Category: Therapeutic Issue

Working in the Here-and-Now of the Therapeutic Relationship

Posted on by rezendevknowfully.com

When clients arrive at our office, they’re hoping we can help them feel better. Often they assume it’s their outer conditions they need to change: “if only my husband would…” or,  “once I find a new job…” or, “I don’t know why I’m feeling bad because I have a great life, but…” It’s not that we don’t listen to their concerns, but these are all situations that exist outside our consulting room.
 
In order to help clients change, we have to allow ourselves to be changed by what we, in the therapeutic relationship, do together. Working in the present, in the room directly with what is happening, demands that the therapist emotionally connect with the client and not just sit back, hidden by our professional role of “helper” or “expert.” It requires emotional involvement, reflection, vulnerability, transparency, and risk.
 
Research repeatedly tells us the therapeutic relationship is the curative factor over and above all theoretical orientations. A figure commonly cited in the literature is that up to 50% of clients drop out of therapy after the first session. These figures are established regardless of finances: in private practices, agencies, and free clinics. Researchers attribute these high numbers to two things: lack of emotional engagement and failure to deal with ruptures.1            
 
If the therapist and client only talk about relationships that exist outside the consulting room, they miss many opportunities to deepen their work together. As therapists, we need not make generalizations or assumptions about what the presenting problems of our clients mean or how they came to be. These scenarios are acted out and worked with in the transference and counter-transference of the therapeutic relationship.
 
We also risk losing our clients through impasses and unattended derailments. “The first phone call can be a deal breaker before things even get started, because clients’ relational patterns begin to be reenacted from the minute they make contact with us.” If we let these moments go by and don’t address them at an appropriate time, we sacrifice the teachable moment as it’s happening between us.
 
The mutual engagement in the here-and-now of the therapeutic relationship is a deep, internal conduit for change, and it entails our clients experiencing the impact they have on us. It empowers them in personal ways we can seldom predict that speak to the uniqueness of who they are. It’s different from a prescriptive, goal-oriented, solution-focused model where we therapists are the all-knowing ones with advice and answers. It is instead dealing in the moment with things as they are, in the client, in the therapist, and the space between the two.
 

Nick: A Case Study

We can see how this way of working played out with Nick, a 48-year-old divorced man who came to treatment complaining of “loneliness and relationship problems.”2 He wanted to know why he always ended up alone and what he did in relationships that made women leave. He was also confounded by his rejection of women before things even got going. An additional problem that came up later in our treatment was his compulsive overeating. I wondered why it had taken several months for his concern about his weight to come up between us. Later I learned he had tremendous shame around his body, had been cruelly taunted as a kid about being fat, and became inured to his body as if he was destined to carry this “dead weight” around.
 
In our first session, Nick appeared overweight, with little attention given to grooming: a rumpled denim shirt, an unpressed pair of chinos, and well-worn tennis shoes. His hair was combed but hadn’t seen a pair of scissors for a while. He sat near the door, in the chair furthest from mine. As he settled, his movement seemed labored and uncomfortable, squirming in his seat, as though his body was a rough place to inhabit. It’s bound to be painful in there, I thought as I observed him.
 
“I don’t seem able to sustain intimate relationships,” he said softly, gazing down at his shoes, puzzled by his own incapacity. When I asked why he thought this was the case, he replied, looking everywhere but at me, that he didn’t know, but then mentioned he was too picky when it came to women. He realized he was a perfectionist—not that he thought he was perfect, but he always found something about the women that became objectionable.
 
“They don’t have a decent job, or we have little in common, or they’re not smart enough, they have no sense of humor, they talk incessantly about themselves…” “He said this staring out the window, as if talking to the trees. I didn’t feel like I was in the room with him.” His list was endless, and I wondered if it was the tip of the iceberg, saying more about him than the women he was rejecting.           
 
During one session after we’d been working together for a year, he shook his head and proclaimed, “Relationships are too much work.” Much of our conversation took place while he fidgeted with his clothes, his hands, or the couch. Inquiring into these nonverbal motions in the past had yielded little information and alerted us to the likely disconnect he had with his body. He acknowledged however, he thought the nonverbal gestures were about his “discomfort with intimacy.” I had seen him through two short romantic skirmishes, only to find him alone yet again.
 
“I must be afraid to get close to people, so I’m always discovering excuses to find something wrong with them.”
 
I nodded, suspecting he was on to something. “Sounds like a good insight.” Then, almost wondering aloud, “How is it trying to get close to me?”
 
He thought as his leg started kicking back and forth. “Well, it seems easier compared to others.”
 
“How so?”
 
“You’re not judging me, you accept what I’m saying, don’t need anything from me.”
 
I confess I was pleased to hear this, but suspected there was more to the story.
 
“Do you feel close to me?” I literally felt my body heating up, as if we were moving closer to something important happening between us in the room.
 
“I guess,” he said, looking out the window, fidgeting in his seat.
 
“You’re not sure?” I asked, trying to keep him present and accounted for.
 
“Well, I know we’ve talked about coming twice a week and I think I’m afraid to do that.”

The last several weeks we had been discussing his aversion to adding a session, making it a twice-a-week treatment, an opportunity for us to become more intimate. I could see him bristle at my suggestion when he mentioned “not enough time” at the end of the last few sessions. I suspected this was one version of how his fears of intimacy got re-enacted between us. “And what scares you about being together twice a week?” I asked.
 
“That you will discover something really wrong with me,” he said softly, picking at his buttons.
 
“And what would I see that’s wrong with you?”
 
He thought. “I don’t know––that I’m missing a gene that’s required for intimacy and a healthy relationship,” he said. “Maybe I have some incapacity, or I’m damaged goods, unable to be resurrected for a real marriage.” He said this with a big sigh, hanging his head, shaking it back and forth.           
 
We explored what he meant by “damaged goods.” This was a painful process with long silences and quiet tears running down his face.
 
“Once you see that, you’d give up on me, feel I’m unable to change.” He said this under his breath, choking down the tears, almost as if his words are stuck in his throat. “Maybe you’d think I’m a hopeless case, give up on me and want to get rid of me.”
 
He was barely audible. Were these new thoughts for him? My heart ached for him. Now we were getting to how fear of intimacy played out between us.
 
“Is that what you think? Are you the one who thinks you’re a hopeless case?” I asked. He was afraid I’d reject him. Perhaps this was why he rejected some women so quickly so they didn’t have a chance to reject him first.
 
The conversation segued into his first marriage failing. For the nine years they were together, it had been harder and harder to extend the intimacy, both sexually and interpersonally. Here in the room, elbows on his knees, head in his hands, he was unable to say why he had withdrawn from his wife. I also wondered about the pain he had been holding regarding his failed marriage. He didn’t understand why he felt so bad about himself; he just did. He always remembered feeling this way: not wanted, made fun of for being heavy, not feeling worthwhile or responded to. I imagined his weight, which had been with him his entire life, was an insulator for many of these feelings.
 

Ruptures

A few weeks later, Nick came rushing in late—highly unusual for him—and stormed across the doorway to my office. He appeared excited, invigorated, as he waved his arms around and stumbled hard onto the couch.
 
“I don’t know what’s going on,” he said breathlessly, “but recently I’m feeling angry—angry all the time.” My eyebrows rose as I nodded, suspecting this was a good thing.
 
He settled himself, took a breath and added, “Truthfully, I think it’s just I’m aware I’m angry.” Normally, Nick struggled to connect with his feelings and suffered with a blunted affect that resulted in a lot of fatigue and apathy. I suspected the overeating fueled the fatigue and depression and served to numb out painful feelings. “Since our work together,” he continued, “I see how there’s always been this under current of anger, but now see I’m allowing it to register. Not the usual denial of how I feel, and so I’m seeing how pervasive it is.” I can see how the food allows me to bury my frustration. He appeared animated and incredulous.
 
“Sounds like a good insight,” I said. I waited. Silence.  “Are you feeling angry now?”            
 
He considered this. “I…I don’t know. I guess I am,” he said surprisingly, almost as if to himself. I waited.
 
“Is there something you’re angry with me about?” I asked, not having anything in mind, but thinking about his being late and coming in angry.
 
“Well, no,” he pondered, “that seems like a stretch. Why would you ask?”
 
“You’ve come late today, which is uncharacteristic of you; in fact I can’t recall you ever being late, and you’re talking about being angry right now. We’re the only two here, so I thought it might have something to do with us.”
 
“I’m thinking it’s more about the spat my boss and I had this morning. I’m feeling stirred up by that,” he said, repositioning himself. After a minute, he stilled himself, focused and continued, “You know, now that I think about it, I did leave here kind of ticked off last week.”
 
He talked about his disappointment with me because I hadn’t had a chance to read an article he had written. I had told him I’d be happy to read it, but hadn’t done so between our two appointments. I certainly understood his disenchantment with me; had I been honest, I would have told him I couldn’t read the article for a couple weeks. I now realized my counter-transference had prevented me from saying anything, not wanting to disappoint him—an old habit of avoiding and pleasing people so they’ll like me.
 
As he said this, I remembered the look of disappointment and surprise on his face at the end of our last session, after asking me for my feedback on the article. I had since forgotten this moment, his facial expression being so subtle and fleeting. The moment had slipped by me; it was possible I didn’t want to see or feel his anger coming at me, a feeling that’s difficult for me.
 
“I felt unimportant and dismissed by you, not valued,” he said somewhat sheepishly, as if I were going to explain myself or make him wrong.
 
In this situation it was necessary to feel my own frustration and guilt for not reading the article, watch how this impacted my client and not collude (by evading his anger), retaliate, or defend myself. I stayed with what was happening between us to further explore his anger and frustration with me.
 
“Here was a rupture between us, and if I hadn’t made a point of contacting what was happening in the room, this incident would have gone underground.” I suspect our relationship would have hit an unconscious impasse, creating a lack of trust and distance between us. As we talked about his anger and hurt with me, he saw he could acknowledge it, feel it, express it, and that I could hear it, and we could still stay connected despite the difficulty.
 
Tracking Nick’s feelings in the context of the intersubjective field showed us how my need to please and avoid anger and Nick’s unspoken hurt and disappointment manifested unconsciously between us. Coming in late and angry, despite neither of us knowing why, acted out Nick’s feelings. I represented the “Bad Mother,” as Melanie Klein calls it, by not attending to reading his article. This re-enacted the parental relationship he had growing up. In Nick’s formative years he hadn’t had responsive parents as a mirror to reflect what his own thoughts and feelings were. This left him feeling devalued and ignored, as well as cut off from his own sense of self—a feeling that had a long and painful history and showed up in his depression, isolation and eating habits.
 
As we can see in this re-enactment, it was not just Nick’s feelings being acted out, but mine as well. In my attempt not to disappoint him, I had done just that. The disjuncture was something we’d created together, a common experience within the therapeutic relationship. As therapists, we’re going to make mistakes. The important part is how we bring the current experience to good account. This is the working through of therapy in the relationship, in the moment, in the room—the unpacking of what just happened.
 
“As therapists, it’s important to carefully monitor what gets stimulated, not only in the client, but in ourselves as well.” We allow ourselves to be moved, provoked, bewildered and, above all, impacted by our clients. What emerges in a session is a result of our unconscious subjective world colliding with theirs. We notice our personal reactions and distinguish them from our clients’ in order to help our clients with theirs. Each session is a mutual discovery. This creates a present aliveness, illuminating the issues lurking in both of us, often occurring under our radar of knowing.
 

The Past as Present

A few months later, after Nick’s hours were reduced at work, he requested to see me every other week. He said he was feeling on shaky ground with finances and didn’t want to risk spending more money at this time. Money had never been discussed between us, other than the initial payment, and I was curious what his financial situation was. He reported that his house was paid for, no alimony, and he had investments, but felt it wasn’t a “good time” to be spending additional money.
 
I understood his concerns and wondered with him if there might be any other additional reasons for wanting to cut back sessions. To ask for additional reasons beyond the cost of therapy can be a rich window into emotional issues obscured between the therapist and client.
 
“No, it’s really just a monetary thing,” he said with a shrug.
 
During the transition to therapy every other week, I mistakenly charged him for an extra session, perhaps a result of my own anxiety about money or disappointment about the reduction in sessions. Since Nick didn’t mention my mistake, I brought it up towards the end of our next session and asked him if he had noticed it.
 
“I did, but figured you were the therapist and knew best so I wasn’t going to say anything about it.”
 
I told Nick that I felt bad about my error, let it go, and imagined we had handled it.
 
But here was a reenactment. He was going to ignore his own need and accommodate to mine, a painful, reoccurring pattern established early in his life.
 
At every moment in therapy, there are multiple levels to which the therapist can respond, including the content, process, body language, affect, or relational field.  Looking back, this moment with Nick was a missed opportunity to explore our relationship. Nick had a hard time speaking up for himself and was often oblivious to his emotional needs, looking to accommodate and please others before knowing or asking for what he wanted.  We had discovered together over the months how overeating often took the place of his ability to be aware, feel and speak up about his own needs. But one missed opportunity is no reason for despair; core issues undoubtedly find a way to come around again, especially when they aren’t handled.
 
A couple months went by and Nick neglected to pay for the month’s sessions. When I billed him for them, he objected, saying he remembered writing me a check. After several phone conversations, which I found stressful, afraid I hadn’t calculated correctly, he came to see he had indeed missed the payment. The check he wrote had been buried on his desk and was never delivered.
 
The following session he came in with a check, sat quietly and finally said, “I feel the therapy is moving along too slowly and not making enough of a difference. I’m not sure I should keep coming,” he said flatly, without affect.
 
Not feeling he’s getting his money’s worth, I thought. Aloud I said, “I’m surprised to hear this since you’ve repeatedly remarked how much therapy is helping you change by speaking up for yourself, feeling more (mostly anger,) and reaching out to people.”
 
“I said those things because I figured you wanted to hear them,” he said as his face reddened.
 
“What makes you say that?” I wondered out loud.
 
“Well, I like to keep people happy… it’s automatic pilot for me and easier than figuring out what I want or think.” He’s trying to give me what he thinks I want, while dismissing how he feels.
 
Again, I suspected this had something to do with how he learned to adapt to his early caregivers. I realized I had missed the transference and might lose him–– and was not feeling good about that.
 
His anger and disappointment with me were being acted out through his non-payment. His affect and compliance had been well hidden from me. As uncomfortable as it is for me to be the object of anyone’s anger, I knew it was necessary to endure. This was another window into working with Nick’s anger that had prevented anyone from getting close to him, myself included. He’d make a decision, not always conscious, to withdraw from relationships so he wouldn’t have to deal with his own aggression, and to soothe a hurt, scared self.
 
“At times the unpredictability of the here-and-now encounter in the therapeutic relationship forces us to emotionally confront ourselves in a way that no amount of training fully prepares us for.” If I had not allowed and distinguished my own internal responses from Nick’s in this moment, we would have been more prone to an unconscious enactment. In these scenarios, one of the likeliest impediments in the treatment is therapists’ fear of their own feelings, which could potentially steer the therapy in the wrong direction.3
 

An Ending or a New Beginning

Not long after that, Nick left me a voicemail saying he was dropping out of therapy. I called him back encouraging him to come in for at least one last session to wrap things up.  He did come in, and much to his credit, he was finally able to say what was on his mind, allowing us to complete the final chapter in the therapy. This was a tremendous achievement on Nick’s part, being willing to stay connected, even if only to terminate and tell me what was going on. He felt I didn’t have any answers for him and that he couldn’t get comfortable being the only one doing the revealing. We eventually came to understand how his acting out was an unarticulated way of telling me how angry he was with me for not giving him more direction. Nick felt I was too concealing and he wasn’t happy with the relationship being “so one-sided.”
 
The vulnerability had become intolerable for him (like in his marriage?) despite the knowledge that intimacy was something he longed for. It had become too uncomfortable emotionally; he felt exposed and at risk (i.e. with money). I wondered if it was easier for him to find fault with me, as he did with other women in his life, than to take a chance being vulnerable with me. Better he reject me first than be rejected by me.
 
“How do you think this reluctance to jump into ‘risky waters’ helps you?” I asked.
 
“It keeps me safe. I can stay home in my cave, play computer games, and eat junk food rather than come here, face you and feel how screwed up I am.”
 
“I can see how courageous you are to come in and admit all of this to me,” I said, knowing how true this was. I was touched by his admission.
 
As we talked, Nick began to see how his reluctance to engage with people let him off the hook; he could retreat to his comfortable, numb solitude by reducing sessions. He would distract himself with Sudoku, crossword puzzles, computer games, etc., and saw now how this contributed to his shutting down and isolation.
 
As we continued to discuss times he had been uncomfortable with me, for instance ending a session on time even if he was in the middle of something, or initially not being able to address his food issues, “Nick came to see how he erected a “demilitarized zone” around himself so he wouldn’t be hurt and judged by me (and others).” He saw how the distance “helped” him not to have to live with uncomfortable feelings, the meaning it had, and how he was the only one who could change it. He came to see his loneliness was located inside himself—self-imposed in an attempt not to be hurt anymore.
 
As Nick became aware of his loneliness, rather than making others responsible—particularly his ex-wife, imperfect girlfriends, or even me—he saw how the pattern was an unconscious state of mind and body that protected him. Once we linked his thinking and behavior to his history, and the template of habits it created, he recognized how it had been a successful strategy for survival growing up. This unconscious strategy had helped him live through the emotional neglect of his childhood, and protected him from the constant hurts of unresponsive, dismissive parents. He realized the distance he felt earlier with his ex-wife, and now with me, was an outworn way of taking care of himself so he wouldn’t be hurt again. Staying isolated allowed him to avoid the grief, shame and anger that got stimulated in close relationships; food became his biggest comfort and companion.
 
By linking what was happening in our relationship with his history, Nick’s behavior made sense to him. This changed his relationship to himself, replacing his anger and internal saboteur with compassion. Instead of hating himself, eating to dull the pain and withdrawing from relationships, he came to see how hard he was struggling, not only to connect with others, but to himself as well. By working with the relationship in the present, we saw how his past was alive today in the present.
 
Nick also saw how his protection of extra weight helped him adapt to the deprivations of his early life. What was once a strategy of soothing and protection now became a lifetime of habits, using food, withdrawal and emotional numbing in an unconscious attempt to avoid being  hurt. We had worked for two years without any success with his weight, however, this realization was the beginning of a life-long effort and success at slow weight loss. He no longer needed the extra padding to defend himself and terminated therapy shortly after he lost 40 pounds. It wasn’t that all his issues had been resolved, particularly the relational ones; but he felt he could manage things going forward. I felt good about the work we had done together, and he successfully terminated.
 

Working with Disjunctions and Derailments

Tracking the derailments in the therapeutic relationship is a way to bring the life of the transference and counter-transference right into the here-and-now of the inter-subjective field. The disjunctions between the therapist and client have to happen so we can understand how they’ve developed. We therapists stand in for the internal object through which the client’s conflicts are experienced. And then we get to repair what’s happened between us.  Nick wasn’t used to anyone wanting to know about his needs, so he tried to stop having them. When this became impossible, he simply walked away, a pattern that left him painfully lonely.
 
The disjunctions that occur in sessions usually have a long history attached to them; making the pattern explicit, in the present moment of the therapeutic relationship, helps the client identify the pattern. Just as a mother must hold, contain and partially work through the experience her child cannot hold and work through by himself, so must a therapist help digest and metabolize experiences for the client. While the relationship creates moments of disruption, we can use our mutual attentiveness to help the client own formerly disavowed feelings.4
 
For me the challenge comes when I get caught in my own complexes, my own feelings of inadequacy, anger, helplessness, of not knowing what to do, or of wanting progress to look a certain way. I have to set my agendas aside of wanting to help, heal, or have a specific outcome. I keep my meditation practice active so I can concentrate on the here-and-now, notice my own feelings and not let them intrude on my client’s, continue with my own growth and development and utilize consultation/supervision when I suspect my own material is interfering.
 
Noting what gets acted out in the therapeutic relationship, and helping the client to articulate what this might mean, is the working through that reveals these old patterns and frees the client to make healthier choices. Staying present in the relationship helps clients release long stored up affect, integrate the disowned parts of themselves, and inhibit the reactive patterns that spoil the natural joy of being. As clients learn to tolerate and digest their internal world, their connections with themselves and their world transform. More creative aliveness becomes available. As a result of sharing and participating in the joys and suffering together, discovering what’s unknown, unfelt and unpredictable, I feel humbled, privileged, and enlivened by our encounter. We are changed by each other.

Footnotes
1 Barrett, S., Wee-Jhong, C.,  Crits-Cristoph, P., & Gibbons, M.B. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training,45(2), 247—267. 

2 I have constructed Nick as a compilation of people, events and situations to protect confidentiality.

3 Russell, P. (1998). The role of paradox in the repetition compulsion. In J.G. Teicholz & D. Kriegman (Eds.), Trauma, repetition, and affect regulation: The work of Paul Russell(pp. 1-22). New York: Other Press.


4 Riesenberg-Malcolm, R., ed. Bott Spillius, E., (1999) On Bearing Unbearable States of Mind, London: Routledge.

Interacting Sensitivities in Couples Therapy

Posted on by Psychotherapy.net Team

It is a typical night at Tom and Betsy's house. Tom has his nose in a newspaper.  Betsy is leaning in the door of his study trying to talk to him, getting more and more frustrated at his periodic, vague “Uh huh.” After a few minutes of trying to entice him into a conversation, Betsy starts complaining, and then criticizing him for being cold. Tom snaps, “Can't you just once leave me alone?” Betsy yells, he withdraws further, and Betsy stalks out, thinking, “I'll give him all the alone time he wants!” 

Tom and Betsy are caught in “interlocking vulnerabilities” (Carol Jenkin’s term) or “interacting (or reciprocal) sensitivities” (my term). Each partner responds to having his or her sensitivity inflamed in a way that inflames that of the other. Tom is sensitive to criticism and responds by disengaging; Betsy is sensitive to disengagement and responds by criticizing. Michele Scheinkman and Mona Fishbane call this pattern “the vulnerability cycle.” Scott Woolley calls it “the EFT (Emotionally Focused Therapy) Cycle.” Robert-Jay Green calls it the “problematic couple interaction cycle.” “Pursuer-distancer” (coined by Thomas Fogarty) and “demanding-withdrawn” (researched by Andrew Christensen) are earlier ideas out of which the notion of interacting sensitivities developed.
 
My purpose here is to distinguish two major subtypes of interacting sensitivities—“pursue-withdraw” and “attack-withdraw”—and to describe how the pattern of interacting sensitivities plays out in the couple relationship. Awareness of this pattern will help the therapist follow the flow of the session and enable the partners to appreciate what they are caught in.
 
In “pursue-withdraw,” one partner is sensitive to the other’s withdrawal (feels ignored, shut out, abandoned, rejected, lonely, uncared for, unloved, unlovable, or just not as close and connected as he or she wants) and responds by pressing for connection (time together, intimate talking, affection, sex), and the other partner is sensitive to pressing (feels engulfed, smothered, suffocated, bombarded, besieged, flooded, controlled) and responds by withdrawing (disengaging, abandoning, shutting down, closing off). The self-reinforcing nature of this exchange is clear. The more Bob disengages, the more Gloria needs reassuring contact. The more Gloria presses, the more Bob needs to disengage.
 
In “attack-withdraw,” the other major form of interacting sensitivities, one partner is sensitive to attack (complaint, blame, criticism, anger, reproach, scolding, demands, sarcasm, rejection, disapproval, humiliation, exposure) and responds by withdrawing; the other partner is sensitive to withdrawal and responds by attacking. Again, the self-propelling nature is clear. The angrier Ben gets, the more Alan withdraws. The more Alan withdraws, the angrier Ben gets.
 
In a fight, the withdrawn partner typically seeks to end the fight or, at least, take a time out. He or she is the one more aware of the destructive and stalemated quality of the fight. The pursuing partner typically wants to keep talking. He or she dreads ending the exchange without a resolution and on bad terms.
 
In practice, “pursue-withdraw” typically morphs into “attack-withdraw.” At some point, and in some cases very soon, the pursuing partner becomes frustrated and shifts from pressing for connection to reproaching for failing to connect: “Why are you so defended?” “How come you never talk to me?” “Living with you is like living alone,” “Hello, are you alive over there?” Such reproach creates an “attack-withdraw” pattern (unless, of course, the other partner responds with anger rather than with withdrawal, which would then trigger an “attack-attack” pattern.  I’ll get to that in a moment). Here is an example of the shiftfrom “pursue-withdraw” to “attack-withdraw”.
 
Sally (inviting): What do you say we go for a walk?
Tom (vaguely): Maybe later.
Sally (encouraging): Come on. Let’s go now, while it’s still sunny out.
Tom: I want to read this book.
Sally (pressing): You can do that when we get home. Come on. You’ll feel different once we’re out there.
Tom: I’m really into this book.
Sally: (pressing): Well, okay, we don’t have to walk. Why don’t we just hang out and talk for a while?
Tom: I’m not in the mood.
Sally (shifting to attack): You’re never in the mood.
Tom (shrugs)
Sally (blurting out a hidden fear): Admit it—you just don’t want to do things with me anymore; that’s it, isn’t it…
Tom (looks up for a second): That’s not true.
Sally: Well, it is true. You’re like your father—the way he treats your mother. You’re getting to be more like him all the time.
Tom (Looks down at his book)
Sally: Aren’t you going to say anything?
Tom: I don’t know what I can say.
Sally (sarcastically): You could say, “Sure, let’s go for a walk. What a great idea! Thanks for suggesting it. You always make things such fun.”
Tom (looks unhappy)
 
Such “attack-withdraw” can go on for some time. At some point, and with some couples very soon, the attacking partner thinks, “I’m tired of being angry,” or “Oh my god, I’m sounding like my father,” or “This is starting to go nowhere fast,” or “I hate how whiny and needy I sound, even to myself,” or “You can’t change people, especially some people” or “You can’t get all your needs satisfied by just one person; I’ll call my sister,” Thinking such thoughts, the attacking person joins the withdrawn partner in disengaging. The result is a “withdraw-withdraw” pattern.  
 
At times, the pursuing partner purposely withdraws, creating what looks like a “withdraw-withdraw” pattern. He or she secretly hopes that the withdrawn partner will miss the engagement and start pursuing. But the withdrawn partner is usually just relieved by the decrease of pressure and doesn’t pursue.
 
While one partner has remained withdrawn, the other partner has shifted from “pursue” to “attack” to “withdraw.” At some point, and in some cases very soon, the latter partner again becomes distressed by the lack of emotional connection and again starts pursuing, which triggers a repeat of the three-part sequence. Couples can go on for years repeating the sequence of “pursue-withdraw,” “attack-withdraw,” and “withdraw-withdraw.”
 
At some point in this repetition, the pursuing partner may become so resentful about the withdrawn partner’s lack of engagement that he or she bypasses the “pursue” and goes directly to the “attack.” From then on, the partners shuttle between “attack-withdraw” and “withdraw-withdraw.” The “pursue-withdraw” has dropped out. At yet a later point, the “attack-withdraw” may drop out, too. The attacking partner becomes so discouraged that he or she gives up, and the couple slips into a chronic “withdraw-withdraw” devitalized state.
 
The discussion so far portrays one partner as remaining in the withdrawn state even when the other gets angry. In some cases, however, the withdrawn partner responds with anger of his or her own: “Why do you always have to get so angry about every little thing?” “Don’t yell at me!” “You could use a crash course in anger management—my treat.” In some cases, the withdrawn rather than the pursuing partner is the first toburst into anger: “Stop trying to control me,” “Get off my back!” “Give me room to breathe,” “Back off,” “You never let up, do you?” “Can’t you do anything by yourself?” “You’re the neediest person I’ve ever known.”  When the withdrawn partner attacks, the result is the pattern of “attack-attack” (if the other partner fights back), “attack-pursue” (if the other partner continues pursuing), or “withdraw-attack” (if the pursuing partner is now the one to withdraw).
 
Withdrawal and attack are not always clearly distinguishable. When you give your partner the silent treatment, you appear to withdraw. You relate to your partner in a grim, wooden, disengaged, monosyllabic way. But all the time, you are communicating anger. You are simultaneously withdrawing and attacking.
 
In summary, interacting sensitivities (the vulnerability cycle, interlocking vulnerabilities) has two main forms: “pursue-withdraw” and “attack-withdraw.” If the withdrawn partner remains withdrawn, the couple repeatedly passes through “pursue-withdraw” “attack-withdraw,” and “withdraw-withdraw.” As time goes on, the “pursue-withdraw” may drop out as may also the “attack-withdraw.” If the withdrawn partner doesn’t remain withdrawn, but instead attacks, the couple shifts into “attack-attack,” “pursue-attack,” or “withdraw-attack.”
 
We customarily think of a couple as being a particular type—for example, volatile, withdrawn, or pursuer-distancer. But if we look at what actually happens moment-to-moment, we see that couples often shift among several phases.
 
Knowledge of this shifting helps a therapist follow the flow of what is happening in the couple and understand how the partners are triggering each other—how, for example, Alex pursues because he feels abandoned and Judy withdraws because she feels cornered, which leads to mutual accusation, and, in an effort to avoid further damage, to mutual withdrawal. The therapeutic goal is to enable the partners themselves to observe their relationship in this way: to give them a compassionate vantage point above the fray—a platform—from which to monitor and manage their relationship. Such a vantage point is created by developing the couple’s ability to hold recovery conversations in which they go over their alienating interactions and appreciate how the position of each made sense.

The Lake Wobegon Effect

Posted on by Psychotherapy.net Team

How good a therapist are you?

Odds are, you think you’re pretty good. A recent study[i] of 129 therapists found that over 90% self-rated their psychotherapy skills at the 75th percentile or greater.  All of the therapists rated themselves above the 50th percentile.

In his fascinating new book on therapy outcome, Michael Lambert calls this positive self-assessment bias the “Lake Wobegon effect”. While it is true that the overall industry-wide effectiveness rates for psychotherapy are very good, our blindness to our weaknesses is dangerous.
 
Lambert points out that 30% to 50% of our clients don’t improve in treatment. Even more alarming, roughly 8% of clients get worse in treatment.  (Deterioration rates of children and adolescents may be as high as 12% to 24%.)
 
If all of us are above average, then who is causing the problems?  

Lambert cites a study in which 20 experienced therapists and 20 therapist trainees were asked to predict the progress of current clients in their caseloads. Of the 550 total clients, the therapists in the study predicted that only three were deteriorating. The actual number of clients who got worse was 40.

Notably, none of the experienced therapists predicted any of the clients in their caseload getting worse, even though they were reminded at the beginning of the study that the industry-wide average deterioration rate is 8%.

How can we fix our blindness towards our weaknesses?  The traditional method of addressing therapist deficits is supervision and consultation, but those only work when we can correctly identify which clients in our caseload are deteriorating.

Lambert proposes using an intriguing actuarial model, in which the clients’ session-by-session data on outcome measures is entered into a computer program. Using a large database of client outcome data, the program is able to alert the therapist when the probability of client deterioration is high. In his book, Lambert cites a few studies that indicate promise with this method.

Understandably, many therapists will be loath to make clinical decisions based on a computer’s calculations. But then how else do we overcome our self-assessment bias and seriously deal with the risk of client deterioration? Whatever tool we choose, this is an important question for our field to address.


[i] Walfish, S., McAlister, B., O’Donnell, P. & Lambert, M. Are all psychotherapists from Lake Wobegon?: An investigation of self-assessment bias in mental health providers. Submitted for publication.

Eysenck, Rogers and Psychotherapy Effectiveness

Posted on by Psychotherapy.net Team

In the 1970s I worked as a psychology lecturer in Hans Eysenck’s department at the Institute of Psychiatry, London. He was a controversial figure, quiet and introverted when met face to face, but on the academic stage a formidable and ruthless opponent. Rod Buchanan’s recent biography, Playing with Fire:The Controversial Career of Hans J Eysenck, nicely captures the complexity of the man, part prolific scientist, and part inveterate showman. Whether it was race and IQ, cancer and smoking or the effectiveness of psychotherapy, Eysenck did not hold back from taking the unpopular position. His 1952 paper challenging the effectiveness of psychotherapy triggered off a fierce debate that resonates today. How do we determine that psychotherapy works? Many therapists believe the question is either meaningless – like asking if medicine works – or has been loudly answered in the affirmative following thousands upon thousands of research trials. But the question is not as simple as it sounds.

In the 1970s I recall researching into Encounter groups that were all the rage then and coming across a statement by Carl Rogers. He claimed that a positive consequence of a successful Encounter group was for the members to become aware of their psychological problems and go on to have individual therapy for them. So the measure of success in Rogers’ terms was (a) having a problem and (b) going into therapy, the opposite of what most people see as psychotherapy’s goals! What Rogers claim illustrates is that any notion of outcome is based upon a set of values. For him authenticity was paramount and therapy was not a means of getting rid of symptoms but a chance to explore oneself, a process of self actualisation that was the key to the well-lived life. To be happy was not to be free of problems but to feel comfortable in oneself and to relate to others in a genuine and empathic way. Attractive as this philosophy may be, it is not one that the researchers into the effectiveness of psychotherapy have adopted. On the contrary, a quasi-medical model has been all powerful. Researchers have sought to prove that any specific therapy works in terms of making people feel better and enabling them to get rid of depression, anxiety, addictions or whatever ‘illness’ they are deemed to have. The problem I have with that it does not describe psychotherapy as I know it. Most psychotherapists realise that these simplicities mask the truly interesting part of therapy which is determining what the client’s problem actually is.

In my memoir, The Gossamer Thread. My Life as a Psychotherapist, I describe my first therapy case whom I call Peter. Peter’s problem was a phobia about using public toilets. His anxiety would rise exponentially when any men came in so he avoided public toilets altogether and led a restricted social life. I took over the therapy from another clinical psychologist (who went on to become a distinguished researcher into psychotherapy) and plugged away at Wolpe’s systematic desensitisation, first in imagination then in reality. The reality I chose was to see Peter in a bar where we would chat and drink beer in a way that is unthinkable today. In the course of these conversations I got to know him well, and he me, since I had no idea about boundaries being young and totally inexperienced. The result was a great success but it was in Rogerian not quasi-medical terms. When by chance two years later I met Peter again, he was a changed man, relaxed, happy in himself, content in his career. When I asked him about the original problem, at first he looked puzzled and then said, ‘Oh, that. I still have it but it doesn’t bother me anymore.’ There was a lesson to be learned about what psychotherapy outcome really means but it took me many years to learn it.

Psychotherapy outcomes: The best therapy or the best therapist?

Posted on by Psychotherapy.net Team

I’m often asked, “What’s the best therapy for anxiety/depression/trauma/etc?”  CBT, EMDR, ISTDP, ACT, DBT – the alphabet soup of therapies – how do we (and our clients) choose?  Research shows that psychotherapy outcomes often vary more between therapists than therapies, suggesting that picking the right therapy may actually be the wrong approach. In other words, choosing the most effective psychotherapist is more important than choosing the most effective therapy.   

How can our clients pick the most effective therapist? They can’t. There is no industry standard for tracking and reporting psychotherapy outcomes. This won’t last. Regulators and consumers are going to demand public accounting of treatment effectiveness. If I have the right to ask my surgeon for their success rate, then why can’t my clients ask for mine?

In a recent panel, the eminent psychotherapy researcher David Barlow noted the “inexorable trend” toward outcomes measurement. He believes it will bring “enormous benefit for all of us,” by improving the connection between clinical research and the effectiveness of actual clinical practice.

Many therapists, however, dread the movement towards measuring outcomes. They raise important concerns about the ability of outcome measures to assess subtle nuances of psychotherapy in long-term treatment. Other concerns include paperwork hassles, and the danger of “therapist profiling” by outcome. (You can join a lively discussion of these concerns in the forums here.)

However, the benefits of embracing outcomes far outweigh the concerns. I’d like to suggest four major benefits to tracking psychotherapy outcome:

  1. Measuring outcomes will help us become better therapists. How else can we know if all the workshops, trainings and supervision we do are actually helping?
  2. If we get out in front of this movement then we will have a stronger hand in designing it. If we resist the push towards accountability, it will be forced upon us. (For example, the Los Angeles Times recently published a report outcomes of public school teachers in Los Angeles county, by teacher name.)
  3. Online therapist-review websites (such as yelp.com or healthgrades.com) lets one or two disgruntled clients hurt your reputation. A public system for reporting outcomes gives a fair perspective of your work.
  4. Most importantly, our clients deserve to know about the treatment they are getting. Research consistently shows that most therapy is very successful. Dodging accountability can foster the impression that our failures are more common than our successes.
One good example of a therapist who has embraced outcome measurement is Allan Abbass. He tracked and reported his therapy outcomes for his first six years in private practice, and then published the results.

How can a therapist start tracking their outcomes?  I use the Outcome Rating Scale, which takes about one minute at the beginning of each therapy session. The free scale and instructions can be downloaded here  and here. There are also three online services that help therapists track their outcomes: myoutcomes, oqmeasures, and core-net.

[This blog is dedicated to exploring training tools and techniques that help us become better therapists. Please email me at trousmaniere@yahoo.com if you have any feedback or new psychotherapy training techniques you would like to share.] 

Preventing Psychotherapy Dropouts with Client Feedback

Posted on by Psychotherapy.net Team

“You understand me thirty percent of the time.”

“I need to you to slow down.”

“I was sad and you cut me off.”

These words of dissatisfaction are from my clients. They weren’t easy to hear, but they have changed how I practice psychotherapy and have significantly reduced my dropout rate.

Anne: A Case Study

I had been treating Anne, a Latin-American woman in her early 20s, in psychotherapy for six months. She presented with weekly panic attacks, daily cutting, severe sleep disturbances, a range of somatic symptoms that she attributed to her anxiety, and persistent interpersonal difficulties. She presented as attentive and likeable, though beneath her mask of smiling and compliance she clearly hid a tremendous amount of pain. Anne has a history of sexual abuse by multiple family members over a six-year period starting before age four. Her mother had been a prostitute for most of Anne’s life, and both her biological father and stepfather are in prison for sexual assault. Despite these and many other challenges, Anne demonstrated tremendous resiliency and had just graduated from college with a very strong GPA.

Anne had been in individual and group therapy for much of her childhood and teens, but by her own report she had never really tried to make it work. After graduating from college, Anne decided she wanted to find a solution to her anxiety, sought out individual therapy, and found me.

Anne’s treatment progressed well at first. In the first few months her panic attacks stopped, her general anxiety decreased, she stopped cutting, her somatic symptoms decreased, and her sleep gradually improved. Anne’s interpersonal difficulties, however, persisted. We had been digging into that material for a few months but had made little progress. In fact, her social and romantic life was getting worse. Anne was becoming restless and frustrated. I pulled out my two favorite “getting therapy unstuck” tools: consultation groups and additional training. Neither helped. As a dynamic therapist, I knew what I was supposed to do: work in the transference, bring insight to the dynamics in the room, monitor my counter-transference, and above all hold the frame. But “the frame of a therapy case cannot be stronger than the frame of a therapy practice, and mine was starting to splinter.”

Existential Threat

In the same month that my treatment of Anne was getting stuck, I had two new clients drop out after one session in the same week. I knew about the research that we are all told in graduate school about how the modal number of psychotherapy sessions nationwide is one, and how not every client and therapist is a good match, and yada yada. But for a new therapist trying to build a practice during a recession, having two new clients drop out in one week is an existential threat. I decided something had to change.

On my commute home one evening that week, I listened to a recording of Scott Miller’s presentation at the 2009 Evolution of Psychotherapy Conference regarding his pioneering work on feedback-informed psychotherapy. Scott got my attention when he referred to dropouts as the “largest threat to outcome facing behavioral health” in the United States and Canada. He was talking about my practice! I realized that I was not the only therapist with a dropout problem, and there was no reason to hide it out of embarrassment. I resolved to seek counsel from my colleagues and mentors.

The Ubiquitous Scourge

In the first, difficult year of building my private practice, I ate a lot of lunch. Networking lunches are like lottery tickets: one in ten results in a few referrals, and every referral was worth its weight in gold in that difficult first year. I enjoy networking lunches, because it’s fun to meet senior clinicians and hear their war stories. They tell me that they enjoy the lunches because they get to pass on the gift of mentoring that was once given to them. Senior clinicians are a generally calm, relaxed and self-assured bunch; they have established referral sources and can easily afford to lose a client here and there. Want to make some highly regarded pillars of the therapeutic community stop eating their free lunch and sweat a bit? Ask about their dropout rate. It’s as if you’re asking what sexually transmitted diseases they may have. It’s not polite. Never mind that dropouts are one of the ubiquitous scourges of our profession, affecting all diagnoses and treatment modalities. Therapy dropouts are the dirty secret of our profession: everyone has them yet few want to talk about them. Unfortunately, avoidance has not proven to be an effective solution to the problem. With few exceptions, the overall psychotherapy dropout rate is as bad now as it was fifty years ago, despite decades of treatment research and empirical certification.

What Counts as a Dropout?

For 2010, the overall dropout rate for my private practice was 37%. Unfortunately, it is hard to know whether this number is good, average or poor, because there is no general consensus in the literature on what exactly constitutes a “dropout.” The average psychotherapy dropout rate has been reported to be from 15% to 60%, or higher, depending upon whether you define dropout as quitting therapy before all treatment goals were achieved, terminating without the therapist’s agreement, or a variety of other definitions. For my own practice, I define dropout as any time a client terminates therapy without telling me that they are stopping because they have achieved enough positive results. I chose this definition because I think it points most directly to the problem I want to resolve: clients who could benefit from more therapy but choose to not be in treatment with me anymore. Of course, this definition is not precise and won’t work for all therapists. If a client terminates due to factors that make continued treatment impossible, such as moving out of town, then I do not count it as a dropout; but if the given reason is that he or she cannot afford therapy anymore, but isn’t interested in talking about a sliding scale, then I do count this.

Of course, there are many reasons a client may drop out. Most of the research on dropouts has focused on what we call client factors, such as the client’s diagnosis, demographics, rate of progress in therapy, etc. But this research doesn’t help my dropout problem because I’m trying to keep my practice full, and I don’t have the luxury of excluding clients who are at high risk of dropout. So instead I have to focus on therapist factors: what can I change about how I work to reduce my dropout rate.

Insisting on Feedback

“Of course I ask for feedback from my clients. I do it every session!” Every therapist believes they ask for client feedback. True for you too? Then tell me why your last three dropouts happened. Sure, we ask for feedback, in the same way that my previous dentists asked—as an offhand, pro-forma fly-by at the end of the root canal. “Was that ok?” And the information we get is usually as meaningful as the effort we expend asking. “Yeah, that was great,” or “You’re a great therapist,” or “I’m really feeling better.” Vague and general; even worse, polite. Just enough for the client to think that they have satisfied the therapist and just enough for the therapist to keep the specter of dropout in the closet. It’s a mutual con-job—a wink and a nod to accountability. But if we don’t embrace accountability in the therapy room, then it will make itself known in dropouts.

Sure, some clients are tripping all over themselves to give you feedback. Sometimes you can’t stop the feedback. But those aren’t the clients I’m worried about losing to dropout. Maybe some therapists are able to get meaningful information through informal soliciting of feedback, but I’ve found the hard way that if I don’t make a Big Formal Procedure out of it, I end up with empty, vague generalities.

Another fruitless session had just ended with Anne, and I was pretty sure that she was about to drop out. I handed her a feedback form and asked her to complete it. “She looked at the piece of paper, snorted and said, “Are you kidding me?”” As a beginning therapist, I have a lot of practice hiding my nervousness. I replied, “I need your feedback in order to learn how to help you better, but also to become a better therapist overall, so I appreciate your time and candor in filling this out.” Anne snorted again, rolled her eyes, and completed the Session Rating Scale, an ultra-brief tool that measures the working alliance along four dimensions. She handed the form back to me and I saw that our working alliance, as I would have guessed, was a sinking ship. I asked what specifically I could do to help her better. Anne replied, “You could listen.”

I said, “More specifically, tell me how I don’t listen and how I can help you better.”

She gave me the look clients give you when they’re not sure if you really mean what you say or if you’re just doing a canned intervention. “You understand me thirty percent of the time,” she said, visibly angry. I asked for an example. “When I mentioned my cousin you cut me off,” Anne said. “That was important.”

I couldn’t remember Anne mentioning her cousin. “What else?” I said.

“You tuned out two or three times this session. I can always tell you’re tired when we meet this time of day.” I thought I had managed to hide my mid-afternoon fatigue.

“What else?”

“There are times when I am sad that you really don’t understand how I’m feeling—even though I can tell that you think you do.”

None of Anne’s feedback struck me as accurate. Above all, I pride myself on accurate empathy. What kind of therapist am I if I don’t feel a client’s sadness?

Four Rules for Receiving Feedback

We all have areas of known weakness. Take cultural diversity, for example. I am a straight, white, middle-aged male. Anne is a young bisexual Latina. I would expect for her to tell me about culturally based misunderstandings. This would be ego-syntonic for me and not cause anxiety. But tuning out or missing sadness—that’s not me!

The feedback I get from clients that is confusing or seems inaccurate is the most important feedback I get. “Why is it that we trust our supervisors to point out our blind spots, but not the people who are actually in the room with us?” It’s odd how we spend so much effort and money getting feedback from peers and experts, yet so little effort on getting formal feedback from our customers.

I’ve come to see that there were two major problems with how I had been using feedback. First, my collection of feedback was pro-forma. I wasn’t invested in getting it, and my clients could tell. Second, I interpreted the feedback. I conceptualized it as part of the therapeutic process, which meant that it was ultimately about the client, not about me. Of course, getting and using feedback affects and informs the therapeutic process. I needed to learn, however, to set aside the process for a moment to accurately hear the feedback as it pertained to me.

Since then I have developed a four-step feedback rule. First, I make a Big Deal out of it. I use a paper form (the Session Rating Scale) because the act of pulling out the paper and pen serves as a symbolic shift in focus away from the client’s process towards my performance. If a client always gives me high marks on the form, or responds with platitudes like, “Tony, everything is great,” I’ll say, “Well, there’s always something I can improve. Can you give me one or two specific ideas on what I could be doing better?” In therapy, it’s all about the client. In feedback, it’s all about me—I’m downright selfish!

The second rule of feedback is that I don’t interpret. If I make the feedback about the therapeutic process then I am missing the actual feedback. As a dynamic therapist, all my training was telling me to interpret Anne’s response as transference or a projection: she was reliving her past pathological attachments in our relationship. But I’m convinced this approach would have caused Anne to drop out, because she would have seen (correctly) that I was ignoring her.

Scott Miller calls this kind of attribution “burden shifting”—when we misattribute our mistakes to client factors. He warns therapists that blaming dropouts on client demographics or diagnostic categories can block our insight into our own mistakes.

The American Psychological Association is moving towards requiring trainees to learn how to collect clinical outcome data. Likewise, Michael Lambert1 and others have developed tools to predict and reduce dropout by tracking clients’ session-by-session clinical progress throughout treatment. This data is valuable, but still focuses on client factors, and thus can miss important information that only the client has on what the therapist is doing wrong. I need to know my part in the story so I can stay ahead of potential dropouts. Without session-by-session feedback, when a client drops out, it is already too late to find out why.

As therapists we claim clinical legitimacy by using empirically certified treatments. We advertise our professional trainings and certifications proudly. But just as important are our personal treatment data, including our dropout rate, which we generally hide in the closet. Krause, Lutz and Saunders2 have argued that instead of having empirically certified therapies, we should have empirically certified psychotherapists. As public health providers, assessing outcome is an ethical responsibility. If we continue to hide to our mess then we run the risk of others exposing it for us. (For example, teachers’ unions across the country are getting clobbered for their resistance to incorporating meaningful outcome evaluations into their work.)

Incorporating Feedback

How do I actually use feedback? Sometimes it is easy. For example, in response to Anne’s feedback, I moved her appointment to a time of day when I wouldn’t be tired. (Now I use her previous time for a midday nap, so other afternoon clients are benefiting from Anne’s feedback as well.) Other feedback can be harder to use, especially when it is about my own unconscious behaviors. Anne insisted that I cut her off when she had brought up her cousin, but I couldn’t remember doing so. Likewise, I had no awareness of avoiding her sadness. While I did want to take her comments seriously, I also didn’t want to automatically assume her perceptions were correct.

However, feedback that points to my unconscious behaviors is also the most valuable. This is the third rule of feedback, which is the hardest rule to follow: to “focus most on the feedback that seems inaccurate, confusing, or anxiety-provoking. This is where the treasure is buried. “

When I’m unsure about the accuracy of the feedback I am getting, I use a strategy I call perspective triangulation. First, I videotape my sessions with that client and review the video myself. I then review it with colleagues in consultation groups. Comparing the perspectives of the client, myself and my colleagues usually results in a definitive answer.

In my experience, the client’s perceptions are correct at least two-thirds of the time, and I make consequent course corrections in their treatment. It is important to note, however, that even when I think the client’s perceptions are incorrect, I still have to substantively address their feedback, or else there is a growing risk of dropout.

My review of the video showed that, yes, I had cut her off. Colleagues in a consultation group watched the video and pointed out multiple instances where Anne was about to have a rise of sadness, but I had blocked her sadness by refocusing on her anger. (Later sessions revealed that the two were in fact connected, as her sadness was about being unable to protect her cousin from abuse.) This was the hardest feedback for me to receive; I never would have believed it, had it not been clear as day on the video. Investigation of videos revealed that I had an unconscious pattern of re-directing from sadness with a range of other clients in addition to Anne. I never would have found out had I not insisted on feedback.

The fourth step in my feedback process brings it back to the client. If I agree with their comments, then I make appropriate course corrections in our work. If I disagree, then we discuss our different points of view. Either way, I make sure to be clear and transparent in my process, and to let clients know that I take their feedback seriously. So in this case Anne and I had a discussion about her feedback. I agreed to be more attentive to not cutting off her sadness. She agreed to let me know, in the moment, if she saw me doing it.

I was trained to get a review of my clinical weaknesses from my trainers and supervisors. Now I also get it from my clients. They have given me an amazing gift: an empirically validated list of my clinical weaknesses. I can’t think of a better resource to prevent dropouts.

Now, six months later, Anne has made significant progress on her interpersonal challenges. She has improved her relationships with friends, roommates and employers. She started setting firm boundaries with previously abusive family members. Her sleep, anxiety and somatic symptoms all continue to improve. Every session Anne teaches me how to better help her.

Before using feedback, I had one to three dropouts per month. Since getting serious about feedback, I’ve had only one dropout in over three months. While this is too soon to draw definitive conclusions, the results so far are very encouraging.

The client sitting across from me knows something about my dropout problem that I don’t. All I have to do is ask, and listen.

2011 Update

 I am pleased to report that my dropout rate for 2011 was 18%, one-half what it was in 2010. I'm confident that getting serious about client feedback contributed to this improvement. This raises the question: how low can a dropout rate realistically go? Besides improving as a therapist, what else can help lower the rate further? (One of my clients recently suggested offering coffee in the waiting room for night sessions!) Hopefully we will find answers to these questions from future research.

Footnotes

1. Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients' progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.

2. Krause, M.S.; Lutz, W. & Saunders, S.M. Empirically certified treatments or therapists: The issue of separability. (2007). Psychotherapy: Theory, Research, Practice, Training. 44, 347-353.

Further Reading

“When I’m good I’m very good , but when I’m bad I’m better”: A New Mantra for Psychotherapists. by Barry Duncan, PhD and Scott Miller, PhD.

Psychotherapy Training on Steroids: Remote Live Supervision

Posted on by Psychotherapy.net Team

Note to readers: This blog is dedicated to exploring new training tools and techniques to help us become better therapists.  May we all become “supershrinks!"

Learning a psychotherapy technique can be like a romantic tragedy.  You go to the workshop, fall in love with the technique (and occasionally the presenter), and go home with fantasies of all your therapy cases getting unstuck.  On Monday morning in your office, however, everything falls apart:  you can’t remember the techniques (despite the post-its), you can’t do them correctly, or, even worse, you do the interventions perfectly but the client responds totally differently than how the clients in the presenters’ videos responded.  Sometimes I want to yell, “No, you are supposed to cry when I say that line, and get angry when I say this line!”

Most training and supervision lacks the most important variable in therapy:  the client.  The best training occurs in an actual therapy session.  I want to know what techniques to use with my client, not the client in the case reports or videos.  But what if the expert I want to learn from lives across the country, or I don’t have a one-way mirror room?   Now, thanks to internet, I can bring him into my office.

I would like to share a new method of supervision that has been made possible by recent technological advances.  “Remote live supervision” allows a supervisor to observe a therapy session over the internet and give feedback to the therapist in real time.  The technology is inexpensive and easy to setup.  This new method has promise to greatly increase the accessibility of top-quality supervision and training across the field of psychotherapy, as therapists will no longer be limited by geographic distance. 

Specific instructions on how to set up the remote live supervision for both PCs and Macintosh computers, along with a discussion of technical issues, can be found here.

Combining the video of the therapy session with the transcript of the supervisor’s moment-to-moment comments makes for a powerful training tool, as trainees get to see the actual results of following (or not following) the supervisor’s interventions.  Another option for training is group video, where a team of trainees can observe a remote live supervision in real time.

I do remote live supervision with Jon Frederickson, MSW, to accelerate my learning of Intensive Short-Term Dynamic Psychotherapy (ISTDP), an affect-focused therapy effective for healing trauma, anxiety, anger, relationship problems and somatic symptoms.   One aspect of ISTDP that can be challenging for trainees to learn is how to identify and address the automatic, unconscious behaviors clients use to maintain an emotional distance between themselves and others (including the therapist), such as rationalizations, talking in hypothetical terms or being vague.   In a review of my work, I found that I was missing my clients’ distancing behaviors, and many sessions could go by without a significant emotional experience or change for the client.  

Of course, the client is not the only person in the therapeutic dyad who can unconsciously create emotional distance.   Colleagues in a consultation group helped me identify my own pattern of unconscious emotional distancing, especially when working with male clients who were emotional distant or angry.   However, I was unable to translate this insight into change in the therapy room.

Through remote live supervision I have been able to get immediate, moment-to-moment identification of distancing behaviors, by both the client and myself, in real therapy sessions.  Live supervision can be very challenging, especially when it addresses my own avoidance.  It is, however, extremely effective: Jon’s real-time feedback has resulted in multiple breakthroughs of sustained, heavy grief and character change in clients for whom therapy had previously been stuck.

If you have a new psychotherapy training technique you would like to share on this blog, please email me.

Rules for a Good Relationship

Posted on by Psychotherapy.net Team

1. Never go to bed angry.
Stay up all night yelling and screaming. After the way your partner behaved, he doesn’t deserve to sleep.
 
2. Don’t jump in to help when your partner is telling a joke
–unless, of course, you can tell it much better.
 
3. When fighting, take a time out.
That will give you a chance to come up with more devastating putdowns.
 
4. Don’t interrupt your partner.
You need to have all the facts in order to show her how totally wrong she is.
 
5. Don’t mind read.
Your partner might be thinking awful things about you that you don’t want to know.
 
6. Don’t dump out all your stored-up complaints.
Keep a few in reserve so you won’t be caught with nothing left while your partner still has four or five.
 
7. Restate your partner’s message.
Let him see how truly irrational it is.
 
8. Make “I” statements, not “you” statements
–except when nothing but a good “you” statement will do.

9. Don't say "always" or "never"
–except when you need it for added emphasis when your partner won't admit how totally wrong he is.
 
10. Don’t raise your voice.
You can have so much more effect by speaking softly between clenched teeth.
 
11. Don't  try to change your partner
–except, of course, for the few things that really do need changing. In fact, make a list.

Alan Marlatt on Harm Reduction Therapy

Posted on by rezendevknowfully.com

Harm Reduction Defined

Victor Yalom: We're here to interview you today about your work with addictions, and specifically your contributions to the field of harm reduction. Just to get started, the name harm reduction gives a hint of what your approach is about, but maybe you could say a few words to introduce the concept.
G. Alan Marlatt: We are basically trying to support people that have addiction problems. If they want to quit, we'll help them do that. That's our relapse prevention program. If they would like to be able to reduce their drinking or drug use-harm reduction—we want to support them there too.

Many people with alcohol and drug problems are not getting any help, and I think part of the problem is they don't want to identify as drug users, or if they're using illegal drugs, they're afraid they're going to be arrested and put in jail or something like that. They're holding out. But if you talk about moderation, many people say that's an enabling strategy.
VY: Many professionals.
GM: And others. So it’s a very controversial topic, but basically my position is, “We’ll help you, whatever your goal is. You want to quit, we’ll help you. You want to cut back, we’ll help you. We’re not going to shut you out.”
A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”
A lot of the traditional treatment programs are saying, “Unless you’re totally committed to abstinence, we’re not going to work with you.”
Rebecca Aponte: If somebody wants help cutting back, is that something that they can work on with a harm reduction therapist for life?
G. Alan Marlatt: With some people it's for life. Let me give you an example of a case. This is a woman that was being treated by a psychiatrist for depression at the University of Washington. The therapist called me up and said, "I've been seeing her for about three months, and today I found out that she has this drinking problem. So, I said to her, 'I can't really help you or continue to treat you unless you go into alcoholism treatment, and I don't know how to do that.'"

VY: He doesn't know how to do alcohol addiction treatment.
GM: Right. Most psychiatrists don’t know how to do that; it’s not part of their training. So he wanted me to do an evaluation of her. When she came in to see me, she’d already been to the alcohol treatment center that the psychiatrist referred her to. I said, “How it’s going?” She said, “Everybody’s telling me something different. The psychiatrist said I was probably drinking a lot to kind of self-medicate my depression.” And that was partly true.

Then, when she went to the alcohol treatment center in Seattle, they said, “No, your alcoholism is causing your depression. Unless you are into our abstinence-based program, it’s just going to continue. Are you ready?” She said, “No, I’m not ready. This is the only thing that works for me and I know it’s causing other problems, but I’m not ready to give it up.”

So she was stuck in the middle. For a lot of these kinds of people, harm reduction therapy is the best alternative. So I said, “Let’s do harm reduction therapy. I can help you keep track of your drinking, and see what’s going on.” So she agreed to do that. A lot of people at that point will drop out. If all they have are abstinence-based alternatives, they’re not going to do it.

But she agreed to do it. She worked with me for three months and we kept track of her drinking. She reduced her drinking significantly.
VY: What was her goal?
GM: Her goal was to drink more moderately and to figure out what was going on in her marriage about drinking, because her husband said, "You're a chronic alcoholic and unless you stop drinking altogether, I'm going to leave you." That made her more angry and depressed. She tried to stop drinking, and then when he would go out of town, she would get loaded—this kind of thing.

We finally figured out there was a lot going on in terms of the marriage and her anger. Then I taught her meditation, which was the most helpful strategy for her. Then, one day she was going shopping and she saw her husband in a car embracing another woman and it just made her start drinking again. She said, "I can't do this anymore."

She went to a meditation retreat center in France—Plum village, the Thich Nhat Hanh Center. You go there, you take these precepts. One of them is no use of intoxicants while you're here. She said, "I took that and I thought, 'That's it. I'm never going to drink again.'" She's been now abstinent for five years.

So harm reduction was the bridge to get her there. If you say, "You've got to stop now," a lot of people go, "I can't stop now." But if you start getting them into a harm reduction program and they realize they can reduce their drinking and begin to figure out what their triggers are, they feel a lot more confident that if they want, they could quit. That's what happens a lot of the time.
VY: Getting back to the basics of it, what do you mean by harm reduction and how did it originate?
GM: I did a sabbatical at Amsterdam in the early '80s. That's where harm reduction originally developed, because they were the first country to realize that injecting drugs can increase HIV and AIDS—so why doesn't the government provide needle exchange instead of [the addicts] sharing needles, which spreads HIV much more readily? This was when HIV and AIDS really broke out and a huge number of people died. So they said, "If people are going to use, we want to help them stay alive. We want to reduce the harm." The needle exchange program was really the first type of that.

In Vancouver, Canada, where I grew up, there are many homeless people living in the lower east side that are injection drug users, and a lot of them are overdosing and dying.

What did the mayor's office do? After some persuasion from harm reduction specialists, they opened a safe injection center. This is where, instead of shooting up in the alley and not knowing what you're getting, you can go to this site. They'll give you clean needles. They'll allow you to shoot up there. There are nurses and doctors available if they need help. Since they opened that, the fatality rate has dropped. Of course, many people say, "Why is this happening? You're just enabling them to continue using."
VY: Right. "This is illegal and the government is helping them do something illegal."
GM: Exactly. The second program in Vancouver that just started and is also having good results is basically prescription heroin from doctors. Of course, that started in England years ago. Physicians there called it the medicalization approach. If they were dealing with a heroin addict, they could say, "Look, we'll prescribe you heroin while you're doing treatment because we don't want you to overdose from buying it on the street where you don't know how potent it is." These are harm-reduction kinds of approaches.

Another example is methadone treatment; that's harm reduction because you're reducing the rate of potential for overdose fatalities.

The Bar Lab

I was interested in applying it to alcohol problems, which means moderate drinking. Mainly we’ve been working with college students who are binge drinkers, because the NIH report has been showing about 1,400 to 1,500 college students die every year from alcohol-related problems—overdose drinking, car crashes.
 
At the University of Washington, there was a recent case of a student who died. A 19-year-old freshman was living in a dormitory, and a woman that was his friend just turned 21. What do you do when you turn 21? You want to have a party because you can drink legally—even though her friends were 19 or underage. So they go, “Where can we go and not be caught by the dormitory advisors and things like that?” If you catch you drinking and you’re under 21, you could lose your room. So one guy said, “Hey, there’s a balcony on the seventh floor. Let’s bring all our alcohol up here.”
 
 So they took their vodka and rum and everything else up. There were six of them. They said, “We’ve got to drink quickly just in case—otherwise we’ll get caught.” They all got loaded pretty fast, and the guy who died was sitting on the edge of the balcony telling a funny story, lost his balance—head-first down in the cement, killed on impact. His blood alcohol level was 0.26. In Washington state, 0.08 is the legal limit. He was triple that.
 
 We found out from his family and friends that he wasn’t a big drinker in high school. Once he got to college and all of his friends were drinking, he just went overboard.
 
 So harm reduction for college students means we’ve got to train you how to drink more safely, even if you’re underage—that’s when the highest risk occurs. We developed a program called BASICS—Brief Alcohol Screening and Intervention for College Students.
We’re teaching them, “Just like safe driving, this is safe drinking.”
We’re teaching them, “Just like safe driving, this is safe drinking.” Your blood alcohol levels, what’s going on, how alcohol affects you—we teach them all that. We bring them into our bar. We have an experimental bar on campus called Bar Lab. We give them drinks.
VY: This is like John Gottman's Love Lab.
GM: Yeah. This is the Bar Lab. It's a cocktail lounge on the second floor of the psych building. What we do there is bring students in and give them drinks. They can drink anything they want for an hour—usually about 12 to 15 students. They're usually getting pretty loose and playing drinking games. Then we tell them, "Guess what? None of the drinks that you had had any alcohol in them whatsoever. They're just placebos." They go, "What?"

We tell them, "Look, when you go drinking, three things are happening: what your actual drink is, number one; what the setting is, like a bar, there's music or whatever; and most importantly, what your set is—your expectancy about how alcohol's going to affect you. Those things make for big placebo."

So, people who go through this—we call it the "drinking challenge"—end up drinking about 30% less after they go through that particular program.
VY: How do you get them to agree to do the program?
GM: They get paid for follow-ups and assessments over a four-year period—only about $200, but still. We had an abstinence-based alcohol awareness program on our campus, and they would show car crashes and things like that—people who get killed. And they were trying to say to people, "You can't drink legally until you're 21." Who showed up for that program? Hardly anybody—maybe 2% of the students.

But if we go into the fraternities and the sororities and the dormitories and others and say, "Would you be interested in a program that would help reduce your hangovers and your driving, sexual problems and things like that?" They all go, "Yeah." So you bring them in.

So harm reduction is typically user-friendly. It's not saying, "You've got to stop or we won't talk to you." People with addictive behaviors—there's so much shame and blame and stigma. They don't want to show up. Instead, we're saying, "We're going to meet you where you are. We're not asking you to quit right away. We're just saying let's talk about what your drinking or drug use is like and see what you might want to do. We'll try and help you, whatever your goal is"—rather than confronting them and saying, "you've got to quit."

Moral Objections

VY: Why do you think there's such vociferous objection to the harm reduction approach?
GM: Many people buy into the moral model of drug abuse, the war on drugs—it's called a black-and-white model. Either you're abstinent or you're using. You're an addict. There's nothing in between. So the door is pretty tight. Kurt Olkowski, the new drug czar that we just got under Obama, said that the war on drugs has failed. Thank God, because the previous administrations under Bush and Nixon said, "Lock them up. If they're using illegal drugs, punish them." We now have 2.3 million people locked up in this country, which is more per capita than any country in the history of the world. Sixty percent of them are there either directly or indirectly incarcerated because of drug or alcohol problems.
VY: It's clear you take issue with the moralistic approach.
GM: Yeah.
VY: Is harm reduction a countervailing philosophy?
GM: It’s a public health approach.
VY: Is it a more scientific, research-based approach?
GM: Yes, it is based on research, and there are more and more studies coming out that show that it is really helpful. It's working. Our BASICS program for college students is now listed on the national registry for evidence-based practices. We've got about 2,000 universities that are now using it. That's really working. People don't like to call it harm reduction. They would call it an alcohol skills training program or something.

Alan Leshner, who's the director of the National Institute on Drug Abuse, published an article last year saying, "Drop the term 'harm reduction' because it creates so much controversy. Let's call it something else"—sort of like the word "communism" or something. Up until recently, if you were presenting a paper at the APA or any other conference where there was sponsorship from NIH, if you used harm reduction in the title, it was eliminated. They said, "No, we won't let you talk about it."

I've run into this a lot. I've given talks about harm reduction where half the people walk out of the room while I'm talking. Huge resistance.
VY: Why do you think that is?
GM: They're from the moral perspective and they think all the harm reduction technique is doing is enabling people. I received an award yesterday, and one of the people that gave me the award told me he remembered when I was first talking about harm reduction and people claimed I was murdering alcoholics and allowing them to die.
…when I was first talking about harm reduction…people claimed I was murdering alcoholics and allowing them to die.


What we’re doing, like in Housing First, is trying to keep these people alive. That’s what the research has shown. So I think harm reduction is going to take off under the new administration. Ninety percent of the people who have alcohol and drug problems aren’t getting any treatment unless they’re busted for something. How are we going to bring them in? We’ve got to allow harm reduction to be a middle way. 
VY: You're not against abstinence as a goal.
GM: No. We’re for both. We’re just trying to get more people in the door.
VY: You're for both abstinence and moderation.
GM: We’re for whatever your goals are. We’re going to help you do that.
VY: If someone has a goal of moderation, but is unable—some people apparently can't control their drinking—
GM: You’ve got to put them through a program, and then they finally get to realize that they can’t do it even though they’ve had the best program. If it’s not working, they’re much more willing to consider abstinence. You’ve got to try something.
VY: Do you agree with this idea that there is a subset of addicts that just can't do moderation?
GM: It depends on the moderation program. Now there are more pharmacology treatments coming in to help people moderate drinking, and many more cognitive behavioral skills training programs. A lot of people can't achieve moderation if they just try and do it on their own. If they get into a good program that teaches them the skills, like how to use a blood alcohol level chart—if you're a male or a female, how many drinks over how many hours, what your blood alcohol level is going to be—what are you going to do instead of drinking? You want to keep your BAL lower. A lot of the young people that we work with that do binge drinking—they drink two beers in 15 minutes. They don't feel anything so they drink two more, and things like that. We tell them to slow down. Drink two beers and wait half an hour. Then they can actually feel the effects of these two beers. "I don't really need any more," this kind of thing.

We're not telling them that it's all bad. We're just telling them it can be harmful.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.
Alcohol is biphasic. The initial effects are euphoric, but if you keep drinking, it gets dysphoric.You start losing your coordination. You have blackouts and other kinds of problems. What is your limit here, where one more drink is not going to make you feel any better? You learn that. You stick with it. That's been working very well.
RA: Do you see a lot of parallels between the opposition to the harm reduction approach and the opposition to anything other than abstinence-only sex education?
GM: Totally, yes. It's the same issue because they're saying, "If you teach people about safe sex and condoms and things like that, that will enable higher amounts of sexual activity, so we should promote abstinence." But those programs are not working.

It's just like the DARE program—the drug abuse resistance education—totally abstinence-oriented. Now they're finding that kids who went through the DARE program in school are doing worse in terms of alcohol and drug use. Harm reduction applies, I would think, to what we call the 3 Ds of adolescence-the three dangerous drives—drinking/drug use, dating (sexual behaviors), and driving. So if you teach people how to do those things more safely, whether it's sex, driving or drugs, you're going to reduce harm. There's plenty of research to show that it's true, but the political resistance has been amazing.

For example, one of the big harm reduction programs we have done in Seattle is for homeless alcoholics, people living on the streets who are drinking. We worked with the Downtown Emergency Services Center, which provides housing for homeless people. There was a program in Canada called Housing First where they give people housing and let them drink in their housing if they want. Compare that to what they tried in New York, in which people had to quit drinking or they wouldn't get the housing, so almost everybody got expelled or kicked out because they couldn't give up drinking.

So the Seattle program, which we received a big grant on, basically asked, "What's going on?" We wanted to compare people who got housing right away with the people who were under waitlist control. The people we looked at were selected by the King County and Seattle government; they were people that had the highest health costs over the last year. These were very sick people; the average life expectancy for them is about 42 years. So the government referred these people, who either got the housing right away or were on the waitlist. In our program, they were allowed to drink in the public housing and the opposition in the media was huge. "What? We're using taxpayers' money and letting them drink? What is that all about? You're just enabling them."

One year later, we found that the people who got the housing had reduced their drinking. For many of them, having housing gave them more reason to live. As we published in the Journal of the American Medical Association, the most important thing was the health cost savings of four million dollars over the first year. All of a sudden, people said, "Maybe harm reduction saves money compared to what we were doing before." We keep getting these flips in terms of reactions to harm reduction.
RA: I've heard you mention before that therapists can unwittingly enable their clients' addictive behaviors by ignoring the addictions that are going on: treating the emotional issues that they bring into their sessions, but not talking about their alcohol or cocaine use.
GM: Yeah. A lot of people do have both kinds of problems, and they’re using alcohol or cocaine or whatever it is to self-medicate when they’re depressed or when they’re anxious. That’s still a big split between the mental health and the addictions fields, even though many people have both kinds of problems. How are we going to approach them and teach more mental health folks to think, “Hey, there are alternatives here”?

Harm reduction is one of them, and brief interventions have become very popular now. For example, Tom McLellan, who is the associate drug czar/psychologist that everybody knows, was saying we should train primary health care physicians at general hospitals, so that when people come in with whatever their medical problem is, if they have an alcohol, smoking or drug problem, do a brief intervention. It doesn’t mean confront them, but just say, “Hey, have you thought about doing something about this? I have some information for you. Try it out. See if it works.”

They include harm reduction programs to cut back as well as programs to stop. That is very radical, but it has been happening in trauma centers around the country. In the Seattle trauma center, if people are brought in from a car crash that involved drinking or something, Larry Gentilello, a physician there, would do a brief intervention, meet with the person once their medical care is handled. “Hey, there are some programs that could help you cut back or quit drinking. Are you interested?” A lot of them said, “Yeah.” The trauma center would give them the information, and provide the referral. That turned out so well that now all trauma centers around the country have to show that they utilize brief interventions in order to get their license. That includes harm reduction.

I think we’re going to see more of it because, first of all, it works.
The research is very strong. It saves lives. It saves money.
The research is very strong. It saves lives. It saves money.It gets more people on board.

Right now, most people with these problems are just staying out. They go, “All there is is Alcoholics Anonymous. I went one time. I don’t like it, and there’s nothing else that I know about.”

Harm Reduction in Psychotherapy

VY: Let's get into the nitty-gritty of how a typical psychotherapist, who doesn't specialize in drug and alcohol use, may deal with a patient struggling with an addiction. How do you start applying these principles in the course of counseling and therapy?
GM: First of all, you’re going to ask the person what’s going on in terms of their alcohol or drug use. What are the risk factors? We adopt a bio-psycho-social model. Biologically, you want to know maybe the family history and alcohol or drug problems. You want to know about whether that’s going to increase their risk. Then you would go on to psychological issues, what we call psychological dependency on alcohol or drugs. Why do they think it’s helpful, and what are their outcome expectancies about drinking or drug use?
VY: So you ask why they think it's helpful.
GM: Or harmful. We want to look at both sides. We want to meet them where they’re at, enter their world. We use a lot of motivational interviewing.
VY: Yes, it seems very similar to motivational interviewing.
GM: So we're trying to figure out whether this person is in pre-contemplation stages of change or contemplation, or looking at possible plans of action—and matching our intervention with that. You can determine that pretty easily. Have they thought of doing anything about this? What do they think of the pros and the cons [of their drug or alcohol use]?
VY: Can you give an example of how you match an intervention to where they are?
GM: If they're in pre-contemplation, we're just going to try to talk about, "Did you know that the amount of smoking that you're doing is going to increase your risk of lung cancer and emphysema? Are you aware of this?" We try and enhance awareness of the risks. And then if they're in contemplation—
VY: Which would mean they're contemplating quitting?
GM: Or they don't know quite what to do. They're going between the pros and the cons: "Maybe I could quit, but I don't know what's the best way to quit. Maybe this isn't the right thing to do." That's when we meet them and help them look at the reasons why they like drinking and what some of their concerns are about it, and then try and move them on to the preparation and action stage.

In the BASICS program with college students, we just meet with them twice, one on one. In the first session, we give them feedback about their risks. They've filled out all these questionnaires so we know about family history and expectancies. We know about their cultural factors. We give them feedback in a friendly way. We could say, "Hey, you said that 80% of the students at this university drink more than you—actually, you drink more than 75% of the students."
VY: You're giving them some data.
GM: Giving them feedback, but in a friendly way. So they're getting a lot of feedback and awareness. And in the second session, it's the action plan. "What are we going to do about this?" We don't tell them what to do. We collaborate with them. What have you thought about doing? One young woman said, "In my sorority we usually drink and get drunk Thursday, Friday and Saturday nights. I was thinking of maybe not doing it Thursday night." We would support that—something that they come up with.
RA: Although it's not something that's necessarily spoken to directly, it sounds like this approach has a high sensitivity to the shame around addiction.
GM: Oh, yeah—shame, blame, guilt, stigma, moral issues. We're trying to let people know what their level is, how many other people have this kind of problem, and what kinds of things could help them. If they would like to quit, we'll say, "Great, we can put you in an abstinence-based program." Most of them are saying they just want to cut back. They're very positive about these kinds of skills we teach them. After we bring them in a bar lab and give them placebo drinks, then we teach them about blood alcohol levels and give them charts. We have them keep track of their drinking for two weeks so that we can see which days and what situations, whether they drink by themselves—which is more dangerous than social drinking—things like that.
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
We just give them a lot of feedback, but not in a punitive moralistic way: "What can you do to change? We'll try and help you."
VY: You're not coming at it from a moralistic way, but you do have some stance. You have an idea that if people are drinking in a way that you define or you think is destructive, you would like them to change that.
GM: Sure, yeah. It’s pragmatic. That’s where we’re coming from. It’s not moralistic.
VY: One thing I noticed in the video I saw of you with this black male, you got into really nitty-gritty details. He said he wanted to quit, but you really drilled down into, "What does that mean, to quit? What's your first step?" He said, "I'd go to the program." "What do you have to do to go to the program?"
GM: Right—break it all down into different steps. Also, we found that what triggered his relapses was, whenever he had cash, he'd go down to "buy a pack of cigarettes," and, "There's my beer"—these kinds of things. We're trying to teach people cognitive behavioral strategies around things that can set you up for relapse. Whether you're doing harm reduction or abstinence, there can be occasions where you just do way too much. What are the steps that lead up to that? We're using a lot of mindfulness and meditation to get people more aware of their choices.

Victor Frankl wrote this saying: "Between every stimulus and response, there's a space. In that space is our power to choose our response."So we use this idea in our work, and it's turning out to be very helpful, especially for people trying to stay on the wagon.
VY: How have you integrated mindfulness? It seems like a hot topic that's integrated into many approaches these days.
GM: Yes, mindfulness-based stress reduction—Jon Kabat-Zinn's work inspired us. I'm a good friend of his. Zindel Segal's mindfulness-based cognitive therapy for depression is very effective. Ours is mindfulness-based relapse prevention. All these programs are group-based, outpatient weekly programs for eight weeks.

We've gotten funding from the National Institute of Drug Abuse to evaluate the program, and we're finding that it's working pretty well for people with chronic alcohol and mental health problems. Of course, it's voluntary, so if people don't want to do it, that's fine, but a lot of people, once they talk to their friends who have gone through it, they go, "Hey, I'd like to do that." It's relaxing. It's stress reduction. It also gives you a different perspective on craving.

In the last study, we found that people in the control group, the more depressed they were, the more their craving went up—this was in an abstinence-based program—but if they went through mindfulness when they were more depressed, craving did not go up. The depression and craving was kind of disassociated. We're very enthusiastic about that.
VY: How do you explain that?
GM: Because mindfulness gives you a little bit of a different perspective, so you don't over-identify with situations like when you're depressed or feeling like you have to self-medicate to feel better. It gives people more of a choice. It doesn't mean they always do it, but a lot of times they do.

If you think of addiction treatment, the 12-step program, which is very popular, is basically Christian-based. The word God shows up in six of the steps, although they say the higher power could be anything. But a lot of people don't connect with that. The mindfulness program is more based on Buddhist psychology. It's a whole different approach. It's also very consistent with harm reduction—the middle way and things like that. It basically tells people there is another way. Instead of the 12-step program, you could do the eightfold path in Buddhism—right mindfulness, right activity, all that kind of stuff. So I think it's an alternative.

Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state.
Carl Jung originally said that a lot of people with addiction problems are kind of like frustrated mystics. They're looking for an altered state. Many of them are hooked in the spirits in the bottle, where they're really looking for another spiritual approach. I think mindfulness is another pathway. A lot of people relate to that pretty well.

The Disease Model of Addiction

RA: Do you have a problem with the disease model, from the standpoint that it classifies a person as an addict in a way that integrates into their self-identity?
GM: Yes. Phillip Brickman identified four models: the moral model, the disease model, the spiritual model and the cognitive behavioral model.

The disease model says, "You have a disease and it's due to factors beyond your control: your genetics and your physiology and it's all the same disease for everybody, so we're not going to give you any individualized treatment. We're going to put you in a 12-step program"—which also buys into the disease model. The theory is that there is no cure whatsoever. All you can do is arrest the development of the disease by maintaining abstinence. If you have one drink, it's a relapse. In AA, you have to go back to the beginning again.

In harm reduction, we take the attitude, "Hey, lots of people have slips. Let's look at what happened. You made a mistake. How can you learn from it?" We're not saying, "You've got to go back to the beginning."
RA: That's very shaming.
GM: It's very shaming, yeah. I asked a lot of the disease model people, "Why do you say that there's no cure?" They said, "If there was a cure, people could go back to drinking. We don't want them to do that."

Even though the research at NIAAA—the National Institute in Alcohol Abuse—shows that quite a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
… a large percentage of people who have what we would call alcohol dependence, alcoholism, later moderate their drinking and do fine.
They don't want to say that. The disease model says that's enabling. I'm much more in the cognitive behavioral model.
VY: So you don't buy into the disease model at all.
GM: I don't want to put people in jail and say that they're moral failures. Sure, they have a problem—but for me, the disease model is: if you're a heavy smoker or a heavy drinker, there are potential disease consequences. You could develop cancer. You could develop cirrhosis. Is what you're doing a disease?
VY: Is the act of reaching your hand out and picking up a drink caused by a disease?
GM: It's a habit with potential disease consequences. In one of my most recent books, The Complete Idiot's Guide to Changing Old Habits for Good, we talk about changing old habits for good. Habits are what's driving this. It has disease consequences, totally. We're talking a huge health problem. But just to say the whole thing is a disease—what's the point?
VY: You haven't convinced everyone, obviously.
GM: No, of course not. But we’re out there. There are more and more people coming over to the cognitive behavioral model because, treatment-wise, that’s what is most effective.
VY: So you consider your approach consistent with the cognitive behavioral model?
GM: Oh, yeah. Many people call mindfulness a meta-cognitive coping skill, so it’s consistent with the cognitive behavioral approach. Plus lots of research shows that it’s stress reducing.

The biggest trigger of relapse is negative emotional states. People are upset. They’re angry. They’re depressed. They’re anxious. They want help from the drug. So meditation is an alternative way of giving them stress reduction. That’s what a lot of the patients that we’re working with are saying: “Wow, this is really helping. I’m meditating and giving myself a choice instead of giving into my cravings.” We’re showing a big reduction, as I mentioned before, between negative emotions and craving for relapse risk.

Consumer Choices

VY: I know back in the days, they tried to study and come up with an alcoholic personality or an addictive personality, and it seemed like there wasn't too much success with that.
GM: The main kinds of personality factors that keep coming up are sensation seeking—people that crave the high, altered state—and self-medicating—what they call coping. Those are the two main personality traits. Some people have both. That does increase the risk.

There are personality models. Right now, NIDA and other people are saying, "Addiction is a brain disease. It doesn't matter what drug you're using—it's all releasing dopamine in the brain. The pleasure centers are lighting up. We need pharmacotherapies that can reduce the effects of these different drugs or replace them, whether we're talking about methadone or any of these other kinds of things."
VY: What do you think of that?
GM: It may be helpful. Some of the medications do reduce craving on the short run. I think if we combine that with mindfulness, maybe the two of them would work together.
My position is, if you think something is going to work for you, try it.
My position is, if you think something is going to work for you, try it.It could be a pharmacotherapy. It could be psychotherapy.

In the addiction treatment field, there was Project Match that came up a few years ago. They were saying therapists should match patients with a particular type of therapy that the therapist thinks would work. In Project Match, they assigned hundreds of alcoholics to get Alcoholics Anonymous, cognitive behavioral therapy, or motivational enhancement interviewing. Those were the three groups. They followed everybody up for two years. They found—guess what?—there was no difference. All three groups did equally well.

What really worked the best was therapeutic alliance: if there was a good relationship between the therapist and the client, it worked.
VY: This has been the finding in all of psychotherapy research.
GM: Yeah. So I think instead of doing treatment matching, we should switch to consumer choice. People come in: “Hey, I’m interested in getting some help. What have you got?” There are some programs that are saying, “We’ve got a lot of different programs here. I’ll show you some videos. Here’s what’s happening with 12-step programs. Here’s a cognitive behavioral program. Here’s something on moderation management. Take a look and see what you think might work for you and have a backup.” Give people a choice of pathways.
VY: Back to being pragmatic.
GM: Back to being pragmatic. "If the thing you're trying doesn't work, there are other things you can try. Don't give up." The average number of serious attempts that smokers make to quit before they are successful is twelve. Twelve attempts! So people that have tried to quit smoking and say, "I can't do it. I've tried it three times"—I tell them, "You're not even there yet. Each time you learn something."

Therapeutic Mistakes

VY: What do you think are some of the typical mistakes that therapists make if they don't specialize in working with addicts?
GM: Like the psychiatrist I was telling you about earlier, a lot of them say, “I can’t handle this so I’m going to refer you to alcohol treatment. Until you get that under control, I’m not going to see you anymore.” That happens so much. It’s the wrong thing to do. People just get stranded. They get caught. They don’t know where to go.
VY: What would you tell the therapist to do?
GM: Integrative approach: look at addictive behaviors like any other behavior issue. Read about it, get some training, take some courses and things like that; don’t leave these people stranded.
VY: If someone's having problems with anxiety, you don't say, "I don't treat anxiety. You've got to go to an anxiety program." You integrate that into the treatment
GM: Not being able to see how the addictive behavior and the mental health problem relate to each other—thinking they're separate diseases. In reality, they're often extremely interactive. One is relating to the other—like the person with depression is trying to self-medicate and he gets caught in between. I think that is the main thing.

Sometime after that psychiatrist called me, I asked him, "How much training in alcohol and drug problems did you get when you were in medical school?" He said, "One half day." Christ. Of course they don't know anything about it.
VY: That's amazing.
GM: Yeah. That's the biggest issue—even in psychology. When I was a graduate student in the late '60s, I said to my professor at Indiana University, "People are studying behavioral therapy and they're doing all this kind of work with different behavioral problems. What about drinking as a behavior problem?' He said, "You don't want to get into that field." I said, "Why not?" He said, "The addictions field is very low prestige. Why don't you get yourself a real problem like snake phobias?" That's what was going on then.
VY: As a social policy health problem, there are a lot more people with problem drinking than with snake phobias, let alone snake bites.
GM: I said to my professor, “I don’t know anybody with a snake phobia, but I’ve got a lot of people in my family with heavy drinking problems. Why can’t we do something about that?”

The disease model didn’t really look at drinking as a behavior or as a habit. The big shift was to try to move it from strictly genetic into habits. “Smoking is a habit. It’s not a disease in itself, but it causes diseases.”
VY: That is changing, that field.
GM: It’s gradually changing. When I got into the field, people were saying, “Stay out.”

I Like to Drink

RA: There are some addictions that are considered controversial, like sex addiction. From your perspective, is it the object of the person's desire that is addictive, or is it the relationship between the person and what they're going after that's addictive?
GM: The new DSM-IV revisions have been including other kinds of addictive behaviors, like gambling, sexual addictions, shopaholism, things like that. From a cognitive behavioral perspective, there are a lot of similarities. There’s a lot of craving, whether it’s sex or gambling. There are differences in terms of the effects, of course, but I see there being lots of common issues.

One of the biggest things is the problem of immediate gratification. We call it the pig problem. “I want to hit the jackpot. I want to have a sexual experience. I want to get drunk.” All these kinds of things are very similar in terms of the neuroscience of what’s going on.

So I’m totally open to talking about addictive behaviors as including ones that don’t involve drug or alcohol use.
VY: You've been doing this for a few decades now, and addictions has been a career-long interest for you. What are some things you've learned that have made you a better therapist?
GM: I think having these experiences myself. I like to drink. I have drinking problems in my family. I wouldn’t consider myself an alcoholic. Many people in the addiction treatment field are in recovery so they’re saying, “Don’t use at all.” I’m much more user-friendly to these people because I do it myself. I’m helping to teach them that there are better ways to do this.

Since I’ve been more of a Buddhist psychologist, I took the bodhisattva vow, which is to reduce suffering in people that have these kinds of problems. If I can relate to them and identify with them rather than saying, “I am abstinent and you’re using,” it works a lot better.
VY: Thanks for taking the time to meet with us.
GM: You’re welcome. It’s been a pleasure.

Trusting the Client as the Agent of Change

Posted on by Psychotherapy.net Team

After thirty-three years as a psychotherapist, I find that my insights regarding human beings and the change process are becoming simpler and easier to articulate, although I cannot establish whether this phenomenon is due to mounting wisdom or to some form of affable cognitive corrosion. Regardless of their source, my accumulating insights have provided me with a true compass that allows me to approach each client with respect, purpose, and hopefulness. I’m certain many readers have experienced the same thing.

Clients as Agents of Change

One guiding principle that emerged many years ago was a simple one: Our clients are the most essential and fundamental component of the change process. Appreciating this oft-obscured and -minimized truth of psychotherapy multiplies our options for understanding and assisting clients, and invites them to participate in the search for understanding and change, a quest that itself serves the client’s life well.

This basic idea—that clients most directly cause psychotherapeutic change—stands in stark contrast to the professional world that today’s therapists inhabit, a world dominated by the medical model, managed care, and the search for empirically supported and/or evidence-based, off-the-shelf treatment approaches, which most often attempt to match technique with diagnosis. Their resulting equations, of course, leave out essential components of psychotherapy: living human beings. Psychotherapists are expected to be capable of essentially “inserting” psychotherapeutic interventions into a human being who is nothing more than an embodied diagnosis—clients are perceived as passive recipients of our expert care. Since the beginning of my professional career, this has seemed to me to be a wholly wrong-headed approach, one that dehumanizes both client and therapist and, in doing so, neglects the most important and meaningful dimensions of human change.

A Casual Conversation

Like many, during my education and even early in my career, I maintained some ever-dwindling hope that an enchanted handbook of foolproof techniques might appear. Happily, my clients taught me differently.

A memorable example occurred approximately twenty-five years ago, when I was working as part of a rural medical practice. A seven-year-old girl was referred to me by her parents for continuing difficulties with bedwetting. While her mother remained understanding, her father had become increasingly intolerant and punitive. Although they had already set an appointment, one day they stopped by the office and asked if I would take a moment between sessions to meet their daughter, perhaps to allay the girl’s anxiety about seeing a therapist. I agreed and soon they brought the girl to my office, where she and I spoke privately. After chatting a bit about her life and interests, she told me how much she wanted to stop wetting the bed. I replied, “Yeah, I wonder what would happen if you could tell your brain, right before you went to sleep, ‘Hey, if I have to pee, go ahead and wake me up.’”

Prior to our scheduled session, about two weeks after our introduction, the girl’s parents called to cancel her appointment, telling me she had quit wetting the bed after our brief meeting. Six months later, they informed me that the change had been maintained. Her presented problem never occurred again. What was the healing factor here? Should I have copyrighted the sentence I uttered, trademarked “Single-Sentence Therapy (SST!),” and begun offering national workshops on its appropriate delivery? Of course not. The healing factor was, without doubt, the girl. She sought an answer and, in the mysterious and magnificent way that human beings often accomplish change, actively and creatively used my tossed-off sentence to forge the change she desired. Of course, at the time my utterance reflected nothing more than sincere musing on my part. Still, this experience dramatically highlighted the client’s central role in successful therapy.

Beyond my experiences, we increasingly see exceptions to the dominant narrative that therapists directly cause client change. Most notably, the work by Bohart and Tallman—their book How Clients Make Therapy Work is, in my view, a classic in the field—lucidly and convincingly makes the case that clients creatively use whatever the therapist offers in order to effect personal change, which explains why techniques have not been found to be the most influential psychotherapeutic factor.

One could argue that the seven-year-old girl’s change was nothing more than an isolated episode of kismet or coincidence, a spontaneous remission that proves nothing. However, another client with whom I worked two decades ago brought the centrality of client self-healing into even sharper focus.

Florence: A Single-Session Case

A case in which a client requests assistance in resolving an undisclosed problem sounds not unlike a patient presenting to a dentist for treatment while refusing to open his or her mouth. This was not an overly dramatic case, but it is unique in that the client shared neither the history nor the nature of her difficulties, and presented only isolated factors for my consideration, yet we achieved success after a single session of treatment.

The client was a 32-year-old unmarried Caucasian female—whom I will refer to as Florence—who lived alone in a rural Midwestern community. For the eight years before her request for therapy, she had been employed as a professional health care provider. At the time of the initial consultation, she had resigned from the facility for which she worked after accepting a similar position in a larger community two hundred miles away. She planned to relocate to her new home in five weeks.  Because she and I had both been involved in health care in the community, we were acquainted with one another on a professional basis and aware of one another’s work with patients.

Florence requested a brief consultation with me at the end of a workday. She disclosed that since early adolescence she had experienced chronic, unspecified problems with relationships and mood, and that before moving to begin her new job, she wanted to address the difficulty, allowing her to “start fresh.” Through our professional association with one another and her discussions with patients over the years, she had come to the conclusion that I was an effective therapist who would be able to provide her with the assistance she desired. She thus entered the therapy relationship with positive expectations about my ability to assist her, as well as her own ability to reach her goal.

While revealing that as a six-year-old child she had suffered a massive trauma that continued to haunt her, she stated kindly but clearly that she had no intention of revealing to me the details or even the nature of that trauma, having long ago come to the conclusion that to do so would hold no benefit for her. She further stated that after extensive research she had decided that hypnosis would help her to resolve her difficulties. She asked me to provide one session of hypnotherapy to resolve the undisclosed difficulty.

From her presentation, my options were clear: to provide the requested treatment or to refuse to do so, in which case she would simply not pursue treatment “until I find another therapist I’m willing to work with.”

Florence had grown up in a suburb of a Midwestern metropolitan area, raised by both parents and having three younger brothers and one older sister. She completed a Master’s degree, which allowed her to provide professional health care services. Never married, she indicated that she had dated in the past, but that recurrent relationship difficulties always interfered with developing a more serious and lasting involvement. Since earning her professional degree, Florence had worked for the local health care facility, where she had been a consistently reliable, popular and successful employee.

According to Florence, she had on three occasions traveled to nearby cities and consulted with therapists. After each of those consultations she elected not to return, believing that the therapists were intent on “doing things their way or no way,” and that a commitment to treatment on her part would have led to extended therapy which, to her mind, was completely unnecessary: “It would be like standing on the caboose of a train, looking backward just to satisfy the therapist. I want to focus on where I’m going. I want to be in the engine.” In particular, she had become disenchanted with therapists’ fascination with her trauma; when she had revealed in the past, it seemed to her that therapists wanted to “worry it like a dog with a bone” rather than to address her current concerns.

Although I had received significant training in clinical hypnosis years prior to our initial consultation, by the time of our session I used the approach only in cases of chronic pain management, for which it seemed ideally suited. My initial training orientation was humanistic-existential, although in the subsequent years I had availed myself of a variety of advanced training opportunities and had become increasingly flexible in my treatment of clients, although I maintained a humanistic-existential view of their functioning. I received training in a permissive, Ericksonian approach to hypnotherapy, since to my mind it was most congruent with my perception of client potential and agency. I therefore had the clinical ability to provide Florence with the service she requested. I was also positively persuaded by my clinical experience to accept Florence’s implicit challenge; I had come to the conclusion that therapy in many ways is a process of my clients and me collaborating to create “doors,” possibilities for change that clients can actively use to effect personal transformation.

In this case, assessment was indirect and decidedly not disorder-focused, instead concentrating upon Florence’s general functioning and history, as well as the presence of other factors that would inform my decision whether to provide the requested intervention. Although one could argue that her vague report could lead to reasonable hypotheses about her disorder(s), there was no way to validate those hypotheses, so basing any treatment decisions on them would have been moot. Therefore, I chose to focus upon other factors that would determine my decision.

After she signed an appropriate release of information form, I reviewed her medical file, which indicated no history of serious medical or psychiatric illness in her or her family of origin. She had not been prescribed any medication other than for short-term specific illnesses, such as infections.

Most importantly, Florence had a precise “theory of change.” She had contemplated her life problems at considerable length and reached a conclusion about what procedure would assist her in resolving her difficulties. She possessed a positive view of the clinician and an expectation for resolution that bordered on certainty, indicating a positive expectation for outcome. Despite her maintenance of a conceptual hedge around her trauma and resulting troubles, she was otherwise quite open, personable and cooperative, more than willing to undergo her preferred treatment. Thus, she appeared to embody the client whom therapy would benefit, even if the specifics of her situation remained unknown to me.

In agreeing to provide the requested treatment (hypnotherapy), the question facing me was how best to provide that treatment in a fashion that would allow me to keep front-and-center the notion that Florence was an active agent capable of using what I offered in a therapeutic fashion. In short, my responsibility was to create a hypnotic approach to treatment that would allow her to actively use both her positive expectations and creativity to change what she wanted to change. More specifically, my approach would ideally provide to Florence what Bohart has described as a “supportive working space.” It was clear: my task was to provide the canvas; she would paint the picture (and not necessarily show it to me).  What type of canvas would I provide? Since she deemed the trauma that occurred when she was six to be central to the formation of her subsequent difficulties, and because she reported experiencing her younger self as being always nearby, her construction of herself as a youngster needed to be included. Furthermore, bridging her experience of herself as a six year-old with that of her present self was important, given her connecting the two “selves” in her presentation. In short, some indeterminate flow of information and affect between her younger self and her current self needed to be invited; a bridge needed to be supplied. She would be the one to cross that bridge. Doing more than that would have been presumptuous on my part if I were to remain committed to respecting her agency and creativity.

I arranged to use a recovery room (the symbolic nature of which was not lost on either of us) in the medical office complex. I asked her to lie down on the bed, to close her eyes and begin relaxing. She responded excellently to the basic twenty-minute guided relaxation and induction process (focusing both on physical relaxation and the development of imagery). Her breathing became diaphragmatic, and I noted little to no muscle movement otherwise. I then asked her to visualize what I would describe in whatever way she chose.

While the entire session lasted about eighty-five minutes, it consisted of my providing only four basic suggestions, after which I allowed Florence to process and work with the provided images, then signal with a raised finger when she was ready for me to continue. Time between delivery of the suggestion and her signal for me to move on averaged ten minutes.

Prior to the suggestions, I asked her to visualize her current self and her six-year-old self standing face to face, and encouraged her to imagine as much detail as possible. After she indicated with a lifted index finger that she had constructed this image, I provided these four suggestions (with significant time between them):

  1. “You can tell your younger self the one thing you want her most to know, and then notice her response”;
  2. “You can ask your younger self to tell you what it is she most needs from you, and then notice your response”;
  3. “You can ask your younger self for the one thing she most wants to know from you, hear her answer, then respond to her”;
  4. “You can ask your younger self the one thing she most wants you to know, hear her answer, and notice your own response.”

Shortly after I provided the first suggestion, tears began streaming from Florence’s eyes and continued until the session ended.  Although I didn’t discourage verbal responses from her, she said nothing during the process. I ended the session by suggesting that she slowly return to normal consciousness and to remember as much or as little as she wanted to regarding what she had learned through overhearing the conversation between her current self and her younger self.

Immediately following the session, Florence indicated that already she was feeling a great sense of relief and movement, but provided no further details. We met once prior to her relocating for our follow-up session, and she reported that her mood was significantly improved and that she was viewing her relocation and new job as an adventure that she was, for the first time, regarding with optimism rather than measured dread.

Two months following her move, she sent me a lengthy letter in which she described the happiness she was feeling and the vague but confident sense that she had successfully left her problems behind her. She was no longer feeling “haunted” by what had happened to her when she was six. Although she remembered it, such remembrance seemed more voluntary, according to Florence; she was able to experience the memory “like a photo in an album, rather than the only picture on the mantle.”

After that initial letter, she sent me holiday letters for nine years. In each one, she detailed her successes not only in her profession, but in her personal life as well. Several years ago she married and, at last report, she and her husband had adopted two children and were living happily and productively.

“To this day I remain unaware of the trauma she had suffered and the resulting difficulties it caused.”

Doors of Possibility

What Florence brought to center stage, more plainly than any other client with whom I’ve worked, was the centrality not only of the client’s trust in me and the treatment I would provide, but also of my trust in the client and her inherent potential for change. For me to proceed with treatment, it was necessary to recognize the level of trust I had in Florence, specifically, and in the clients’ agency and abilities to self-heal, in general.

In attempting to understand the human beings who present for services, it is important that clinicians go far beyond the process of assigning a diagnosis and prescribing a treatment accordingly. Since the validity of most DSM-IV diagnostic categories is questionable at best, assigning a treatment approach based on that designation is at least equally dubious. Furthermore, a significant body of research emphasizes the importance of the common factors, such as the therapeutic relationship, positive expectations, and client self-healing. Both students and practicing clinicians should immerse themselves in the existing literature in these areas, providing themselves with a set of assumptions that counterbalances the medical model with which our culture seems currently enamored. By doing so, we will generate more opportunities and options for clinical intervention, the centrality of our clients’ attributes will not be reduced or neglected, and our treatment effectiveness will be enhanced as we respect our clients’ considerable gifts and abilities that, for the time being, have unfortunately been reduced to faint footnotes in our understanding of the human change process.

Florence’s case illuminated one of those simple truths that come with experience, age and attention, a truth not only about what clients bring to therapy, but also what clients most desperately need in their journey toward change. It’s not complicated.

They need doors of possibility, and they need company.