Category: Clinical Efficacy

Suggested Tips for Clinicians: 

• Practice methods for strengthening your therapeutic presence.
• Ask yourself if you are or are not empathically attuned with each client.
• Explore barriers to full presence and empathy with more challenging clients.

A capacity crowd in the large conference hall rose to its feet in applause. Daniel Siegel, renowned author, clinical professor of psychiatry at the UCLA School of Medicine and Executive Director of the Mindsight Institute, had finished his presentation. I too stood with enthusiastic appreciation, not only for this lecture, featuring the clinical significance of therapists’ mindfulness, but for all the ways his research and writing about developmentally informed parenting, neuroplasticity, and the incorporation of science into the practice of psychotherapy. All of these had influenced my thinking and work over the past ten years.   
 

Dan had begun to move away from the podium when he seemed to catch himself and walked back to centerstage. He stood, fully facing the hall, hands clasped in front, nodded his head and bowed. For our part, the applause of several thousand therapist attendees showed no sign of relenting. Then an event unfolded I have carried with me since. 

It began with the simplest of gestures. Dan took and held Tadasana, a standing yoga pose. His feet parallel and facing forward, Dan released his fingers, opening his hands which moved to the sides of his legs, palms open, shoulders relaxed as he appeared to empty himself and stand receptive before the crowd.  
 

The audience responded with delight and gratitude at this embodied receptivity. The volume of the applause rose, and Dan, smiling gently, took a deep breath. The crowd responded again. Waves of mindful presence, enthusiasm and gratitude rolled through the large hall back and forth, until Dan took a final bow and joined the crowd he had just helped to unify.  
 

Gratitude is amplified by its reception. Reception is its own expression of gratitude. A feedback loop, formed by gratitude and receptivity, generates a mindful, compassionate field that feels very much like love.  
 

Tears rolled down my professional cheeks. I quickly brushed them away hoping the strangers around me noticed neither my intense emotion nor its expression. Unleashed by the power of that loving field, my tears flowed freely and powerfully, apparently straining for release. I felt seen, heard, and appreciated. I was included, a true part of this collegial, communal event. There was a transcendent quality in which this loving field was not so much being created but being acknowledged as existing before this moment. All of us stumbled into an awareness of a much larger and enduring field of love.   
 

I was awed by the immediacy and goodness of the human family. But it was an ecstasy undifferentiated from loss and longing. My tears expressed my grief at how seldom I had been aware of my presence in such a space. Having often felt unseen, unheard, and unappreciated, I suddenly experienced a sense of loneliness and despair of enduring connection. The pangs of longing and the shame of my dissatisfactions with self and others were ignited by my embrace of this mass symbiosis. Yet, there was also relief at the quenching of my childhood thirst for an uninhibited expression of mutual affirmation and solidarity.   
 

In the religious experiences of my young adulthood as a youth minister, a shared faith and religious ritual turned what might have been merely an experience of communal intimacy into an encounter with the metaphysical. My peers and I tasted, not merely the immediate experience, but elements of a universal interconnectedness: with one another, with the Church, and even, it seemed, with God.     

As I grew older and my religiosity subsided, the felt importance of that faith and my need to participate in a loving field never waned. If Dan Siegel had continued off stage to privately appreciate the applause, he may very well have experienced a profound sense of what his work meant to us, he may have been moved to tears and even been motivated to write another great text, but his personal experience of appreciation and inspiration would not have generated the mindful, compassionate field of love we all shared. To generate such a field, he had to turn around and move back to the edge of the stage, putting himself on display. He needed to make the mindful choice to allow his body to express his emotional state, ultimately taking a posture of reception easily understood by the community before him.  
 

As an audience member, I too had a role in creating the moment. While Dan closed his presentation, I might have remained seated, turned to a neighboring attendee and, in a relatively hushed tone, remarked upon an outstanding insight or application. My neighbor may have responded with her own insight and drawn my attention to aspects of the presented theories elucidating my thinking. This might all have had a positive impact on my practice, but none of it would have generated the field of love.   
 

 All of us that day physically manifested our emotional reaction by standing, applauding loudly, and maintaining focus on Dan. We allowed his gestures to carry meaning and translated that meaning into action with vocalizations of delight and even louder applause.  
 

After any professional conference I strive to identify the clinical application of what I have learned, knowing that for me to retain information I need to utilize it. While I came away from that conference with much information, it was this personal, emotional experience that I most wanted to incorporate into my life and work.  
 

But where would this powerful manifestation of gratitude and receptivity play out in the consultation room? Although, as a psychotherapist I am sometimes the recipient of heartfelt expressions of appreciation, I have never received a standing ovation. Nor do I often feel deserving or desirous of one! The emotional waves of gratitude between therapist and client are smaller and quieter and, as a possible result, the loving field we generate is more easily dismissed or completely overlooked.  
 

It is a process that unfolds in many sessions. It unfolds with the subtlety of a raised brow, a silence, the slightest of gestures. It is carried by a word, a smile, a tear. We know it as empathic attunement and the creation of a therapeutic space. It is enacted when a client experiences acceptance in response to long held shame. I wonder how open my stance is in receiving such gratitude. Does the client feel my reception and the gratitude I feel for their gracious expression?  
 

Recently, in a relational-process group I co-facilitate with my colleague Aisha Mabarak, a field of love made a surprising appearance. Sheila* arrived late due to complications at her job that held her past the end of her shift. She reported being exhausted and ill-prepared to share her feelings with the group. 

“I’m in a fog,” Sheila said with an uncharacteristically flat tone. I responded by thanking her for making it to the session and affirming her inclination to take a restful, though present, pose. Aisha, however, had a different approach. Not wasting any time, she asked: “Sheila, why don’t you share with the group a little more about this fog you feel stuck in?”  
 

Sheila proceeded to describe, with increasing emotional range, how deadened she felt by a sense of invisibility in multiple facets of her life. Examples spilled forth of her efforts to meet the needs of others only to be met with thoughtlessness and a glaring absence of gratitude from family members, friends, colleagues, and bosses.  
 

Other group members expressed empathy and support. One member voiced these sentiments succinctly, saying that she felt Sheila’s pain and she was, at that moment, imagining how hurtful and difficult it must be to feel so unappreciated by people who care for you. In approximately fifteen minutes Sheila had gone from a depression-based brain fog to expressing her anger and upset assertively, leading to smiling and expressions of appreciation for her fellow group members.  
 

My inclination to support Sheila by giving her space was intended to express, both to her and to the group, that it was acceptable to feel your pain in session and to choose to set self-protective boundaries. This intervention may have been simply wrongheaded, or it may have, by reminding members of their autonomy, laid the foundation for co-facilitator Aisha’s fruitful follow-up. While I had responded to Sheila’s verbal communication and her depressed presentation, Aisha responded to another expressed impulse—this one non-verbal.  

Sheila expressed her impulse to participate in the group by showing up and letting us know how bad she felt. Rather than disappearing off stage, a space she was also entitled to occupy, she had moved her body to a visible place. Rather than closing herself off, she showed us how she felt, as Daniel Siegel had opened his hands and exposed his palms.  

Aisha’s response might be analogous to the convention applause. This applause was an essential welcoming saying: “Sheila, your sadness, hurt, embarrassment and anger are all welcomed here!” Group members said: “This is your group! Take the time you need. We are here for you. We see you. We hear you.”  

Hearing and feeling this welcoming presence, Sheila responded at first with tears, then with expressions of anger and ultimately with smiles and the laughter of gratitude for the group’s support. The faces of the other members lit up with warmth and solidarity.  
 

*** 

Facilitating such moments of conscious gratitude and receptivity is something I try to bring to all my sessions. Of critical importance is my understanding that my role in this regard is that of facilitator, not creator. It is a powerful, organic experience that can only be had within the context of a collaborative effort. Daniel Siegel, for all his talents and wisdom, could not create that field of love by himself. Nor could the audience of thousands of therapists, even if they were consciously working in unison to do so!  

As a therapist, my receptivity to gratitude only increases the availability to the client of a mindful, compassionate field. A field, that I argue, has the healing qualities of love.  
 

While love is not “all we need” in the consultation room, it is a quality of human experience necessary to both healing and health.  

*This client’s name has been changed.  

My work with Nathaniel was focused on the growing intensity of his depression. Things were going badly at work, his intimate relationship was not providing him joy, and he felt increasingly lethargic and unmotivated. His affect was flat and his voice emotionless as he assessed his life through the lens of this depression. I reflected these feelings back to him, showing him the picture he had just painted. Nathaniel seemed to take it in and as we sat with it for a bit and expressed hope that one day he’d get over the sadness. I assured him he would but acknowledged the frustration that comes with not knowing when a bout of depression will end or what can be done to make it end. Nathaniel sighed and said, “I guess the sun'll come out tomorrow.” He groaned and slumped down further down in his seat, as if that phrase had just added rather than reduced the weight of his sadness.

Phillipa had goals. Our main topic of discussion was dissatisfaction with her career. She was, however, in the process of taking steps to change this. She was exploring other areas of professional interest and talking to people in those fields, preparing both logistically and emotionally to engage in the kind of change she had expressed a desire to experience. After a few sessions in which she felt hopeful and inspired based on positive feedback from friends and family, Phillipa was riding high, until our most recent session, that is, when she learned that the career she most wanted to pursue required an advanced degree that she felt she was not in a position to pursue. Phillipa shook her head forlornly as she verbalized her frustrations, saying, “It just feels like it’s always two steps forward, one step back.”

Ravena craved a committed romantic relationship. We had identified her pattern regarding the development of these types of relationships, and her frustration that they did not end up in the place that she wanted. There was a cycle of intense attraction at first, with both emotional and physical connection, but these enjoyable beginnings always devolved into conflict, with Ravena experiencing difficulty understanding her instincts regarding boundaries and intimacy, and frustration that her instincts seemed to run counter to what she wanted. Ravena became more open to exploring her family of origin and the type of relationship modeling her parents provided, and our work became more about identifying how the best way to work towards positive relationships in the present was to examine the lessons imprinted on her from the past. “I guess I just have to learn to love myself before I can love someone else,” said Ravena, as she rubbed her temples and laughed bitterly in a physical manifestation of the frustration she was feeling inside.

***

These examples of work with clients are both specific to my experience as a therapist and universal to what it means to be human. The vignettes all demonstrate how, when assessing their progress and desires in therapy, clients often come to a point where they express their feelings and insights through cliché, and how the use of that cliché usually has a negative connotation. Why is this? Why does something as simple and universal as a cliché seem to leave such a bad taste in the mouths of these clients?

A cliché is an overused phrase or opinion that can often mimic an original thought or even epiphany. We call something a cliché when we’ve heard it a million times, so often that any meaning it once had has been eclipsed by our collective shrug when we hear it again. We sometimes experience negative thoughts about ourselves when we use these clichés because it implies we are lacking in original thought. And for some reason, to be lacking in original thought is a bad thing. We should suffer in original ways!

In addition, the fact that we are in therapy can color our response to clichés. When our clients are out in the world interacting with friends and family, they might find themselves using a phrase like “It’s always darkest before the dawn” or the classic “It is what it is” and feel okay about it. Or, more specifically, they don’t feel bad about it. The use of a cliché in these situations seems to pass by without much consideration, with no bad emotional taste being left in the cliché user’s mouth. However, in session our clients are at their most vulnerable, and often come in already feeling depressed or anxious or unsettled, and this baseline combined with the triteness of a cliché can make them feel worse. It’s a common reaction, and a wonderful opportunity to explore what these particular clichés mean and why our clients react the way they do, both in terms of what the clichés mean in general and what they mean to them.

Nathaniel seemed more depressed when he said that the sun will come out tomorrow. It seemed that in trying to make himself feel better, he had actually created more material to be depressed about. I mentioned Nathaniel’s mood and his reaction to the cliché, which he immediately responded to, almost eager to talk about how using this particular cliché made him somehow feel worse, even though the intended outcome was the opposite. I spoke a little about the meaning of clichés, how they come into existence, trying to work backwards from their origin to their original intent. We imagined the first person to use this phrase long ago, perhaps to cheer up a sad friend, and how that friend might have reacted. Nathaniel admitted that yes, this long-ago friend must certainly have been cheered up by this realization that the sun will come out the next day. We took turns interpreting what “the sun will come out tomorrow” actually means, both in terms of life in general and Nathaniel’s specific situation. By the end of the conversation, Nathaniel was sitting up in his chair, was more engaged, and spoke with more passion in his voice. I noted this, and Nathaniel admitted that he felt better. Talking more about clichés and how we react to them helped in this case. Our cliché journey had come full circle, from inspirational to trite and back to inspirational again.

Phillipa became frustrated at the first sign of resistance. After weeks of positive feedback and relative success, she would shut down at the first sign of trouble. She took plenty of steps forward, but those one-step-backs were devastating. We examined more closely the cliché about taking two steps forward and one step back, how this fit into a pattern for her like a dance step. When do we usually talk about things in terms of two steps forward, one step back? It’s usually when we have a goal and that goal feels like it’s far off in the distance, and we are slowly getting closer to it but we’re not moving fast enough to get over the frustration of not being there yet. I assured Phillipa that experiencing this cycle could just as easily be construed as a good thing. Two steps forward minus one step back equals a net gain of one step! For Phillipa, the frustration of not reaching the goal was eclipsing the very real process she was making. Our work together became about reframing the cliché as actually taking one step back from a kind of failure into a healthy break on the path of overall progress, as a necessary step in the dance of personal growth. Examining this cliché helped us realize together that the one step back is just as important as the two steps forward, and in the process we normalized that one backward step.

Ravena was so concerned with finding a partner that she had never pictured herself being alone. Just the idea of talking about what it would be like to live life by herself without a partner made her uncomfortable. The cliché about loving oneself became an opportunity to explore the fear that came up when we discussed the idea of being alone. This led to some significant insight into the nature of Ravena’s intimacy issues when relationships started to become serious, and after some time working on these issues, she noted that it was nice to focus only on her and the things under her control rather than on a relationship. In later sessions when Ravena had reflected on some understanding about why she reacted to some issue in “the old way” and recognized how she could change it, I noted that it seemed like she was really learning to love herself. This time the cliché was met with a smile and a knowing laugh.

***

Something about talk therapy I particularly enjoy is when the client and I identify a simple thought, perhaps one that is a part of the very foundation of how we see ourselves, and we turn this thought on its head. We examine it from a different perspective. We ask if this thought is still valid. When this occurs, things clients assumed they already knew transformed into opportunities for self-exploration and growth. I also react similarly when a client uses a cliché in a sad, pessimistic way. We take that seeming truth, turn it on its head, and ask, “Why does this cliché that purports to make us happier make us feel just the opposite? Let’s discuss.” This often results in clients begrudgingly admitting that yes, these clichés do have value, and sure, “maybe I should feel better than I do about using this cliché, and perhaps maybe even feel better about my life in general.” These cliché-dependent clients often benefit from the realization that they don’t have to feel bad about engaging in a cliché or have to necessarily feel better just because they happened upon on in a moment of seeming clarity. Sure, it’s trite, but let’s own that. It’s okay to feel trite. Better trite than depressed! Let’s give ourselves permission to not be original. I like to tell my clients that if they find themselves using clichés more often, it’s not something to sulk about, it’s a good thing. It means they can and often do actually see the light at the end of the tunnel and smell the greener grass on the other side of the street. Using and then mining the clichés can be and often are a sign that they are on the right path!

During my early training in psychotherapy, I was struggling to understand my role and what to say to patients. A wise supervisor introduced me to the term “corrective emotional experience” and said that once I fully understood its implications, my job would seem a whole lot simpler and I’d have much less trouble finding useful things to say to patients. He taught me that the main and unifying goal of all psychotherapies is to help patients have new and better experiences, both in the sessions and also in the rest of their lives. Such experiences could heal wounds from the past, change perceptions and attitudes in the present, and result in healthier behaviors and virtuous cycles in the future. Virtuous cycles are positive mirror images of the negative vicious cycles that so often grease a slippery downward slope for people with emotional problems. A virtuous cycle starts with a small corrective emotional experience which triggers a chain of other desirable experiences in a continuous cycle of improvement. An example would be where someone afraid of socializing screws up the courage to take a tennis lesson and gets invited to a party, which results in a new friendship, which makes it easier to approach other people socially in a variety of other social relationships, which improves job performance, which results in a raise, which increases confidence, and so on. This advice hit home, stuck with me, and has ever since guided all my clinical work and teaching. Corrective emotional experience is, I think, the best way to understand the mechanism of psychotherapy process and change—and also to integrate the bewildering variety of therapy techniques into one unified and harmonious psychotherapy. The process best explains the process of change as it occurs across all forms of psychotherapy. Sandor Ferenczi introduced this experiential way of viewing psychotherapy change in the 1920s. He was a master clinician who understood and made use of the healing power of the therapeutic relationship. His suggestion, radical at the time, was that emotional experiences in therapy, not intellectual insights, are the real drivers of change. As his student Sandor Rado would put it much later, “Insight alone never cured anything but ignorance.” It’s fair to say that Ferenczi, not Freud, had the most important influence on psychotherapy as it is practiced today. Freud readily admitted that he found clinical work interesting mostly as a research tool, necessary to build and test his theories of mental functioning, but was much less engaged in the human and healing elements of therapy. His patients were often disappointed, describing Freud as talking too much, too abstractly, and too didactically. In 1946, Franz Alexander (another of Ferenczi’s students) named and concisely defined Ferenczi’s theory of change: “The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.” In answering the crucial therapy question of how best to promote corrective emotional experiences, the first insight I have is that psychotherapy sessions are not all created equal. Change tends to occur in leaps, not in small steady increments. I have treated some patients intensely for years—with absolutely no discernable progress. In contrast, I have seen many patients for only fifteen minutes in the emergency room who years later said something along the lines of “you probably don’t remember me, but you said something I’ve never forgotten that changed my life.” This makes every patient contact an adventure, potentially ripe with opportunity, never routine. There is always the possibility of a magic moment in therapy—saying something that promotes a corrective emotional experience and sets off a virtuous cycle. We can’t expect magic moments to happen often, we can’t predict them, we probably won’t even know that they have happened—but we can and should always be alert for the potential and try to create favorable conditions through our relationship with the patient. While the unifying goal of all therapies is, or at least should be, to help patients have corrective emotional experiences, there are many different ways of getting there. Sometimes the corrective emotional experience comes from an insight that clarifies how the past is influencing the present or how unconscious conflicts are causing self-destructive behaviors. Sometimes it comes from changed behavior, such as facing phobic situations instead of avoiding them. Sometimes from testing and correcting cognitive distortions. Sometimes from emotional catharsis. Sometimes from a paradoxical injunction. And sometimes from the simple therapeutic act of validation. These are just to name a few. Corrective emotional experiences are also, of course, constantly happening as part of everyday life—a new friend or love relationship, adopting a pet, beginning an exercise regimen, getting acquainted with nature, a better job, an act of resilience in the face of stress and disappointment, or just about any other positive new experience. Therapy is just a way to increase the odds of having (or noticing) corrective emotional experiences, speeding things up, and triggering virtuous vs. vicious cycles. Too often these days, therapists adhere slavishly to one or another therapy school, and schools compete with one rather than join forces. This guild warfare is bad for psychotherapy, bad for therapists, and, most of all, bad for patients. Every therapist should have eclectic training that provides a full tool kit of techniques that promote corrective emotional experiences. No one school has a monopoly on wisdom or therapeutic power.

The field of psychotherapy has been around for quite a while—well over 100 years. According to sociologists of science, a field only reaches “maturity” when there exists a consensus amongst those working in the field. Within psychotherapy, we have yet to reach that stage. Instead, psychotherapy is characterized by someone coming up with still another new form of therapy. What seems to be most revered is what is “new.” As therapy practitioners and researchers, we are therefore confronted with some important questions: Are we destined to continue to forget what we know and instead focus on what is new? Will it always be the case that we emphasize who, not what, is right? Will the field forever be characterized by “dogma eat dogma?” “Is there nothing about psychotherapy about which we can agree?

Having spent approximately 60 years teaching, researching, supervising, and practicing psychotherapy—and ruminating all these years about these questions—I believe that one day we will have answers to them. In the meantime, where do we stand? I would suggest that there are indeed a few things we have learned over the years from the convergence of both clinical observation and psychotherapy research that can provide a crude, if not basic understanding of a few points of agreement.

To begin with, if we step back and temporarily set aside our theoretical perspectives, it might be possible to say that most (all?) therapies proceed along somewhat similar stages of change. If effective, therapeutic change progresses as follows:

1. Unconscious Incompetence
2. Conscious Incompetence
3. Conscious Competence
4. Unconscious Competence

What does this mean? The patient comes in and says that there's something about their life that's not working, be it relational or symptomatic, but they don't know the factors that are contributing to this lack of effectiveness or incompetence. Thus, they are in an initial phase of unconscious incompetence.

As a result of the therapy—either what occurs in session or between-session self-observations—patients become more aware of the thoughts, actions, and/or emotions that may be creating problems in their life and contributing to their lack of competence. They may be misinterpreting what other people's motives are; not recognizing how their actions may be having a negative impact on others; becoming angry over not getting what they want instead of asking for something directly; and a host of other factors that are uncovered over the course of therapy. There are numerous ways that patients can come to understand why things are not working for them. Through the methods used to come to this understanding, they are now in the phase of conscious incompetence.

Becoming better aware of the reasons for their lack of effectiveness/competence may then lead to the need to function in a different way, taking into account those factors that are causing the lack of their intrapersonal or interpersonal competence. It is then that patients need to make deliberate efforts to behave, think, and/or feel differently: conscious competence.

If the therapy is successful, and over a period of time they benefit from numerous instances of corrective experiences, patients’ conscious competence may become more automatic, resulting in the final phase of unconscious competence.

In order to move patients through these phases, there are certain transtheoretical principles that cut across different schools of therapy.

• To begin with, our patients need to have some degree of positive expectation and motivation that therapy will help. The most effective of therapies will not do anything if the patient's negative expectations and lack of motivation causes them to do nothing—or to terminate.
• There also needs to be the presence of an optimal therapeutic alliance. Much has been written about this, and there's both research evidence and clinical observations that this is an important transtheoretical principle.
• Helping patients to become better aware of themselves and their world can be implemented clinically in varying ways, depending on one’s theoretical approach and individualized case formulation.
• A most important principle of change involves encouraging the patient to try out new ways of functioning—corrective experiences—that help them become more effective emotionally, cognitively and behaviorally in their lives.
• Over the course of effective therapy, there develops a synergistic reciprocity of having corrective experiences that enhances patients’ awareness resulting in an ongoing reciprocity between corrective experiences and increased awareness—a form of ongoing reality testing.

The following is a graphic depiction of the how transtheoretical principles of change articulate with the transtheoretical stages of change in therapy:

None of this says anything about the specific techniques that different schools of therapy may use to implement the strategic principles, nor does it say anything about the overarching theoretical interpretation of why the interventions may work. At the level of abstraction that I have proposed, it clearly does not say it all. Still, it can provide the foundation for practice, training and research.
For those interested in learning more about this topic, I have written elsewhere on the topic. You can find these articles listed below.
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I would appreciate it if you could take this very brief survey (approximately 5 minutes) about transtheoretical principles of change: Please click here.

__________

Obtaining consensus in psychotherapy: What holds us back? — American Psychologist, Issue 74, pages 484-496
Consensus in psychotherapy: Are we there yet? — Clinical Psychology: Science and Practice, Issue 28, pages 267-276

Jack, a forty-three-year-old insurance executive, was referred to me by his family doctor for help with severe panic attacks that had suddenly begun for reasons that were completely unclear to both of them. Jack's symptoms were disabling and resulted in his missing work for several days before his initial appointment with me.

In the first session, I listened to him describe his difficult breathing, chest pains, sleeplessness, occasional choking episodes, along with his fear of losing complete control and “going crazy.” He told me that he has always been an anxious person and had contemplated entering psychotherapy for several years, but never actually did…until now.

The initial consultation with Jack was, in my view, a mixed success. According to Jack however, it was “an unbelievable success.” We were able to quickly identify the sources of his current anxiety symptoms, which almost immediately provided him with some much-needed relief. We began to outline some of the likely goals of the ongoing therapy he was “very happy to be starting, finally,” and for which he eagerly arranged his next appointment with me.

As the session wore on, I began to feel concerned that the initial and speedy benefits of this first session might have implications for Jack's ability to fully engage in the challenging, ongoing work of psychotherapy, something I believed he needed and from which he could derive greater benefit than immediate symptom relief only. I became especially concerned when Jack described his first session as “maybe the best hour of my life!” and described me as “undoubtedly, the best therapist in America!” That's when I thought, I probably will never see Jack again.

As it turned out, Jack did attend his second session, and a third, and described the continuing benefits of the work thus far. He was hardly symptomatic, felt “great,” no longer thought that he was “losing it,” and was wondering whether or not he really needed therapy after all. Somewhat surprisingly, he asked me to tell him what I thought he should do. In order to help Jack figure this out for himself as much as possible, I did what any therapist worth their stripes would likely do as a first response to such a question: I asked Jack to try and decide independently of my input, so that we could both learn something about his attitudes, thoughts, and feelings, rather than have him simply react to mine. My input followed and consisted of my ideas about the differences between relief and change, with the latter, obviously, being the more ambitious pursuit and perhaps the more durable. I also was mindful, as always, that for some people, relief may be all they want or need. Not everyone wishes to or has the wherewithal to undertake a full course of psychotherapy, especially if they are not in active distress.

After a meaningful conversation about his dilemma, i.e. to stay or to go, Jack decided that he was quite happy with what had occurred and chose not to pursue further therapy at the time. He asked for and received assurance that my door would always be open, and we both acknowledged that we may or may not ever see each other again. He left describing himself as the “three-session wonder.” I later heard from his physician that he was doing quite well, with no further panic attacks. It led me to wonder whether or not I should revise my thinking to include the fact that sometimes and for some people, relief is change, and not necessarily something less or less meaningful.