illnesses, mood disorders, certainly the autism spectrum, that really are the luck of the draw, in the same sense that type 1 juvenile diabetes is. So the best we're going to do is help you cope. And I think that the rhetoric is useful there.

The problem is that that's the model for everybody, and we have no way of determining who it is that we should consider that way and who we shouldn't. It's like not knowing the difference between who's got type 1 diabetes and who should just eat less sugar, and just treating them all the same way. That's a problem. And it's not a problem that's been intentionally created by psychiatrists. I'm not a Scientologist. I don't believe that that's what's happened here. But I do think that because of its blindness to its power—and I do hold psychiatry more responsible than the rest of us because you and I are just living off of their crumbs when it comes to this stuff—psychiatrists have failed to make those distinctions, have failed to start with the assumption that only a small minority of people who are suffering with mental illness, even severe mental illness, have that classic disease structure. Now it’s reasonable to say, “Let’s err on the side of caution.” We’re talking about serious stuff here, and it's a useful model.
DK: So you sometimes use it with your clients?
GG: I just had a patient go into the hospital because she was sure that laser beams were doing something to her bones. She was a howling, psychotic mess. She's in the hospital and I'm really hoping that one of the psychiatric drugs that they throw at her will work, because her brain's on fire. It’s a useful way to look at it in this instance.
DK: So you pull it out of your toolbox when you need it.
GG: Yes, but do we know when we should and when we shouldn't? Absolutely not. But to get back to your patient who came in with the bipolar diagnosis, you took out the DSM and then what? You never finished the story. Did you then get them to tell their history of manic episodes?
DK: I did. We went through all of the assessment and then I said, “Okay, according to this book”—I mean I literally said this—“you qualify, but I need to qualify that this book is also a load of B.S.”
GG: Yes! Now was this bipolar 1 or bipolar 2?
DK: It's still not clear.
GG: So my guess is, if somebody shows up in your office and they're basically okay, and they tell you they just got diagnosed with bipolar and you're thinking, “What?!” chances are that person is going to qualify for the bipolar 2 diagnosis.
DK: Right, with the less intense mania.
GG: It only requires hypo-manic episodes. And so what you have there is the diagnostic creep that I just outlined.
All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?”
That diagnosis just arrived in 1994. I don't know how long you've been in practice, but I've been in practice for a long time and I remember when these people started showing up in my office with their diagnoses and their anti-psychotics and their stabilizing drugs. All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?” I think there's cases where that's a totally useful and justified approach, and I think there's cases where it isn't, and that's where all the trouble lies.

The Serotonin Myth

DK: In your book, Manufacturing Depression, you say that serotonin came along and seemed to make people happier and so the drug companies had to find an illness that would make people need it, right?
GG: It's not quite that conspiratorial. In the case of depression and antidepressants and neurotransmitters, it’s like strands of a braid that came together advantageously for some patients, and many doctors, and most of all for the pharmaceutical industry, which was brilliant, clever, and lucky.

I guess that's a little cynical. I have to be fair, the cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit. They knew that it was wrong, and then they did tone down the rhetoric to some extent in their advertising. The consumer advertising started right around the same time that scientifically the serotonin myth fell apart, the late 90s, but you wouldn't know that to look at the ads. That, to me, was their most egregious move.
DK: They didn't correct for it, they just took advantage of it.
GG: Exactly. They knew that if you could sell it as that kind of disease, it was so overdetermined that it would succeed and they could not resist it. You would have to be some kind of Boddhisattva of advertising to resist that temptation.
DK: A lot of people, myself included, only recently came across this information that it's really not about serotonin deficiency. We literally have no idea why they work, and for whom they work.
GG: Right. Now you say you just came across that. You're an intelligent, well-educated person with a PhD, right?
DK: Yes, but I’ve also benefited from antidepressants, so I had a little bit of denial in the game around it. I’m one of those people with a seeming genetic predisposition for depression for whom SSRI’s just helped, with no bad side effects. I thought I understood why they were helping, but it turns out no one knows yet what they do.
GG: There's two ways to look at that question of why. One of them is, do we know neurochemically what's going on and what, if any, deleterious consequences there are? And the answer to that question is no.
DK: Well, we know a little bit.
GG: We know that you're increasing the activity at certain receptor sites, including some of the serotonin receptor sites, although these drugs aren't as precise as they are sold as. And we know that serotonin appears to be associated with increase in neurogenesis. And we know that at really high doses you can see the axonal growth that appears to be the direct result of increased serotonin activity. So there's all these things that we know, but why that changes a person's mood…
DK: There's no causal correlation.
GG: Right. In order to know that you would have to have an account of how the brain produces consciousness, and good luck with that, because that's just not going to happen. So what you're left with is to say, “Okay, well this drug makes me feel better.”
The cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit.
And I don't mean that necessarily in the same way that smoking a joint or whatever makes you feel better. It just makes you feel better, and it works, and it doesn't hurt my life in any other way, and I'm going to take it. To me, anyway, the only problem I have with that approach is the same as with any drug. It's like, “Okay, well, am I hurting myself in any way?” It's the same question I have about vaporizing nicotine. Obviously, the reason that that's become controversial isn't because we know that it's bad for you.
DK: It's because we don't know that it isn't bad.
GG: No, I think it's because we are an anti-drug society, and it just makes it really clear what's going on in smoking cigarettes. People don't smoke cigarettes to get cancer. They smoke cigarettes to get high, and the vaporizer just eliminates the middleman and delivers to people the drug that they want. And in our society, unless you're on antidepressants, or happen to be addicted to caffeine or alcohol, you can't just openly say, “I'm going to do this in order to change my consciousness.”

So I think that the controversy arises because of that, and then it is also true that we don't really know the long-term effects of using nicotine—although we know enough to know that it is not carcinogenic.
DK: And we don't know the long-term effects of taking an antidepressant.
GG: Right.
DK: So how do you deal with people who come in and seem to suffer from depression—have a family history of it and display severe depressive symptoms—who then respond really well to antidepressants?
GG: The way you do with anything that you're wondering about. You just take it as it is. You support it. “Okay. So, tell me about it.” Of course, people aren't stupid, and they tend to expect, particularly from me because of my relatively high profile, that I will disapprove. So I have to spend a little time reminding them that I really don't disapprove. If they actually read what I wrote, as opposed to listening to what people say about it, they would know that. You have to start by letting them know that, for the most part anyway, it's cool with me if this is what you decide to do. But one of the hallmarks of being mature and self-possessed is recognizing that you can't have it both ways. If you want to be on drugs, you've got be on drugs, and live with whatever that means to you and with whatever the implications are. And among the things that it means to be on antidepressants, particularly long-term, is struggling with the question of what's you and what's the drug. People have these severe doubts about their functioning and about their success. There's a whole version of the imposter syndrome that goes along with being on long term antidepressants.

Does Depression Exist?

DK: Do you think depression exists? Is it real?
GG: What does that mean?
DK: Is it an actual illness? You say that it is manufactured.
GG: No, I’m saying that I’m sure there are situations, brains, people who certainly qualify. Let's say that the ability to feel depression as it's described in the DSM is heterogeneous—in other words, there are many ways to get there, both existentially and biochemically. I'm sure that's true. And let's say that some subgroup of people who qualify for the diagnosis—which is insanely broad—
DK: It covers a large swath of American culture.
GG: —nine symptoms, five of which qualify you; there's 125 different combinations to be depressed, just for starters. But let’s say some subgroup of the people that qualify are suffering from some identifiable biological fuck up, some hiccup somewhere. Or maybe more than one. And it wouldn't matter what their circumstances were, once the depression was kindled, they're screwed. Again, I don't know who they are. Nobody knows who those people are. In the meantime, the presumption is that everybody is. And that's the problem.
DK: There's not a model for the remaining majority.
GG: Yes. And I also think that the question of, “Is it an illness? Is it real?” is, in some respects, a red herring. Because why are you asking the question? What is the importance of that question?
DK: Hmmm. That’s a good question.
GG: Why does it matter to know that it is or it isn't?
DK: I guess I’m interested in how much of our internal lives are constructed by social structures and beliefs. I listened to an amazing podcast called "Invisibilia" recently, an episode entitled “How to Become Batman” where a blind guy, blind since birth, learned to “see” by using echolocation, a clicking sound with his mouth, and because his mom let him run wild and didn’t treat him like he was blind. Let him ride bikes, climb trees, fall and get hurt, all of that. Apparently his visual cortex has actually created something like sight for him. It made me think about how we are both blinded and liberated by our beliefs. So if we had an entirely different model and way of seeing depression, it could transform the world.
GG: So the reason that you're asking the question is because you see certain shortcomings, at least potential shortcomings, to understanding it as an illness.
DK: Oh, for sure, at the very least.
GG: The advantage of seeing it as an illness is that certain social resources become available to you if you see it that way. Drugs, medical care, sympathy, understanding, none of which is to be sneezed at.
It's notable that one of the major ways of getting social resources in our society is to be sick.
It's notable that one of the major ways of getting social resources in our society is to be sick.

But there are also disadvantages, as you just pointed out. If you see yourself as sick then you act sick, and if you're sick you're less empowered, maybe you're less active, maybe you take less responsibility for yourself. You cited an extraordinary example, but you're certainly not going to do that if what you decided to do is to live the life of a blind person. So, yes, there's something liberatory about it which is much more likely to be achieved if we understand illness as a contingence category as opposed to an absolute category. As something human-made as opposed to something scientific and medical.
DK: I’ve written extensively about psychologists’ complicity in torture at Guantanamo and other CIA black sites, and in researching what led to it, I found that the profession of psychology emerged out of war, has been funded in large part by the military in terms of training programs and research grants, and is thus inexorably linked to the American war machine. I haven’t had a chance to delve into the role that scientism plays in all of this—and I understand scientism to be viewing science as a religion, basically—but one of my speculations was that this desire for the profession to be perceived as a hard science, to be seen essentially as a “man among men,” was a big part of the problem. You wrote some about this in your article in Harper's, where you take on positive psychology guru Martin Seligman, whose own research is deeply embedded with the military and who coached the very psychologists who created the program at Guantanamo in his theory of learned helplessness. I'm wondering if you have any thoughts about the role of scientism in the militarization of psychology or if you see any connections between what you're critiquing in your work and what's happened with the psychology profession becoming kind of an arm of the military.
GG: Well, I think to start with, there's lots of psychologists like yourself who are appalled at that outcome, so it's pretty clear that it's not a necessary outcome. There are even psychologists who don't buy Marty Seligman's self-serving excuses for his own implication in these things. That conference that I wrote about in Harper’s took place in 2009 and the issue was still alive at the time, and Seligman had some very greasy responses to those questions.
DK: Yes, he claimed to have had no clue what they were intending, which wasn't very credible given where and when he delivered his lectures and the meetings he was involved with.
GG: But there are people who don't buy it and who are critical when these discoveries are made. But, having said that, I think your point is well taken. There is a kind of wish among all the medical health disciplines to be on the inside rather than on the outside. And whether you're on the inside by virtue of having a professional license or by virtue of having the authority to declare people mentally ill, or to get services for kids through special education, or to help the military figure out how to make soldiers resilient, I think this desire to be considered an insider can be problematic. And that in itself is complicated because sometimes it's simply wanting to make a living, or to make a decent living. Obviously, if we didn't have our professional licenses then we probably wouldn't make as much money as we do. If we didn't have our ability to bill insurance companies or, in my case, help people get reimbursed, then we would make less money. So some of it is just about that, but a lot of it is about wanting to be in the mainstream, because, like I said earlier, you can't have it both ways. If you're not in the mainstream, there are some severe prices to be paid.

A Foot in Each World

DK: Do you feel like an outsider in this profession?
GG: I have one foot in each world. Yes, I feel like an outsider in the sense that there's lots of things that I don't do that I would do if I wanted to be on the inside, like joining insurance panels and stuff like that. I probably feel better about that than I ought to though because it's not that important. It does restrict my access in some ways, but mostly what it does is restrict my income.
DK: Right, it can be a tough choice to side-step the whole insurance industry.
GG: Yes. But I'm clearly an insider in the sense that I described before. I pick up the phone and say, “This is Dr. Greenberg,” then I get somewhere on the phone tree.
DK: Do you do that with a smirk?
GG: No. I do it totally straightforwardly, because I'm just trying to be effective and that is the way you're effective. These questions can come down to a kind of moral anorexia—a sort of refusal to take in the goodies that are out there because we all know they're tainted. I think that in some ways you've got to be fair to yourself and to others and say that the life lived entirely outside is very, very difficult and in some ways less effective. There are people who I have helped not by virtue of my education, or my training, or my insider-ness, or my license. It is something inherent to those that have allowed me to help them, but my availability to them, even if it's not about money, just the fact that I'm out there and legally practice my trade, just the fact that I'm available to them is what made it possible for me to help them.

The Writer as Therapist or the Therapist as Writer?

DK: I also was a journalist before becoming a psychotherapist, and I tend to come at things with a critical point of view, and I often have the experience of being critical of the “profession,” of training programs, of the way that we organize—and don’t organize—around issues of justice, etc. But at the same time, I simply love the work, itself, with clients and some of my very best friends are therapists. I feel like I’ve got a real love-hate relationship with the profession that I haven’t fully worked out yet.

One of the reasons I’m so interested in your work is that you seem to be able to traverse both worlds—to be a writer, and to write honestly and critically and self-revealingly about the profession while still very much being in it. Do you see the writer in you and the psychotherapist in you as fundamentally complementary? Do they ever come at odds? Do you ever not write about things because you're worried about your clients?
GG: In both of the books that we've been talking about, I write a little bit about my actual practice, but I hate doing it. I would not be disappointed if I never did it again. I don't know if that's a principled stand—I just don't like doing it. I think it's really hard. I don't know if you ever saw the TV series “In Treatment.”
DK: Yes, I loved it. It rankled me, but I loved it.
GG: That was the most realistic handling of psychotherapy ever, that I've seen, in the mass media—and it was boring. Nothing happens.
The person that I am as a therapist is not someone that I want to write about.
I mean, it's okay with me, I was interested in it, but I don't think it did well because it's just day-to-day what goes on in therapy. It's really hard to write about. There are some people who can pull it off nicely, like Irvin Yalom, but for me anyway, the person that I am as a therapist is not someone that I want to write about.
DK: What do you mean?
GG: If someone comes into my office for therapy, I feel like it's a total breach to write about them, even if I ask for permission. Even if I disguise them. That's how I feel about it, having done it now a few times. The Book of Woe went through a very, very extensive legal review and the case material was altered to the point that it was no longer factual. It was really fiction, and if I'm going to write fiction I should write fiction. I really believe that. I don't know that a reporter has any obligation, or even ability, to be objective, but to intentionally make shit up? If you’re going to make it up, make it up. If you're not going to make it up, don't. And if you can't write about it without making it up, don't write about it.
DK: Do you feel like you have to sort of forget about your therapist self when you're writing? Are you split off in some way?
GG: I guess so. I never really thought about that. No, I would say it’s the other way around. I have to forget about my writer self when I'm doing therapy. I can't really think about myself as a writer when I'm working with people. Once in a while something so fascinating occurs, so remarkable that you picture yourself writing about it, but in general therapy is something that I go and I do, and it's a performance—and I don't mean that in a cynical way—it's a thing that I do. But the writing draws on all of me in a way that the therapy doesn't.
DK: So do you feel you are more of a writer than a therapist?
GG: I guess so. I never really thought about it before. There's something that I do as a therapist—there's a way that you use yourself, and all of you has to be available to yourself. But you also as a therapist have to bracket certain things.
You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient.
You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient. It's like, “Okay, yeah, that's something that I feel, and I've got to figure it out, and I've got to deal with it here.” But I can't take it for granted any more than I can take it for granted if I had a sexual impulse, or some strong negative reaction to somebody. Whereas with writing, that's a whole different kind of discipline, where you have to take whatever it is and transform it into words.
DK: You aren't thinking, “What if Sheila reads this?” when you write?
GG: No. I probably should, but I think if I did I wouldn't be able to maintain both disciplines, because people actually do read my writing.
DK: And they come in to talk about it sometimes?
GG: Oh yeah. Sometimes they do. I've got a relatively wide readership, but I'm certainly not a famous writer, and therefore most of the people that I work with may not even know that I have a writing career.
DK: So you don't bring it in.
GG: No. I don't bring it in at all. My books aren't in my office. I don't mention it.
DK: Do you feel like it would be an intrusion?
GG: Yeah, of course. I don't talk about the argument I just had with my son either. Actually, there are situations in which I might talk about writing, but it very much depends. I see people who are artists or writers, and with those people I do sometimes bring it in.
DK: That’s interesting. I'm struggling with my identities in a way that it sounds like you haven't and don’t. You just write, and you're not tormented about it.
GG: Well, I was doing therapy for many years before I got into writing.
DK: Well this has been a fascinating interview. Thank you so much for your time.
GG: Thank you.

Psychotherapy and the Care of Souls

Posted on by Psychotherapy.net Team

To Serve the Soul

In Greek mythology, the wise healer and teacher Cheiron is part horse and part human, a centaur of sorts, but quite different from his wild and hardly civilized half-horse/half-human brothers. He did his work of healing and teaching in a cave. As a therapist, I sometimes think of myself as part animal, sitting in my cave, dealing with primal aspects of human existence, barely able to distinguish healing from teaching.

The modern therapist seems to think of the problems that come to him or her as deviations from the standard of normalcy and health. The point is to restore a person to a point where the presenting symptoms have been removed, as if by psychological surgery. I don’t see it that way. People come to me because deep down they can’t experience the joy of being who they are. They don’t feel in the positive flow of life. They may feel stuck in some repeating pattern that seems to go back far into their history. They may be focused on, or better, mesmerized by some symptom like an obsession or paranoia or anxiety. Generally, it’s the nature of life to flow, like a river, and not to be stuck or stopped.

Whenever I want to get on track with my work as a psychotherapist, I think back on the word. It is made of up two key Greek terms: psyche (soul) and therapeia (serve). “Psycho-therapy” means “to serve the soul.” Psyche is not mind or behavior, and therapeia does not mean healing or making better. I always keep in mind that my job is to serve the soul, or care for it. When I used an ancient phrase, common in Platonic literature, as the title of my most popular book, Care of the Soul, I was simply putting the word “psychotherapy” into English.

I think of the soul as the life in us that is immeasurably deep. Sometimes it feels like a spring or font of existence, making us feel alive and giving us something of a direction and identity. To a large extent it is autonomous, having its own purposes, desires and intentions. When you delve deep into it, you encounter basic human themes and patterns, what Plato and Jung and others call “archetypes.” The need for love, the desire to create, the comfort of home, the excitement of travel—these aren’t the characteristics of any particular person. They are, at least potentially, ways in which all people may experience life.

When these archetypal patterns come to life in a person, they usually have a strong force and allure. You are happy to be in love and can think of nothing else. You fear illness and death, and that emotion, with its clinging thoughts, gets hold of you. You glimpse a certain career, and you go after it with a passion.

Soul is intimate, embedded in life, vital and energetic. It seems to constantly want more life and vitality and therefore can be a threat to the status quo. “As you tend your soul, you may try to sense what it needs and wants, and you may discover that its needs may not dovetail with your own wishes.” In that spirit, the Irish poet W. B. Yeats said that his poetry came out of a tension between his own ideas and those of an antithetical self he felt inside him.

As I see it, this other being in us, the soul, is vaster than our small minds can contain. It’s strong and mysterious, and at times a true adversary. Our job is to get to know the soul and cooperate with it, understanding that our happiness and peace on earth depends on a positive and creative response to it. Psychotherapy may entail simply living in a way cognizant of the soul and its purposes.

Soul offers a deep and powerful sense of identity that counters any tendency to be caught in the limited understandings and values of the family or the culture. It asks that we each become individuals, not so identified with the structures around us. This need is so strong that I imagine it in the familiar imagery of rebirth: we are born into biological life and culture, and then we have to be born again into our own individuality and uniqueness. Along with Socrates, I would describe psychotherapy as a kind of maieutics, or midwifery. We have to assist at the birth of the soul into life, which implies the arrival of a unique person. Socrates said: “My concern is not with the body but with the soul that is in the travail of birth” (Theatetus, 150 b).

The Travail of Birth

The travail of birth is exactly what happens in therapy, to one degree or another. Travail means labor, but I see it more as a process. In formal therapy you reflect openly and seriously on the past, on dreams, on emotional difficulties, on relationships and a number of other issues, the material of a life, and process them. As you look more deeply and imaginatively at them, you see better what wants to be born and what hinders the birth. For many people, early traumas and bad parenting and unfortunate adult influences and threatening injunctions keep their longstanding hold and stand in the way of the soul’s movement into life.

Years ago I read the religion scholar Mircea Eliade’s unsettling description of a primitive rite of passage, and it has stayed with me. Young people would be placed in the earth, naked, perhaps under a pile of leaves, overnight or for several days, within a ritual context of masks, drums, body paint and dance. Then they’d be taken out and washed and clothed, adults now and fully part of the community.

I see therapy along these lines. “To be born into your individuality is no light matter. You need an impressive experience of death and rebirth.” Most of the time a real and transformative round of therapy is a step-by-step process of being reborn. The therapist is the elder in charge of the rite, but he or she is only the guide, not the healer. The point is to arrange an effective rebirth, letting the person then go on to discover his life. The therapist does not decide what life is best for the person, whether to be more dependent or independent, emotionally contained or effusive, whether to be married to a different person or to live somewhere else. The therapist doesn’t know what is best for the person, he or she can only assist at the birth of the soul.

Above all, a therapist needs purity of intention, the capacity to hear stories of suffering without responding unconsciously out of his own prejudices. A therapist has to know himself so well that he will pass on any temptation to engage in his own typical reactions. He will not take credit for any progress, and in fact will not think in terms of progress, but only care. Care is not heroic, it isn’t getting anywhere and it has no need to solve problems. A good therapist doesn’t see life as a problem to solve but as a gift to be observed closely and supported.

A therapist will not be deluded by the delusions of his patient. He will not be taken in by any loose complexes in his patient that try to trip up the therapist. If a patient says, “You haven’t given me your full attention today,” a good therapist won’t defend or explain himself. He might simply say, “You’re right. I’m preoccupied with my own situation today. Let’s start again.” He will not feel the guilt the patient wants him to feel and will not accept any adulation the patient tosses his way. Both are traps. He is neutral, not willing to get pulled away from his center by a patient’s neurotic need. In the face of sober and heavy influence, he may find neutrality in lightness of spirit and good humor. He may laugh easily but never sardonically.

Overcoming Our Complexes

A good therapist has moved past his need to help. While it’s true that doing therapy is being in therapy—the therapist may work through some of his own issues while being with another—the therapist is also neutral about his life work. He is not thrown when a patient doesn’t respond well to the therapist’s ideas and efforts. He doesn’t himself need a patient to get better or to go through the therapeutic process the way the therapist thinks is best. The therapist surrenders any pet enthusiasms, such as hoping that his patient will become more independent, artistic, self-aware, or emotionally expressive.

This neutrality is not indifference but an achievement in the therapist’s own opus, the work of his soul. He is not led on by his complexes in relation to his patients, the deeper meaning of the interesting classical notion of counter-transference. He is not at all perfect, but he is not acting out with his patients. He has an unusual degree of self-possession. He can reflect effectively on his own allegiances, philosophies, theories, techniques and ideals. He has developed his own approach and is not completely identified with a given figure in psychology or with a special theory.

A therapist also has to know how to deal with complexes of the people he assists. Jung described a complex as a sub-personality. I would put it differently: a complex has a face. Acting out a complex is like putting on a costume, though you don’t know that you’ve put it on. These figures of the deep psyche that take over a person, like Dr. Jekyll swamping Mr. Hyde, are unusually intelligent, convincing and full of shadow.

A person with a mother complex may strike you at first as being caring, thoughtful and capable of deep emotion. Only later do you see that this figure, this daemonic possession, dominates the person and may suffocate and overpower others who come into its domain. A mother who is atrociously critical of her daughter may believe that she is only doing what is best. Others may tell the daughter how lucky she is to have such a wonderful mother, and the daughter is thrown into painful confusion. Should she be grateful, or should she run away?

The therapist has to deal cautiously with the complex that enters his consulting room. He must not get caught, but that kind of neutrality is not easily achieved. He may be especially susceptible to certain complexes and not see them for what they are.

Complex is not the best word, perhaps, but it is traditional and important. A complex is more like a powerful presence that can assume the cohesion of a personality, although sometimes it is only an urge or an impulse. It can completely overwhelm a person or it can be merely an influence. In any case, a therapist needs courage and circumspection to deal with one, whether in his patient or in himself.

Religious traditions teach as much about these presences as psychology does, and it might help a therapist to do some study in religions and even see his role as being both psychological and spiritual. Religion specializes in rituals that help us meet the complexes in highly symbolic ways. In traditional Catholic confession, for example, you acknowledge dark spirits that invade your life, and the confession of these presences goes a long way toward dealing with them.

Personally, I have cultivated powers of intuition, skill at working with images, and knowledge about traditional spiritual rites and images so I can be prepared for images people use in telling their life stories and reporting their night dreams. I have drawn on the model of C. G. Jung, who was concerned both to be an intelligent, rational thinker and researcher and at the same time to go to great effort to employ the non-rational methods of the spiritual traditions. He was a stone-cutter, calligrapher, painter, and architect in his own way, making his personal environment link closely with his inner life.

Guide of Souls, Leader of Rituals

My mentors—Jung, James Hillman, and Rafael Lopez-Pedraza—have emphasized the role of the mythic Hermes in the work of therapy. Jung said that the work or opus begins and ends in Mercury (the Roman name for Hermes). This means that in this work you have to be imaginative, clever, quick-witted and skilled with language. You appreciate paradoxes and apparent opposites. You see past and through any material that is presented, and you go beyond the modern notion of the highly educated, trained expert. You need a deep and probing appreciation for the intricacies of the psyche, and your preparation has to be both scholarly and personal.

I have a deep appreciation for the work of therapists and I honor and support any therapists I meet. They have a key role in modern life as they address matters of the soul and spirit. In some ways they are the modern priest, priestess, guide of souls and leader of ritual. Their work is challenging for all its depth and mysteriousness, but it is equally rewarding precisely because it goes so deep.

But some therapists make a mistake in thinking of their position as one of a trained advice-giver or aid to adjustment and smooth living. Their job, rather, is to be courageous enough to face the demons with their patients and get tangled in the complicated mysteries of a human life. To do their job effectively, they need to know depth psychology, philosophy, solid religious thought and art. They should be at home with dreams and extraordinary fantasies. They should be able to see through aggression and masochism to glimpse the positive mysteries trying to be expressed and lived.

This kind of therapist has thought deeply about the mysteries of human personality and doesn’t reduce them to simple patterns. Throughout his life and career this therapist continues to explore complex matters, prizing any resources that help, and faces his own complexes. He is always on the border, Hermes-like, between the inner and the outer, the personal and the universal, ordinary life and the sacred, and the surfaces and the depths. He is shaman-like, able to traverse levels of reality and experience. He has adapted to the mysterious nature of his work by being himself a mysterious person, not too easy to read and comfortable being neutral in the face of another’s passion.

The Cheiron therapist works in a cave, a place set apart from the normal way of seeing things. He needs a lot of animal in him to sense the many messages from his patient and from within himself. He has to take on the mythic dimensions of a centaur because work with the soul is too much for the human mind. “The therapist is willing to be bigger than life and almost other than human, a person of huge imagination, able to hold almost any manifestation of human struggle.” He has to be naturally religious, in the sense of honoring the natural life flowing through himself and his clients and responding effectively to the great mysteries that only the best art and religious forms have been able to grasp. He is a person able to contain the immense joys and sorrows that visit every human life. And all of this in an ordinary person, humble in the best sense, in love with life and able to love those in distress. It’s a wonderful calling and a grace to those who accept it.

Bad Therapy: What You Didn’t Learn in Grad School

Posted on by Psychotherapy.net Team

The Problem with the "Great Masters"

Going through graduate school training, we were barraged with examples of “good therapy” from every well-known therapist of the last century. We learned unconditional regard from Carl Rogers, the empty chair technique from Fritz Perls, the nature of deep intrapsychic conflicts from Freud, the collective unconscious from Jung, group therapy from Yalom, EFT from Sue Johnson. We were treated to endless case studies of poor souls trudging through the morass of their unmanageable lives, whose problems were deftly transformed by analysis, exposures, emotion-focused “interventions” and, when all else failed, that ineffable “therapeutic alliance” the great Masters of therapy seemed to so effortlessly form with their clients.

We learned the art of “case formulation,” whereby a complicated human’s life was distilled into three or four paragraphs of neutered narrative, followed by a plan of action that conformed to the theory and world view of whoever was supervising us. Depending on the supervisor, we either shared our real anxieties about our work with clients, or we manufactured false narratives to avoid their opprobrium—but in either case, we endeavored to tie the loose ends of our work into pithy parables with tidy endings. We all make mistakes, our teachers said. Even the great Masters made mistakes! But fortunately for them, through concerted effort, self-analysis and the lucky fact that clients tend to make good use of us even when we suck, everything always seemed to work out in the end.

Notably absent from our lectures, case conferences and readings? Terrible, no good, very bad therapy. Irreparable empathic failures, sexual transgressions, narcissistic hostage-taking, wounding reservedness that traps clients in unrequited longing, client suicides, damaging advice, damaging refusal to give advice—these topics weren’t on our syllabus. If we were really lucky, we found a friend or two in our training cohort who we could dish the truth with, and if we were really, really lucky, we had a supportive supervisor somewhere along the way who encouraged our self-honesty with their own. Otherwise, it seemed that the collective ego of the therapy profession was a bit too fragile to handle its own dark side.

This is tragic, if you think about it. It has created a professional culture that values vulnerability on the part of clients while encouraging therapists to keep tight-lipped about our own. When we are stuck in the mire of our own crappy work, we’re taught that our clients must have “primitive defenses” and just can’t “take in” our “good breast.”* As we progress through training, the laid-back, open, casual style of interacting with clients we began with takes on a weighty “professionalism” that turns what is simple into something complex, and what is complex into something simple. Love, which one might argue is the basic foundation of good therapy, becomes “countertransference,” a narcissistic use of the client’s idealized “transference” with us. Meanwhile, a complex amalgam of "bio-psycho-social factors" (a favorite grad school term) are boiled down to “maladaptive patterns,” “unconscious drives” and “negative thought cycles.” With no one showing us how to fumble and fail, we become very invested in our “look good,” at great cost to both us (it’s a straight jacket that literally takes the form of our therapy “outfits”; I once had a supervisor advise me against wearing open-toed shoes—too suggestive) and our clients.

Thankfully, I was one of the lucky ones, with both colleagues and a few supervisors willing to be authentic and vulnerable, as well as a therapist who shares her weaknesses and vulnerabilities with me. The safety of these relationships allowed me to come to terms with the bad therapist in me. The one who wants all of her clients to love her, who has omnipotent savior fantasies, sometimes fuzzy boundaries and who, in my first year of training, felt compelled to continually ask a client, “How is it for you that I’m white and you’re black?”—a directive from my multicultural therapy class—to which she replied, “I don’t give a shit!” She was a poor, old, disabled widow living alone and I did house visits. I brought her baked chickens and occasional groceries, even though I was explicitly forbidden from doing so by the agency I was working for. I was supposed to be doing psychodynamic therapy with her, but how do you do psychodynamic therapy with someone who doesn’t have enough to eat and doesn’t give two sticks about her unconscious? Was baked chicken good therapy? Yes, I think it was. Would I do it again? Probably not. I had very little sense of my own boundaries back then (nor the financial ruin that lay ahead of me due to years and years of school loans that were never enough to live on) and today would be more self-protective. But do I regret it? Nope.

In future "Bad Therapy" blogs, I will dive into some vulnerable, messy material in an attempt to correct for the “look good” problem we therapists have. Besides, bad therapy is incredibly good learning material, an object lesson on what not to do, and an opportunity to reflect on how and why we miss the mark. I will share some of my bad therapy experiences, on both sides of the couch (I will heavily encrypt those in which I’m the bad therapist), and want to hear yours. I am more interested in your experiences as a client than as a therapist, since it’s hard for therapists to really deliver the bad word on ourselves—and we are also bound by confidentiality—while as clients we can be more truthful about the badness of our therapy.

A Case Study

For example, when I first moved to the Bay Area in my early twenties, I innocently tore off a phone number of a therapist posted in a local grocery store. In that first session, he took off his shoes and sat with his legs wide open, his dick bulging against his pants unfettered, like a co-therapist. After recounting my travails (sweet, naïve thing that I was), he said, “Are you sure you want to be telling me all of this in your first session?” What therapist says that??! I left Dick Guy’s session feeling horribly exposed and vulnerable, knowing something wasn’t quite right. The following day I got the courage to leave a message for him saying that I didn’t think we were a good fit. He then proceeded to phone stalk me for the next week, alleging that we needed a few more sessions to really process this and I was giving up too early. Shouting “leave me the hell alone!” at his voicemail ended the sordid ordeal. Almost. The following year I went to a local hot spring where people go to relax and be naked in nature for retreats (this is the Bay Area, remember) and … well, you see where this is going. We pretended we didn’t know each other and I got the heck out of there. Sometimes a cigar would be a welcome relief.

What caused this guy to be overly familiar, strangely awkward around my self-revelations, and a stalker? Honestly, I think he was kind of a sicko, but it does bring to mind this thing we do with clients when they want to leave: “OK, how about we take three months to talk about termination?” “Let’s explore your resistance a bit further before making any changes to your therapy schedule.” Sure, sometimes that’s appropriate, but a lot of times clients feel trapped, and if there is any care-taking of family in their past, they’ll take care of us…for years!

What I know is these stories are not unusual. There is so much bad therapy going on that it deserves some attention. I’ve got lots of stories in my arsenal already, both from my life and those of my friends, and I want to invite you to send me yours. Now that I’ve introduced the idea behind this blog, we can dive right in.

One favor: Please don't reveal the identities of the therapists in question, as these are meant to be anonymous anecdotes that will serve as object lessons, help us therapists hone our craft and view ourselves with a bit more humor and humility. I don't want to be in the position of having to report illegal behavior; please do that directly with the Board of Psychology, or your version of the equivalent in your state.

If you (or a friend) would like to submit anonymously, you can set up a pseudonymous email account with gmail or another service provider, and submit your email from there. Again, this isn't about nailing anyone publicly (we all fail at times) and I will take every last precaution to make these stories as generalized and unidentifiable as possible. If you're fine telling me your story directly, you can email me your anecdote and your identity will be kept confidential. Send your stories to: deborah@psychotherapy.net and spread the word to others who may have bad therapy stories!

*True story.

Francine Shapiro on the Evolution of EMDR Therapy

Posted on by rezendevknowfully.com

When a Cup Isn't Just a Cup

Ruth Wetherford: Francine Shapiro, you are the originator of EMDR therapy, the founder and executive director of the EMDR Institute, and author of numerous books, articles, and other interviews about this process. I want to begin by asking you a basic question: What is EMDR therapy?
Francine Shapiro: Eye Movement Desensitization and Reprocessing, or EMDR, is a form of therapy that focuses on memory and the brain. Every different form of therapy has a different model, a different way of conceptualizing cases and different procedures. For instance, in cognitive behavior therapy (CBT), pathology is based on inappropriate beliefs and behaviors. In psychodynamic therapy, it’s intra-psychic conflicts. In EMDR therapy, pathology is based on unprocessed memories that are stored intact—so if someone has some irrational beliefs or negative behavior, that’s not the cause but rather the symptom.

For example, let’s say we’re humiliated or bullied in grade school, and instead of the brain digesting it and making sense of it and letting it go, it actually gets stored in the brain with the emotions and the physical sensations and the beliefs that were there at the time. One of the functions of the information processing system of the brain is to make sense of the world, so if something happens 30 years later as an adult that is similar in any way, it has to link up with the memory networks to be made of sense of. In other words, if I’ve never seen a cup before, I don’t know what it is or what to do with it. The perceptions that we have about something in the present link up with the memory networks, and if it connects with that unprocessed memory, it gets triggered, and the emotions, physical sensations, and beliefs—“I’m terrible, I’m not good enough, I can’t succeed”—get triggered as well.

People may have no idea why they continually feel anxiety in social situations or when they talk to somebody at work, because the situation is linking them to an unprocessed memory, and those feelings are coming up automatically.
People may have no idea why they continually feel anxiety in social situations or when they talk to somebody at work, because the situation is linking them to an unprocessed memory, and those feelings are coming up automatically. We really are at the mercy of our memory networks, and if an experience hasn’t been processed, we’re just buffeted hither and yon by all of these negative emotions and feelings. With EMDR therapy, we identify what those earlier experiences are and we process them. We bring that information processing system back online. And what happens during an EMDR therapy session is that very rapid associations and connections or insights are made, and the emotions, physical sensations, beliefs—all of those shift to a level of learning and resilience, so we simply aren’t triggered that way any longer.
RW: You’re making the point that the mind and body connection cannot be separated. The cognitions, feelings, and other thought activities of our minds are so integrated with our bodies. This is not new, of course, but it does seem to be getting a lot more attention lately. In a recent interview with Bessel van der Kolk on Psychotherapy.net, he describes having done the only NIMH funded study on EMDR, and as of 2014, the results were more positive than any published study of those who developed PTSD in reaction to a traumatic event as adults. He goes on to talk about the impact of trauma on the somatosensory self, that it changes the insula, the self-awareness systems—which is exactly what you’re saying.

But EMDR therapy is also very easily integrated into other kinds of therapies. In fact, I saw that you won the Sigmund Freud award from the City of Vienna.
FS: People who have been trained as psychodynamic therapists say that EMDR lets them use what they know. They use EMDR therapy to help identify the earlier memories that cause maladaptive defenses and intra-psychic conflicts, and it helps people process those memories and experiences. It’s the same with those who practice cognitive behavioral therapy. EMDR therapy is used to process the memories that are causing dysfunctional behavior and irrational cognitions.

It’s a remarkably efficient treatment. There are three studies that have indicated that for single trauma victims there’s an 84 to 100% remission of PTSD within about five hours of treatment.
RW: That’s great.
FS: A study with EMDR therapy in combat veterans found that after only 12 sessions, 78% no longer had PTSD. Of course, the amount of treatment time it takes depends upon the number of memories that have to be processed, but you don’t have to process each and every event because memory is connected. Instead, you choose one that represents a whole group, and then you have a generalization effect. It rapidly shifts.
RW: This is the phase that has so much in common with all approaches to trauma. Learning self-soothing skills is consistent with all mindfulness meditation and stress reduction methods. It gives people a sense of confidence that they’re not going to be lost when they leave the session. It’s remarkable how fast the dysfunctional beliefs can shift from “it was my fault that I was abused” to “I didn’t deserve that.” It doesn’t happen all in one session, but—
FS: Well, it can.

The 8 Stages of EMDR

RW: Perhaps you could tell us a bit more about the stages of EMDR therapy?
FS: EMDR therapy is an eight-phase approach. During the first phase, the clinician takes an appropriate history of the client, finding out what the current problems and symptoms are, how long they’ve been going on, what the systems issues and the relationship issues are, etc. Then we begin to identify what earlier memories are causing many of these problems.

If you’re coming in with relationship issues like, “I always overreact to criticism,” we try to see what’s causing the overreaction. What earlier memories might there be that are pushing it? Does the sound of your husband’s voice remind you of your father’s voice before he hit you? We have specific techniques to identify these problematic memories.

The second phase involves preparation. We teach a variety of self-control techniques so that people learn to shift from negative feelings to positive ones.
You don’t have to process each and every event because memory is connected. Instead, you choose one that represents a whole group, and then you have a generalization effect.
These techniques can be very useful for everyone, but ultimately we’re trying to lessen the need for them. That is, if I’m always buffeted by these unprocessed memories, and I’m constantly needing to shift out of negative feelings into positive feelings, what I really want to do is process these memories so I’m not getting triggered by them any longer. A preparation technique will allow the person to feel in control so that when we start the processing, if a disturbance comes up, and they feel like they want to stop, we just stop. We use the technique to shift back into feeling good, and then when they’re ready, we go back and continue the processing.

The amount of preparation depends on how debilitated the client is to be begin with. Some people have never had good experiences—they had a terrible childhood, were beaten, ignored, neglected; they didn’t have anyone in their life that they could turn to or count on. These folks can be extremely debilitated emotionally, so we may need to spend more time preparing them. For most people it doesn’t take very long at all, maybe a session or so.
RW: That’s true, it can.
FS: For an individual trauma, it might take two or three sessions. And you simply want the client to be in the best possible state, not only during the processing but also in between sessions.
RW: So they can shift into and out of the self-paced imagery?
FS: Exactly. It’s not homework, as you would get with cognitive behavioral therapies for trauma. But let’s say it’s going to take three sessions to finish an individual trauma—you can do that morning and afternoon, or you can do it three consecutive days. In other words, the treatment can be done in days or weeks, rather than months or years.
The treatment can be done in days or weeks, rather than months or years.
And because all of the therapy is done with the clinician, they don’t have to go out and confront negative feelings and experiences on their own in order to try to make things change.
RW: So the history, identifying the memories, and preparation are the first phases. What happens next?
FS: Then we move into processing. We identify a memory that has been causing the symptoms and then we identify different aspects of it—the image, the negative thoughts associated with it, where they’re feeling it in their body, what the emotion is, etc. And once we access the memory in a certain way, we start the processing, which involves stimulating the brain’s own information processing system that allows the different connections to be made.

One of the procedures in the processing involves a form of dual attention stimulation—meaning the client follows the clinician’s fingers with their eyes as they move rapidly back or forth, or it can be tones or taps. It seems to stimulate the brain’s information processing system, and the client then has different, rapidly moving associations. They may have new thoughts about the memory, or other memories may emerge, or new insights can come up. It allows the brain to do the digesting by making all of the appropriate links that it hadn’t been able to make before.

Eye Movement

RW: After the preparation phase, I usually introduce the eye movement component. First I do the protocol, the target image. Many people don’t want it to be a memory—they’re coming in with some anxiety that they’re dealing with right now, and they don’t necessarily make the connection to memories. So I might start with a target image like, “when my husband’s face gets angry and frowny, I go into a panic.” Then I write down the negative self-beliefs after and rate their anxiety on a scale of intensity from zero to ten. I see where that anxiety is felt in the body. While they’re doing this protocol, they’re identifying what they’re feeling, what their beliefs are—“I’m a bad person. I’ll be a failure. I’ll be humiliated. I’ll be punished.”

And then I draw a line across the tablet and say, “What beliefs would you like to have?” This is straight out of your protocol. It’s often surprising to people, but once they get it, they can really elaborate. “I’d like to feel confident that I can handle this moment.” “I’d like to feel certain that I can stay calm and reasonable”—that sort of thing.

It’s a powerful moment when I move my ottoman over in front of the person and hold my hand up after customizing it for them. The rapidity of the motion back and forth, how wide the sweep is—these are custom tailored for each person, and then they go into that image—they’re seeing the husband’s face, angry and escalating, and they can actually feel their beliefs: “I’m getting ready to be demolished.” It is phenomenal. It’s very different.
FS:
It’s been demonstrated in about 16 randomized controlled trials now that the eye movement also rapidly causes the vividness to shift and emotion to decrease.
It’s been demonstrated in about 16 randomized controlled trials now that the eye movement also rapidly causes the vividness to shift and emotion to decrease. So they may start out with a disturbance, but it very rapidly decreases and shifts to that new understanding—from “that’s how my father used to look at me” to “that was wrong of him” to “It wasn’t my fault” to “it was his fault.” It’s getting liberated from how they felt as a child so that they can see the present more clearly.
RW: It’s so true.
FS: Of course there might be a need for couples counseling, but in many instances, these overreactions are caused by early childhood events stored as unprocessed memories.
RW: We all know that when our sympathetic nervous system gets aroused, clear thinking goes out the window.
FS: Right, exactly.
RW: The point here is that when you’re doing the eye movement part of it, after having prepared the self-soothing and the cognitive component of the beliefs and the desired beliefs, the shift is so remarkable.

The person may have four or five associations: “I see my parents fighting. I see myself hiding behind the door. I feel terrified. I feel like I should stop their fighting. It’s my fault.” The therapist picks out one of those, which I think is an area of the art of the therapist, knowing which one to pick that will lead to the next set of associations. But when it’s very, very accepting, no judgment, no anxiety on the part of the therapist, that calmness is often rewarded. After the next set of repetitions, the person says, “I do not have to rescue. It’s not my fault.” They’ll say it. You never have to say it. They get to it themselves.
FS: Very often the therapist can stay completely out of the way and foster and support the client nonverbally. We’re conveying acceptance because we do accept it. We are conveying unconditional regard because that’s part of the therapy process, so the clients don’t have to be afraid of their own emotions. They don’t have to be afraid, and they can reveal as much as they want.

With other forms of therapy, you have to describe the memories in detail. With EMDR therapy, that’s not necessary. The client says as much or as little as they want to.
With other forms of therapy, you have to describe the memories in detail. With EMDR therapy, that’s not necessary. The client says as much or as little as they want to. As a matter of fact, in many instances, you can do it content free, and the client just gives you enough information to know that it’s changed. So rape victims, molestation victims, who may feel so much shame and guilt that they don’t want to talk about it initially—they don’t have to. You don’t have to force the client to do or say anything that they don’t want to.
RW: Your point about the calm, accepting, unconditional regard is a component you’ve emphasized in the trainings, but I don’t know that it comes across to some people who think EMDR is technique-y.
FS: There are specific procedures about when you continue the associations and when you return to the target, but the beauty of it is to allow that internal, intrinsic healing mechanism to take over and to make the appropriate associations and not take a clinical stance that you know more than the client, that you are the one that has to give the answers. In most instances, the connections are all there for the client and when they’re not, we have specific EMDR therapy procedures to kick start it again. It’s not about clinicians imposing themselves on the client, but rather allowing the appropriate healing to take place.
RW: So what is the next stage?
FS: Assessment is the third phase, where you’re identifying the memory and the different components of it, and then you move into a phase that we call Desensitization, which is allowing the insights and connections to be made until they’re a zero on the Subjective Units of Disturbance Scale (SUDS). It could start off at an eight or nine, but it’s down to a zero.

Then we move to a phase we call Installation, which has to do with concentrating on that desired positive belief the client wants and seeing if we can strengthen it so that it feels completely true to the client.

Then we move to the Body Scan phase, where we have the person think of that memory, think of the positive belief, and scan to see if there’s any disturbance in the body; and if there is, we process it.
We process the memory, evaluate, reevaluate, reassess, and see what else needs to be done until we've basically addressed all of the issues, and the client is feeling empowered.
For instance, a molestation victim who is feeling good and powerful scans her body and notices that there is a strange sensation in her back, and we focus on that. It turns out that’s where she was held down when she was raped. So we process that.

At the end of the session, the Closure phase brings the clients back to the full state of equilibrium. We remind them of their self-control techniques and the in-between-session processing they can continue to do. We also suggest that if a disturbance comes up, to just write down what happened very briefly—“I walked into X situation and I got triggered”—so that they can be targets for next time.

Then the eighth phase at the next session is Reevaluation, where we bring back the memory and see how it feels. See if there’s anything else that needs to be addressed. For instance, I worked with a girl who had been molested by her grandfather, and by the end of the session she was saying, “He was really weak. I ran into the bathroom and he tried to get in, and I just kept telling him to go away, and he went away.”

At the next session when I saw her, she felt fine. She didn’t feel dirty. She didn’t feel shameful. She didn’t feel powerless. She had a good grip on it. But in asking her what else might be coming up, she said, “Well, I was thinking of my grandmother, that she didn’t believe me when I told her I was molested.” So that’s the new target. We identify what else needs to be processed, and that’s how the therapy continues.

We process the memory, evaluate, reevaluate, reassess, and see what else needs to be done until we've basically addressed all of the issues, and the client is feeling empowered. It’s not only that the major symptoms are gone, but they feel like a positive, healthy, resourceful human being and are now able to establish and maintain positive relationships in their life.

Death by a Thousand Cuts

RW: In my own practice, the vast majority of my clients don’t come in to do EMDR therapy. They are coming in with other problems in living—anxiety, depression, relationship problems, etc.—and then I introduce it to them. It’s looking at the current target image, the current source of the anxiety, that then leads to association with past memories of actual trauma. But another source of trauma is the reaction of the social environment to the trauma. Like in the example you just gave, the woman’s grandmother, in her disbelief, was another source of trauma in addition to the molestation.

This is a common consideration in most trauma therapies—that it’s not just the trauma, it’s everybody’s reaction to the trauma that makes it worse, so I think that’s such an important component. It’s all interconnected.
FS: PTSD has commonly been thought of as a response to major traumas—earthquakes, rape, molestation, combat, etc. But the research now is very clear that general life experiences can cause even more PTSD symptoms than major trauma. Childhood experiences, humiliations, divorce, conflicts in the home—these things can be a source of chronic PTSD.
RW: Death by a thousand cuts. All the micro traumas that get accumulated.
FS: It doesn’t even need to be accumulated. You can have individual childhood events, like an individual being pushed away, being left behind, being humiliated in grade school, having people laughing at them. Any of these things can get stored in the brain with terrible feelings and thoughts of, “I’m not good enough. I can’t succeed. I’m not powerful.”
PTSD has commonly been thought of as a response to major traumas—earthquakes, rape, molestation, combat, etc. But the research now is very clear that general life experiences can cause even more PTSD symptoms than major trauma.
They get locked in and run the person for the next 30 years. So it’s important for people to have some compassion for themselves and not just dismiss their anxiety or their depression or their insecurity just because they don’t know where it came from. Many of us simply don’t remember because it’s a long past childhood event, and we don’t recognize that the problems we’re having in relationships or at work are influenced by these earlier events.

Also there’s a lot of research now showing the negative impact parents can have on the lifelong health of their children. There was a study done at Kaiser Permanente that clearly showed that adverse childhood experiences were the leading causes not only of mental health problems in adults, but of physical health problems as well—cancer, lung problems, etc. So I think we need to be more aware of how these experiences are being stored in our brain and constantly pummeling us with negative feelings that impact not only our minds but our bodies. These problems are transferred easily to children because research has clearly shown that mothers who have posttraumatic stress disorder are more likely to mistreat their children—not purposely, but they simply react more harshly.

Research has also shown that highly disturbing experiences within two years before childbirth can prevent the mom from bonding with her child, which has extremely negative effects. Maternal depression is one of those factors that Kaiser Permanente identified as causing these lifelong negative effects for adults because depressed mothers may not be able to bond with their children. It’s not only major traumas that are the problem—all kinds of experiences can have long-lasting detrimental effect on individuals.
RW: That is certainly corroborated by all the new imagery and radiology advances that have been made in which various autonomic processes—not only the body but the brain—are shown to react during negative interactions with people. There is this whole cascade of activity—everything from cortisol to high blood pressure to galvanic skin response to a change of blood flow to the frontal cortex and the amygdala. We all have this sympathetic arousal over traumatic interactions.

What is the latest research on how neurological reprocessing of trauma actually works?
FS:
EMDR processing seems to link in to the same processes that occur during rapid eye movement sleep.
EMDR processing seems to link in to the same processes that occur during rapid eye movement sleep. REM sleep processes the events of the day in order to make sense of them, and it moves them from episodic memory to semantic memory, where you can remember what happened, but you no longer have those emotions and physical sensations locked into memory. Until that happens it’s stored in episodic memory, which seems to get triggered with PTSD.

People who have posttraumatic stress disorder often wake up in the middle of a nightmare. That’s the brain attempting to process the event, but it’s too disturbing, so they wake up in the middle of it. What EMDR therapy appears to do is to take the brain further than it’s able to go in its natural state. The eye movements tax working memory and stimulate REM processes, which allows the rapid shift in imagery, emotion, cognition and sensation.
RW: A possible physiological analogy would be how insulin produced by carbohydrates causes the pores of fat cells to open and take in fat, and it’s only when we have proteins that the cells open and the fat comes back out so that we can lose weight. Similarly, there’s some unlocking of synapses where the memories of the trauma are stored. The anxiety has to go down, but there’s something about the bilateral movement that not only allows the memory to be stored, but also then connect with current, more rational, more safe feelings that give people a sense of identity and agency. It connects together and desensitizes the memory, which loses its power, while the current situation gains power. The current sense of self gains power.
FS: What we say is that it arrives at an adaptive resolution. What’s useful from the event is incorporated and the learning takes place. What’s useless is let go, so the negative emotions and physical sensations and beliefs are basically all gone. But it’s different than the concept of “extinction” employed in cognitive behavioral therapies, where the person is asked to describe the memory in detail as if they’re reliving it, making sure they don’t think of anything else but just stay there with that memory. It allows desensitization to occur, but the original memory that’s being targeted doesn’t change; rather a new one is created. The theory is that the person has been disturbed because of avoidance behavior—they haven’t allowed themselves to stay with it because they believe they’ll go crazy, they’ll die. And as their therapist causes them to tell the story over and over again, they realize they won’t die, and that creates a new memory that competes with the old one—but the old one is still there.

With EMDR therapy, there’s a short exposure where you ask the person to think about it, have the eye movement for about 30 seconds or so, and then you specifically elicit associations. They often move right to another memory.
It appears that the original memory is transformed as these connections are made, and the new learning and the new insight is made, and then it’s stored in this changed form.
It appears that the original memory is transformed as these connections are made, and the new learning and the new insight is made, and then it’s stored in this changed form. They no longer feel terrible about themselves. The transformed memory is stored and the original form it began with no longer exists. We call that “reconsolidation,” not extinction. So with exposure therapy, the original memory is still there, but in EMDR therapy the original memory is no longer there in its old form. This may be responsible for certain differences that we’ve seen in treatment.

For instance, there was a study comparing exposure therapy and EMDR therapy for those who had complicated mourning—intense grief that wasn’t changing. When somebody dies suddenly, very often the person who is bereaved continues to have negative imagery, negative thoughts of the person dying, seeing them in pain, guilt about what they should’ve done, could’ve done, etc. When individuals were treated with EMDR therapy and with exposure therapy, the EMDR was more rapid with better outcomes. Interestingly, there was twice the positive recall of the deceased than after treatment with exposure therapy. The fact that the original memory was still intact might be the reason for that.

Another example is the EMDR therapy treatment of phantom limb pain, where accident victims and combat veterans, who lost limbs in a traumatic experience continue to feel pain in a limb that’s no longer there. What we’ve found from the articles that have been published so far is that by identifying the trauma in which the leg was damaged, for instance, and processing it with EMDR, at the end of the treatment, 80% of people either no longer had any pain or it was substantially reduced.
No other form of therapy has reported elimination of chronic phantom limb pain.
No other form of therapy has reported elimination of chronic phantom limb pain.

One last example. In a treatment of psychotic people who had suffered trauma, when treated with EMDR therapy that targeted the trauma, not only were the PTSD symptoms eliminated, but a majority of those who had started out with auditory hallucinations reported that they were completely gone at the end of treatment, which was only about six sessions. That had never been reported with CBT. So there’s a lot more to explore over the next decade or so.

Neurons That Fire Together…

RW: Particularly as we learn more about specifics of the neurophysiological underpinnings of each mind function, like the functions you were talking about just now—extinction and consolidation. This reminds me of the work of Norman Doidge, the Columbia psychiatrist and psychoanalyst who wrote the book about neuroplasticity, The Brain That Changes Itself. He believes that EMDR therapy is one of the greatest breakthroughs in psychology in his lifetime. He would say that there’s probably a neuroplastic underpinning to each one of these very dramatic changes. He talks about how when we are really listening to something, the auditory cortex will make acetylcholine. And when we have a sensation of pleasure or decreased anxiety, there’s a little bit of dopamine secreted, and it’s that combination of acetylcholine and dopamine that creates the brain’s dendritic growth factor, which causes the dendrites to grow a few microns per hour.

Over time these dendrites find each other, which is why a dog will salivate at the sound of a bell once he learns that he’ll be fed after the bell rings. The auditory cortex has absolutely nothing to do with saliva, but the bell creates salivation because those dendrites have found each other. In other words, neurons that fire together, wire together. During EMDR therapy, there must be a lot of firing going on—self-soothing and the reduction of anxiety is getting wired together with the old memories and the new sensations of agency and safety and new cognitions. They somehow get wired together, and that really does replace the old wiring. I believe at some point we’ll be able to confirm this on the molecular level.
FS: I think ultimately that’s where the field is going, but the field of neurophysiology is still in its infancy, so as of yet no one has ever seen a memory network. But there are more than a dozen studies showing how the brain functions both before and after EMDR therapy, and you can see many differences including growth of the hippocampus as well as changes in cortical and limbic activation after EMDR therapy. Why and how that happens will probably take another decade or so to discover, since imaging will need to become much more sensitive.
RW: I just read, I think in Wired magazine, that the new MRI machines can measure 10,000 times greater detail than the current ones, so they can actually see the electrochemical impulse go down the neurons. Isn’t that wild?
FS: Yes. We have a very exciting decade to look forward to.
RW: What about critics who believe that the research is weak because the dependent variables are all self-report? It makes me think about how innovations are accepted in any field, but particularly scientific fields. There are the early adopters, who are just a few, then the middle adopters as more people hear about it, and then there’s a tipping point where everybody jumps on and incorporates the new learning or the new innovation. It seems to me like you’ve been working on this now for 25-plus years. Where do you think we are in that curve of adoption?
FS: I think we’re in the latter stage now. Those critics you’re talking about were responding to research from 15 years ago. At this point, there are more than 25 randomized controlled trials that have demonstrated the positive effects of eye movements, and a recent meta-analysis has shown there’s a significant effect. In fact, one of EMDR’s original vehement critics has completely turned around and stated that it’s clear that the eye movements have been demonstrated to be effective. Critics who make derogatory statements are very much out of date.

The same is true about the research on EMDR’s effectiveness. There are now more than two dozen randomized controlled trials that have demonstrated the positive effects of EMDR therapy with all of the bells and whistles of good research, including standardized measures, interviews, etc. The World Health Organization (WHO) has even stated that trauma focused cognitive behavior therapy and EMDR therapy are the only psychotherapies recommended for the treatment of PTSD across the lifespan. That is for children, adolescents, and adults.

The Trauma of Everyday Life

RW: I want to return to this idea that is so prevalent in our society that if you didn’t have any major traumas, then you should be all right. In fact, that’s not the case at all, as you pointed out. There are so many life events that become traumatic based on cultural influences. There are so many traumatic and worsening aspects of our culture—the increase in poverty and unemployment as wealth is sequestered in smaller and smaller groups; the emphasis on extroversion and positive feelings over fear, anger and grief; the pathologizing of normal problems in living. All of these things are enormously traumatizing, but we don’t think of it as something that our culture needs to look at.
FS: That’s one of the reasons I wrote the self-help book, Getting Past Your Past—to bring attention to the many things that can be causing our negative reactions and symptoms in the present and explain what to do about it. There are so many events in life and so many things about our relationships that can cause anxiety, depression, insecurity and PTSD. It is explainable and it’s treatable.

We have a nonprofit organization that came into being after the Oklahoma City bombing in 1995. We got a call from a FBI agent, who said, “Can you please do something because the mental health professionals are dropping like flies.” There were no empirically validated treatments for trauma back then. We sent out clinicians to do free treatment for the frontline providers and victims, and the program evaluation showed that it had the same positive effects—about an 85% success rate within three sessions—as a randomized controlled study that was published that year. Since that time our Trauma Recovery/EMDR Humanitarian Assistance Programs, has been providing free treatment for victims of natural and manmade disasters throughout the world and low cost programs for inner city areas in the U.S.
RW: How many people do you have volunteering or doing low cost treatment?
FS: There are hundreds. We have responded to all the major disasters in the US such as Katrina, Sandy, the Boston Marathon Bombing and Newtown shootings. Trauma Recovery Networks have been established in about 30 cities throughout the country. And we’ve also sent teams out after the tsunamis and earthquakes around the world. EMDR Asia came into being a couple of years ago, so now they’re able to do the humanitarian work on the continent themselves.

But there are so many more that need help. People who have been hurt can hurt others. Child molesters, for instance, are often viewed as intractable. Many people don’t want to have anything to do with them. We basically keep them ostracized from society.
RW: Further traumatizing.
FS: But a director of a program incorporated six sessions of EMDR therapy for those molesters who seemed the most incorrigible. They themselves had been molested in childhood—which is often the case with those who molest children—and when their own molest was targeted and processed, they came in contact with how they felt at the time.
We can take people that seem intractable and transform them into positive human beings so they’re no longer hurting others.
They recognized that they hadn’t wanted it and empathy emerged for their own victims. They no longer felt sexually attracted to children. It was measured by something called a penile plethysmograph, which measured their arousal, and 90% no longer exhibited deviant arousal towards children. So we’re attempting to conduct more research in this area.

The bottom line is that we’re looking at the potential that no one needs to be left behind. We can take people that seem intractable and transform them into positive human beings so they’re no longer hurting others. We want to make sure that we’re able to get the treatment to all who need it, so that we stop the pain for future generations.
RW: For any clinicians who are reading this and are interested in getting EMDR training, what’s the best way for them to do so?
FS: It’s extremely important that clinicians who are interested in being trained go to a program certified by the EMDR International Association in the U.S or the EMDR Europe Association in Europe. There are people out there offering programs that are not up to snuff. Certified trainings are six days plus consultation. There are international standards that have been developed to make sure that clinicians know what they’re doing before they treat any clients. Non-profit agencies can arrange for low cost trainings from the Trauma Recovery/EMDR Humanitarian Assistance Programs.
RW: Any final comment you’d like to make before we sign off?
FS: I’m hoping that interviews such as this will really allow people to get a better understanding of EMDR therapy and its potential for healing. The unimaginable amount of suffering that’s going on out there does not have to continue. People can truly heal in a comparatively short period of time and move to a state of happiness, strength and resilience, with healthy relationships.
RW: Thank you so much, Francine, for a very good interview.
FS: Thank you.

When the Therapist Loves and Hates

Posted on by Psychotherapy.net Team

That creatures must find each other for bodily comfort,

that voices of the psyche drive through the flesh

further than the dense brain could have foretold,

that the planetary nights are growing cold for those

on the same journey who want to touch

one creature-traveler clear to the end;

that without tenderness, we are in hell.

—Adrienne Rich

The Embrace

She looked deeply into his eyes and he looked into hers. Their bodies were very close, melding with one another. He touched her breast, grazing, and then holding it. Responding with her all, breathing in his fragrance, she embraced him. They were enthralled with one another, the love chemical flowing with the delight that they shared.

Although this may sound like a description of lovers in the first phase of their sexual relationship, it is a description of a mother-infant embrace. Many mothers, myself included, can easily call to mind and re-experience the intensity of having newborn infants. Longing for skin-to-skin contact, needing to engage in the reciprocal dynamic of breastfeeding (the baby needs her empty belly to be filled, the mother needs to have her swollen breasts emptied), the baby’s absolute dependence on the mother and the mother’s experience of total responsibility for the baby—in the earliest days between mother and child, only the other exists.

This “altered state” of consciousness, shared by new lovers and the mother-infant dyad alike, is also commonly experienced by the psychotherapeutic “couple” in much the same way—with longings for contact, a desire to feed and be fed, and the shared experience of total dependence on the other, as if no one else exists during the therapeutic hour. Yet unlike the merging love experienced by mother and infant, this love between therapist and client remains somewhat taboo in therapeutic culture. Because of this, clinicians often unwittingly (and unconsciously) let their clients carry all of the loving feelings for the dyad. “We’ve all heard many stories of therapists abusing their power and acting out sexually with clients in the name of “love.” But what of the damage inflicted by avoiding, denying, or otherwise minimizing love in the therapy relationship?”

Hate

And then there’s hate.

We have all felt critical, angry, hateful, and exasperated toward others at some point, so it only makes sense that therapists have both hateful and loving feelings toward our clients. We need to be flexible feelers, comfortable with the variety of feelings we experience and also wiling, when appropriate, to express these feelings with clients. But feeling hateful toward clients is extremely uncomfortable for therapists; it is defensive in its very nature when we are expected to be open, undefensive, unreactive, thoughtful.

In the history of psychoanalytic ideas, aggression has generated enormous controversy and continues to be the subject of sustained and intense interest. Sigmund Freud wrote extensively about aggressive impulses and, for him, they were more than a mere branch of human motivations. In Civilization and Its Discontents, he characterized antagonistic tendencies as the primary, dominating, “central and abiding part of human experience.”

Like love, hatred is enormously complex, and warrants serious reflection when it comes up with clients. Without self-awareness, hateful feelings can lead us to hurt and blame our clients, to harm them. How therapists understand and relate to aggressive feelings is critical in the clinical setting, but too often we suppress and repress them, just as we do with love.

In my experience, making room for—welcoming, even—our deepest feelings of love and hate for and with our clients is what makes the relationship truly transformative. If we can bear the vulnerability (which, frankly, we should), our work can be deeply healing for both our clients and ourselves. I present my therapy with Lucy to illustrate the depth of feeling that arises in our work, and to caution against repressing and denying these feelings out of a mistaken belief that we are somehow serving our clients by staying more “neutral.”

Lucy

My new patient was a hooker. She spit this out right after my conventional introduction of “Hello, I am Chris Peterson. Please come in.” There it was, right up front, as if Lucy needed to get past this, deal with whatever she might have expected my reaction to be, and move on.

I felt an immediate liking for Lucy. She was 30, beautiful in a Bohemian way, and sported multiple piercings on her ears, eyebrows, and nose. Her face looked younger than her years, her eyes sparkled, and she practically bounced with energy. She talked about the various men she serviced in lurid detail in an attempt, I surmise, to shock (and test) me. I was rapt, but not ruffled. This was the third time a sex-worker had found her way to my consulting room and, like the others, Lucy was dealing with a past that included abuse, abandonment, and conflicted relationships. All such patients struggle with their own histories, which can include an abusive parent or parents, a competitive relationship with their mothers, and/or leaving home at an early age to escape further pain or degradation. These women want to be loved and to be healed, but are often “looking for love in all the wrong places.” Growing up in an emotionally volatile and abusive family, Lucy had little experience with feeling loved and nurtured. Love came to her through pain, abuse, and incestuous boundary violations.

I focused intensely on her stories, trying to understand her perceptions of herself and her fear of and longing for relationships with others and the greater whole of life. She seemed to have a sense of engagement with me and it seemed like she was open when we were in session, but for many months there was little carryover from one session to the next. She struggled with exposing herself and being vulnerable, and so did I.

I often found myself frustrated—sometimes to the point of utter exasperation—with what seemed like the snail's pace of Lucy’s progress. The stagnation and endless repetition of highly predictable and ritualized patterns in each session were difficult to tolerate. When she was feeling vulnerable and too dependent on me, she would attempt to control the situation and create distance between us by moving into a blatantly seductive role. She would arrive to session dressed in provocative attire, and when the end of the session drew near, she would jump up to leave, announcing that both of us had someone waiting.

This kind of behavior happened most consistently when there was a break in our usual session time or when I left on a scheduled vacation. I wondered aloud with her about how she experienced these changes and absences. Initially she responded to my queries with a look of stunned astonishment, a negation of the importance of the break, followed by a cavalier comment discounting any connection between our separation and her behavior. My attempts to connect with her in a loving way were effectively blocked, and I was aware of how I began distancing myself from her.

After many months of treatment, however, I grew more optimistic and heartened by the increasing depth and overall sense of warmth and engagement that began to evolve in many of our sessions. Lowering my own distancing defenses—and my heightened awareness and sensitivity to how these functions served Lucy—helped me to do a better job of helping her modulate her responses, which in many instances recapitulated her early childhood traumatic experiences and painful feelings. At the beginning of treatment she knew no other way to respond to invitations of what she thought was intimacy; she knew no other way to survive. Yet gradually she developed an awareness of the sources of her difficulty in maintaining relationships.

These obstacles to relationship intimacy had begun during her earliest childhood, followed her through her grade school years, and continued into adulthood; consciously she did not recognize the empty and often self-degrading aspects of her encounters with others. Lucy had been a prostitute for close to 15 years, having started at the age of 15 in a desperate attempt to survive in a very primary way. With few exceptions, her experiences of sexual intimacy were comprised of her being penetrated in an abusive manner. Sexual vulnerability and human dependency carried risk for Lucy and challenged her sense of her capacity to survive.

The Breakthrough

In the real world of therapy there are few “breakthroughs” of the Hollywood kind. However, Lucy and I did experience such a moment in our work, which we both continued to recreate in later sessions. In the beginning of the third year of our work, following a month of increased focus on her longings for and terror of close and loving connections, a silence fell on us during one session. It was not an awkward and painful silence; rather, we both felt it as a deep and meaningful stillness. As we sat together, she looked up at me and I met her gaze directly. We held this gaze for several moments, both enthralled with each other, both moved to an almost orgasmic connection. The long months of avoiding emotional attachment began to give way to a new and intimate connection between us. The energy she had so desperately needed to use to hold me at arm’s distance was now more available for the task at hand—to begin to get critical needs met and to experience a safe, nurturing, and healing relationship.

Throughout the course of my work with Lucy I was brought to the brink of both love and hate. We had to navigate through both extremes in the service of helping her first allow dependence and then to separate. As a psychotherapeutic “couple” we both longed for contact, wanted to feed and be fed, and initially feared one another, but with time enjoyed the occasional shared experience of total dependence on each other. I came to understand the frustration I felt initially as my longing to have her work at my pace and to accept me quickly as a safe and reliable mother. Her defenses against that kind of merging were difficult for me to withstand. I wanted her to taste how sweet and warm my breast milk was and to know I would feed her well—to trust me and depend on me. Her resistant defiance enraged me at times, and as much as I intellectually understood some of what had occurred in her life to create this defensiveness, emotionally I felt rejected. She triggered feelings in me of inadequacy and powerlessness—feelings that, I came to appreciate, she had carried throughout her life. With time we could begin identifying what feelings were hers, mine, and ours.

The more loving feelings arrived gently, but grew steadily. These did not completely replace the hateful feelings, but balanced them in such a way that while both were in play, they were more tolerable and open to a deepening analysis. Lucy initially enacted a bit of sadomasochism in her mode of relating with me, creating pain for both of us. In response, I felt her resistance to my attempts to care for and nurture her, which triggered a sense of impotent, hopeless rage in me.

Lucy and I were able to explore the sexualization of her aggression, along with its possible roots. She recalled moments of intense longing for her withholding mother. The transference-countertransference enactment that occurred early in treatment was interesting and demonstrated an aggressive but essentially erotic interplay. When I was able to ask what she noticed when the seductive behavior took over, she could only say that she worried I was frustrated with her (and I was) and seduction was her way of dealing with that worry. In time, we were able to explore this. Lucy was moved to frustrate me or make me angry in some way so as to defend against the longings she felt at the beginning of many sessions. She also added that she became more certain of where she stood with me if she made me angry.

Her seductive relating was a defensive effort to change negative experiences into positive ones. As noted by Harriet Wrye and Judith Welles in their book The Narration of Desire: Erotic Transferences and Countertransferences, this idea is based on an associative model, which claims that both positive and negative experiences occur together in childhood and can become fused so that seduction (sex) is in the service of an irresistible pull toward a destructive interplay. This destructive interplay had been the only way Lucy could make contact with people, and her aggression projected the illusion of strength. It summoned the armor surrounding and hiding her vulnerability, making her feel self-protected rather than relying on my goodwill. But, to paraphrase Ellen Liegner in The Hate That Cures, although at times the therapeutic relationship might be characterized by a mutual hatred, the patient wants a positive relationship. The therapist must not act upon his/her own feelings of outrage, vexation, or exasperation, but through self-analysis recognize her intense emotions and use them in the service of authentically understanding and connecting with the patient.

Lucy’s feelings of hate subsided and, in time, were replaced by feelings of appreciation. She began to act like a loving person. It is likely that the narcissism of her early caretakers and their failure to act in mature and loving ways toward her were responsible for the development of her pathology.

The Primacy of Love

Why is it challenging to honor the healing potential of loving feelings in psychotherapy? What gets in the way of valuing and expressing love? Is it easier to abandon the issue than to be vulnerable and do the self-reflection and analysis that such feelings call upon us to do?

The capacity for love and concern on the therapist’s part is actually evidence of a healthy and thriving individual, and was considered by Winnicott to be an accomplishment that “develops out of the simultaneous love-hate experience, which implies the achievement of ambivalence, the enrichment and refinement of which leads to the emergence of concern.” In other words, a clinician’s ability to love is vital to the therapeutic endeavor, no matter what theoretical model is being used.

If we as therapists value others and are genuinely interested in serving their well-being without displacing or diminishing our own, we don’t respond first from within a theoretical model—we respond with our hearts and let love guide us. Having our needs felt by an influential and trusted other is critical when we are children, and dynamic, loving relationships remain important throughout our lives. Healthy dependency is embedded in Winnicott’s capacity for concern; it is needed to prevent psychological rigidity and to foster a willingness, and even enthusiasm, for being influenced by others. Loving is a distinct way of perceiving and being with our patients, ourselves, and others. It is rooted in vitality and wonder, and in therapy this feeling comes alive in an emotionally interactive, mutually transformative dance.

People have been grappling with definitions of love for thousands of years and there is no uniform agreement on what exactly love is. Erich Fromm defined loving as commitment of oneself to another without a guarantee. That is hard work. It means trying again and again despite pain and hurt, teaching others how to help us, extending a helping hand toward others at the exact moment we need a hand extended toward us. Is it possible that love is often sidelined in our field not because it is ineffective, but because it is so demanding?

Whereas there is considerable lip service given to what Carl Rogers referred to as “unconditional positive regard,” it is often misconstrued as neutralized affect, not the deep and authentic love and caring Rogers meant it to be. There is an undercurrent flowing steadily through many psychoanalytic tributaries that whispers, “Care less, keep your distance, don’t work too hard.” The implication is that if we as therapists care too much, believe too readily, or get pulled in too deeply, we are foolish. But love is an experience of a deep human connection—on an unconscious as well as a conscious level—that involves generosity, recognition, acceptance, and something like forgiveness.

Being with patients in the therapy room, allowing for an intimate exchange (intercourse, in fact), holding them with words rather than with arms, and containing their intense feelings as they learn how better to contain these themselves is the very essence of my work. It is important that we as therapists devote our clinical, educational, and personal consideration to our love for the client within the therapeutic context as an essential and valuable element of effective therapy, regardless of our theoretical orientations. Psychoanalyst Judith Vida, when asked how love contributes to psychoanalysis, responded:

"It is not possible for me even to enter my office in the morning of a clinical day without the hope and the possibility of love. How can I say what it 'contributes' when it is not an option or a conscious choice whether it is there or not? This is like saying, 'Does it contribute to the therapeutic action that the analyst draws breath, has a blood pressure, and a pulse?' For me, the proper question is not 'whether' or 'if' but 'how.' How is love present—and absent—in the therapeutic situation, and how is it manifested?"

In essence, it is love that makes psychotherapy work. It is the element, beyond theory or technique, that makes transformation possible. And there is no love without hate, as they are inexorably linked. We must we willing to experience all of it so that our clients can too.

The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

Posted on by Psychotherapy.net Team

The following is an excerpt from The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk, MD. Reprinted by arrangement with Viking, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © Bessel van der Kolk, MD, 2014.

****

Marilyn was a tall, athletic-looking woman in her mid-thirties who worked as an operating-room nurse in a nearby town. She told me that a few months earlier she’d started to play tennis at her sports club with a Boston fireman named Michael. She usually steered clear of men, she said, but she had gradually become comfortable enough with Michael to accept his invitations to go out for pizza after their matches. They’d talk about tennis, movies, their nephews and nieces—nothing too personal. Michael clearly enjoyed her company, but she told herself he didn’t really know her.

One Saturday evening in August, after tennis and pizza, she invited him to stay over at her apartment. She described feeling “uptight and unreal” as soon as they were alone together. She remembered asking him to go slow but had very little sense of what had happened after that. After a few glasses of wine and a rerun of “Law & Order,” they apparently fell asleep together on top of her bed. At around two in the morning, Michael turned over in his sleep. When Marilyn felt his body touch hers, she exploded—pounding him with her fists, scratching and biting, screaming, “You bastard, you bastard!” Michael, startled awake, grabbed his belongings and fled. After he left, Marilyn sat on her bed for hours, stunned by what had happened. She felt deeply humiliated and hated herself for what she had done, and now she’d come to me for help in dealing with her terror of men and her inexplicable rage attacks.

My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem. Therapy often starts with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when somebody looks you in the eye, finding yourself covered with blood after cutting yourself with a piece of glass, or deliberately vomiting up every meal. It takes time and patience to allow the reality behind such symptoms to reveal itself.

Terror and Numbness

As we talked, Marilyn told me that Michael was the first man she’d taken home in more than five years, but this was not the first time she’d lost control when a man spent the night with her. She repeated that she always felt uptight and spaced out when she was alone with a man, and there had been other times when she’d “come to” in her apartment, cowering in a corner, unable to remember clearly what had happened.

Marilyn also said she felt as if she was just “going through the motions” of having a life. Except for when she was at the club playing tennis or at work in the OR, she usually felt numb. A few years earlier she’d found that she could relieve her numbness by scratching herself with a razor blade, but she had become frightened when she found that she was cutting herself more and more deeply, and more and more often, to get relief. She had tried alcohol, too, but that reminded her of her dad and his out?of?control drinking, which made her feel disgusted with herself. So instead she played tennis fanatically, whenever she could. That gave her a feeling of being alive.

When I asked her about her past, Marilyn said she guessed that she “must have had” a happy childhood, but she could remember very little from before age twelve. She told me she’d been a timid adolescent, until she had a violent confrontation with her alcoholic father when she was sixteen and ran away from home. She worked her way through community college and went on to get a degree in nursing without any help from her parents. She felt ashamed that during this time she’d slept around, which she described as “looking for love in all the wrong places.”

As I often did with new patients, I asked her to draw a family portrait, and when I saw her drawing, I decided to go slowly. Clearly Marilyn was harboring some terrible memories, but she could not allow herself to recognize what her own picture revealed. She had drawn a wild and terrified child, trapped in some kind of cage and threatened not only by three nightmarish figures—one with no eyes—but also by a huge erect penis protruding into her space. And yet this woman said she “must have had” a happy childhood.

As the poet W. H. Auden wrote:
Truth, like love and sleep, resents
Approaches that are too intense.

I call this Auden’s rule, and in keeping with it I deliberately did not push Marilyn to tell me what she remembered. In fact, “I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know.” This may take weeks or even years. I decided to start Marilyn’s treatment by inviting her to join an established therapy group where she could find support and acceptance before facing the engine of her distrust, shame, and rage.

As I expected, Marilyn arrived at the first group meeting looking terrified, much like the girl in her family portrait; she was withdrawn and did not reach out to anybody. I’d chosen this group for her because its members had always been helpful and accepting of new participants who were too scared to talk. They knew from their own experience that unlocking secrets is a gradual process. But this time they surprised me, asking so many intrusive questions about Marilyn’s love life that I recalled her drawing of the little girl under assault. It was almost as though Marilyn had unwittingly enlisted the group to repeat her traumatic past. I intervened to help her set some boundaries about what she’d talk about, and she began to settle in.

Three months later Marilyn told the group that she had stumbled and fallen a few times on the sidewalk between the subway and my office. She worried that her eyesight was beginning to fail: She’d also been missing a lot of tennis balls recently. I thought again about her drawing and the wild child with the huge, terrified eyes. Was this was some sort of “conversion reaction,” in which patients express their conflicts by losing function in some part of their body? Many soldiers in both world wars had suffered paralysis that couldn’t be traced to physical injuries, and I had seen cases of “hysterical blindness” in Mexico and India.

Still, as a physician, I wasn’t about to conclude without further assessment that this was “all in her head.” I referred her to colleagues at the Massachusetts Eye and Ear Infirmary and asked them to do a very thorough workup. Several weeks later the tests came back. Marilyn had lupus erythematosus of her retina, an autoimmune disease that was eroding her vision, and she would need immediate treatment. I was appalled: “Marilyn was the third person that year whom I’d suspected of having an incest history and who was then diagnosed with an autoimmune disease—a disease in which the body starts attacking itself.”

After making sure that Marilyn was getting the proper medical care, I consulted with two of my colleagues at Massachusetts General, psychiatrist Scott Wilson and Richard Kradin, who ran the immunology laboratory there. I told them Marilyn’s story, showed them the picture she’d drawn, and asked them to collaborate on a study. They generously volunteered their time and the considerable expense of a full immunology workup. We recruited twelve women with incest histories who were not taking any medications, plus twelve women who had never been traumatized and who also did not take meds—a surprisingly difficult control group to find. (Marilyn was not in the study; we generally do not ask our clinical patients to be part of our research efforts.)

When the study was completed and the data analyzed, Rich reported that the group of incest survivors had abnormalities in their CD45 RA?to?RO ratio, compared with their nontraumatized peers. CD45 cells are the “memory cells” of the immune system. Some of them, called RA cells, have been activated by past exposure to toxins; they quickly respond to environmental threats they have encountered before. The RO cells, in contrast, are kept in reserve for new challenges; they are turned on to deal with threats the body has not met previously. The RA?to?RO ratio is the balance between cells that recognize known toxins and cells that wait for new information to activate. In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells.

Our study showed that, on a deep level, the bodies of incest victims have trouble distinguishing between danger and safety. This means that the imprint of past trauma does not consist only of distorted perceptions of information coming from the outside; the organism itself also has a problem knowing how to feel safe. The past is impressed not only on their minds, and in misinterpretations of innocuous events (as when Marilyn attacked Michael because he accidentally touched her in her sleep), but also on the very core of their beings: in the safety of their bodies.

Note: Find out about Bessel’s new in-depth, online Trauma Certificate Course. 

Scott Miller on Why Most Therapists Are Just Average (and How We Can Improve)

Posted on by rezendevknowfully.com

Escape from Babel

Tony Rousmaniere: Many people know you as a Common Factors researcher, but recently you’ve transitioned away from that. Could you explain both what Common Factors is and your transition away from it?
Scott Miller: Sure. As old-fashioned as it sounds, I’m interested in the truth—what it is that really matters in the effectiveness of treatment. Early on in my career, I learned and promoted and helped develop a very specific model of treatment, solution-focused therapy. We had some researchers come in near the end of my tenure at the Family Therapy Center in Milwaukee who found that, while what we were doing was effective, it wasn’t any more effective than anything else. Now, for somebody who had been running around claiming that doing solution-focused work would make you more effective in a shorter period of time, that was a huge shock.
All models are equivalent. Pick one that appeals to you and your client.


It was at that point that I started to cast about looking for an alternate explanation for the findings, which concluded that virtually everything clinicians did, however it was named, seemed to work despite the differences. That led back to the Common Factors—the theory that there are components shared by the various psychotherapy methodologies and that those shared components account more for positive therapy outcomes than any components that are unique to an approach. It was something that one of my college professors, Mike Lambert, had talked about, but that I had dismissed as not very sexy or interesting. I thought, how could that possibly be true?

It was at that time that I ran into a couple of people that I worked with for some time, Mark Hubble and Barry Duncan, and we had written several books about this. If you read Escape from Babel, which we coauthored, the argument wasn’t that Common Factors were a way of doing therapy, but rather a frame for people—therapists speaking different languages—to share and meet with each other. They were a common ground.

But by 1999, it was very clear to me that Common Factors were being turned into a model by folks, including members of our own team, and viewed as a way to do therapy. But you can’t do a Common Factors model of therapy—it’s illogical. The Common Factors are based on all models. This caused a large amount of consternation and difficulty, numerous discussions, and eventually I suggested to the team that the way therapists work didn’t make much of a difference.

What was critical was whether it worked with a particular client and a particular therapist at a particular time. Mike Lambert was already moving in this direction and said, “Let’s just measure them. Let’s find out. Who cares what model you use? Let’s make sure that the client is engaged by it and that it’s helping them.” So we began measuring, and what became clear very quickly was that some therapists were better at it than others.

So, since about 2004, Mark Hubble and others at the International Center for Clinical Excellence (ICCE) have been researching the practice patterns of top performing therapists. It’s not that I don’t believe, and in fact know, that the Common Factors are what accounts for effective psychotherapy. It’s just that an explanation is not the same as a strategy for effecting change. And the Common Factors can never be used as such. All models are equivalent. Pick one that appeals to you and your client.

The Siren Song

TR: So Common Factors are a way of studying the effects of psychotherapy, but not a way of actually implementing it.
SM: Well, by definition, you can’t do a Common Factors model because then it’s a specific factor. I’m not saying the Common Factors don’t matter—what I’m saying is that they are a therapeutic dead end. They will not help you do therapy. You still have to have a method for doing the therapy, and the Common Factors are not a method. Why?
What I say is, pick one of the 400 that appeals to you and then measure and see: Does your client like it, too? If not, then it’s time for you to change, not your client.
All treatment approaches return equal efficacy when the data is aggregated and methods compared in a randomized controlled trial. So you still need some kind of way to operationalize the Common Factors.

Since we have 400 or so different models of therapy, why invent a new one? It seems to be because in our field, each person has to have it their own way. The promise of a new model is a siren song in our profession that we have a hard time not turning our ship towards. What I say is, pick one of the 400 that appeals to you and then measure and see: Does your client like it, too? If not, then it’s time for you to change, not your client.
TR: You have an article out in Psychotherapy where you mentioned three keys for therapists to improve their work. Your major focus now seems to be how therapists improve their work with each client. Can you describe those three keys?
SM: The first one is knowing your baseline. You can’t get any better at an activity until you actually know how good you are at it now. We therapists think we know, but it turns out that data indicates that we generally, as a group, inflate our effectiveness by as much as 65%. So you really have to know just how effective you are in the aggregate. That means you’re going to have to use some kind of outcome tool to measure the effectiveness of your work with clients over time.
We generally, as a group, inflate our effectiveness by as much as 65%.


The second step is to get deliberate feedback. So once you know how effective you are, then it’s time to get some coaching, get some feedback, and you can do that in two ways. Number one, you can use the very same measures that you used to determine your effectiveness to get feedback from your clients on a case-by-case basis. Meaning that you can actually see when you’re helping and when you’re not, and use that to alter the course of the services provided to that individual client.

The second kind of feedback to get is from somebody whose work you admire, who has a slightly broader skill base than you do, and have them look at your work and comment specifically about those particular cases where your work falls short. In other words, you begin to look for patterns in your data about when it is you’re not particularly helpful to people, and seek out somebody who can provide you with coaching. It’s like in golf, once you know what your handicap is you can hire a coach who can look at your game and make fine tweaks. It’s not about revamping your whole style, or about learning an entirely new method of treatment, but pushing your skills and abilities to the next level of performance.

The third piece is deliberate practice. The key word in that expression is “deliberate.” All of us practice. We go to work. But it turns out the number of hours spent on a job is not a good predictor. In fact, it’s a poor predictor of treatment effectiveness. So what you have to do is identify the edge of your current realm of reliable performance. In other words, where’s the next spot where you don’t do your work quite as well? And then develop a plan, acquire the skills, practice those skills and then put them into place. Then measure again to see, have you made any improvement?

I can’t take credit for coming up with these three steps. We’ve simply borrowed them lock, stock, and barrel from the performance literature, and in particular, Anders Ericsson’s work, which has been applied in fields like the training of pilots, chess masters, computer programmers, surgeons, etc. If we have any sort of claim to fame, it’s that we’ve begun applying these to psychotherapy for the first time.
TR: One of my first reactions to this is, aren’t some people just born better therapists?
SM: Well Ericsson notes that the search for genetic factors responsible for the performance of eminent individuals has been surprisingly unsuccessful. In sports we often think, “Oh, there must be some genetic component involved here,” or “he just has the gift of music.” But it turns out that virtually everyone that researchers looked at where the “gift” is implied, even with Mozart—he had been playing the piano for 17 years before he wrote anything that was unique, which happened at about age 21. He’d been playing since he was 4. His father had been doing music scales with him since he was in the crib. So once you remove the practice component, you just don’t find any evidence for genetic factors—with very few exceptions.

For example, in boxing it appears that people with a slightly longer reach have a slight advantage. But we also know that if baseball pitchers don’t start pitching at a particular age, their arms will not make the adjustment required to throw the ball as fast and accurately as professional pitchers do.

There was another study that looked at social skills. You often will hear, in addition to the genetic claims, that, “Good therapists just have great social skills.” Well, they’ve measured that. It turns out not to be the case, and the reason is that these kinds of ideas are too high or general a level of abstraction. The real difference between the best and the rest is that they possess more deep, domain-specific knowledge. They have a highly contextualized knowledge base that is much thicker than average performers, and much more accessible to them and responsive to contextual clues.

Deep Contextual Knowledge

TR: Could you give a specific example of what a deep contextual knowledge would look like in a therapy room?
SM: Well the classic one—and I say it to make fun of it—is suicide contracting. Or the suicide prevention interview.
Somebody comes in and says, “I’m going to commit suicide.” And we respond with, “Do you have a plan? Have you ever attempted this before?” Blah, blah, blah. That’s decontextualized knowledge. You could ask those questions to a stick.
Somebody comes in and says, “I’m going to commit suicide.” And we respond with, “Do you have a plan? Have you ever attempted this before?” Blah, blah, blah. That’s decontextualized knowledge. You could ask those questions to a stick.

What a top performer does is ask those questions very differently, nuanced by the client’s presentation, in ways that the rest of us can’t see. Because of their more complex and well-organized knowledge, they can actually see patterns in what clients present that the rest of us would miss and respond to in a much more generic fashion. Is this making sense?
TR: Absolutely.
SM: So the real question is how to help clinicians develop that highly contextualized knowledge. Because once you have it, not only can you retrieve that knowledge at the appropriate moment, but it turns out you can make unique combinations and use them in novel ways that would never occur to the rest of us, or would only occur to the rest of us by chance.
TR: This also doesn’t suggest that treatment manuals are necessarily the best way to train therapists.
SM: We know that following a treatment manual doesn’t result in better outcomes and it doesn’t decrease variability among clinicians using the same manual. So you still get a spread of outcomes, even when everybody is doing the same treatment.

At the same time, I think it’s critical that therapists learn a way of working, and, in the beginning at least, they hew to that approach. Why? Well, if you begin to introduce variation in your performance early on, you will not have the same ability to extend your performance in the future.

Let me give you an example. The first time I had a guitar lesson, I was taking classical guitar with this really interesting teacher. We spent the entire first lesson on how he wanted me to hold the neck of the guitar with my left hand—and I’m right handed. He said, “If you try to vary your hand grip from the outset, you’ll never have the same reach and ability to vary reliably when you need to in the future. So start with a common foundation, and then when we need to introduce variations later, we will.” My sense is that therapists instead begin in a highly complex, nuanced way and introduce variations into their style randomly and without much thought.
TR: So it would be better to begin with a frame or structure that provides a stable base, and then develop the deep contextualized knowledge later on.
SM: And to vary your work in ways that allow you to measure the impact of your variation against what you usually do. This is the key. Otherwise, what you have is a bag of tricks. You can do them all, but there’s no cohesiveness to it, and you can’t explain why you vary at certain times rather than others.
TR: Starting with a manual isn’t necessarily a bad idea then.
SM: Absolutely not. In fact, I would suggest grabbing a manual and going to a place where they are teaching a specific approach that will allow you to practice and also watch others in a two-way mirror. Once you have that foundation down, you can introduce your own variations.
TR: I hear therapists say, “I have 20 years experience,” or “I have 30 years experience.” Does this research find that experience, itself, makes someone better?
SM: No, it doesn’t. We know that not only in therapy, but in a variety of activities. If you think about it, you’ll understand why. While you’re doing your work, you don’t have time enough to correct your mistakes thoughtfully.
The difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.
So what we found, which I think is quite shocking, is that the difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.  Let me give you an example from a field that is similar—figure skating. If you watch a championship figure skater perform a gold medal winning performance, you can describe what they did, but it won’t tell you how to do it yourself. Do you follow me?
TR: Yeah.
SM: In order to be able to accomplish that performance, that figure skater must do something before they go on the ice, and after they leave the ice. It’s that time that leads to superior performance. You can go out and try to turn triple axels during the performances as much as you want. That experience will not make you better. You have to plan, practice, perform, and then reflect. Most of us don’t see all of the effort that goes into that great performance. We just appreciate how good it is.
TR: But one of the tricky differences is that we’re trying to help each client. And if we’re practicing new skills, invariably we’re going to make mistakes. And that’s emotionally harder because you’re making a mistake with a real person sitting across from you.
SM: Well, number one, we’re all already making these mistakes. And the ones that I’m referring to are generally small and not fatal. So your performance doesn’t improve by isolating gross mistakes, or gross skills. Your performance improves when your usual skills begin to break down—meaning they don’t deliver—and remembering those, thinking about them after the session, and making a plan for what to do instead. That’s where improvement takes place.

When I hear people mention this kind of objection, I think they’re thinking that the errors are far grosser than what I’m talking about. Once therapists assess their baseline, most are going to find out—to their, perhaps, surprise—that they’re average in terms of their outcome, or slightly less than average. So if we’re average, then it’s not about bringing your game up to the average level. It’s about extending it to the next. That requires a focus on small process errors.

Let me give you another example. We have a pianist come and perform at one of our conferences. She is eight years old and she is really unbelievably able as a concert pianist. She plays a very difficult piece. I ask her if she made any mistakes. She says, “Of course, I made a lot.” I tell her I didn’t hear any, to which she says, “Well, that’s because you’re no good at this.”

I then say, “What do you mean? And what do you do about your mistakes?”

She says, “Look. I made lots of mistakes, but you cannot get better at playing the piano while you’re performing.” This is an 8-year-old.

I say, “So what do you do?”

She says, “Well, I hear these small errors. I remember them. My coach in the audience remembers them, and then that’s what I isolate for periods of practice between performances.”

Most of Us Are Average

TR: How many therapists really practice between sessions? I mean, that’s pretty rare, isn’t it?
SM: Most of us are average.
TR: Right.
SM: And 50% of us are below average, right?
The best performers spend significantly more time reading books and articles….and reviewing basic therapeutic texts.
So very few people do it, and this is the real mystery of expertise and excellence. Why do some go this extra mile? There’s no financial pay-off. I think this will change in the future, but at the present time, you don’t get paid one dime more if you’re average, crappy, or really good. The fees are set by the service provided.
TR: That is a great problem with our field and I hope that does change in the future.
SM: I think that we’re seeing movement in that direction. I think that our field will become like other fields, where outcome of the process is what leads to payment, rather than the delivery of it.
TR: So back to practicing. Therapists read books and go to workshops, but that’s kind of passive learning. What are your thoughts about that?
SM: That’s a component of practicing. A graduate student that I’ve been working with, Darryl Chow, who just finished his PhD at University of Perth in Australia, did his dissertation on this topic and found that the best performers spend significantly more time reading books and articles. We also know that the best performers spend more time reviewing basic therapeutic texts.

Therapists are often in search of the variation from their performance that will allow them to reach an individual client they’re struggling with. Top performers not only do that, but they’re also constantly going back to basics to make sure they’ve provided those. They spend time reading basic books that may be hugely boring but are nonetheless really helpful. Gerard Eagin’s The Skilled Helper, Corey Hammond’s book on therapeutic communication—these basic texts that remind us of things that we often forget in the flurry of cases we see every week.
TR: So reading counts. What about workshops?
SM:
We don’t know about workshops. I’m cynical about them, simply because they’re not set up in a way that respects any principles of the last 30 years of research on human learning.
We don’t know about workshops. I’m cynical about them, simply because they’re not set up in a way that respects any principles of the last 30 years of research on human learning. Six hours, chosen by the person who needs the continuing education, and there’s no testing of skills, acquisition of skills, no awareness of particular deficits in practice. Greg Neimeyer has done a fair bit of research on this and he finds no evidence that our current CE standards lead to improved performance. None.
TR: There’s a psychotherapy instructor I know, Jon Frederickson, who has his students go through psychotherapy drills, kind of like role-playing drills in a circle. Would that count as practice?
SM: It depends, but I like the sound of it. Not a scrimmage, where you do a whole game, but rather drilling people in very specific small skill sets again and again. That aligns with the principles of Ericsson’s researchers.

If you’re an experienced professional, your motivation for going to a CE event can be really varied. I know for me, I’m often just grateful to have a day off and hang out with friends. The particular content of the workshop, I’m ashamed to admit, is less important. The incentives are just all wrong.
TR: It goes back to your motivation question.
SM: I don’t think our field incentivizes that kind of stuff. In fact, you can be punished.
TR: Well, one incentive I discovered myself in my own private practice was my drop-out rate. That motivated me to get further training. Maybe other therapists don’t have the same problem I had, but I know that was a powerful motivation.
SM: Drop-out can be both a good and a bad thing. For example, our current system incentivizes therapists to have a butt in the seat every available, billable hour. What that means is that therapists may be incentivized—we have some data about this, too—to keep clients, whether they are changing or not. That’s what I mean when I say that the incentives are all screwed up. There are, every once in a while, motivated people like yourself who say, “Wait a second. There has to be something beyond this.” But that requires a degree of reflection that may be difficult for most of us, especially if we are well defended. For these folks, people drop out because they are in denial about their own problems, not because of anything they, themselves, might be doing.

You put those things together and it can be a fatal combination. We need to take a step back as payers for services and as consumers of services and think about the incentives in our current system. I know this sounds terribly economic, but I think it’s important for our field.
TR: That sounds sensible to me. What about watching psychotherapy videos by psychotherapy experts like the ones psychotherapy.net produces. Would that count as practice?
SM: Yes it would. Especially in the beginning, when you have identified a particular area or weakness in your skill set that you may need some help with. In essence, you’re spending more time swimming in it while reflecting, which is the key part.
TR: Do you have other examples of deliberate practice that you’ve heard of therapists engaging in?
SM: Well there’s the stop-start strategies that Darryl Chow has been talking about. And Chris Hall is doing a study at UNC that we’re involved with, where therapists will watch short segments of a video and then they have to respond in the moment in a way that is maximally empathic, collaborative, and non-distancing. So they’re training therapists to develop a certain degree of proficiency with fairly straightforward clients.

Then you begin to vary the emotional context, or the physical context, in which the service is delivered. So now the client’s not just saying, “Hey, I feel sad.” They’re threatening to drop out or to commit suicide. More difficult and challenging things. And then simply spending time outside of the office planning and discussing individual particular cases with peers or consultants is another strategy.

In Darryl Chow’s research, which I think is the most exciting stuff, he found that within the first eight years of practice, therapists with the best outcomes spend approximately seven times more hours than the bottom two-thirds of clinicians engaged in these kinds of activities. Seven times.
TR: Wow.
SM:
The key to this is really starting early and investing a little bit at a time. It’s sort of like how you’re advised to save for your retirement. Not in the last five years. Not in the first five years, but a little bit every year.
The good news is, now that we know this, we can start this process earlier. The bad news is, if you’ve been at this for awhile, it becomes impossible to catch up with the best. We just age out. We can’t do it. The key to this is really starting early and investing a little bit at a time. It’s sort of like how you’re advised to save for your retirement. Not in the last five years. Not in the first five years, but a little bit every year.
TR: One advantage that great athletes have is that their coaches gets to determine day by day what moves or what performances they’re going to practice. I run a training program here at University of Alaska, Fairbanks, at the University Center for Student Health and Counseling, and I don’t get to pick what clients come in day to day. It could be anxiety, depression, any number of different things, so I’ll do a training on, let’s say, working with anxiety, but the client that comes in will have depression. So what do you do about that?
SM: Well, in essence, we’re violating John Wooden’s primary rule, which is, we are allowing students to scrimmage before they drill. And I have to tell you, all students want to scrimmage, but what you need to do more of, before and during, is drilling. The kind of drilling that I think your colleague was talking about. Or you go back to, “Here’s how we hold the guitar.” And we play very simple songs and then we begin varying the drill with greater degrees of complexity once easier tasks are managed.
TR: So you’d recommend a longer period of training and practice and drills before seeing clients.
SM: I’d want to see that kind of mastery. Let me give you an example. Do you want the pilot to be proficient at flying in fair weather, as demonstrated on the simulator, before they fly a plane?
TR: Yes.
SM: You want them to be prepared for all the complications: “Wait a minute, it’s raining,” “Wait a minute, you’ve got problems with your rudder.” These are complex skills and, yes, we can teach people to manage them as one-offs, but then they never integrate it into a coherent package that makes it easier to retrieve from memory later on when they need that skill. If it’s viewed as a one-off—“With the anxiety client, I did this”—it’s not integrated into an organized structure for retrieval later on.
TR: So on a therapist’s resume, you’d want to see not just hours of direct service provided, but also hours spent practicing and learning.
SM: Or, better yet, somebody who has measured results, like yourself. All I need is an average pilot. I don’t need the best pilot in the world, because most of the time there’s not huge challenges. If you can document your results, and if you’re checking in with me, we’re going to catch most of the errors anyway. And then I want a therapist who has a professional development plan, that’s working on the aggregation of small improvements over a long period of time.
TR: So for tracking results, I know you recommend quantitative outcome measures, like the Outcome Rating Scale or the Outcome Questionnaire. But I have found that there are certain clients that quantitative measures just don’t seem valid for. It’s not a large percentage of clients, but there are some that underreport problems at first. So it can look like they’re deteriorating even while they’re improving. Can you recommend any kind of qualitative methods or other methods of trying to accurately assess outcome in addition to those measures?
SM: I don’t buy it. Personally, I just don’t see that stuff and I would offer a very different explanation for it. Let me give you an example.

We know that each time there is a deterioration in scores, the probability of client drop-out goes up, whether or not the therapist thinks that it’s a good sign that the client is “getting in touch with reality and finally admitting their issues,” or had inflated how they really were doing for the first visit. So the key task here is not to say, “There must be another measure,” but to figure out what skills are required for me to get a higher score.

Dig Into the One You Know

TR: That’s a new perspective. To look at what I can change about my performance, rather than a new measure to assess it.
SM: Now you see why I think our field is forever chasing its tail. Because instead of becoming fully connected to our performance, we are constantly looking for the trick that will make us great.
Instead of becoming fully connected to our performance, we are constantly looking for the trick that will make us great.
It’s like a singer looking for the song that will make them famous rather than learning how to sing. We’re forever going to workshops, and the level of the workshops are often so basic even when they’ve claimed to be advanced. The truth is, you can’t do an advanced workshop on psychotherapy for 100 people. You can’t do it. The content is too abstract and too general. You need to see a clinician’s performance and fine-tune it. So therapists go around and around, constantly picking up these techniques that they use in an unreliable fashion, and their outcomes don’t improve, but their confidence does.
TR: So instead of picking up a new modality every year, dig into the one you know, preferably with a real expert, and get individualized or maybe small group training and practice.
SM: I think that once you’ve achieved a level of proficiency, the only hope for improvement is to get feedback on your specific deficits. And yours will be different from mine.
TR: It sounds like you’d definitely be a fan of videotaping sessions and reviewing them and that kind of thing.
SM: Not alone—with an expert eye reviewing small segments. Otherwise the flood of information from video will have you second-guessing yourself, which can actually interrupt the way you work in an unhelpful way.
TR: What about live supervision?
SM: I’m not averse to it, but I think it’s a little bit like a GPS—it can correct your moves in the moment, but you become GPS-dependent and you don’t learn the territory. What’s required in learning is reflection. If you don’t reflect, you can’t learn. As my uncle used to say, “You got to study that thang.”

I actually had great opportunities with live supervision when I was at the Family Therapy Center and got corrected in the moment by two really masterful clinicians. But I also think that what really made a difference was sitting behind a mirror, without any financial worries, watching endless hours of psychotherapy being done, and then talking about it afterwards. “This was said. What could you have said? How come we said this? What do you need to do?” It was a heavenly experience and as a result, I came away with a very highly nuanced and contextualized way of delivering that particular model.

And today, when I’m doing my Scott Miller way of working and I notice that a particular client wasn’t engaged or interested at a particular moment, I think, “What could I have said differently?” It’s at that small micro level that improved outcome is likely to be found. As opposed to just gross generic level.

People go to workshops and say, “I’ve had some traumatized clients. Maybe I’ll learn that EMDR thing.”

“Really?” I think. “Do you know how effective you are in working with these clients already?”

“No, I don’t.”

“What makes you think you need to do EMDR?”

“Well, it just seems so interesting.”

And I think, “Oh, you’re doomed.” Not that there’s anything wrong with EMDR, but I have to tell you, I watched Francine Shapiro do it and it looks a lot different than some other people I’ve seen doing it.
TR: So the problem there is switching modalities rather than getting a lot better at the one you’re currently using.
SM: It’s looking for a trick rather than thinking through, what else could I have said? What else could I have done that I already know how to do? Or getting a little bit of tweaking from a trusted mentor.
TR: I know you present this information all over the world. Do you find therapists are open and receptive to these ideas?
SM: Yes. I think that there are some very real barriers that we need to address, but yes, I do.
TR: This has been a really fascinating conversation. Thank you for making the time.
SM: I like this stuff. I’m fascinated by it and I’m very hopeful about the direction we’re going research-wise, so thank you for giving me the opportunity.

George Silberschatz on Psychotherapy Research and Its Discontents

Posted on by rezendevknowfully.com

What is Empirically Known About Psychotherapy?

David Bullard: Let’s start with a little background information about your work. I first met you through the San Francisco Psychotherapy Research Group—can you talk about your involvement there?
George Silberschatz: Certainly. It was originally called the "Mt. Zion Psychotherapy Research Group,” founded by Joe Weiss who was joined by Hal Sampson, both psychoanalysts, in 1971. They were just starting to publish some research papers and were very active teachers at Mt. Zion Hospital when I began working with them in 1975. Their work together formed the basis of what is now known as Control Mastery Theory.
DB: You’ve been in private practice about thirty-five years and are a clinical professor at UCSF with a multitude of research papers on psychotherapy process and outcome.
GS: My book Transformative Relationships (Routledge, 2005) is on Control Mastery Theory, and my papers are almost evenly divided between research and clinical work, because they are so intertwined and I go from one to the other very easily.
DB: You are currently the president of the international Society for Psychotherapy Research, which includes chapters in North America, Europe, Latin America, and Australia. Would you talk a bit about the concepts “empirically-validated” and “empirically-supported therapies.” What are your thoughts about what is truly empirically known from psychotherapy research?
GS: Well, I have very mixed feelings about all of it because I don’t think it’s fundamentally based on scientific evidence.
I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy.
I believe that the term “empirically-validated” is largely used when people are trying to market their specific brand of therapy. You know, “Our empirically-validated therapy is better than everything and everyone else, so if you need therapy, come see us!"

It seems a bit overdone and over-hyped. A lot of people have started saying “evidence-based therapy” instead of “empirically-based,” but what counts as evidence and how is the evidence portrayed? There’s a great deal of subjectivity in that process.
DB: In the early mention of “empirically-validated treatment,” researchers made another distinction between efficacy and effectiveness. Is there such a distinction in the real world versus laboratory research?
GS: It’s a big controversy. The term “efficacy” is used by people who believe that empirical evidence can only come from randomized clinical trials, i.e. in the lab. It has its roots in both medicine and pharmacology in the way drugs are tested and, basically, the proponents of this research paradigm feel that anything else isn’t empirical, isn’t evidence.
Manuals are essentially useless for practicing clinicians.
I wrote an article about this for the Journal of Consulting and Clinical Psychology called “Are results of randomized controlled trials useful to psychotherapists?” It was basically a debate between myself and my co-author, Jackie Persons, who is a cognitive behavioral therapist. She took the position that people should only be practicing empirically validated therapies—by which she meant Random Control Trial-Based Therapies or RCTS—and that it might even be unethical to do anything other than that.
DB: Which implies following a manual that such studies usually use so that the treatment condition is uniform across therapists?
GS: It does often imply following a manual. They punted on this a little bit and said there was some wiggle room for therapists to stray from the manual, but what’s a manual? I took the position that manuals are essentially useless for practicing clinicians.
DB: That’s refreshing and helpful to hear.
GS: There’s a lot of variability among clinicians, you know? There are a lot of very thoughtful people who think like Jackie, but there are also people that see the limitations of that as a model, especially for psychotherapy.
There is no support for the idea of one therapy being better than another.


The current—and I would say balanced and intelligent—position of the American Psychological Association is that when you really look at the evidence carefully, as they’ve done, there is no support for the idea of one therapy being better than another. But a lot of the proponents of the Randomized Control Trial for psychotherapy use their results to say, “Our results show that our method is better than yours.” That’s led to a rash of people trying to do trials on their new model of therapy. Every time there’s a new therapy, somebody has to do a trial showing that their new therapy is as good or better than some other one. That hasn’t been very productive, in my opinion.

Psychotherapy Works

DB: Overall, what would you say has been shown? For example, Consumer Reports did their research on their readers’ reactions to psychotherapy in 1995.
GS: That was a very large survey of psychotherapy effectiveness. I think it had a very useful purpose because it was actually asking the people who were using the service what they thought of it. It was pretty impressive.
DB: So there have to be quite a substantial number of technical issues within the field of psychotherapy research that we won’t go into today, but I heard Daniel Kahneman, who won a Nobel Prize for Behavioral Economics research, state in a recent interview that the most relevant, reliable outcome measures for a person’s happiness should be based on the report of the person’s friends. In other words, their evaluation would be more valid than anyone else’s. What would you say is the most useful outcome measure for psychotherapy?
GS: Certainly not the therapist’s!
DB: No!
GS: It turns out to be a very complex problem. I respect Kahneman's work very much. He’s a brilliant man. But I’m not sure that I would necessarily agree with him that a friend or significant other in a person’s life would have the best perspective. This is something that has troubled psychotherapy researchers for a long time: How do you measure outcome? Whose perspective do you rely on? There are plenty of people who feel the therapist has the best position. There are other people who feel that the patient is in the best position. There are yet other people who—
DB: How about the patient’s mother?
GS: She may not be in the best position either! Because someone like a mother or a spouse may have a particular vested interest. But it’s a very thorny problem in psychotherapy research and I don’t think anyone’s come up with a definitive answer yet. I think we tend to use multiple perspectives now but that creates its own particular difficulties as well.
DB: You have studied both outcome and process-oriented research. Overall, hasn’t it been shown through meta analyses of lots and lots of studies that psychotherapy works for the vast majority of people who undertake it?
GS: Yes.
DB: And other studies of process show the elements that seemed to have the most impact within a psychotherapy relationship.
GS: Well, you’re quite right that there’s evidence available now that shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind.
Evidence available now shows unequivocally that psychotherapy works. There should be no more questions about that in anyone’s mind….The issue of what it is about therapy that is causing it to work is still up for a lot of debate.
It definitely does work. What that means, concretely, is that a person who is having any one of a variety of psychological, emotional or behavioral kinds of problems will do far better getting psychotherapy than not. The issue of what it is about therapy that is causing it to work is still up for a lot of debate. And, of course, every school of psychotherapy, every brand, has their own particular perspective on that.

One thing that people do generally agree upon is that the therapeutic relationship, the nature of that relationship that some people call the “therapeutic alliance,” is a critical factor. Other people say the relationship is a necessary, but not sufficient, condition, but what is it about the relationship? If you’re a clinician, and you’re about to meet a new patient, the research doesn’t really tell you what you might do to enhance that relationship. What are the things that are involved? What are the steps involved in creating these productive therapeutic relationships?
DB: Versus looking up in the manual to find out which antibiotic to give for which infection?
GS: Yes, but even with antibiotics, it turns out that a lot more of that is art and trial-and-error than we are led to believe. It’s not quite as cut-and-dried and as narrowly evidence-based. People try one thing and that may work on half the patients. But it doesn’t work on the other half, and then you have to start experimenting with tweaking it.
DB: I guess we’d like to pretend that we live in a world of certainty.
GS: Yes. There is something inherently reassuring about that. But it’s also quite elusive, in my opinion.
DB: I’m reminded of an old saying: “There is no Zen, only Zen teachers.” In a way, there is no “psychotherapy.” It’s only each unique interaction between two people (or three people if it’s couples therapy).
GS: I think that framing it this way goes back to a very old argument in psychology. The controversy about nomothetic versus idiographic principles. Ideographic being very individualized kind of principles, and nomothetic applying to large general populations. And in psychotherapy, my own view of it, both clinically and per research, is that it is very individualized.

So what’s going to work well for one person is not going to necessarily work well for another.
Therapy has to be tailored to the particular needs and goals of the patient we’re working with.
Therapy has to be tailored to the particular needs and goals of the patient we’re working with. But, having said that, I also think that there are some general principles, and here is a good example of one: If therapy is tailored to the needs of a particular person, all other things being equal, it will be more effective and more successful.
DB: Your background and your extensive work with Control-Mastery Theory, developed by Joe Weiss and Hal Sampson, is all about that.
GS: Yes. Very much so. It’s one of the things that really drew me to their work. It really takes into account the particulars of a person, the nature of their particular problems, what their particular history is, and how the therapy can address that in a very individualized way.

"We Forgot to Ask the Patient!"

DB: What’s your opinion on getting regular feedback from clients? The research that I’ve seen, both for individual therapy and couples therapy, seems to be clear that having clients give written feedback after every session improved either the alliance or the outcome. Should therapists be encouraged to incorporate that more into their clinical work?
GS: It’s a very good question, and it’s an area that is really taking off like wildfire right now, not just in psychotherapy, but in the field of healthcare generally. One of the biggest initiatives in many, many years, at the National Institutes of Health, is what they call “Patient-Centered Outcomes Research.” A lot of research in healthcare, for decades actually, was really just based on what lab tests showed, or what a physician concluded. Nobody bothered to get the patient’s perspective, and suddenly people are saying, “Oh, my God, we forgot to ask the patient!”

So now there’s this huge catch-up game going on in terms of trying to get the patient’s point of view. In psychotherapy research, we’ve certainly taken the patient’s view into account a lot, but what is newer in psychotherapy is this point that you’re raising about feedback, and getting patients’ feedback after every session. People have tended to use symptom-based measures, so patients fill out a form at the end of each session to see how they rate the severity of various symptom profiles.

I think that getting the patient’s feedback is very useful, but I’m not particularly impressed with symptomatic measures. I think there are probably more important things that one could find out from the patient after a session. What did they find useful? How did they feel the therapist was responding to them? That’s useful information for therapists to know, and historically we just relied on our own impressions to get that kind of information.
Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which.
Sometimes we’re right; sometimes we’re wrong, and we often don’t know which is which. Having the patient be the arbiter of that information is very valuable.

Even without written feedback, one would hope that an experienced practitioner would draw out the patient’s feelings and perceptions if he’s seeing some kind of transference to what a therapist has said or done. We hope that that would be an integral part of the work.
DB: Sure.
GS: Some therapists, of course, explicitly ask patients at the end of or at some point in the session, “Well, how do you feel things are going today?” Or, “How do you feel you’re doing?” Or, “How are things with us?” That’s a useful thing to do, but the people that are more into systematic feedback would say that you may get more reliable data if the patient is outside of the session, sitting, thinking about the influence of the therapist. You may get a more complete picture of the patient’s experience that way, instead of—what’s that old term in research?—the “socially desirable” answer.

"What Exactly Does 'Cured' Mean, Anyway?"

DB: Let’s switch back to the marketing aspect of “evidence-based therapies.” I recently came across a practitioner’s website where he claimed that his particular brand of marital therapy has proven to be effective with 90% of his couples and 70% were “cured.” What are your thoughts about that?
GS: It strikes me as primarily marketing. It’s hard for me to wrap my mind around numbers like that. What exactly does “cured” mean, anyway?
DB: Talk about the medical model! As if the people came in limping and left skipping merrily along.
GS: There’s plenty of evidence that therapy, including couples therapy, is effective. It works. But there’s no evidence whatsoever to support the idea that one particular brand is systematically better than another. There just isn’t evidence for that. People make all kinds of claims, but it just isn’t supported when you look at it on the broadest possible level.
DB: I found a couple of articles through the American Psychologist with tables about empirically validated therapies. One broad grouping is “well-established treatments.” And then they have “probably efficacious treatments.” I’m sure you’ve seen all of that.
GS: Yeah, absolutely.
DB: And someone cited 420 different defined psychotherapies. Do you think those are also marketing attempts to differentiate themselves from the rest?
GS: Yes, I think it is primarily marketing. I mean, there just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.” People have variations on cognitive therapy, to take a few examples. Albert Ellis, “Rational-Emotive Therapy.” You have Aaron Beck’s “Cognitive Therapy.” You have Jeff Young’s “Schema Therapy.”
There just can’t be 420 fundamentally different ways of doing this work. It flies in the face of common sense. I see it as what somebody called the “narcissism of small differences.”


And then there are probably 20 other variations of it. Well, are they really all that different? I don’t think so. I think it’s just people wanting to create a brand rather than looking for commonalities. They’re looking for, “this is my way,” so that they can develop empires and training institutes and all that.
DB: I’ve talked to a number of colleagues, a few of whom I guess may be possibly nearing retirement, and they look back over the years and wonder, “How did I do? How did it all go?” Arnold Lazarus, years ago, did some follow-up with as many of his patients as he could. Could you comment on how he did that, or your knowledge of that?
GS: I don’t know the specifics of Lazarus’ work on that, but I do know therapists who do this routinely. I’ve always had a lot of fascination and admiration for it, where a therapist will, after a number of years, get in touch with their patients and ask them to come back and to check in and to see how they’re doing. This is, obviously, without charging a fee. It’s just the therapist wanting feedback. Lou Breger wrote a book recently called Psychotherapy: Lives Intersecting in which he describes his experience contacting a lot of his former patients, and asking them how they’ve done. I think more of us should do it, probably.
DB: There are ways to do it, obviously, that ensure ethical reconnection with past patients.
GS: Yes. One has to be sensitive to respect their privacy. I mean Lou Breger got permission from all of his patients and any identifying data were disguised in his book. But even if one isn’t writing about it, just for one’s own edification, systematically getting a patient’s point of view several years after the end of therapy—what they felt about it, whether it was helpful or not helpful—could help sharpen us as clinicians.

We Are All Skinner's Pigeons

DB: Do you feel your clinical work with people is impacted by research results and, if so, to what degree? Or are you more impacted by what has happened in the session? One person pointed out to me quite a while ago, that in a sense, we therapists may be similar to Skinner’s pigeons—we get reinforced to do the things that work for us with our individual clients or couples. Research and theory can, perhaps, clarify and codify what we are doing or should do, but meanwhile, we’ve been getting these experiences with people about what works and doesn’t work. Do you have a sense of whether your own direct experience of doing therapy is most influential, versus reading research results?
GS: I’d say that my own work has been more influenced by my patients’ feedback and from teaching and observing what other therapists are doing in their work and how that’s going. In that case, I have the luxury of not being in the room at that point so I can think more broadly about what’s happening or not happening. I would say that those experiences, along with my own supervision—I’ve had therapy supervision for many, many years by really good people—have probably shaped my work the most.

There are some things from research that have also affected me. In my early training, which was largely psychoanalytic in the 70’s, the role of interpretation, particularly transference interpretation, as a primary mutative factor, was thought to be the primary effective ingredient of psychotherapy. My colleagues and I did some research on that and found, along with others, that there was no evidence that transference interpretations were especially powerful.
My colleagues and I did some research … and found, along with others, that there was no evidence that transference interpretations were especially powerful.


So that certainly led me to rethink everything. I thought, “Wait a minute. All the stuff that we’ve been learning from very senior psychoanalysts—there isn’t really any evidence supporting it other than the fact that they say so?” That really led me to question the role of interpretation in psychotherapy.
DB: Is that close to the idea that information—insight—can be imparted that will change people versus people having an experience that changes them?
GS: That’s exactly right. There’s a very gifted psychoanalyst, Frieda Fromm-Reichman, who said patients don’t come for insight; they come for experience. So this view has been around for a while, particularly in the so-called interpersonal school of psychoanalysis. I think that more often than not, people do learn from their experiences.

Having said that, I also want to say that in terms of my commitment to individualizing psychotherapy, it is true that there clearly are people who do learn a lot from new information, so I don’t privilege one or another. I don’t privilege the idea that there’s a particular technique that is across the board better than others. We might even say that for some people, having a new insight, a new thought about themselves or their lives or their childhood or current process, gives them a new experience.
DB: Yes, it can.
GS: Maybe more compassion for themselves.
DB: It could work both ways. It can work that the insight gives them new experiences. It can also work that new experiences opens them up to new insights.
GS: I would say it really does work both ways. And there’s no way to know in advance which it’s going to be for any given individual.
DB: What are your thoughts more generally about the role of research in a practitioner’s life?
GS:
Unfortunately research hasn’t given clinicians and practitioners a lot that they can use.
Unfortunately research hasn’t given clinicians and practitioners a lot that they can use. That is changing and will continue to change in a positive way, but the whole emphasis on the Randomized-Control Trials and so on has not helped clinicians much in my opinion. Other people have different views about this, obviously.

I think what can begin to help clinicians more is the very consistent research finding that “therapist effects” trump treatment effects. In other words, if there are therapists doing a trial of three different therapies, it turns out that there are particular therapists in all three of those conditions who are actually better than their peers.
DB: Those must include what some have referred to as “non-specific treatment effects.”
GS: And those effects are bigger than the particulars of the therapy that’s being practiced. To me, that’s a really interesting finding. And the question that it begs is, well, what are those therapists doing? Let’s figure that out. And, if we can figure out more about that, we could try to train other people to do that or try to incorporate more of that in our own work.

"He Was a Wise Dude, That Buddha"

DB: The final area I’d like to discuss with you is your own interest and involvement in Buddhist concepts. You’ve done very well-received seminars and workshops with Steve Weintraub, a Zen priest and psychotherapist, on Buddhism and psychotherapy. Is there anything that you would like to say about that?
GS: Overall, Buddhism, for me, as well as just the experience doing psychotherapy, has taught me that much in human life seems to get better when you can have more self-compassion. I’ve been interested in Buddhist thought for a very, very long time. My interest in it probably dates back to when I was studying psychology as an undergraduate. I was really interested in Freud. I was interested in Carl Rogers. I was interested in the Human Potential Movement.

Then I had this kind of—I don’t know what to call it—like an insight. I thought, “Wait a minute. People have been thinking about these things way before Freud, way before Rogers or Maslow; there’s a history to this. And it’s a very, very old and long one.” I would say that
Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else.
Buddhist thinkers have been paying attention to the nature of mind and suffering for longer than just about anybody else. They’ve had a lot of valuable insights into what causes people to suffer, and how people’s suffering can be alleviated and reduced and so on. So at that broad level, I think Buddhism has a lot to teach us about just basic human psychology, and particularly the nature of suffering and what causes people’s suffering.

It’s different, in my opinion, from organized religions, in the sense that it doesn’t say one’s salvation will come through this or that route. I would say it’s a very broad model. It allows people to apply the teachings in their own lives in their own way. It doesn’t really require going to church or synagogue every week or every month or that kind of thing. But it does give certain tools that people can use in a very reliable and useful way.
DB: I’ve seen a commentary attributed to the Buddha, where he sounded like an empirically-based fellow. He essentially said, “Don’t believe anything I’ve told you. Try these things out for yourself. And if they work for you, great. If they don’t, go onto something else.”
GS: Yeah. I think that’s one of the things that has contributed to Buddhism gaining enormous popularity in the West right now. We have something that fits very well with the kind of individualized and democratic mindset that we can learn things by seeing what works for us. There is a lot of wisdom in that. He was a wise dude, that Buddha.
DB: They’ve updated it. I’ve run across some people who are espousing “Open-Sourced Buddhism,” that we are free to choose from those schools of Buddhist thought, from the very cognitive-based wisdom of Tibetan Buddhism to the no-thought idea of Zen.
GS: I love the idea, and would love to see more of that open-source thinking applied to psychotherapy. One of the things that we have right now in therapy is the equivalent of proprietary systems, where people develop one of those 420 brands of therapy, and then you just have to get in and do it that way. As opposed to an open-source model, which is people getting in there and using it for their own purposes and contributing to it, growing it in their ways—which is what’s happened to Buddhism. People are growing in all kinds of ways in the West, and I’d love to see more of that actually happen in psychotherapy.
DB: Supposedly a graduate student went to Jung one time and asked, “How do I become the best therapist I possibly can?” And he replied, “Go to the library, read everything good that’s been written about the art and science of psychotherapy, and then forget it all before you peer into the human soul.”

Well, thank you. I really, really appreciate having had this time with you.
GS: Thank you.

Grief and Gratitude: Working with Stroke Survivors

Posted on by rezendevknowfully.com

Together

May we sit with wisdom and compassion

at the ancient fires
of dashed hopes
and lost dreams.
May the pain which brings us together
become the cave we enter
in reverent descent
and surrender
to what
IS.
May we have the courage
to bear this rebirth
together.
—Carol Howard Wooton

 

An Interruption

In 2005, our circle of six met in a poorly lit room of a community hospital. This afternoon, Tom had the floor. A former surgeon, he had been looking forward to cutting back his practice to spend time with his grandkids.

Tom had lived his life in constant motion. He had been a football star in high school and college before going to medical school. Now, at 67, he was paralyzed on his left side: his left forearm contracted in spasm, his once-dominant left hand clenched into a permanent fist in front of his belly, his left leg rigid below his knee. His chiseled face still handsome, he sat straight in his wheelchair, strong muscles supporting his torso—a powerful presence. But his eyes always gazed down; he barely looked at anyone.

“I used to be able to ski, drive, do everything around the house,” he said. “I loved my work. This summer, I planned to take the grandkids to the ocean, show them how to dive into the surf. What can I show them now? Nothing.” The other group members listened quietly to his grim litany; all of us recognized his truth.

One day in 2004, Tom had come home from work and eaten dinner as usual. His wife was in the next room when he felt himself lose balance and topple over. He called out to her.

“I’ve had a stroke. Call 911,” he told her from the living room floor. She made the call, then came back into the living room and sat her petite frame on Tom’s head until the paramedics came, knowing he would try to get up.

“I had it all planned out,” Tom said to us. “And now I can’t do any of the things that I want to do. All that time I spent in medical school and working hard while my wife raised the kids—this was supposed to be my time with my grandchildren.” Each week he repeated these thoughts while gazing at the fingers of his left hand, pulling each one out as straight as possible, then resting it on the arm of his wheelchair or in his lap. On this day, the door banged open, interrupting him.

In barged a large woman in a motorized wheelchair, which she drove fast and well. Her left leg was swollen huge, the bare right foot discolored, her skirt hem hardly covering the Foley catheter bag strapped around her calf. In a croaking voice, she declared, “There’s only two kinds of people in the world: keepers and assholes. And you’re all keepers!”

Everybody, including Tom, guffawed. Amidst the belly laughter, she zoomed over to our small circle, which had opened to give her room. She told us she had been sitting outside in the warm air for 45 minutes, thinking she was early. When no one else arrived, she’d opened every unlocked office door until she found us, arriving with only 30 minutes left in the session.

“Hi there,” she said with a wide grin. “I’m Alexandra.”

None of us could have guessed that day how much Tom and Alexandra would change each other’s lives.

The Group

When I’d spoken to Alex on the phone for the group screening, I hadn’t been sure whether I should allow her in at all. I could tell immediately that she would be a handful. She spoke nonstop. Her history included two violent deaths in her family and probable childhood verbal and physical abuse. There was no way to determine what aspects of her personality resulted from the innumerable medications she was taking, and what was caused by her stroke and or by PTSD. The nurse case manager referred her to me because of her complex medical conditions and because the psychosocial situation at home was especially difficult. Along with the stroke, which had left her completely paralyzed on her left side, she suffered from diabetes and lymphedema. Her husband was away at work or commuting during their waking hours, leaving Alexandra isolated at home with only the companionship of a part-time caregiver.

Any group therapist would have been concerned about the severity of her situation, her apparent need for attention, the feasibility of containing her, and the unpredictable impact she could have on others. However I also realized that she needed the group and had many stories that needed witnessing, as well as much wit and spice to offer her groupmates. And this was my mission: to create a community of belonging for stroke survivors to grieve, heal, grow, and keep hope alive—the space I wished I’d been able to find in the first years of my own “recovery.”

The Beginning

“I had a stroke in 1985. I was 38, with no high-risk factors.” Having just been minted as a licensed MFT, I was living a typically stressful existence building a practice and taking whatever jobs I was offered. It happened at a work-related event, a friendly barbecue for a support group of women Vietnam veterans which I co-facilitated. All of a sudden, I grew dizzy and wasn't sure if I was sitting up straight; the world receded to a distant buzz. I slept on the hostess’s couch that night, unable to drive home. When I woke to find I couldn’t stand, or even crawl, she brought me to the ER, where my husband met me.

The neurologist diagnosed me with a cerebellar stroke or CVA, etiology unknown, and gave an excellent prognosis: I would be fine, and it would take a while to learn to move again, to walk, to have a brain that worked at “normal speed.” When I asked what “a while” was, he hedged. “Six months from now, you and your husband will know,” he said finally, “but other people probably won’t be able to tell.”

Six months later, that was not true. Two colleagues who had suffered a stroke and a traumatic brain injury, respectively, told me, “Don’t worry about your progress for at least a year or even two. Just keep at it, no matter what.”

“You Don't Get It”

Before my stroke, I’d consulted with a therapist named Helen on my own cases. She was a smart, warm, empathic woman several years older than me with a well-established practice. Within 24 hours of my hospital admission, I asked my husband to call her: I needed her help in formulating a plan for handling my caseload. After we made arrangements, she continued to call me during my rehabilitation. Our regular contact reminded me of my professional-self while being a patient.

Returning home a month later brought me face to face with my new limitations outside the safe hospital environment. I was frequently overcome by waves of strong emotion, mostly frustration and sorrow. I determined that weekly psychotherapy would assist my physical recovery. My therapy with Helen began on the phone; when I was able to leave the house, my husband or a friend would drive me.

My neurologist had advised to me to wait six months before driving. After about nine months and many practice drives with my husband, I drove myself for the first time to Helen’s office. “During the entire drive from San Francisco to the East Bay, I held onto the steering wheel so tightly that my knuckles turned white”—not out of fear, but because I wanted the pressure of my hands against the steering wheel to anchor my attention. Without that strong sensation reminding me to keep my eyes on the road, I might have become so riveted by anything moving alongside me—the beauty of leaves dancing in the wind or the blue BMW passing me—that I might forget about looking straight ahead.

I was drained by the time I reached Helen’s office. “You made it! How was it?” she asked.

When I mentioned that it was hard for me to concentrate, she replied, “Oh, that sometimes happens to me, too. I’m driving and thinking about what I’ll buy at the grocery store or the calls I need to make.”

With a pit in my stomach, I realized, “She doesn’t get it. It’s not like that now.” I didn’t have words yet to tell her how it was for me, or to explain to her what she was missing. So I said nothing.

It happened that I also knew a therapist who had suffered a traumatic brain injury in a car accident. I knew he would understand, so I began to meet with him. Together we explored and named the difficult parts of our experience: slow thinking, unreliable memory, trouble concentrating, having to relearn everything, wanting to be “normal” while also being impaired. He supported me with anecdotes from his own experience and comments indicating that he understood. This was enough to allow me to go back to Helen and have the words to talk with her about our rupture.

“No, no, no, you didn’t understand,” I told her when I returned. “Part of me wanted to pass as normal, as someone who’s simply distracted by making a mental shopping list. Not being able to rely on my capacity to direct my attention was frightening.” As we talked, I came to understand that her well-intended response grew from her wish to join with me to help me feel understood and less flawed. Later, we also spoke of her fear and grief in the face of all my sudden losses.

Be Curious

As I learned with Helen and would keep learning in my group work, it’s essential for a therapist to acknowledge discomfort in the face of the sudden profound loss of physical, communicative, and cognitive capacities, all highly valued abilities that may lead to loss of social, family and vocational roles—loss of identity. Making assumptions that he or she understands is a great defense against that discomfort, but it doesn’t help the client.

Therefore, it is especially important to practice curiosity. When clients say something’s hard for them, ask, “How,” or, “What’s that like?” or “What’s that mean to you? Exactly what part of it is hard?” “Asking questions like these gives the survivor an opportunity to attend to inner experience and attempt to articulate it.” Stroke survivors’ process of authoring their own new stories enlarges rather than diminishes their sense of self.

The process of articulating a narrative doesn’t happen during rehabilitation, which currently averages 16 days in the U.S. There, the focus must be on the rapid regaining of lost function so the discharged patient can perform as many ADLs (activities of daily living) as possible: the basics like sitting up, transferring from bed to wheelchair, standing up, walking, toileting, climbing up and down stairs, swallowing, feeding yourself, putting your pants or bra on.

Since there is little time and training for rehabilitation staff to focus on enhancing the patient’s new identity, we therapists have a big job. It is all too is common for patients to feel diminished and “less than” in medical settings: imagine having to focus most of your attention on exactly what you can’t yet do. How we respond as therapists, friends, and family makes a big difference in the healing process.

Sometimes it can be hard for a therapist to remain curious when a client seems to simply repeat the same story over and over, as Tom did. But consider this: it’s exhaustingly hard work for an already injured brain to develop new neural pathways. This spurt of neuroplasticity is nonetheless necessary for both physical and emotional recovery. No wonder survivors often repeat the same stories; pure neurological exhaustion can lead anyone to opt for the better-established neural route. If you keep hearing the same story, you might want to say, “I hear you. You are working so hard just to stand up again.” Follow-up questions will prompt clients to experiment with new thoughts and stories.

Finding a Community

Even though I had loving friends and a devoted husband and family, I felt isolated when I returned home. After the crisis, my life consisted of weekly physical therapy—learning to walk again, regaining strength—and resuming tasks like buying groceries, balancing my checkbook, making dinner. Meanwhile, my friends and family went back to their busy lives. I was left moving through my day incredibly slowly, and mostly alone.

“I began to wonder: “Where do I fit now?” What were my chances for a career, or any role in society?” Would I be able to resume a full professional life like my colleague who had a traumatic brain injury?

Three months later, with the help of my therapist Helen’s consultation, I resumed seeing one client a day in my home office. Despite lingering but outwardly subtle attentional difficulties, I discovered that I could still listen deeply and skillfully to one person at a time. After walking my client to the top of my long stairwell, I had to rest for several hours before a simple dinner with my husband and bed. Still, this was a personal triumph, and the beginning of reclaiming my professional confidence.

I also began to search for a community group where I might find guidance and a place I could belong. City College of San Francisco had a program for Acquired Brain Injury survivors, but the organizer told me I was too high-functioning. Yet I was not high-functioning enough to occupy my own life in the way that I had before.

Through friends, I found my way to the Stroke Club, which met monthly at a local YMCA. First I was a guest speaker, then I became the volunteer co-leader. The group provided the opportunity to test my ability to perform professional functions I had used before my stroke. I was pleased to find that my attentional difficulties didn’t interfere with my ability to lead the group. In fact, I proved to myself and to others that I could still conduct a group class for a few dozen adults, using my skills as a counselor and educator as well as my personal experience to serve others as we learned to cope with life after stroke.

The Stroke Club provided social connection, education and some support. It was perfect for some, but it didn’t satisfy the therapist in me. My professional experience as a therapist working in a psychiatric halfway house and with Vietnam vets had taught me how potent small group intervention is for marginalized and stigmatized populations. I wanted to start a small group for stroke survivors. But how?

After hearing a local neuropsychologist give a talk to mental health professionals about his group work with brain-injured adults, I called him and told him my idea to organize a group for folks who’d had strokes. He suggested we talk more over lunch. He was very encouraging.  After we discussed logistics and recruitment, he asked me, “Are you going to volunteer to do this?”

“Well, I’ve been volunteering for the last two years and seeing clients in my private practice,” I responded. “I’d like to ask people to pay me. I am a therapist, after all.” In response, he expounded on the rewards of volunteering. It was as though he was saying, “Oh, you’ve had a stroke? I’ll let you volunteer. Oh, yes, I think you’re competent, but you want to charge money?” I held my ground, and was proud of myself for doing so, despite my own still-shaky sense of self-efficacy.

To his credit, he listened, thought about it, and said he would try to work out payment. A few weeks later, there was an envelope waiting for me in the staff mailroom of his hospital, St. Mary’s, where my group had begun. He had written me a personal check.

When I asked him about it, he told me, “We can’t get the money from St. Mary’s yet and I often make donations. I know you and think this is a good idea, why not help you launch this? Seems more important than giving to United Way.”

This was a pivotal moment. Not only was it a kind and generous gesture, but even more than that, it was a sign of the neuropsychologist’s professional dedication and esteem. Neither of us knew for sure where I belonged in the medical model—star patient or competent professional. The donation moved us both across an invisible threshold.

A Different Kind of Challenge

The loss of competence and control over his daily life was understandably trying for Tom, the former surgeon. During his first years with the group, he said no to every suggestion that his loving family offered, most especially his wife. He refused physical therapy. He refused occupational therapy, though his wife had already arranged his eligibility and prescription. “No, no, no, no.” The only suggestion he took was coming to this group, which his wife had also recommended, worrying about how little he left the house. She had to learn to tolerate Tom’s “no.”

It was easier for me, as the therapist, than for Tom’s family to see that “saying no was the only control Tom could exert in his life.” Still, I advised them that if they could just let it be and stop pushing, maybe he would say yes, but on his own schedule.

Of course, I did break my own rule occasionally. Countless times over the course of the group, I had given Tom the name of an extremely talented and competent physical therapist who specialized in neuro-rehabilitaton. Each week, I would ask him, “Did you call her?” And, like a high school student, he always had an excuse. “I spilled coffee on it.” Or, “I’m going to call. I just haven’t gotten to it.”

Finally, I called the physical therapist and asked her if she would come to the group in order to provide a short lecture and demo to all the members. She knew that I had referred her to Tom. When she came, she made a special pitch to him. We watched her use all her strength and skill to pull his contracted left arm as straight as she possibly could against the resistance of all its spasticity. His look of surprise grew into a smile as she uncurled his fingers one by one and placed them on his lap. It helped, of course, that she was confident and attractive. Finally, he asked her in front of the group, “When can you come over?”

Over the next several months, Tom progressed from being wheeled into the room in his wheelchair, to walking while holding onto the chair with his caregiver nearby, to using a four-pronged cane while his caregiver wheeled the chair in behind him.

The group witnessed and applauded his progress week after week. Nevertheless, Tom’s grief trumped all: “Yeah, but the wheelchair’s still here.” “Yeah, but this isn’t really walking. Walking would mean that I would be out there on my own again.”

Tom’s despair did lead him to make a suicidal gesture. I classify it as a gesture, not an attempt, because he did it at home, with his wife in the other room and the physical therapist scheduled to come.

After this incident, Tom didn’t return to the group for a while. When he did, it was clear something had shifted. Before his stroke, he had always been healthy and well adjusted. He had lots of great coping skills that had enabled him to focus on achieving external goals; he hadn’t had a reason to reflect on his interior life. Now, even though it was physically and emotionally painful, Tom was learning how to face and cope with his own despair. He began to see a cognitive-behavioral therapist who helped him utilize his intellect to gain insight into his own thoughts and feelings. In this way, he learned about depression.

When Tom came back, he was initially subdued, and at the same time, sardonic—a new sign of energy appeared in his eyes and voice. His mantra became, “Well, I guess I’m not going to be taking the grandkids to the ski slopes,” as opposed to wishing he could. He hadn’t yet fully accepted his new life, but he was getting there.

The arrival of a new group member soon afterward gave Tom the push he needed. George was also in his late sixties, a medical professional, and paralyzed on his left side. Only several months post stroke, he was still wheelchair-bound. But George had explored his dark side prior to his stroke: he’d been in a 12-step program for years.

One day in group, George addressed Tom point-blank. “You were a surgeon,” he said. “You knew what to do if you wanted out.”

Tom had met his match. No more BS. George called him on his actions, and set him some new expectations. He wanted Tom to be a role model. “How long did it take you to stand up on your own?” George would ask him. “What do you think about stem cell transplants? Neuroplasticity?”

They met man to man, and began swapping golf and football stories and off-color jokes. With George’s support, Tom not only became the group’s in-house physician and renewed his medical license: he had found a new role for himself.

Look for Wholeness

Tom’s struggles exemplify the profound grief and loss that can engulf a stroke survivor’s perspective. As the facilitator and a fellow survivor, it was hard for me to hear Tom’s despairing litany week after week. While the group had made space for Tom to speak his dark truth, I also knew from personal and professional experience that it was possible to move beyond the focus on what had been lost.

It is crucial for survivors and their therapists to know that recovery doesn’t stop at six months or a year, or even at two years. Now, with new research into neuroplasticity, we know that people can continue to progress 10, 15, even 20 years after a stroke. Although, there is no way to know how much healing is possible for an individual survivor.

Oftentimes, people become focused on regaining their capacity to ski, like Tom, or to go back to work. But if the goal is too concrete and narrow, they might be severely disappointed. It took a couple of years to go from mastering the stairs to my apartment to being able to walk six miles; in order to appreciate my successes, I had to stop comparing myself to who I had been.

Grieving is necessary, along with the acceptance that there’s a new normal. That’s why I hate the word “recovery”: it implies a return to a prior state. But moving forward from a stroke is not as simple as trying to get your life back to the way it was before, because it will never be the same.

So instead of aiming for the impossible goal of returning to a previous state, clients must re-imagine themselves and their lives. The term I have chosen, for lack of a better one, is “revisioning.” And neither feeling—the sense of loss nor the sense of possibility—ever goes away completely for a stroke survivor. “I think that the best outcome for folks with strokes is that grief and gratitude live side by side.”

A Good Boy and a Bad Girl

As the group progressed, Tom and Alexandra formed an unexpected bond. They seemed like polar opposites: he was the quintessential altar boy, the high school football star, the successful surgeon. He did the best he could at whatever was in front of him. On the other hand, Alex was a troublemaker who questioned authority, and who gave everybody a hard time probably from her first words. Tom and Alex had actually gone to the same religious school, but Alex had been suspended for asking questions about birth control.

When, week after week, Tom was stuck in his “yeah, buts”—“I walked a little further with my physical therapist this week, but it’s still not throwing a football” —Alex would finally be the one to say, “I’ve had enough of that. You’re just feeling sorry for yourself. Come on, I’m happy for you! You’re out there walking. If I could walk, I would be really happy.”

Tom would break his self-absorbed downward gaze at his spastic left hand and look at Alex, in her motorized wheelchair, who hadn’t stood on her own two feet in who knows how long and wasn’t going to be walking two inches. That stopped him dead in his tracks.

Alexandra’s directness and her outrageous sense of humor unfailingly got her the attention of the group, along with her stream of hilarious stories about her past traumas and clever triumphs during her checkered career. Her level of her socioeconomic dislocation and physical disability was also the most profound in the group. Her husband ended up losing his job, so they lived on food stamps and MediCal.

When Tom had been absent from the group following his suicidal gesture, I used the opportunity of that emotional upheaval to ask, had they ever felt suicidal? We all talked about our own moments of despair and discouragement. Alex’s half-joking response was, “Suicidal? Heck no. I might have felt homicidal.” And the truth was, that’s how she dealt with things. Because of the extent of her disability, she was constantly undergoing humiliating and painful medical treatments. Instead of becoming passive and defeated, she chose to be a “difficult patient.”

Alex had a suprapubic catheter, which went through a hole in her abdomen directly into her bladder and had to be changed weekly. Sometimes, predictably, this routine procedure was very painful. Once, Alex related a story about a nurse who replaced the catheter especially roughly, jamming his elbow in her face in the process. She begged him, “It hurts! Stop! Please stop.” When he ignored her, she bit his elbow hard enough to draw blood. She laughed raucously as she told us this story. And while we appreciated the comic relief, we were horrified at what she had been put through, and awed by her behavior.

Though I had initially worried about Alex dominating or disrupting the group, I learned to let her have her way and to let her speak. She also learned to restrain herself when I glanced her way. The group’s attention began to transform her. Alex was always self-aware enough to know that she played the role of the bad girl, and that she used her own humor as a defense. Over time, she began to able to talk about what was really difficult for her, without the defenses.

For instance, in order for Alex to get out of bed and be put in her wheelchair, because she was large and because she was completely paralyzed  on one side, a machine called a Hoyer lift had to be used to move her around. After several years, Alex began to talk more about her own sense of humiliation and discomfort around this device. She once told us that, moving her from her chair to her bed, her husband had dropped her by mistake. She told this story without her normal humor and outrage. She let her sense of vulnerability be seen and felt. The empathy and resonance in the other group members as she shared was palpable.

She also began to name some of the things that were especially difficult for everybody to talk about: What it’s like to be incontinent. What it’s like to wake up in a bed filled with your body fluids, and have to wait for somebody to come change you. Her bringing up these difficult moments in turn freed up some of the more reticent men to comment on the reality of those experiences for them.

So, as it happened, Tom, the good boy in the group, was learning from the “bad girl” about how to resist passivity and defeat in the face of his condition. And at the same time, the bad girl had gained the attention, respect, and admiration of the surgeon, the archetypal good father. Thanks to these relationships and the support of the group, Alexandra gradually moved from being the negative leader who challenged authority—mine and everybody else’s—to becoming a positive leader and thinking about herself in a constructive way. I believe that the group’s curiosity and openness to her perspective of the world allowed Alex to fully own not only her story but her personality, her own way of being.

Warrior Heart

The extent of Alexandra's transformation became clear to me when she organized an award ceremony for the group. She came up with the idea of awarding a former group member with the Warrior’s Heart Award. The award had been inspired by a group conversation I initiated about what it means to have a strong heart and be courageous. In that discussion, most of the members, including Alexandra and Tom, had agreed on John.

John was in his early forties, with red hair and an elfin smile. He used to be a chef, and still loved food. He was partly paralyzed and had expressive aphasia, which means he understood almost everything, but his verbal capacity was limited. He spoke primarily with gestures and facial expressions: his hand on his heart, wide smiles, quizzical looks. He had joint custody of his eight-year-old son, for whom he prepared meals with his one functional hand. And even though he was partly physically disabled and his speech was limited, he was always out in the community, swimming, grocery shopping, helping with events at a local community center. When people saw him around, he was always happy.

When Alex brought up the idea of the ceremony, I agreed it would be wonderful. I decided to wait and see if she was serious about putting effort into helping to make this happen. Several months later, Alexandra approached me about it in the group. “What about the celebration, Carol? Are we going to do this? I really want to.”

And so, with the group’s help and Alexandra’s leadership, we put on the First Annual Keeping Hope Alive Warrior Spirit Award Ceremony. It was moving to see her in her new role: as a leader, an organizer, an eloquent writer. For the award ceremony, she composed a poem that captured for all of us the strides we continue to make together as a group:

“John, you stand tall
your head above others, your back straight.
You are universally liked, your friends, legion. You inspire
us with your dogged
persistence in the face of challenges that defeat others.
Your warrior spirit proves to the rest of us, you are our representative
as we stand upright against the vagaries
of our conditions, and proof we will recover,
and contribute to each other’s success.
Thank you for being who you are:
Our warrior spirit.”

[This article was written with the consent of the group members portrayed therein.]
 

Psychotherapy: Terminal or Interminable

Posted on by Psychotherapy.net Team

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

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

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

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

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

“Well, that’s partly what I mean.”

Suddenly, her eyes fill with tears.

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

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

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

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