Category: Therapeutic Issue

Psychotherapy with Medically Ill Patients: Hope in the Trenches

Posted on by rezendevknowfully.com

Psychotherapists who work with medically ill clients often feel adrift between two seas. One ocean is the fast-paced world of medicine, in which we, as medical consultants, must efficiently develop complete answers to complex questions. The other ocean involves the deep and dark undertow of emotions: our clients are often dealing with terrifying bodily limitations and unknown outcomes. As therapists, we are called upon to integrate and understand the hypomanic world of medicine, while helping our clients tolerate the unfair and arbitrary aspects of illness and, more ominously, the inevitability of death. Though providing psychotherapy to these clients can at times feel overwhelmingly tragic, it is the solace we are able to offer those beset with illness and death that makes the work so gratifying and meaningful.

As therapists we are privileged to have access to some of the most intimate recesses of the human mind. However, those of us who work with medical patients also have to bear the burden of our clients' concrete suffering. The toll on us is significant: having to tolerate the arbitrariness of illness can either make us cynical and scared, or jolt us into appreciating the finite aspects of life. Working with people beset by medical illness can make us, as therapists and people, able to appreciate life with all its benefits, limitations, joys and disappointments. Working with clients who are medically ill not only requires us to learn more about the seemingly distant and disembodied relational aspects of medicine, but also forces us to confront painful existential realities on a daily basis.

Illness in Psychology and Medicine

When I was not yet 30 years old and had been in private practice only a couple of years, I met Anne*, a pleasant and motivated 70-year-old whom I saw as an outpatient for mild depression. I had known her only briefly, but was very fond of her. Like many elders, Anne had gotten depressed after the death of her husband. Though she had not been in therapy before, she was open to learning how her mood might impact her ability to take care of herself. And like many older clients, she was unsure how talking could help her. But she often noted that after our meetings she felt better, even if she just talked about how she was struggling with getting used to taking care of the finances herself or how much she missed her husband. She also took our appointments very seriously.

One day, Anne uncharacteristically missed an appointment and I had been unable to get in touch with her. The next day, while at a nurse's station in the cardiology unit of the hospital I worked in, I saw her primary care physician, who had referred Anne to me. Upon seeing me, the physician said, “"Oh, Tamara, your patient, the older lady, she died two days ago. She had a heart attack." He then walked away as I stood at the chaotic nurse's station, stunned and tearful.” I had known Anne only a few months, but I had been feeling hopeful about her treatment. Given that she did not have any previous history of heart disease, I couldn't believe that she had died so suddenly.

Anne's death and her physician's manner of disclosure illustrate aspects of medicine that many of us in the field know all too well. The fast-paced, energetic facet of medicine in the U.S. can be characterized as being "hypomanic." Although I am referring loosely to the familiar Diagnostic and Statistical Manual of Mental Disorders1 criteria of hypomania, my understanding of the intensely energetic nature of medicine is more akin to the ideas of Melanie Klein and what she called "manic" defenses. Briefly, Klein described manic defenses as when idealization, feelings of being powerful, and hyperactivity are employed to ward off sadness, worries about aggression, and ambivalence2. In other words, manic defenses are used to avoid difficult feelings. And since difficult feelings abound in medicine, energetic defenses offer a perfect antidote to sadness and loss.

Even minimal experience in the medical profession inevitably leads one to appreciate the consequences of a hypomanic culture. Particularly in hospitals, people talk fast, move fast, and think fast. Many healthcare workers are constantly engaged in goal-directed activity. Even in outpatient settings, patients remark that they spend only five to fifteen minutes with their physicians and commonly complain that doctors are pressed for time. This pressure- and speed-driven culture has a rational component: when a patient is critically ill, physicians and medical staff need to move quickly in order to administer urgent care, which could be life saving. Additionally, many physicians, especially those who work in inpatient settings, are chronically sleep-deprived due to the demands of long hours, call schedules, and other professional and personal responsibilities. In the outpatient setting, physicians are often tightly scheduled to see a large number of patients in a limited amount of time.

As medicine has advanced, the kinds of interpersonal connections within the profession have changed as well. Donald Winnicott described the way he noticed interpersonal differences as a result of modern medical practice:

It is a sad result of the advances in modern medicine that there is no personal clash between patient and doctor as whole persons; there is a visit to the doctor, a disease process found, treatment is given, and the disease is cured, but no one has met anyone, no one person has bumped into another person.3

What I experienced in my conversation with Anne's physician after her death seems to be a common symptom of modern medicine as Winnicott described. Medicine demands a great deal from its practitioners, and a hypomanic style in the personalities of medical professionals can be viewed as a kind of acculturation to seemingly endless demands. On the other hand, the perpetually fast pace in medical facilities also reflects a tendency and desire to not engage with patients in an emotional way.

Bodies Breaking Down: Challenges for Therapists

Although physicians often experience the hypomanic trappings of medicine, as therapists we are also subject to these intense pressures. When I worked in medical settings with a large number of clients both as inpatients and in my outpatient practice, I often found myself wishing I could offer something simple and concrete to ease my clients' suffering. But I also wanted to ease my suffering; at times it felt like helping people who were ill was too much to bear. Sitting with someone with a rare autoimmune disease who had a guarded prognosis and uncertain future, helping someone with lung cancer who was overwhelmed with self-blame regarding years of heavy smoking, or trying to soothe a young adult randomly afflicted with heart disease forced me to face the complex reality of health and illness: we can all try to take care of ourselves and do the right things in terms of our health, but the sad truth is there are many variables we cannot control. Even when clients might have endangered their health knowingly or unknowingly (as in the case of older adults with lung cancer, who grew up seeing physician advertisements for cigarettes), they still have to deal with the fact that illness has happened to them and that their body has let them down and they might not live—or, for some, live with limitations they may never have dreamed possible.

I felt more emotionally vulnerable regarding death and serious illness in my clients when I was younger. Especially then, I had a hard time knowing how to manage the feelings that were stirred up in me. This was probably exacerbated by the difficulties with mourning that are present in medicine, as I had little support in a culture in which people simply move on to the next task, even after someone dies.

One way my intense anxiety manifested at the time was that I frequently feared that I would develop the same diseases of those I was treating. Especially when I worked with people who had been subject to random or mysterious illnesses (often those thought not to have links to lifestyle behaviors), I worried that I too, would be subject to the same bad luck. When I was seeing large numbers of patients in the hospital, it often seemed unbelievable to me that anyone could be in good health, and not sick with some terrible disease! Clinicians I have supervised in hospital settings, in which they were working with severely ill people, have echoed similar sentiments. These feelings and anxieties seem especially prevalent in younger clinicians and those who have not experienced illness or death in their personal lives. However, all of us, in working with people with medical illnesses, need to come to terms with the intense anxieties and overstimulation that are associated with treating this population.

Though our feelings and experiences are filtered through our own psychology, there are many common reactions to working in medical settings and with clients who are severely ill. “Intense fear, anxiety, and thoughts and images of our own death are common reactions and not necessarily related to our own psychological problems; what we encounter is simply difficult to bear.” Serious illness and the possibility of death inherently evoke intense and disorganizing emotions in therapists when we are with our very ill clients. Since many people experience considerable shame in confronting these emotions, reinforced by a cultural mandate to move on, therapists need to create an internal and external space for these intense feelings. This involves a lot of interpersonal work, and often requires a lot of our own psychotherapy.

Those of us who work with medical patients suffer vicarious trauma. We don't talk about it much, as we are not so sure that our colleagues won't pathologize us. In fact, I felt quite misunderstood by a therapist I was seeing when I first started working with severely ill clients in a hospital setting. “When I tried to articulate my terror regarding seeing people my own age who were dying, my therapist interpreted these fears as "unrealistic."” My view was, how could my fears be unrealistic? The young people I was seeing had not engaged in risky lifestyle behaviors; they just were victims of bad luck. How was I to know that this could not happen to me?

Therapists who don't work with medically ill clients often remark that those of us who do have a skewed view of the world or that we don't have good boundaries between our clients and ourselves. Regarding the former idea, our colleagues are right. Therapists who specialize in work with medically ill adults primarily see people who have been subjected arbitrarily to illness. I did have a skewed view of the world, especially when I was younger. As I have gotten older, I realize that many medical illnesses are rare and unfortunate, and I feel privileged to have been able to help my clients at a time in their lives in which they needed someone who could tolerate randomness and unfairness of disease and illness, to acknowledge the potential of death, and most importantly to help them know they are not to blame. Indeed, many people feel that random illness must be caused by something they have done. Feeling that they have caused the illness is a way to believe that they can stop it. Sadly, this is not true. But the idea that we can predict and know of our potential to cause (and cure) our own illnesses is seductive.

A younger colleague, who works with people who have rare lung cancer, said to me recently, "When I cough, I think I have lung cancer." When she said this, I was reminded of the claims launched at me over the years by well-meaning colleagues: that my work was reducing me to a state of lowered boundaries, and that it was crazy to think I might be in the same boat as my clients. And though on one level I can understand these criticisms, on the other it feels so profoundly misplaced and misunderstood. As I said to my younger colleague, "Of course you feel this way. There is no way to work with such an unfairly beleaguered population and not feel scared about what this can mean for you. Bad things just happen."

Psychology, and especially psychoanalytic psychology, can be funny in that “we as therapists are "allowed" (especially in training) to indulge in whatever ideas and fantasies we might have about our own psychological problems, but we immediately pathologize whoever is talking if they have worries about their own bodily health”—they must be too "concrete," they must have some difficult psychological problem that allows them to somatacize. The reality, however, is the opposite of what people often perceive. When we work with medically ill people and are confronted with the random nature of illness and the cruel distribution of severe illness, it is natural that as therapists we would imagine ourselves in the same situation. After all, what else can be described as the true seed of empathy? And in my experience and those of students I know, it is this kind of empathy, "What would it mean if this were happening to me?" that is the most profound and ideal empathy we need to have inside of us to help our clients manage the painful and difficult aspects of illness they are confronted with.

The Difficulty of Engaging Clients

A few years ago I was teaching a class on psychodynamic perspectives of medical illness and mentioned a common phenomenon: many cancer patients who engage in therapy do so when they are in the active stages of their medical treatment (e.g., chemotherapy or radiation); once these stages are completed, many of them leave therapy. The therapists in the class who had worked with people with cancer laughed and seemed relieved to know that this is a common experience and not necessarily based on the therapist's individual psychotherapeutic style or practice.

While it is true that many people with medical illness (not just those who have cancer) present for psychological treatment in the more acute phases of illness and then leave when illness becomes chronic, is in remission, or in the best of circumstances, is cured, it raises the question of why this happens and how it affects the psychological health of people we try to help. One possibility is that those who are acutely ill and undergoing intensive kinds of treatment need acute and intensive psychological support, and once that phase of medical treatment is finished, they may feel that less intensive psychological treatment is needed. Although this rationale may appear to make sense, I have been surprised over the years at the number of people who have left psychotherapy after the acute phases of medical treatment, as some of these clients clearly had issues that would have benefited from longer-term psychotherapy. And even though it is true that some people, particularly those who have had psychotherapy in the past, might be inclined to continue with therapy after the acute phases of treatment, how are we to understand those who do not? And are there things we can do to increase the chance of engaging some of these people in a more meaningful and helpful therapeutic relationship?

People with medical illnesses are hesitant to engage in longer-term treatment with mental health clinicians for a number of reasons. As described, the culture of medicine and modern healthcare reflects a hypomanic culture in which "cures" are provided in a quick and often rushed manner. The practice of psychology within medicine, though valuable, offers a culturally inconsistent approach for people with severe medical illnesses. Even with the approaches often advocated within health psychology and medical care (specifically cognitive-behavioral approaches), the integration of psychology in medicine remains largely difficult.

Integration of psychological approaches and applications in healthcare has improved dramatically over recent years, yet psychological services are largely viewed as an elective treatment within the medical system. To some extent this makes sense. From a practical standpoint, many people undergoing medical care are overwhelmed with medical appointments, as well as the financial expenses involved in receiving care for an illness. Time and money spent on psychotherapy may not seem to be a priority. Physicians may not consider referrals to mental health professionals for those patients who seem to be coping well, even though therapy could be of great benefit.

However, even for people who have financial resources and time for it, therapy is often construed as not only elective, but also a burden. Psychotherapy requires a tremendous amount of resources, both internal and external. “People with severe illnesses are often taxed with the impact of bodily changes and decline, physical pain, and fear of death: surviving from day to day involves tremendous physical energy, and as a result, psychological energy that might be employed to address emotional issues is reduced.”

This relates to the idea that medical patients often present as being more psychologically "concrete." The term concrete has been associated with thinking in patients who are more severely disturbed, such as those who are psychotic or those with personality disorders. However, this way of viewing concrete thinking is very limited—and in itself concrete! A more modern perspective is that, especially under times of stress, we all can regress to a more concrete way of operating, and this is often the case with severe physical illness. In such states, we feel more sensitive to intrusions, more focused on pragmatic aspects of functioning, with less emotional space for reflection.

Trauma researchers have long known that traumatic events make it difficult for people to think in a symbolic way4. The burden is on us, as therapists, then, to help make space for symbolic thought, as opposed to demanding that our clients do so for us.

What Seems Concrete Is

Sara* was a 30-year-old doctorate-level professional when I met her. After a routine doctor visit, her physician had told her that she could not go back to work that day, but needed to be hospitalized immediately for dangerously low blood cell counts. She was diagnosed with leukemia. I met her a few days later in the hospital; she was referred for what her nurses described as almost nonstop crying and excessive controlling behaviors, such as continually asking the nurses to verify the accuracy of her medications, even when they had already told her what they were giving her and confirmed that the dosages were correct.

When I met with Sara, she was guarded and extremely anxious. Although she felt that she wanted help by talking with me, she appeared in genuine shock (as would be expected) but also panicked. When I suggested that she might feel overwhelmingly anxious, and that perhaps she even thought that the feelings she was having would cause her to die immediately, she agreed. She said that at times she felt that she could just "die right there," even though she knew she was getting treated for her disease. The panicked feelings made it difficult for Sara to cope in the hospital. Staff became increasingly concerned because she often asked for higher levels of anxiolytics and pain medications, presumably to manage her anxiety. Sara acknowledged that she just wanted to feel "numb." Although I had suggested an antidepressant, which might provide longer-term and more consistent relief from her symptoms, she refused, objecting that she did not want to feel "controlled" through medication.

As for my role while she was in the hospital, Sara was able to talk to some extent about her anxiety. However, discussions tended to focus on aspects of her life that needed to be managed and taken care of, such as who was paying her bills, what was happening in a recent financial transaction, and how others were managing her projects at work. And although I willingly discussed these topics with her, I felt as if there was little I could do to help ease her tremendous anxiety.

Sara's situation illustrates that when someone is overwhelmingly terrified in response to a serious and life-threatening illness, his or her ability to think about meaning is reduced. Sara's panicked state and her constant checking on the nurses prevented her from slowing down long enough to realize that she was not going to die immediately. They also prevented her from thinking about what she could do to help herself in her situation. She felt that her life was already over, even though she had a long road of treatment ahead of her. Feelings of hopelessness in medically ill clients are common and can be detected by a feeling of helplessness in the therapist, which I felt acutely while I was with her.

Sara attempted to manage her anxiety by becoming more watchful of her environment, including frequently checking that the nurses would not make any mistakes. Not only was Sara terrified and attempting to manage her terror, but I understood that underneath her need to be more in control of her environment was a sense of profound confusion regarding what was happening to her. Attempts at control were a way to reduce the confusion she felt. In her conversations with me, Sara felt the need to go over events in her life that she could not currently control as a way to try to maintain control. She was stuck in this way of thinking and needed me to give ample attention to these external events.

Talking about the more real issue of what she could not control (her body) was not possible, as it made her unbearably anxious and confused. Sara had been caught completely off guard by this diagnosis. As a relatively young woman, she'd had little experience with major illnesses or death. She had no risk factors for malignancies, something she eventually told me she often thought about. Not knowing why or how this had happened to her was a tremendous source of distress. The level of her confusion was so intense that at times she felt as if it would overwhelm her. This is one meaning of panic attacks that sometimes occur in people with medical problems; “anxiety, confusion, and feeling out of control become so powerful that people sometimes feel as if they will die then and there.” It is as if the idea, "Well, I might as well just die now," takes over. The price of such a way of thinking, however, is that Sara and others like her forget that they are still alive, and can maximize coping resources to fight their illness.

Although it is understandable that many people experiencing a life-threatening illness would be terrified, the kind of terror I am describing is the kind where one cannot find refuge in a logical reminder that they are not dying at that moment or that others are helping to keep them alive (meaning, in these cases, medical treatment). This is because the disorienting feelings in reaction to a traumatic illness can become overpowering. Sara could not find solace in the fact that she was being treated for a disease. Sara was so tortured by her anxiety that she feared others, even though these others were desperately trying to help her. She became wary and guarded.

Though I knew that the nurses and doctors caring for her at the time were extremely sympathetic, Sara could not absorb sympathy. Her fears had rendered her helpless, feeling paralyzed and tortured. In this state, no one can really be trusted. Additionally, in this state of mind, the act of thinking as well as having ideas, of any kind, can feel like torture. In other words, the process of thinking as we understand it can feel persecuting, because in a situation in which the body has failed, it is hard to know who to trust. Sometimes in such scenarios, people are even hesitant to access their own thoughts, as thoughts themselves (being present in one's mind) can feel equally as terrifying and persecuting.

This kind of state presents a unique problem to us as therapists, in that the people we may want to help the most are intensely (and often unconsciously) unable to take in what we have to offer. “Their terror becomes our cross to bear. In other words, the intense and barely known emotions become something we have to share and know in order to help. With Sara, I had to tolerate feeling helpless, enraged, outraged, and terrified about what was happening to her.” At the time I knew her in the hospital, she could barely acknowledge these feelings in herself. So I absorbed them and hoped for the best for her, and hoped as well that at some point she could feel her own emotional turmoil.

Sara did well with her medical treatment in the hospital, but was never able to follow up for therapy as an outpatient. And because of that, I can never quite be sure whether my work was helpful to her or not. Such is the case when working with people who are seriously ill. I do not know how Sara fared, or even whether she is still alive. This is another difficult fact of working with severely ill clients, especially in hospital work. As mental health clinicians, we are often not privy to the medical outcomes of those whose lives we become invested in. Clients struggling with illness can't necessarily follow-up in longer-term psychotherapy, for both physical and psychological reasons. As helpers in the world of medicine, we often have to tolerate not knowing whether our clients live or die.

Psychological Ramifications of Cancer Diagnoses

Most of us who are born without chronic illnesses take the functioning of our bodies for granted. When the body stops working in adulthood, this jars one's sense of self. And if the inside of the body does not work, it is very hard to know how and what to trust on the outside. Many cancer patients talk about the eerie feeling that cancer cells have been growing in their bodies without them knowing it. This may be related to both ideas and fears of cancer in our culture. Although heart disease is the number-one cause of death in industrialized countries, many people verbalize not a fear of heart disease, but of cancer.

This is most likely because the imagery associated with cancer, in which bad cells insidiously destroy good cells, resonates with the fear of the internal workings of the body being attacked by itself. This idea has roots in early developmental theories of childhood. Aggression is something we all struggle with as younger beings. Dependency, a sense of not being in control, and anger about that fact that we need to rely on others are facets of young childhood. When things go right in childhood, we can emerge relatively unscathed and able to tolerate our own (and others') limitations and need for dependency.

But when things don't go right, or when parents are preoccupied, we then struggle to tolerate the fact that at times we will need others. The sense that the body is attacking itself is common among clients with medical problems. When this feeling is excessive or pervasive, it can sometimes be a sign that, as children, these clients were often left alone to deal with angry feelings. These feelings can and do often come back to us as adults, especially when dealing with something amiss in the body that we cannot understand. “A sense that the body can attack itself feels like our own toxic anger is turning inward in ourselves, and results in disorientation and mistrust of people in the "outside" world. For some, this results in confusion, collapse, and a feeling that nothing can be trusted either internally or externally.”

Sara tried to remedy these disorganized, helpless, and out-of-control feelings by managing the nurses' behaviors with an attempt to control, in a literal way, what was being put into her body. Such patients need to be able to feel that they can control what we, as mental health clinicians, "put into" them as well.

In these situations, we need to tolerate the fact that due to a patient's suspicions and sense of terror, it may feel at times that we have little to offer. However, just being able to engage with patients like Sara goes a long way. It means a lot to listen and tolerate unbearable feelings when no one else can. People caught up in medical crises often cannot turn to their physicians, as their work requires a kind of detachment. Family members are often so scared themselves that they often tell me they can't bear to hear my clients utter anything other than positive statements. Thus, our clients need us to bear the confusion, terror and disorganization to which they are subjected.

Hope In The Trenches: The Meaning of Our Work

Janet*, a client of mine, died recently after a long battle with cancer. When I saw her for the last time, she told me she was scared of death, but relieved to have an end to her suffering. She grabbed my hand and said, "I can do this now. Thanks for helping me to know that I can let go." Our work together lasted less than a year.

I met Janet in the context of several medical problems while she lived in a skilled nursing facility, but in the process of our working together, she was diagnosed with recurrent cancer. Although she had been told that her cancer had not been cured, and that she would eventually die from the disease, she had convinced herself that her prognosis was otherwise. When she was told that her cancer was not only back, but raging with virulent intensity, I gently suggested that her lifespan was shorter than she had previously thought, and that she might want to say goodbye to those who were important to her. In the context of our relatively close therapeutic relationship, she could hear this, and no longer needed to be in denial about what would be her fate. She was able to say goodbye to those she loved, and was even able to say she was sorry to people she perceived she had hurt.

I could not continue to work with people who were enduring this kind of suffering unless it felt like there was some help I was able to provide, and it appeared that I had helped Janet to relinquish the denial she had so desperately clung to, and had eased her feeling that she was dying alone. These moments remind me of why I got into the practice of working with medical clients to begin with. And more importantly, when I come home every night to my husband, I am so grateful for what we have, now.

*Client names have been changed to protect confidentiality.

Excerpts from this article are taken (with permission) from Psychodynamic Perspectives on Aging and Illness, Springer, 2009. The paperback version of this book was released in June, 2010.

References

Diagnostic and Statistical Manual of Mental Disorders 4th ed.; DSM-IV; American Psychiatric Association, 1994.
Klein M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis, 21,125-153.
Winnicott, D.W. (1966). On cardiac neurosis in children. In R. Shepard, J. Johns, & H.T. Robinson (Eds.), Thinking about children. New York: Addison Wesley
van der Kolk, B.A., Hostetler, A., Herron, N., & Fisler, R.E. (1994). Trauma and the development of borderline personality disorder. Psychiatry Clinics of North America, 17, (4), 715-730.

Michael Yapko on Psychotherapy and Hypnosis for Depression

Posted on by rezendevknowfully.com

Understanding Depression

Rafal Mietkiewicz: Welcome, Dr. Yapko. I am delighted to have the opportunity to talk with you today. Let’t start off with the question of how do you understand depression? Where does depression come from?
Michael Yapko: Depression comes from many different places. There isn't a single cause for it; there are many contributing factors. And in a general way, the factors are grouped into three areas. There are biological factors that contribute: genetic contributions, biochemical contributions. There are psychological factors: your individual temperament, your coping style, your attributional style, your personal history, all those kinds of things and more. And then there's the social realm: the social factors that contribute to depression, the quality of your relationships, the culture in which you live. Those are all three contributive domains. Consequently, the predominant model in the field is called the bio-psycho-social model and simply acknowledges that there are many, many different factors that contribute. And it's because depression is a complex phenomenon, and the fact that there are so many different factors. When I started studying depression 30 years ago, we knew of only two risk factors—one was gender and the other was family history. Now we know there are dozens and dozens and dozens of risk factors, factors that increase your vulnerability to depression. And so we've learned a lot over the last 30 years.

RM: What is the role of childhood, including the first experiences of the child, along with family history?
MY: Childhood obviously is a time when socialization forces are the most intense. And so the quality of your attachments, the modeling that you learn from your family about how to cope with stress and adversity, the way that you are taught as a child to explain the meaning of life events are all factors that can make you quite vulnerable to depression. And so the childhood is important, but I think one of the things that we've learned quite well is that depression isn't about events that happen in people's lives. It's more about ongoing processes of how the person uses information, how the person forms relationships, how the person interprets the meaning of things that happen to them.
RM: Isn’t the way in which a person formulates interpretations determined by his own phenomenology, his own life history?
MY: It's partly determined by that, but socialization goes on your entire life. It doesn't stop when you're five years old; it doesn't stop when you're eight years old.
RM: Some people could say that these are the most crucial years, and that making any changes later is very hard.
MY: People could say that.
RM: Do you agree?
MY: Not entirely. If you look at the fact that some of the most successful therapies for depression never examine childhood, that should tell you something. You look at the three therapies that have the highest treatment success rate—cognitive therapy, behavioral therapy, interpersonal therapy—and right behind it, behavioral activation—none of those treatments focus on childhood.
RM: So, you’re saying you can cure people from depression without taking care of events that happened long ago in the past, without dealing with the big traumas?
MY: Clearly. It's not an opinion—look at the research. In fact, cognitive-behavioral therapy is the most widely researched treatment there is. And this is an approach that has no interest in the past. Now, people will come in and they will naturally talk about the past—"Here's what happened to me when I was eight years old." But a cognitive therapist is not going to sit around and talk about that in great detail, but rather will ask, "So what does that lead you to think, and how does it lead you to behave, and how can we change what you think and how can we change how you behave?" And guess what? It has the best treatment success. And when you look at the analytic approach, it comes in almost at the bottom of treatment success studies—for a reason. See, the problem is, it's a treatment model that you use with everybody, as if everybody's the same, as if everybody has the same pathway into depression. But in fact each person has their own individual pathway into depression. For one person, it's about failed relationships. For another person, it's about trauma as a child. For another person, it's about the surgery they just had and all the drugs they're on. And for somebody else, it's about the hormonal imbalance, and for somebody else it's because their diet is so terrible and they never exercise. There's no blueprint. The model of depression that came out of the analytic world was that depression was anger turned inwards.
RM: Yes…
MY: That was disproved 30 years ago.
RM: However, it’s still considered as something important and valid for many people…
MY: Well, that's wrong. You know, I rarely make a statement that's that flat. Usually there's an element of truth in something, and maybe the truth gets exaggerated, but the idea of depression as anger turned inwards has been disproved. It's an old, outdated concept that doesn't work in the face of modern research. And consider the fact, how many people get out of depression and stay out of depression without addressing anger and without addressing trauma and without addressing childhood. It's always interesting to me that when somebody says, "Well, I think exploring your past is vitally important." Okay. You think it's vitally important. That doesn't mean it is. You want to believe that? You can believe that. You're allowed. You can think whatever you want. But if we go into the realm of research and we compare different treatments and which ones have higher treatment success rates and which ones have lower treatment success rates, such as psychoanalysis—I don't mean to bash psychoanalysis in a global way—but if we ask the question, "Are there some treatments for depression that work better than others?" the answer is yes. It's not as if all treatments are the same. And when we look at which treatments are better, they're the ones that teach people specific skills, whether it's skills in how to use information, how to make decisions intelligently, how to form relationships in a way that's healthy, how to manage yourself and be self-efficacious, and learning skills of emotional self-regulation. And if you look at things that go on in analysis, they actually work against people getting better in two very specific ways. Part of the problem with people who suffer depression is they make meaning out of events and their style of making-meaning hurts them. So to give you a simple example, I call you. You're not home. I leave a message for you. I say, "Call me back."
RM: And I don’t.
MY: And you don't call me back. Now, if I'm a depressed person, how do I interpret that?
RM: Probably like “I’m not worthy…”
MY: "I'm not worthy, you don't like me."
RM: Yes…
MY: "You don't think I'm important. What's wrong with me? How come nobody ever likes me?" It's facing an uncertain or ambiguous situation and projecting negative meanings into it. Analysis is filled with making negative interpretations, negative projections in the face of uncertainty. "What does this dream mean? What does this symbol mean? What does this image mean?" And so much of what happens in analysis is teaching a person to make interpretations that are the same as the analyst. That doesn't help the person learn how to think and use information more critically. And then the second thing that happens in analysis, when we look at coping styles there's a particular style of coping called rumination: spinning things around and analyzing them and analyzing them and analyzing them, at the expense of taking effective action. And when you look at the people who ruminate, they have higher levels of anxious symptoms, more severe depressive symptoms. Ruminating, analyzing, works against getting better. Action is what helps people get better. And when you look again at the therapies that have the highest treatment success rates, it's not a coincidence that every single one of them gives homework. Every single one of them gives tasks to do in between sessions. Every single one of them emphasizes teaching specific skills, whether it's relationship skills, thinking skills, behavioral skills—but the emphasis is on movement, not analysis. That's why people in the other domains call it the analysis paralysis: instead of encouraging people to take effective action, instead, they spend more time thinking and analyzing and miss opportunities to do things that would help themselves.

Nobody Wants to be Depressed

RM: It sounds refreshing and optimistic, but I’m just wondering, if patients are willing to change their behaviors, learn new skills right away, are they ready for it– especially, when we consider secondary benefits from depression.
MY: Who said there are secondary benefits? You said that. I didn't say that. I don't believe that.
RM: You don’t believe the idea of secondary benefits from depression is true?
MY: No.
RM: Why not?
MY: Everything you experience has consequences. Everything. Going to a conference for five days has consequences. It means you're away from your family. Does that mean you want to be away from your family? You make choices. But to suggest that the consequences drive the pattern to me is so offensive because it blames the depressed person. Depressed people don't want to be depressed. What makes it look like secondary gain or secondary benefit is when you see depressed people who don't lift a finger to help themselves, the easiest conclusion is they must not want to change. They must be getting benefits from being depressed. And that is a fundamental misunderstanding that I wish people would let go of already. Nobody wants to be depressed. But the basis of depression is helplessness, hopelessness. Most depressed people don't go for help not because they want to be depressed, but because they don't think help will make a difference. Why would I go see a therapist if I believe that it's never going to help me? That's why depression has so few people who seek treatment. Only about 20 to 25 percent of depression sufferers seek help because they don't believe it's going to make a difference.
RM: So it sounds like you don’t really believe in the unconscious?
MY: You're going off in an entirely different direction now. Of course there are unconscious processes.
RM: I am not blaming a person for being depressed, or saying that it is the choice a person makes; however, there are many benefits of being depressed I could think of…
MY: But by saying it that way, you're suggesting that there is a motivation to stay depressed.
RM: Unconscious ones…
MY: And I'm suggesting that is incorrect. It's damaging. It's unfair to the patient. And it delays getting effective treatment. It's not a useful concept. And again, when you look at the therapies that work, none of them explore that domain because it is theoretically interesting but it isn't really what the nature of depression is about. And it's one of the things that every analyst needs to do, is be able to distinguish between their interest in a particular theory versus what the client's actual experience is. Instead of fitting the patient to the theory, how about if we learn something about how this person generates depression? It's a very different question—how does this person generate depression, instead of why. As soon as you ask why, you're now inviting theorizing.
RM: That is true to some extent.
MY: And what I'm interested in is, "Here's how this person does this. How can I interrupt that sequence so that instead of going from here to here to here to depression, can I introduce some new possibilities that move them in a new direction?"
RM: I see.
MY: That's the problem with when people make theories and then they actually believe themselves.
RM: What you are telling us is that you’re very concentrated on the individual, rather than generalized theories.
MY: Every person's different. And that's the point–
you have to generate a new theory for each person, instead of fitting the person to some preexisting idea.
you have to generate a new theory for each person, instead of fitting the person to some preexisting idea. And that's the problem with any approach that adapts the person to the theory instead of the reverse. And that's the danger for any model. You know, I wouldn't want a cognitive therapist to only read cognitive literature. I wouldn't want a behavioral therapist to only read behavior literature.
RM: The more you know the better for the patient?
MY: Yeah, when I said there are so many factors that have been proven to contribute to depression, it means that each practitioner needs to know something about genetics, needs to know something about epigenetics, needs to know something about biochemistry, needs to know something about social depression and the cultural contributions to depression, needs to know something about cognition, needs to know something about diet and exercise. You know, exercise has a treatment success rate that matches antidepressant medications and has a lower relapse rate. Now, that without ever saying a word to somebody. Doesn't that complicate the picture a little bit when you ask, "Well, how does somebody get better exercising if they never deal with their unconscious and they never deal with their traumas?" That's an important question.
RM: Good point!
MY: And that's where you would hope the people reading this would be curious enough to ask, "What is it that cognitive therapists have learned that have made the treatment so successful without doing any of the things that the people who are loyal to analysis think you should do?" And then, of course, part of the model is to dismiss it as superficial. "Well, that's not really therapy if they're only seeing people for six sessions." Well, you can take that position. It's a very arrogant position to take to say that you know what the right way is, other people are doing it the wrong way, when the other people actually have the data to show that it works better and lasts longer and prevents more episodes than any other approach.

Diagnosing and Treating Depression

RM: How long does it actually take you to cure someone from depression?
MY: When you look at the literature, you look at the science of what the studies have shown us, they're usually around 12 to 16 sessions.
RM: And these sessions are structured?
MY: They're structured and they're educational. There's a lot of teaching—what's called psychoeducation—that goes into the process of teaching people how to think and how to use information, how to think clearly. And the same is true with interpersonal approaches. Interpersonal psychotherapy has a treatment success rate that is even slightly higher than cognitive-behavioral. And it teaches relationship skills, social skills. And when you think about the skills that go into good relationships, and we've known for half a century that people who are in good relationships have lower ratings of depression. Why? And what are those skills that go into good relationships? And what about now, when we're seeing depression on the rise and relationships on the decline? So it's such a complicated picture, but spending more time thinking of depression as only in the person, only in the person's unconscious, misses that there are big cultural differences. There are big differences within demographic groups within one culture. And when you look, then, at how do families increase or decrease vulnerability to depression; how do marriages increase or decrease vulnerability; why is the child of a depressed parent so much more likely to suffer depression than a child of a non-depressed parent now that we know that the main reason is not genetic?
RM: Could you give some hints for beginning therapists on how to recognize a depressed client? It is pretty easy with major depression, but how to recognize the signs of it in ongoing therapy with a client who is experiencing moderate depression or dysthymia? And the second question is about masked depression: do you believe it exists and, if so, how do you recognize it?
MY: It's so interesting how your questions all contain the analytic viewpoint.
RM: Really?
MY: Where it's really hard for you to get outside that long enough to even ask the questions differently. But let's take the first…
RM: I wasn’t aware of this. Maybe that was my unconscious…
MY: Well, "masked depression"—nobody uses that phrase anymore.
RM: I’m sure I’ve heard it many times in Europe, where I live and practice.
MY: I understand, I understand. Well, there are people in New York who would probably use the same language—New York being one of the main centers where analysis is still practiced in the United States.

The first question was, "How do you recognize depression?" Depression takes many different forms, so there are many different ways to answer this. If you look at the DSM IV, which is our diagnostic system, there are 227 different symptom combinations that could all yield a correct diagnosis of depression. So depression is a soft diagnosis. It's not an easy diagnosis to make because of all these different combinations.. The United States government has been pushing physicians for almost 10 years now to recognize depression more frequently. When I said earlier that only 20 to 25 percent of depression sufferers seek help from a mental health professional, more than 90 percent of them have seen a physician within the last year, presented the symptoms of depression, and many physicians miss it. So the government's been asking physicians to just ask two questions. One question is about mood; "Have you been feeling down, sad, blue, or depressed for the last month or more?" And the second question is about anhedonia, or the loss of pleasure; "Have you lost interest in the things that usually interest you, or have you stopped deriving pleasure from the things that normally give you pleasure?" Now, if somebody says yes to one or both of those questions, it doesn't automatically mean they're depressed, but it leads you to take a closer look.

Sleep disturbance is the single most common symptom of depression, and the most common form of insomnia is early morning awakening, what's called terminal insomnia because it interrupts the terminal phase of sleep. But there are other symptoms as well. People who are depressed are most often suffering a coexisting condition. Anxiety disorder is the most common coexisting condition, but there are others including substance abuse problems—alcohol especially—medical problems, and personality disorders. So that complicates the diagnosis. But when you're talking with somebody who is feeling hopeless and helpless—the two biggest characteristics of depression—it leads you to look more closely.

Now, the second question was about so-called "masked depression." And the reality is that moods fluctuate. Depressed people aren't in the same level of depression every hour of every day. Typically there fluctuations, times when they feel a little worse—early morning, for example—times when they feel a little better, times when today they're feeling optimistic, and tomorrow they feel rotten again. Today they can barely get out of bed; yesterday they had a good day. So what is a masked depression? The assumption is that the depression is being hidden by some other symptom or some other behavioral pattern. And a good diagnostician, someone who understands what depression looks like in all of its different forms, would simply say instead of "masked depression" that this person has a comorbid condition. They have another coexisting issue, whether it's an anxiety disorder or alcohol abuse or something like that.
RM: It’s obvious for me right now that you don’t deal with the matter of transference and countertransference, but let me ask you about the role of the relationship between you and the patient.
MY: There are over 400 different forms of psychotherapy, and every single one of them emphasizes the importance of the relationship. If you don't have the connection with the person, then how do you attain the level of influence that it takes to teach them new skills, to motivate them to follow homework assignments, to share your sense of optimism that their life can be different if they do some things different and learn some things differently and approach some things differently? So for me, and I think any therapist would say this, the relationship is critically important.

Learning from People’s Strengths

RM: Let’s move to the area of core techniques. You write about so many different techniques that are useful with working with depressed persons. I’m wondering what are your favorite techniques.
MY: Well, my favorite technique is the one that works.
RM: You’re not attached to techniques.
MY: For me, what defines the work that I do is I respond to these questions. First question: "What is the goal? What does this person want?" And secondly, "What are the resources they're going to need to do it? What specific skills will this person need in order to be able to do this?" You know, I think one of my unique contributions to the field has been in asking how people do things well. Studying how somebody becomes depressed, asking the question, "Why does somebody become depressed?" Okay, that's interesting….
RM: But it’s half-baked?
MY: Yes. What I'm really interested in is people who have faced adversity and didn't become depressed. Why didn't they become depressed ? What's different about the way they think about it? How do they cope differently? For somebody who had a difficult family life or had traumas as a child but didn't become depressed, why not? And you can do one of two things. If you are prone to pathologizing people, then you would say, "Oh, they're in denial and they have great defense mechanisms." And if you're more focused on the strengths of people the way I am, then you say, "Okay, how do I understand these strengths so that I can teach the same strengths to other people?"
I'm focused on what's right with people rather than what's wrong.
I'm focused on what's right with people rather than what's wrong.

So when I encounter somebody who's been through a terrible set of experiences and they're strong and they're motivated and they're positive and they're happy, I don't look at that as a defense. I look at that as health. I want to know how they did that so I can teach it to somebody else. So that's where the techniques that I've developed come from: studying people who cope well in the face of adversity, the people who manage intense stress well, who have lost people and then managed to love again instead of saying, "I'll never love again." The people who fall down and get back up again. And I think there's much, much, much more to learn from them than there is from analyzing people and talking everyday about how bad they feel and how crummy their childhood was. What a waste of time! It's like putting 10 people together in a group who all have airplane phobias. Now you have the blind leading the blind. You're not going to learn anything about how to get on an airplane comfortably by sitting in a room with nine other people who have the same fear you do.
RM: From your point of view the most they could do is just share similar experiences?
MY: There's so much that goes on in the name of therapy that's simply silly. So my focus is, "Okay, here's somebody who has a particular skill that helps them. This person could learn that skill and benefit from it." The techniques that I put in the books are about, "How have I found ways to teach somebody that skill?" Life is filled with uncertainties. The example that I used earlier: I call you, you didn't call me back–it's unclear why you didn't call me back. It is a skill to prevent myself from interpreting it negatively and saying, "He must not like me," because then I'll feel rejected and I'll feel hurt. But for all I know, you had an emergency, and simply forgot to call me back, or somebody else took the message off the answering machine and never gave it to you. But for me to interpret that it's evidence that you don't like me is a big jump, and one of the most important skills you can learn in life is to be able to recognize and tolerate uncertainty.
RM: Changing thinking and the way we make attributions will also affect our feelings or emotions?
MY: That's certainly a big part of it. Well, think about it. You apply for a job. You don't get the job. What does it mean? Well, if you're sensitive about your age, you'll say, "Well, it's because of my age." and if you're sensitive about your gender, you'll say, "Well, it's because of my gender." But you don't know that. You're never going to know that they hired the boss's nephew. You're never going to know that. So to form these explanations that hurt you is what depressed people do very, very well. So one of the skills is knowing when to analyze something and when not to. To be able to make a distinction, what question is answerable and what question can I ask that no amount of research is ever going to generate an answer to? When this woman is depressed because her two-year-old son died from leukemia, and she says, "Why did this happen?" Is there any answer you can give her that's going to make her feel okay?
RM: I guess not.
MY: What can you say? It's a tragedy. And the last thing that you want to do is say, "It happened because you had a drink when you were four months pregnant." We don't know that. Now, can she still find meaning in it that helps her? Can she say, "I want to start a support group for other mothers who have lost young children"? That would be a great thing to do. But it's different than asking, "Why did this happen to me?" It's a very different question than "What can I do about this that will enhance my life?"

Using Metaphors and Hypnosis in Therapy

RM: Let’s talk a while about metaphors.
MY: Okay.
RM: Do you like using metaphors? Do they just pop right into your head or is it hard work to make a metaphor?
MY: I wouldn't say it's hard work. The metaphors are all around us all the time. But let me back up a second. I like the use of metaphor, but not for everybody. And again, techniques don't have any value by themselves. What gives them value is the client. It's not the technique that works. It's the relationship between the technique and the person. No technique is worth anything if the relationship doesn't support it. There are people who will listen to the story and they'll be entertained by it; they'll find it interesting, but they won't learn anything from it.
There are some people who don't value deep thought; they're much more interested in who's going to win the big game this week.
There are some people who don't value deep thought; they're much more interested in who's going to win the big game this week. And then there are other people who listen to the story and they see a deeper meaning in it. What drives metaphor, what makes metaphor valuable, is when you have somebody who engages in what's called a search for relevance. They're willing to actively engage with the metaphor and ask themselves, "How does this apply to me? What can I learn from this? What can I learn from this other person's experience or from this situation?" But not everybody does that. There are some people that the metaphor goes in one ear and out the other, and they just don't think about it.

But the point about the use of metaphor—it has become so basic in the practice of hypnosis to be able to absorb people in a story and encourage multiple-level processing. The conscious understanding, and then stimulating the unconscious processes of the person to build new understandings, build new associations. I'm obviously a big fan of hypnosis. Many of my books are about hypnosis. And hypnosis is such an extraordinarily powerful context for teaching people things and helping people get focused on and absorbed in new ideas and new possibilities. And it helps to understand that hypnosis cures nothing. It's what happens during hypnosis that has the potential to be therapeutic—the new understandings the person develops, the new associations they form in their mind, the new perspectives that evolve for this person as they go through the hypnotic experience. So the hypnosis itself, where metaphor is most commonly used, simply provides a context in which this person can learn things in a much more concentrated way.
RM: You said during your lecture that the viewpoint that hypnosis cannot be used with psychotic patients is wrong…
MY: Somebody asked me that question. My answer was, "Of course it can."
RM: Yes. How so?
MY: There's a distinction that I make between formal hypnosis and informal hypnosis. Formal hypnosis, where you identify this procedure as hypnosis—"Now we're going to do hypnosis. Sit back, close your eyes, focus." But you don't need the announcement for hypnosis to occur. Every time you immerse someone in memory, you're doing age regression. Every time you say to somebody, "I want you to stay focused right here, right now, as you remember," you're doing dissociation. Every time that you focus someone on their feelings, you're focusing them. Every time that you offer interpretation, you're giving a suggestion. And the use of suggestion and how to use suggestion skillfully is what the study of hypnosis is about. But there's no form of treatment—especially analysis, which is a highly suggestive approach—where you're not using suggestions routinely. So the question is how much deliberate focus you create.

I worked in an acute care psychiatric hospital for three years, working with very psychotic patients, very chronic patients. Now with some of them, they could focus long enough, five minutes, ten minutes to actually, "Sit back, close your eyes, let's do an exercise here." And then there are others where it was just being very deliberate about getting their attention for a moment to say something in a way that would focus them and introduce another possibility. Now, that's not formal hypnosis, but it's using the same patterns, the same principles of hypnosis. And so that's what I was talking about.
RM: It seems like everyone can benefit from this form of treatment, this approach.
MY: Yes. What I'm really saying is, I don't know how to separate psychotherapy from hypnosis. They're so merged together because, you know, if you give me a transcript of one of your analytic sessions, I promise you I can highlight suggestion after suggestion and tell you what kind of response that suggestion was trying to create.
RM: So every psychotherapy is partly hypnosis.
MY: Involves suggestion, yes. And what hypnosis involves is the focused use of suggestion. For example, the most empirically supported application of hypnosis is in the realm of behavioral medicine, using hypnosis for pain management. Now, the idea that you can do hypnosis to create anesthesia with someone through language, and this person can now go into an operating room, have their body cut open, and have surgery—that's remarkable. But that's what I do, and that's what many people who practice hypnosis do. Here in the United States, I don't think there's a behavioral medicine program in the country that doesn't have people doing hypnosis, because it is so effective in helping people manage pain with reduced or no medication, to prepare people for surgery so they have better and faster recoveries, and fewer postsurgical complications.

And hypnosis now is such an obvious contributor to our understanding of the brain, and the relationship between brain and mind, because it's an obvious research question: "What changes in a brain when someone is able to go into hypnosis, generate an anesthesia, and have a surgery?" Using fMRI scanning techniques, PET scans, SPECT scans, the person has a scan, then they go through hypnosis and some procedure and then they have another scan, and you literally watch how their brain changes. We're learning about how brains change in psychotherapy or through suggestive procedures, whether it's cognitive therapy or some kind of hypnotic protocol. But the fact that hypnosis is now at the heart of the new neuroscience, this is how fields advance.

No form of therapy that I'm aware of doesn't include suggestion as a basic part of its procedures.
No form of therapy that I'm aware of doesn't include suggestion as a basic part of its procedures. Even the suggestion, "If you lie on the couch, you'll feel better. If you talk about your dreams, you'll feel better. If you feel your deep, innermost thoughts, you'll feel better." That's a suggestion. That "if you come here four times a week and talk about these things, you'll get better in a couple years"—that's a suggestion. And to say to somebody, "It'll take you a couple years to do this," is a very powerful suggestion. Because what you're now telling the person is, "You really shouldn't start to feel any better any sooner than that."
RM: That’s a strong statement.
MY: "And if you do start to feel better sooner than that, then that's a problem. That's a defense. That's a flight to health." It's an unusual way of framing it. But the point is, how is it that somebody can practice a form of therapy and not understand the role they play in how the therapy proceeds? That it's not just uncovering what's in the person. There are two people in the room; you're influencing this person whether you realize it or not. And the danger for me is when people are influencing someone and they don't realize it. It's like the big controversy we had here in the United States 15 years ago, about false memories.
RM: Oh, yes.
MY: You had therapists who didn't know that by digging for the memories, they could actually create them. They thought they were just uncovering memories. They didn't know that they were influencing what kind of memories came up and what the quality of those memories were. That's what's dangerous. That's when therapy goes badly–when people don't recognize they are a fundamental, unavoidable part of the process.
RM: It seems obvious that every therapy approach would benefit from learning something about hypnosis and suggestions…
MY: I certainly feel that way, yes.
RM: Can this approach be combined with any other therapeutic approaches?
MY: Well, it isn't a therapy, so the answer is yes. It is routinely incorporated by practitioners who use hypnosis in different ways. There is one form of hypnosis called hypnoanalysis, where therapists use hypnosis to enhance the processes of psychoanalysis. There are others who do cognitive-behavioral hypnotherapy, and they're doing hypnosis from a cognitive-behavioral framework. You name it and there are people who are doing it. So hypnosis isn't really a therapy.
RM: It isn’t an approach either.
MY: It's a tool. It's a way of organizing ideas, it's a way of delivering information, it's a way of creating a context where this person can listen to what you have to say and can talk about what they need to say. So how any one therapist would use the principles of hypnosis—that's going to be up to them. It's the equivalent of learning a language, and then each person expresses themselves in their own way. So some people will use hypnosis to give commands to someone: "You will do this, you will do this, you will do this." Personally, that's not my style, and I don't particularly care for that style. There are other people who simply introduce possibilities: "You might want to think about this."
RM: And this is your style.
MY: It's closer to my style.. The reason why I think people should study hypnosis is because hypnosis has studied the quality of communication between a therapist and client. It studies whether your approach should be more direct or more indirect, whether you should be more positive or more negative, whether you should give more detail or less detail, whether you should be more directive or less directive. It teaches you flexibility in how to adjust your style to the patient's need—"How does this person process information so that I can present information to them in a way that fits?"—as opposed to fitting the client to, "This is my theory, this is what I do. And if you don't benefit from it, it's because you're really sick."

Surprising Origins, Unexpected Discoveries

RM: All right. Let’s finish with the question that is usually asked at the beginning of an interview. What stirred your interest in depression, and how did your understanding and ways of treating patients evolve during that time?
MY: When I was studying and getting my degrees, it might interest you to know that I spent my first four years studying psychoanalysis and learning to speak that language fluently. I understand psychoanalysis. I've studied it at one of the finest academic institutions in the United States, the University of Michigan, which was at the time a very heavily psychoanalytic school.
RM: So it’s not like you’re rejecting some ideas that you’ve just heard about, but you’re rejecting ideas that you know profoundly well.
MY: I do definitely, profoundly. Some of the most distinguished analysts in the United States were my professors. But I was moved by the fact that depression was and still is the most common mood disorder in United States–indeed in the world. And there were no good treatments for it. A depressed person is never going to go into analysis anyway—they don't have the frustration tolerance, they don't have the ability to feel bad day after day after day for years waiting for the therapist to say something helpful—the problem doesn't fit the solution. Analysis isn't going to be valuable for most depressed people. They want an answer and they want it now. They want to feel better now. And it's part of the pattern of depression to want it now—it's called low frustration tolerance. Do we say, "Well, that's part of the problem and we shouldn't have to change what we do to fit their problem?" To me that is the opposite response I have, which is, "How do I help this person from within their own framework, instead of expecting them to somehow magically come to my framework?"

At that time, cognitive therapy was in its absolute infancy. It wasn't well developed yet. There were no good therapies, and there were no good drugs. And so to watch people suffer in depression, and to know that nobody's doing anything that really makes a difference, for me it was a challenge. "Can I make a contribution here? Here's the most common problem, and I want to be able to do something about it."
RM: You wanted to have some influence. You wanted to be able to help these people.
MY: I wanted to be able to help. I wanted to be a true clinician and help as many people as quickly as possible. And so the idea of developing short-term interventions was obvious in importance. It's how people use therapy. It's interesting that when you look at the studies of people in therapy, the average number of sessions is between six and seven. The most common number of sessions is one. Can you really do therapy in one session? You saw a video of my work, with 10-year follow-up.
RM: Yeah, it was pretty amazing.
MY: So what does that do to the psychoanalytic viewpoint? It challenges it. And that's the point–you can either dismiss it, or you can say, "There's something here worth studying," depending on how open and how flexible you are. If you're rigid, you pathologize it. If you're open, you say, "There's something there worth studying." And so I was very interested in studying people who have recovered from depression, and asking "What made the difference? What helped you overcome all the helplessness and hopelessness and all of that? What changed for you? How did you cope? How did you learn? How did you relate? How did you, how did you, how did you?" What I realized very quickly when I got into clinical practice was that
everything that I had been studying for the last four years was irrelevant in the real world.
everything that I had been studying for the last four years was irrelevant in the real world.
RM: I think you had a lot of courage to make such a statement.
MY: To me it didn't seem like courage. It just seemed like common sense, that one of two things is going to happen: I'm either going to build my own little world and try to bring people to it, or I'm going to go out into the world and talk to people in terms of the way they think and the way they do things. So to me it didn't seem like courage—it seemed like common sense. And it took me years to unlearn everything I learned.
RM: Everything? Or is there anything left?
MY: If you ask me today, is there one thing that I learned then that I still use? I can't think of a single thing. It took me a long time to unlearn that because I had been intensely trained to continually look for symbolism, to continually look for deeper meaning, to continually speculate about unconscious needs and wishes. And those were all things that got in my way of actually helping desperate people who needed help now.
RM: Thank you very much for this very inspiring conversation. I hope our readers will enjoy reading it as much as I enjoyed talking with you.
MY: Well, predictably, readers are going to react in one of two ways. They're either going to get angry and conclude I don't know what I'm talking about, or hopefully they'll say, "Maybe now would be a good time to start to explore what other people have to say about dealing with these same problems," because then the question becomes "What is the most effective way to treat depression?" And there's no single answer for that.

But it's certainly interesting that, of the many different therapies that have good treatment success rate, it's interesting that none of them analyze childhood. None of them focus on symbolic meanings of things. All of them teach skills. All of them have an orientation towards the future that help the client come to understand how the future can be different in very specific ways. So instead of saying that the goal is insight, saying that the goal is change–that poses a direct challenge. And typically when people are challenged, they either get angry or they get open. I'm hoping at least some of the readers will get curious enough to see what else is going on that might inspire them to change some of what they do in ways that they feel good about.
RM: Any concluding remarks that you want to share with the therapists who might read this interview?
MY: You know, I am a clinician. I am treating the same kinds of patients, maybe even more severe patients than the average clinician treats. And I have a great deal of respect and appreciation for people who make psychotherapy their profession. It's almost as if it's a calling. You want to do something to reduce human suffering, and you are forced to make decisions about how you're going to practice and what the goals of practice are. Is the goal to be loyal to a theory, or is the goal to make a difference? Is the goal to continually filter things in life through your preexisting beliefs, or is the goal to be open and curious about what other people are doing to see if what they're doing works better? And for me, everything that I've learned has come from studying people who do things well, recognizing that they have abilities and strengths—even the people I treat who are severely depressed. Okay, they're depressed; it doesn't mean they're stupid. They have great wisdom, they have a great many skills, and we can learn from those. And especially from the people who handle things well, what can we learn from them? So if somebody recovers well from a loss, instead of saying they're in denial, why aren't we studying how they did that? When somebody bounces back from an adversity, why are we saying that's a defense mechanism instead of an asset? I firmly believe that what you notice and what you focus on, you amplify. And if you focus on pathology, you'll find it. And if you focus on strengths, you'll find them. So I would simply encourage therapists to look for what's right. I think they'll be better clinicians for it.
RM: You’ve raised some mind-opening questions at the end of our conversation. Thank you very much. It was a huge pleasure.
MY: Thank you. It was my pleasure.

Dan Wile on Collaborative Couples Therapy

Posted on by rezendevknowfully.com

The Interview

Ruth Wetherford: Dan, thank you for agreeing to be interviewed for Psychotherapy.net. I’m delighted to be interviewing you to bring more information about collaborative couple therapy to the world. Let’s start with the question of how you got into psychology. How did that happen for you?
Dan Wile: Well, it was in the family. My mother is a psychiatrist, and my sister became a social worker. I was planning to be a psychiatrist myself. But when I went to the University of Chicago, I discovered that if I was going to be pre-med, I wouldn't be able to take the University of Chicago Great Books courses. So I decided at that point to be a psychologist.
RW: In your writing, you often credit the work of Berkeley psychologist Bernard Apfelbaum for contributing to your ideas. Do you have specific memories of working with him that stand out for you?
DW: A bunch of us would meet with him every month, we'd present all kinds of ideas and cases, and he'd always come up with a fascinating new angle for looking at the matter. He seemed to be thinking at a higher level than practically everyone else I knew. Whenever I do therapy, I think, "What would Bernie say about this situation?"

The Importance of Non-Pejorative Interpretations

RW: The growing emphasis in psychotherapy on the quality of the relationship between the therapist and the client, more than on the accuracy of interpretation, has contributed to a cultural milieu perhaps more receptive to your ideas, and your approach is gaining more interest and attention in recent years. What is it about your work that makes it more appealing to people at this point in the development of the profession?
DW: I use my relationship with my client couples to improve the accuracy of my interpretations. I make guesses about what they're thinking and feeling but not saying, check with them whether these guesses are accurate, and revise my statements according to what they say. We figure out together what's true about them. And I use my interpretations to create a collaborative relationship with the partners. They like the fact that I take their view of the matter into account, and, in fact, make them the final arbiter of the accuracy of the interpretation. And they like that my theory of personality and relationships leads to interpretations that are non-pejorative. That was the problem with the old style of interpretations and what got them into disrepute—they were pejorative.
RW: Interpretations frequently imply blame, and have the pejorative connotations you just referred to. Your approach emphasizes the opposite of that: acceptance.
DW:
A big problem in couple therapy is that we react to clients in the same way partners do with each other when they fight.
A big problem in couple therapy is that we react to clients in the same way partners do with each other when they fight. When clients act in an arrogant, bullying, or other off-putting way, we get angry at them—though, of course, in a much milder way than the partners do with each other. Being angry, we think of these clients in pejorative terms, make pejorative interventions, and lose the ability to look at things from their point of view. When a client says or does something off-putting, you can stand back in negative judgment and say to yourself, "Well, this is borderline or sadistic or passive-aggressive,"—or you can imagine what it's like being in that person's position and what inner struggle the person is engaged in that's leading them to be stuck in this off-putting behavior. I spend a lot of my effort in couple therapy trying to recognize when I'm standing back in negative judgment so I can overcome it.
RW: That process of putting yourself in the other’s position and seeing how it makes sense that they could be stuck—is that what you call empathy?
DW: Yes, that's a good way to put it
RW: Would you discuss the centrality of empathy in your work?
DW: A big problem in couple therapy is finding yourself siding with one partner against the other, feeling unempathic. And that's not a place where you can do therapy. So I try to think how to shift out of my pejorative view of this person and imagine what it's like being in their shoes and seeing the hidden reasonableness in their seemingly unreasonable and irrational behavior. If I can get myself in a mood where I'm not reacting to them, I can make a pretty good guess as to what that is or think of questions to ask that would bring it out.
RW: You’re pointing to the importance of self-control of the therapist’s own emotional reactions. Do you have some tools you can share or ways that you manage yourself internally?
DW: I have three tools. First,
just recognizing that I am reacting and viewing them in negative ways may be enough to shift me into a more compassionate place
just recognizing that I am reacting and viewing them in negative ways may be enough to shift me into a more compassionate place and enable me to begin to look at things from their point of view. If that isn't enough, the second thing is I have slogans—statements I make to myself or questions I ask myself—that remind me of my theory and help me shift to a more compassionate mode.

One slogan is, "My job is to become spokesperson for the partner I find myself siding against." Another is, "What is the internal struggle this person is having?" It's great to ask myself that question because until I ask it, I don't think there is an internal struggle—I think that person is just enjoying being provocative. Another question I ask myself is: "What is the vulnerable feeling that, because the person can't express it, is causing this person to act in this off-putting way as a fallback measure?" Still another question is: "What can I say or ask that will enable the person to feel listened to?"

If these slogans and questions aren't enough to get me out of my adversarial state, the third thing I do is I try to get myself out of this state by expressing what I need to say to clear my gills, just as I try to get partners out of their adversarial state by helping them express what they need to say.

One of the advantages of couple therapy is you can move in and speak for the partner. I use a psychodrama kind of method—
I move over and kneel next to the person I am speaking for.
I move over and kneel next to the person I am speaking for. For example, if I'm reacting to how one partner seems to be bulling the other, I can move over and, speaking for that person, I can say, "When you get bullying like this, I just stop listening and wonder why I'm in this relationship." The partner I'm speaking for usually likes this, and I feel much better—so much so, in fact, that I'm suddenly able to look at things from the point of view of the bullying partner. My feeling of empathy has returned for that person and I move over and make a confiding statement for him.
RW: What might that be?
DW: I might say for that person, "Well, I know that you don't listen to me when I come on strong like this. I feel helpless and get frustrated. I've lost some friends because I've come across this way. But there's something important I'm trying to say and I wish I could find a way to say it that doesn't blow you away." Of course, I would immediately check with this person to see which parts of this, if any, capture how he feels.

Finding the Leading-Edge Feeling

RW: You talk about the “leading edge,” and I know that’s one of your core concepts. Say more about the leading edge and how you try to elicit the couple to talk about this.
DW: Well, I figure that, at any given moment, there is a thought or a feeling each person is having that is who they are at the moment. It's what Marshall Rosenberg calls "what's alive at the moment." If there's going to be intimacy between the two partners, this is what each needs to confide to the other and feel that it gets across.
I'm looking, at any given moment, for the feeling the person needs to express that would make them sigh with relief and feel closer to their partner.
I'm looking, at any given moment, for the feeling the person needs to express that would make them sigh with relief and feel closer to their partner. And the term "leading-edge feeling" sort of captures what I have in mind.
RW: It seems like at any given moment there could be any number of feelings that they’re having, such as, “I’d better keep my mouth shut—I’m scared.” Another one could be, “I feel lonely; I feel distance.” Another one could be, “I’m so angry—I don’t deserve this.” How do you determine which is the more salient or the one you want to focus on more?
DW: I may be wrong, but I think that there is just one leading-edge feeling at any given moment—but it can quickly shift from, to use your example, fear to loneliness to resentment. But you're right that if I ask partners a multiple-choice question, they might pick the leading-edge feeling they had two moments before, one moment before, or right now.
RW: A multiple-choice question.
DW: If people don't respond when you ask them how they feel, you can help them along by suggesting possibilities. I might say, "Let me make it a multiple choice question: Are you feeling, A, hurt, or B, angry, or C, lonely, or D, something else entirely?"
RW: You’re very clear that you want people to feel more connected by increasingly confiding their inner vulnerabilities in a way that can be understood by the other. But when you’re trying to get them to reveal those things and they’re presenting their default modes of anger or withdrawal, you don’t shy away from that. How does that work?
DW: Well, at times withdrawing or being angry is a leading-edge feeling. So I would help people capture that. I might help them express their anger in a way that is more satisfying to them and easier for their partners to hear. Moving over and speaking for them, I might say, "I'm still fuming about what you said ten minutes ago. I'm not even listening to anything you're saying. It wiped me out." I'm hoping that the person I'm speaking for will express a sigh of relief and, when I ask whether I got her feelings right, will improve what I said to make it more accurate. If a partner is withdrawing, I'd try to give words to that. I'd move over next to that person and, speaking for that person, say, "Well, when you say what you just did, I get despairing, and feel hopeless about us and kind of give up and don't have anything to say." A statement like this—if the person were able to make it—is the way for that person to be intimate at that moment.
RW: It seems like so much of your method is in the nonverbals: your tone of voice and your facial expressions that imply what you want is for them to get closer by being able to confide and have so-called “elegant conversation.” You seem to be equally accepting of rancor and disconnection—you believe it’s just as important to talk about that as well. Is that right?
DW: That's right. I'm looking for the leading-edge feeling of the moment, and it could be any feeling, positive or negative. I'm always thinking that there's a way of confiding it rather than just acting from within it.
RW: That reminds me of another thing you emphasize, which is the “relationship atmosphere.” Talk about that.
DW: My focus in a couple is whether they're in an adversarial cycle, which means fighting—either a quiet one or a loud one—or a withdrawn cycle in which they're disengaged, or an intimate cycle in which they're expressing their leading-edge feelings and it's getting across to the other person. Those are three different moods that a couple goes through. And my task is to shift them from the withdrawn or adversarial mood they're in, into the collaborative one.
RW: That’s where intimacy occurs.
DW: That's right. That's intimacy. And
sometimes I show them what it would look like by enacting the conversation they'd be having right then if they weren't angry at each other, but instead were feeling intimate.
sometimes I show them what it would look like by enacting the conversation they'd be having right then if they weren't angry at each other, but instead were feeling intimate.
RW: By speaking for them.
DW: By speaking for them.
RW: You’ve written in your book, After the Honeymoon, that “a relationship is a busy place. It’s like an airport with lots of things going on and scheduled and unscheduled feelings arriving and departing.” Say more.
DW: In the metaphor of the airport, I was thinking particularly of the observation tower, where people up there would be looking at everything going on—the planes, or feelings, going in, going out. So the couple could be in that observation tower noticing how they shift among those three moods—how there's anger, withdrawal, and tenderness—and having an ongoing way of talking about what's happening in the relationship. The "permanent platform" is another metaphor I use.
RW: This has a lot of implications for your view of what constitutes intimacy. Do you have a summary about that, a distilled view?
DW: Yeah. It's that intimacy is each partner saying what's on their mind, their leading-edge feeling, with the other one understanding. And you could say that a goal I have in couples therapy is to get the partners to develop, or develop further, such a permanent platform from which they can co-monitor the relationship. Intimacy is created by the way partners talk about what's happening in their lives and, in particular, about what's happening between them.  It's a consequence of their ability to be mutual confidants. That's a key point to my approach—the goal of the couple developing the ability to observe their own interaction patterns, the permanent platform.
RW: So it’s not about agreement or consensus—it’s about being more revealing.
DW: Yeah, it's having a way of getting in touch with what you need to say, what you're feeling, and having a relationship in which the other person is able to take it in, is eager to hear it, and has a confiding comment to make in return. And it doesn't become a fight, and the other doesn't withdraw.
When people are saying the main things on their mind, their main worries and concerns, their ache of the moment, and feel it's heard by the other person—well, that's the height of intimacy.
When people are saying the main things on their mind, their main worries and concerns, their ache of the moment, and feel it's heard by the other person—well, that's the height of intimacy.

The Power of Negative Thinking

RW: The ache of the moment—that reminds me of your comment about the power of negative thinking. Say more about that.
DW: Well, that was my cutesy way of talking about the permanent platform, in that the couple would know that there are certain problems that arise, certain conflicts that they have, certain issues that keep coming up, and they have an ongoing way of talking about that in a collaborative way when it arises. That means you're not just trying to talk yourself out of the problem and look on the positive side, but are fully appreciating that it's a problem—that's the power of negative thinking.
RW: So you’re saying that couples who can go in and out of collaboration and intimacy are having conversations, not just about what they’re enjoying in their lives, but about what they’re not enjoying of the important things, including the relationship.
DW: Yeah. So it's an increasing ability, after a period of fighting or withdrawal, to have a recovery conversation where you figure out what happened and get together in an intimate way about what went wrong—which is one of the more intense experiences of intimacy that people can have, if they can have it.
RW: Tell me about the recovery conversation.
DW: It's inevitable that partners are going to fight and withdraw. Some couples are lucky to have the fight end without it escalating too much, and they wake up the next morning and go on as if nothing had happened. And maybe that works for them okay. But for some couples, that doesn't work. And there's a disadvantage anyway, because a fight or withdrawal is an opportunity for intimacy, in the discussion of it afterwards. But it's understandable that a couple might want to avoid having such a discussion, since it often gets them back into the fight. Having productive conversations is a skill that evolves over time. The goal of such a discussion is to end up with a picture of how each partner's position made sense and how the two of them got stuck in something. So it's a compassionate, commiserating, from-the-platform view of what happened in the fight.
RW: It’s been said that your compassion-based approach is compatible with attachment work. How do you see it being congruent with issues of secure and insecure attachment?
DW: Well, I'm trying to create secure attachment by enabling partners to confide their ache of the moment. When, in every given moment, or maybe in just enough moments, a person can confide their ache of the moment—this leading-edge feeling—and feel that the other understands, this increases the security of the bond between them.

The Pleasure of Being Non-Defensive

RW: You know, one aspect of your work that you describe a lot is your role of being utterly non-defensive. Anyone who knows your work would say that. How can you be so non-defensive?
DW: I tell myself to be non-defensive and take pleasure when I succeed.
And if a client criticizes me, I'm grateful the person is doing that rather than just quitting therapy without saying anything.
And if a client criticizes me, I'm grateful the person is doing that rather than just quitting therapy without saying anything. And I believe that such criticizing is often a fallback measure the person engages in because they couldn't say something more vulnerable. So I don't want to make the mistake of reacting to the fallback measure when what I really want to do is help them discover the more vulnerable feeling underlying it, such as, "You know, I feel uneasy about the therapy for this reason or that reason," or "I worry that we're really not getting anywhere," or "I'm afraid that nothing can help me." Well, if they can't get that out, they may be stuck just blaming me for something. So I want to track back to the person's vulnerable feeling rather than react and defend myself.
RW: Right. You’d call that “the pleasure of being non-defensive.” What’s pleasurable about it?
DW: Well, it's a goal I set for myself. Instead of feeling defeated or whipped, I have a certain amount of pride in being able to do that. Also, I find it enjoyable when we escape from polite conversation. So when a person is expressing some disappointment or anger at me that I could get defensive about, that person is likely to be saying something more direct than they've said for some time. For me—and I believe for others as well—there's some intrinsic pleasure in shifting from the level of politeness to that of directness. And so this would be a shift towards more directness—that would be enlivening, you'd get to feel more there. And you kind of slump when there's a movement in the other direction, of people saying things that are just polite and not engaged. Yes, there's more energy, more feeling, more aliveness with the escape from politeness.
RW: You describe things you tell yourself as slogans, implying you repeat them, you remind yourself frequently. And I know the repetition of thoughts and images that we want to acquire does lead to their acquisition. I would imagine that would be an important tool, to have some of these slogans that people can put in their own language and learn.
DW: Yeah—now that you say that, I realize a therapist's orientation can be thought of as developing from the slogans and questions that arise automatically in the individual's mind. For instance, one common automatic question or slogan in a therapist's mind is, "What family of origin issues could create the problem this person is having?" If that's one of the main questions you automatically ask, your therapy will go in a certain direction. Or, "What unconscious purpose does this serve?" Thinking that, your mind and your therapy will go in another direction. So there's the set of slogans and questions already in your mind. When I'm put off by a client's behavior, I can lose certain of my slogans that lead me to be compassionate.
RW: How does that happen?
DW: When I'm feeling okay, one of the questions I ask myself is, "What's the hidden reasonableness in what's going on?" But when I'm reacting to the person, I don't ask myself that—I just think the person is totally unreasonable. I lose the ability to do therapy, since therapy requires my appreciating how both partners' positions make sense. It's a temporary loss, because I get up in the tower of the airport as soon as I can, so I can notice what is happening and regain my ability to do therapy. Yeah, so in any given session, particularly with a difficult situation to handle, or with partners who might feel provocative, I can lose and regain my ability to do therapy repeatedly throughout the session. Hopefully I keep my mouth shut when I've lost the ability and only talk when I have it.
RW: And this is just like the couples—gaining and losing the ability to connect with each other over time.
DW: Exactly, yes.
RW: Well, we’re just about out of time. Is there anything else you’d like to add to this?
DW: You're a great interviewer—the questions you've asked got me more clearly in touch with my own theory. So between the two of us, we created a momentum where I became more able to get at it than if you'd asked other kinds of questions that would have taken me away from my theory.
RW: Thank you so much. We collaborated.
DW: Yes, we collaborated.

Thomas Szasz on Freedom and Psychotherapy

Posted on by rezendevknowfully.com

The Myth of Mental Illness 101

Randall C. Wyatt: I am going to ask you a wide variety of questions, given the diversity of your interests, and I want to make sure to also focus on your work as a psychotherapist. A little background first. You’ve been well-known for the phrase, “the myth of mental illness.” In less than 1000 words, what does it mean?
Thomas Szasz: The phrase "the myth of mental illness" means that mental illness qua illness does not exist. The scientific concept of illness refers to a bodily lesion, that is, to a material — structural or functional — abnormality of the body, as a machine. This is the classic, Virchowian, pathological definition of disease and it is still the definition of disease used by pathologists and physicians as scientific healers.

The brain is an organ — like the bones, liver, kidney, and so on — and of course can be diseased. That's the domain of neurology. Since a mind is not a bodily organ, it cannot be diseased, except in a metaphorical sense — in the sense in which we also say that a joke is sick or the economy is sick. Those are metaphorical ways of saying that some behavior or condition is bad, disapproved, causing unhappiness, etc.
In other words, talking about "sick minds" is analogous to talking about "sick jokes" or "sick economies."
In other words, talking about "sick minds" is analogous to talking about "sick jokes" or "sick economies." In the case of mental illness, we are dealing with a metaphorical way of expressing the view that the speaker thinks there is something wrong about the behavior of the person to whom he attributes the "illness."

In short, just as there were no witches, only women disapproved and called "witches," so there are no mental diseases, only behaviors of which psychiatrists disapprove and call them "mental illnesses." Let's say a person has a fear of going out into the open. Psychiatrists call that "agoraphobia" and claim it is an illness. Or if a person has odd ideas or perceptions, psychiatrists say he has "delusions" or "hallucinations." Or he uses illegal drugs or commits mass murder. These are all instances of behaviors, not diseases. Nearly everything I say about psychiatry follows from that.

RW: Let’s say that modern science, with all the advances in genetics and biochemistry, finds out that there are some behavioral correlates of biological deficits or imbalances, or genetic defects. Let’s say people who have hallucinations or are delusional have some biological deficits. What does that make of your ideas?
TS: Such a development would validate my views, not invalidate them, as my critics think. Obviously, I don't deny the existence of brain diseases; on the contrary, my point is that if mental illnesses are brain diseases, we ought to call them brain diseases and treat them as brain diseases — and not call them mental illnesses and treat them as such. In the 19th century, madhouses were full of people who were "crazy"; more than half of them, as it turned out, had brain diseases — mainly neurosyphilis, or brain injuries, intoxications, or infections. Once that was understood, neurosyphilis ceased to be a mental illness and became a brain disease. The same thing happened with epilepsy.
RW: It’s interesting, because a lot of students of mine, and colleagues, who have read your work or heard of your ideas, think that when condition previously thought to be mental is to be a brain disease, as noted, your ideas become moot.
TS: That's because they are not familiar with the history of psychiatry, don't really understand what a metaphor is, and don't want to see how and why psychiatric diagnoses are attached to people. Ted Kaczynski, the so-called Unabomber, was diagnosed as schizophrenic by government psychiatrists. If people want to believe that a "genetic defect" causes a person to commit such a series of brilliantly conceived crimes — but that when a person composes a great symphony, that's due to his talent and free will — so be it.

Objective, medical diagnostic tests measure chemical and physical changes in tissues; they do not evaluate or judge ideas or behaviors. Before there were sophisticated diagnostic tests, physicians had a hard time distinguishing between real epilepsy — that is to say, neurological seizures — and what we call "hysterical seizures," which is simply faking epilepsy, pretending to have a seizure. When epilepsy became understood as due to an increased excitability of some area of the brain, then it ceased to be psychopathology or mental illness, and became neuropathology or brain disease. It then becomes a part of neurology. Epilepsy still exists. Neurosyphilis, though very rare, still exists, and is not treated by psychiatrists; it is treated by specialists in infectious diseases, because it's an infection of the brain.

The discovery that all mental diseases are brain diseases would mean the disappearance of psychiatry into neurology. But that would mean that a condition would be a "mental disease" only if it could be demonstrated, by objective tests, that a person has got it, or has not got it. You can prove — objectively, not by making a "clinical diagnosis" — that X has neurosyphilis or does not have it; but you cannot prove, objectively, that X has or does not have schizophrenia or "clinical depression" or post traumatic stress disorder. Like most nouns and verbs, the word "disease" will always be used both literally and metaphorically. As long as psychiatrists are unwilling to fix the literal meaning of mental illness to an objective standard, there will remain no way of distinguishing between literal and metaphorical "mental diseases."
RW: Psychiatrists, of course, don’t want to be pushed out of the picture. They want to hold on to schizophrenia as long as they can, and now depression and gambling, and drug abuse, and so on, are proposed as biological or genetically determined. Everything is thought to have a genetic marker, perhaps even normality. What do you make of this?
TS: I hardly know what to say about this silliness. Unless a person understands the history of psychiatry and something about semantics, it's very difficult to deal with this. Diagnoses are NOT diseases. Period.
Psychiatrists have had some very famous diseases for which they have never apologized, the two most obvious ones being masturbation and homosexuality.
Psychiatrists have had some very famous diseases for which they have never apologized, the two most obvious ones being masturbation and homosexuality. People with these so-called "diseases" were tortured by psychiatrists — for hundreds of years. Children were tortured by antimasturbation treatments. Homosexuals were incarcerated and tortured by psychiatrists. Now all that is conveniently forgotten, while psychiatrists — prostitutes of the dominant ethic — invent new diseases, like the ones you mentioned. The war on drugs is the current psychiatric-judicial pogrom. And so is the war on children called "hyperactive," poisoned in schools with the illegal street drug called "speed," which, when called "Ritalin," is a miracle cure for them.

Let me mention another, closely related characteristic of psychiatry, as distinct from the rest of medicine. Only in psychiatry are there "patients" who don't want to be patients. This is crucial because my critique of psychiatry is two-pronged. One of my criticisms is conceptual: that is, that mental illness is not a real illness. The other one is political: that is, that mental illness is a piece of justificatory rhetoric, legitimizing civil commitment and the insanity defense.
Dermatologists, ophthalmologists, gynecologists, don't have any patients who don't want to be their patients. But the psychiatrists' patients are paradigmatically involuntarily.
Dermatologists, ophthalmologists, gynecologists, don't have any patients who don't want to be their patients. But the psychiatrists' patients are paradigmatically involuntarily.

Originally, all mental patients were involuntary, state hospital patients. That concept, that phenomenon, still forms the nucleus of psychiatry. And that is what is basically wrong with psychiatry. In my view, involuntary hospitalization and the insanity defense ought to be abolished, exactly as slavery was abolished, or the disfranchisement of women was abolished, or the persecution of homosexuals was abolished. Only then could we begin to examine so-called "mental illnesses" as forms of behavior, like other behaviors.

Slavery, Witchcraft, and Psychiatry

RW: In terms of involuntary hospitalization and coercive psychiatry, which you’ve critiqued in your works.
TS: Excuse me, all psychiatry is coercive, actually or potentially — because once a person walks into a psychiatrist's office, under certain conditions, that psychiatrist has the legal right and the legal duty to commit that person. The psychiatrist has the duty to prevent suicide and murder. The priest hearing confession has no such duty. The lawyer and the judge have no such duties. No other person in society has the kind of power the psychiatrist has. And that is the power of which psychiatrists must be deprived, just as white men had to be deprived of the power to enslave black men. Priests used to have involuntary clients. Now we call that forcible religious conversion and religious persecution; it used to be called "practicing the true faith" or "loving God." Now we have forcible psychiatric conversion and psychiatric persecution — and we call that "mental health" and "therapy." It would be funny if it were not so serious.
RW: The symbolic nature of psychiatry and the sociology of psychiatry are coercive. Yet, every act isn’t literally coercive. Somebody comes to a doctor and says, “I can’t sleep. I’m depressed. Can you give me something to help me go to sleep, help wake me up?” That’s a free exchange.
TS: That's correct. There are voluntary psychiatric exchanges, at least in principle. As I like to say, I wholeheartedly approve of psychiatric acts between consenting adults. But such acts are pseudo-medical in nature, because the problem at hand is not medical, and also because the transaction often rests on taking advantage of the criminalization of the free market in drugs. Why do you have to go to a doctor to get a sleeping pill or a tranquilizer? A hundred years ago you didn't have to do that, you could go to a drug store, or to Sears Roebuck, and buy all the drugs you wanted — opium, heroin, chloral hydrate. In certain ways, the psychiatric profession lives off the fact that only physicians can prescribe drugs, and the government has made most drugs that people want prescription drugs.
RW: On a side note, isn’t it interesting, and troubling, that most people who go to jail for drug abuse, or drug selling, are black and minority, and those that have the license to prescribe are often non-minority, and they get to be heroes in society for essentially selling what is sometimes the same merchandise, albeit legally, of course?
TS: Indeed. I discuss that new form of black enslavement in detail in my book, "Our Right to Drugs." Because of the kinds of laws we have, physicians prescribe mood-altering drugs, which patients often want and demand; it's a medicalized version of drug distribution. Physicians did the same thing with liquor during Prohibition, which was quite lucrative.
RW: And now psychiatry and pharmacology can be a lucrative business.
TS:
Psychiatry is a lucrative business only insofar as it partakes of these two medical-psychiatric privileges or monopolies — prescribing drugs, which only licensed physicians can do; and creating their own patients, that is, transforming people into patients against their will, which only psychiatrists can do.
Psychiatry is a lucrative business only insofar as it partakes of these two medical-psychiatric privileges or monopolies — prescribing drugs, which only licensed physicians can do; and creating their own patients, that is, transforming people into patients against their will, which only psychiatrists can do.

The Right to Use Drugs

RW: So what is your view on psychiatric medication for people suffering from “schizophrenia” or “problems in living” as you call it, or “interpersonal difficulties,” or “intra-psychic difficulties.” Whatever you call it, people suffer or are troubled internally or interpersonally. What is your view on the use of either legal or illegal drugs to help people cope with these things?
TS: I am smiling because I know you know my views! However, I wouldn't phrase the question this way. In my opinion, using drugs is a fundamental human right, similar to using books or prayer. Hence, it comes down to the question of what does a person want and how can he get what he wants? If a person wants a book, he can go to a store and get it or get it on the Internet. He ought to be able to get a drug the same way. If he doesn't know what to take, then he could go to a doctor or a pharmacist and ask them. And then he should be able to go and buy it.
RW: That brings up the issue of drug and prescription laws, which you have written about extensively.
TS: Indeed. Prescription drug laws are a footnote to drug prohibition. Prescription laws should be repealed. All drug laws should be repealed. Then, people could decide for themselves what helps them best to relieve their existential ails, assuming they want to do it with a drug: opium or marijuana or cigarettes or Haldol or Valium. After all, the only arbiter of what ails a person "mentally" and what makes him feel or function better, as he defines better, is the patient. We don't have any laboratory tests for neuroses and psychoses.

As for insomnia, typically that's a complaint, an indirect communication, to obtain sleeping pills. A person can't go to a physician and tell him: Please write me a prescription for a barbiturate. If he did that, he would be diagnosed and denounced as an addict. So he must say: "I can't sleep." How could the doctor know if that's true?
RW: You ask him how many hours he sleeps, he says two hours a night.
TS: How would the doctor know if that's true? The term "insomnia" can function as a strategic lie that the patient has to utter to get the prescription he wants.

The Therapeutic State and the Medical Model

RW: You seem to have a different view of the medical model of medicine, than the medical model of psychiatry.
TS: Yes, very much so. We don't speak of the medical model of medicine in medicine or the medical model of pneumonia. There is no other model. We don't speak of the electrical model of why a light bulb emits light. Language is very important. If a person says: "I am against the medical model of mental illness," that implies that mental illness exists and that there is some other model of it. But there is no mental illness. There is no need for any model of it.

The important issue is not the "medical model," a badly abused term; the issue is the "pediatric model," the "irresponsibility model" — treating people labeled as mentally ill as if they were little children and as if the psychiatrist was their parent. The pillars of psychiatry are medically rationalized and judicially legitimized coercions and excuses.
RW: If you were to use mental illness as a metaphor, or pseudonym… disease meaning “dis-ease,” people are personally distressed, the psychosocial model of mental illness. If you substitute “emotional troubles”.
TS: No. That won't do. Almost anything can be the cause of emotional trouble — being black or being poor or being rich, for that matter. Innumerable human conditions can create human distress. Which ones are we going to medicalize, and which ones are we not? We used to medicalize, psychiatrize, blacks running away from slavery, masturbation, homosexuality, contraception. Now we don't. Instead we medicalize what used to be called melancholia, and sloth, and self-murder, and racism, and sexism.
RW: To shift gears.
TS: Let's not yet. Because I want to add that
it is this tendency to call more and more human problems "diseases" and then try to remedy them, or "attack" them, as if they were diseases is what I call "the therapeutic state."
it is this tendency to call more and more human problems "diseases" and then try to remedy them, or "attack" them, as if they were diseases is what I call "the therapeutic state."
RW: Certainly everything used to be viewed religiously, and now so much is seen as medical. The transformation is almost pure.
TS: Exactly! And it's perfectly obvious. It requires the systematic educational and political dumbing down of people not to see it. Three hundred years ago, every human predicament was seen as a religious problem — sickness, poverty, suicide, war. Now they are all seen as medical problems — as psychiatric problems, as caused by genes and curable with "therapy." In the past, the criminal law was imbued with theology; now, it's imbued with psychiatry.
RW: President Bill Clinton is a prime example of how we use different models to describe the same problem. His wife said his problems were due to “emotional problems” in his childhood. His brother said he was a sex addict, because he was a drug addict, himself. And Bill Clinton said it was a sin issue — the religious model. He went to a minister.
TS: That's a good point. But note that Clinton didn't go to a real minister. He went to a politician — Jesse Jackson. His job was to make Clinton look good again. And he did it. Clinton hand-picked him as he did the others, much as a medieval emperor might have hand picked a bishop to make him look good.
RW: Can I shift gears now?
TS: Sure.

Liberty and the Practice of Psychotherapy

RW: You’re known as a libertarian.
TS: Yes, I am a libertarian.
RW: It’s a philosophical view, an economic and political view. What does that mean in terms of practicing psychotherapy?
TS: I'll start at the end, so to speak. If you use language carefully and are serious about libertarianism and psychiatry, then the term "libertarian psychiatrist" is, quite simply, an oxymoron. Libertarianism means that individual liberty is a more important value than mental health, however defined. Liberty is certainly more important than having psychiatrists lock you up to protect you from yourself. Psychiatry stands or falls with coercion, with civil commitment. Non-coercive psychiatry is also an oxymoron. This is one of the main reasons why I never considered myself a psychiatrist — because I always rejected psychiatric coercions.

Now, in term of political philosophy, libertarianism is what, in the 19th century, was called liberalism. Nowadays it's sometimes also called "classical liberalism." It's a political ideology that views the state as an apparatus with a monopoly on the legitimate use of force and hence a danger to individual liberty. Contrariwise, the modern "Liberal" view regards the state as a protector, a benevolent parent who provides security for its citizens as quasi-children. To me, being a libertarian means regarding people as adults, responsible for their behavior; expecting them to support themselves, instead of being supported by the government; expecting them to pay for what they want, instead of getting it from doctors or the state because they need it; it's the old Jeffersonian idea that he who governs least, governs best. The law should protect people in their rights to life, liberty, and property — from other people who want to deprive them of these goods. The law should not protect people from themselves.

This means that, as far as possible, medical care ought to be distributed, economically speaking, as a personal service in the free market. There is much wisdom in the adage, "People pay for what they value, and value what they pay for." It's dangerous to depart too far from this principle.
RW: Why does money necessarily have to come into it? If people have less money, they can’t afford as much as others who have more money. A poor person can benefit from therapy.
TS: Of course. The issue you raise confuses the quest for egalitarianism with the concepts of health or psychotherapy and also with the quest for health. Why should psychotherapy be dispensed in a more egalitarian manner than anything else? Also, people often value things other than health more highly than they value health — such as adventure, danger, excitement, smoking.

Let me elaborate on this. Economists and epidemiologist have shown, beyond a shadow of a doubt, that the two variables that correlate most closely with good health are the right to property and individual liberty — the free market. The people who enjoy the best health today are people in the Western capitalist countries and in Japan; and those in the poorest health are the people who enjoyed the blessings of 80 years of paternalistic statist, Communism. In the Soviet Union, where people's political liberty and economic well being were systematically undermined by the state — where they enjoyed "equal misery for all" — life expectancy dropped from more than 70 years to about 55 years. During the same period, in advanced countries, it increased steadily and is now almost 80. And medical care has little to do with it, since Russia had access to medical science and technology. It's primarily a matter of life style — of what used to be called good habits versus bad habits. And of good public health, in the sense of having a safe physical environment.

Psychotherapy, Szasz Style

RW: You wrote, “The Ethics of Psychoanalysis” in 1965. That was your diving into psychotherapy, psychoanalysis. What do you have to say about what is useful in psychotherapy? What theories do you hold to or do you find valuable? When you’re in a free relationship of psychotherapy — simply put, one person helping another with their personal issues — what have you found to be helpful, and what theories have you used in your own work?
TS: You are asking two questions: what did I find useful or interesting and what theories did I use. The kind of therapy one does, if one does it well, in my opinion, is selected and depends primarily on the therapist.
Different people have different temperaments about how to relate to other people. Because the therapeutic relationship is an intimate, human relationship with another human being, the kind of psychotherapy that makes sense to therapists reflects the kind of person they are.
Different people have different temperaments about how to relate to other people. Because the therapeutic relationship is an intimate, human relationship with another human being, the kind of psychotherapy that makes sense to therapists reflects the kind of person they are. In this respect, psychotherapy could not be more different from physical therapies in medicine. The proper treatment of diabetes does not depend, and ought not to depend, on the doctor's personality. It's a matter of medical science. On the other hand, the proper treatment of a person in distress seeking help is a matter of values and personal styles — on the parts of both therapist and patient.

The proper analogies to psychotherapy are not medical treatment but marriage or raising children. How should a man relate to his wife, and vice versa? How do you raise your child? Different people relate differently to their wives or husbands or children. As long as their life style works for them, that's all there is to it. So, first I say that I believe that any kind of so-called "therapy" — any kind of human helping situation that makes sense to both participants and that can be entered and exited and conducted wholly consensually, voluntary, and that is devoid of force and fraud — any and all of that is, by definition, helpful. If it were not helpful, the client wouldn't come and pay for it. The fact that a client returns and pays for what he gets from a therapist is, prima facie evidence for me, that he finds it helpful.

I would compare it, once again, to religion, to going to church. Personally, I'm not religious. But I respect religions and people who find solace in their faith. Millions of persons the world over continue to go to church. They wouldn't be going to church if they didn't find it helpful, assuming they're not just going for purely social reasons, in which case they still find it useful, though not for strictly theological reasons.
RW: What was your initial interest in becoming a psychiatrist?
TS: I was never interested in becoming a psychiatrist and never considered myself a psychiatrist. Psychiatry was a category I had to operate in, given the society in which we live. I was interested in psychotherapy, in what seemed to me the core of the Freudian premise – and promise, which, unfortunately, never materialized as a professional code. Freud and Jung and Adler had a very good idea — that is, that two people, a professional and a client — get together, in a confidential relationship, and the one tries to help the other live his life better. Each of these pioneers emphasized a different aspect of how best to go about this business. There are three aspects to life: the past, the present, and the future.
Freud dwelled on the past, Jung dwelled on the future, and Adler (and Rank) dwelled on the present. All of these make sense. But all this has to be tailored to whether or not it makes sense to the patient.
Freud dwelled on the past, Jung dwelled on the future, and Adler (and Rank) dwelled on the present. All of these make sense. But all this has to be tailored to whether or not it makes sense to the patient.
RW: How does this play out in term of the therapeutic relationship?
TS: The relationship has to be wholly cooperative. The two people may meet only a few times, or they meet many times over many years. The therapist is the patient's agent. This doesn't mean that he must agree with everything the patient believes or wants; far from it. But it means that the therapist is prohibited — by his own moral code — from doing anything against the patient's interest, as the patient defines his interest. That is part of my idea of the contract with the patient. That's why I titled my book, "The Ethics of Psychoanalysis." Therapy is a matter of ethics, not technique.

It was crucial that my patients selected themselves. They came when they wanted; they came to see me, because they wanted to see me, not someone else. And there wasn't any of this business about being "ready" to end therapy. Just as the patient decided when or whether to begin therapy, so he decided when or whether to end therapy. There isn't any of this business that the therapist has to change the patient, or make him better, or control his behavior, or protect him from himself, and so forth. It is up to the patient to change himself. The therapist's job is to help him change in the direction in which the patient wants to change, provided that's acceptable to the therapist. If it's not acceptable, then it is therapist's job to discuss that with the patient and end the relationship.
RW: What are the expectations of the patient then?
TS: The patient doesn't have to do anything except pay. This sounds like a selfish joke. It is not. It is important. It's up to the patient what he or she takes away from the situation. The situation is similar to what happens in school, especially at the university level. If you go to school and have to pay for it, the idea is that you should learn something. But there is no coercion. At the end of it, if you don't learn something, that's your business. It's your loss.
RW: You mentioned that change isn’t a prerequisite, yet most people want some change.
TS: It's not that simple. People want to change and they also don't want to change. The behavior that the patient wants to change must, in some way — this is very Freudian — be also functional for the patient, or else he would already have changed it, without formal therapy. People can and do change themselves.
RW: Adaptive?
TS: Adaptive. Exactly. So-called mental symptoms are rather unlike medical symptoms. A cough, say, if you have pneumonia, is adaptive: it rids the body of mucus and infectious material and tissue debris as sputum. But it's adaptive in this or other similar pathological situation only. It's not adaptive to you as a human being. But a phobia, anxiety, depression, etc. maybe adaptive as some kind of a life strategy, economic or interpersonal strategy.
RW: Your goal for psychotherapy, that is, the fully-functioning human, is to increase their autonomy. You did have that as a goal.
TS: That was my underlying goal, which I communicated [to my clients] as the ethical principle. My premise is that responsibility is, morally speaking, anterior to liberty. So if a person wants to gain more freedom — in relation to his fears, his wife, his work, etc. — he must first assume more responsibility (than he has been) toward them; then he will gain more liberty in relation to them.
The goal is to assume more responsibility and therefore gain more liberty and more control over one's own life.
The goal is to assume more responsibility and therefore gain more liberty and more control over one's own life. The issues or questions for the patient become to what extent is he willing to recognize his evasions of responsibility, often expressed as "symptoms."
RW: That’s a dialogue.
TS: Yes, that is likely to be a focus of the therapeutic dialogue. Actually, some people say they want to do this or that — say stop smoking or be a better parent — but they don't really want to do it, don't want to forego the pleasures of smoking or experience the burdens of caring for a dependent. A person comes to see a therapist and says that he wants to kill himself. Obviously, that's not all he wants. He also wants psychotherapy. In short, people are often ambivalent about basic choices. Ambivalence is not a pathological symptom; it a normal, appropriate mental state of many people, in many situations.
RW: Come back home to therapy, again, you’re not practicing any more?
TS: No, but I did for 45 years.
RW: What was the most difficult and what was the most satisfying for you in working with people one-to-one?
TS: I found practicing therapy very satisfying and not at all arduous. I left Chicago for Syracuse mainly to escape having to fully support myself from doing therapy, which can create financial temptations to make the client dependent on therapy. Of course, everyone who does therapy is likely to say it, but I think a lot of people benefited from having a "conversation" with me.
RW: With all your work in politics and philosophy, your work on psychotherapy is overlooked. That you were in the trenches, helping people, conversing with them.
TS: And many of the people I saw would have been diagnosed as very sick by other people. Some of them would have been diagnosed as psychotic and put on psychiatric drugs.
RW: You never prescribed?
TS: No. Never when practicing psychiatry — psychotherapy —
I never prescribed a drug. I never gave insulin shock or electric shock. I never committed anyone. I never testified in court that a criminal was not responsible for his crimes. I never saw, as a patient, anyone who did not want to see me.
I never prescribed a drug. I never gave insulin shock or electric shock. I never committed anyone. I never testified in court that a criminal was not responsible for his crimes. I never saw, as a patient, anyone who did not want to see me. I went into psychiatry with my eyes wide open. I never viewed psychiatry or psychotherapy as a part of medicine. Perhaps I should add, though it should be obvious, that I had no objections to the patient taking drugs or doing anything else he wanted. As far as I was concerned, things outside the consulting room were not my business — in the sense that if the patient wanted to take drugs, he had to go to a doctor and get them, just as if he wanted a divorce, he had to go to a lawyer.
RW: With the laws today, it’s very hard for a therapist or a psychiatrist to practice psychotherapy. You can shy away from involuntary hospitalization, or other state mandates, or insurance demands, but when push comes to shove, you are pressured to break confidences or end up in trouble.
TS: That's putting it mildly. For all practical purposes, it's impossible. It is the hallmark of totalitarianism that there can be no personal secrets from the state. That's why I call our present political system a "therapeutic state." Such a state is your friend, your benefactor, your doctor. Why should you want to hide anything from it? Keep in mind that it was impossible to do psychotherapy in Soviet Russia, too, or in Nazi Germany. Suppose someone came to you in Nazi Germany and said, "I'm harboring Jews in my cellar." If you did not report that, you ran the risk of being put in a concentration camp and gassed. Today, if you don't report that the patient is suicidal, or homicidal, or a child abuser, among other mandates, you are asking for trouble. So confidential psychotherapy is kaput, finished. Therapists and patients kid themselves that it isn't.

What can you do? Nothing. We have managed to make the free practice of psychotherapy de facto illegal! The psychotherapist has been transformed into a reporting agent, an agent of the state whose job is to betray his patient. Child abuse, drug abuse, violence, suicide — the therapist must stop, must prevent, all these things. The therapist must be a policeman pretending to be therapist. Increasingly, people complain about one or another of these "problems of confidentiality," but they don't see the larger picture. They don't see that this has to do with the alliance of psychiatry and psychotherapy with the state, replicating the alliance of church and state and all its implications.
RW: Even more so, when people go to a therapist who’s working under managed care, they have to have enough problems to get in the door to see the therapist and talk, or get drugs, but not too many problems. If they have too many problems they’re seen as “chronic” and they can’t get help. Do you think a therapist working under managed care is able to freely practice psychotherapy? Is the client free to work in psychotherapy?
TS: Psychotherapy under managed care is a bad joke. It's like religion under managed care, or education under managed care. Even medical care gets complicated and contaminated if the direct relationship between doctor and patient is disrupted by the input of third parties, if the patient doesn't, in some form, pay for what he gets, and if he can't get what he wants with the money he pays.

Modern psychotherapy is based on psychoanalysis, and the psychoanalytic relationship was based on the relationship between priest and penitent in the confessional. The crux of the confessional is self-accusation on the part of the penitent, and the secure promise, by the priest, that the confession he hears will and can have no consequences for the self-accuser in this world (but only in the next). A priest hearing confession and working as a spy for the state would be a moral obscenity. Not in the darkest days of totalitarianism did such a thing occur.

The same thing is true for psychotherapy based on confidentiality and on the premise that the patient "accuses" himself in the hope that, by so doing and with the help of the therapist, he might be able to change himself.
What is truly ugly about psychotherapy today is that many patients labor under the false belief that what they say to the therapist is confidential
What is truly ugly about psychotherapy today is that many patients labor under the false belief that what they say to the therapist is confidential, and that therapists do not tell patients, up front, that if they utter certain thought and words, the therapist will report them to the appropriate authorities, they may be deprived of liberty, of their job, of their good names, and so forth.

Now, it should be clear that to place psychotherapy under the control of an insurance company or the state — that's just heaping nonsense upon nonsense. We can still call it psychotherapy, and we can treat it as if doing psychotherapy, "curing souls," were in principle no different from doing orthopedic surgery, setting a fractured bone. But, psychotherapy is like going to church. You go there voluntarily for a certain kind of service from a certain person. And it's spiritual. It's not physical.
RW: We only have a couple of minutes left. I want to ask you one or two more questions. It was a pleasure to talk about your therapy, because you get very little chance to talk about that work given the vitriol surrounding many of your views.
TS: Thank you.

Critics and Heroes

RW: You’ve had a lot of critics in your career.
TS: You can say that again!
RW: Maybe an enormous amount! In your book, Insanity, you point out all the critics.
TS: Not all of them!
RW: You couldn’t mention all of them?
TS: No. Just a few (laughter).
RW: How do you deal with this? You’re one of the most criticized psychiatrists in history, perhaps. I don’t know anybody else who’s as criticized as you are.
TS: I was very fortunate. I had very good parents, a very good brother, a very good education as a child in Budapest. I have very fine children, good friends, good health, good habits, a fair amount of intelligence. Really, I have always felt blessed. It also helped at lot that I felt there were many people who agreed with me — that what I'm simply saying is simply 2 + 2 = 4 — but that many people are afraid to say this when it is personally and politically improvident to do so. I haven't made any scientific discoveries. I'm simply saying that if you are white and don't like blacks, or vice versa, that's not a disease, it's a prejudice.
If you're in a building that you can't get out of, that's not a hospital, it's a prison.
If you're in a building that you can't get out of, that's not a hospital, it's a prison. I don't care how many people call racism an illness or involuntary mental hospitalization a treatment.
RW: Did the criticism ever get you down?
TS: Of course it did, especially when people actually wanted to injure me — personally, professionally, legally. No need to get into that. I tried to protect myself and escaped, luckily enough. I found boundless support in literature, in the great writers. Ibsen said, among other things, that "the compact majority is always wrong."
RW: My last question. In addition to being criticized a great deal, you are also somewhat of a hero to a lot of people, in what you’ve fought for, liberty, individual rights, and increased freedoms with responsibility. Who are the your heroes, since childhood and now?
TS: Where should I start, there are many? Shakespeare, Goethe, Adam Smith, Jefferson, Madison, John Stuart Mill, Mark Twain, Mencken. Tolstoy, Dostoyevski, Chekhov. Orwell, C.S. Lewis. Ludwig von Mises, F.A. Hayek. Camus and Sartre, though personally and politically, he is rather despicable. He was a Communist sympathizer. He was willing to overlook the Gulag. But he was very insightful into the human condition. His autobiography is superb. His book on anti-Semitism is important.
RW: Camus challenged him.
TS: Yes, Camus broke with him, mainly about politics. Camus was a much better person, a much more admirable human being. He was also a terrific writer.
RW: We could go on about how each of them influenced you, I am sure of it, another day perhaps. I want to thank you for being with us today. I am sure our readers will appreciate your candor.
TS: Thank you.

Ronald Levant on Psychotherapy with Men

Posted on by rezendevknowfully.com

“I was the father without a clue.”

Randall C. Wyatt: Your work has focused on gender, the psychology of men, the problems with traditional masculine socialization, psychotherapy with men, and fatherhood, in addition to your work as APA (American Psychological Association), President and the evidence-based practice of psychology. Let’s start with the psychology of men and your upbringing. What was your upbringing like?
Ronald Levant: I was raised in a really tough neighborhood, and where I grew up, if a boy starts to show vulnerability, he's also so violated the male code as to warrant severe punishment.
RW: Typically, if a boy shows he cannot withstand or deal with the teasing it does not bode well for him as a kid.
RL: Yes, I witnessed scenes as a child where boys were beat up by other boys for crying.
RW: You grew up in Los Angeles? Whereabouts in LA?
RL: Southgate. South Central Los Angeles. No, I wasn't a member of the Crips and Bloods.
RW: But it was a tough neighborhood?
RL: Yes. At that time, South Gate was all white and it bordered Watts, which was all black. Southgate was pretty much a blue collar town. There were two major factories in the town then, Firestone and General Motors, and most of the fathers of my friends worked on the line. So it was a working class, tough neighborhood.
RW: Did these early experiences spark your interest in men’s psychology and psychotherapy with men?
RL: Actually, it was being a divorced, semi-custodial father. My wife and I lived in California. Then she moved to New York, and I moved to Boston, and we worked out an arrangement where I had my daughter for the summers. And I would travel several times a month to visit her in New York.

But the visits when she lived with me did not go well and I felt like I was the father without a clue. I didn't really have a good idea of what a father was supposed to be, because when I thought about my own dad, his idea of having quality time with me and my brother was to have us do some work and he'd supervise.

As a psychologist, young assistant professor at Boston University, responsible for teaching the courses in family psychology and having a research program on parent training,

I felt like I was a fraud, because here I am an expert in parenting and family stuff, and yet, I'm so ineffective with my own daughter.
I felt like I was a fraud, because here I am an expert in parenting and family stuff, and yet, I'm so ineffective with my own daughter.

And like most men, I didn't talk about it with anybody. Again, I was a fairly traditional masculine guy and I didn't talk about it. Just sucked it up and tried to keep doing it, until I saw the movie Kramer vs. Kramer (1979).

RW: I remember that film; it was talked about a great deal, with Dustin Hoffman and Meryl Streep. Did it hit you right away?
RL: Not right away. I had to think about it for a few days, frankly. It led me to realize that it wasn't a case of my personal inadequacies, though I might have been inadequate is some ways. It was more of a case that this was really a shift in roles for fathers, in that men of my generation were doing things that our dads never did. And maybe we weren't really well-prepared for it. Maybe we could get prepared for it. And so that led to a whole chain of thinking that was the proverbial fork in the road in my career.
RW: And then you began to focus on the study of fathering?
RL: I shifted from parent training to fathering. I started the Boston University Fatherhood Project a few years later. I discovered this lack of emotional self-awareness in my fatherhood work. I used to run these fatherhood courses where we would get six or eight guys to meet together for eight weeks and we would teach them a little bit about fathering. We had a grant that allowed us to purchase an incredible amount of video equipment. Video was very cool in the early '80s, and we had a big room lined with video decks, monitors and special effects generators, microphones hanging from the ceiling, and three tripods with cameras in the middle of the room; so when the guys would come into the room for the first time, they would be just blown away. They'd say, "Wow, these guys have some really cool equipment."

And we'd tell them, "We'll teach you how to be a better father the same way you might have learned how to play a sport like golf or tennis. We'll videotape it, do the instant replay, analyze how you could do it better, and try it again. And we'll practice." A very hands-on approach.

RW: One thing I have really appreciated about your work is that you join with the men and use sports metaphors, which many men can relate to. On that note, one of my early supervisors used to say to men in couple’s therapy, “If Michael Jordan only dribbled with one hand; they’d be able to figure him out really quickly and be able to defend him easily. You’ve got to be able to dribble with both hands. And you know how to think and be logical but you’re ignoring the other side of it, your emotions, which can be learned too.”
RL: That's excellent.
RW: Instead of forcing these men into some therapy-contrived way to express emotions, as in, “How do you feel now,” you really join with the men and say “we.” A lot of men are ashamed or embarrassed to come to therapy since they think it won’t relate to their way of thinking. The traditional therapist says “How do you feel? What are you feeling now?” The traditional male replies, “I don’t know” and leaves feeling more inadequate or that therapy is just not for them.
RL: Right. And then, "What's wrong with you?" From what I've said about my background, you can see that it's not that hard for me to empathize with traditional men. A lot of my friends growing up, myself and my family were traditional men, so it's not a stretch for me. I don't have to imagine it, I lived it. Having been trained in the Rogerian tradition, I want to start off by being as empathic with their experience as I possibly can be.
RW: Did getting into the psychology of men and fatherhood change your relationship with your daughter?
RL: Not right away because the fact that I got into this work didn't have an immediate impact on me. I probably didn't really fundamentally change until later when I went into analysis, which would have been in the later '80s. I went into psychoanalysis for four years and, regardless of what the empirical research says about it, it worked wonders for me.
RW: How so?
RL: Psychoanalysis helped me kind of get through a lot of my own constraints as a human being, some of which were about masculinity and some of which were unique to me, but it was a marvelous experience. I'm really glad I did it. And I think it obviously helped me and my relationships.

You know, I have a good relationship with my daughter now. I have a great relationship with my grandsons. So it didn't work out too badly.

A New Psychology of Men

RW: Let’s talk about your work on the psychology of men and gender. Where have we been and where are we now?
RL: When we talk about gender and men in particular, where most of my own work lies, we were pretty blind. Most of the key, long term studies on personality development were done on boys and men at Berkeley and Harvard. And that basic personality development, personality theory, and developmental psychology was the psychology of boys and men until the feminists came along in the '70s and said, "Whoa, women are not simply a deviation from male development. Let's study females, too." So there was a period in time where psychologists thought it reasonable to study only men.
RW: You make another point in your work: that psychologists in their research were studying men a great deal, but in the clinical world, psychoanalysis, it was men studying and treating women, who were the patients. Such irony.
RL: That is a very ironic thing. I'm working with a group in Division 51 of APA, the Psychology of Men and Masculinity, writing guidelines for the psychological treatment of boys and men. We just met a few days ago at the University of San Francisco— we were writing the preamble— and we had to focus on that very same irony because personality and developmental psychology really was based on male samples, but the whole approach of the psychotherapeutic endeavor was, as you pointed out, based on the idea of men treating women.

Like Freud and Breuer with their female patients they considered hysterical. And it pretty much continued that way through the '60s. So our models of psychotherapy have to be revised, really have to be revised radically.

RW: Even the most famous videos in the psychotherapy field… what video do you think of?
RL: Well, the one that would come to mind for me would be Rogers, Perls and Ellis with Gloria.
RW: Exactly. And that’s what a lot of psychologists and therapists were trained on in their graduate programs.
RL: Your mention of the Gloria video makes me think about something related, it's a bit of trivia. I was trained in the client-centered school. My advisor and professor was John Shlien, who trained with Rogers. Shlien and I put together a book in the '80s called Client-Centered Therapy and the Person-Centered Approach in which Carl Rogers contributed two essays, one of which was a story of his continuing relationship with Gloria. Gloria contacted Rogers after the filming and they developed a lifelong relationship as a result of that half-hour interview. She became very attached to him. She died tragically in her 50's of cancer, but she became friends with Carl and his wife, and would visit. And so it's a remarkable essay on what a 30-minute interaction can create.

Traditional Masculinity is Hazardous to Men’s Health

RW: Now let’s jump into the psychology of men. For a long time, in the ’60s and ’70s in particular, the whole idea of men and women being different was frowned upon, that the sexes were not so different after all. Now we see books and studies on Mars and Venus, on gender communication differences. It seems the pendulum goes back and forth in our culture with politics playing as much a role as the research itself. Where can we begin with this discussion without getting lost?
RL: The bottom line to it all is that men and women are really not that different. We're talking about biology here. Sex. You know, male, female.

Going back to the 70's, when Maccoby and Jacklin did the first kind of major synthesis of the psychology of sex differences, all the way up to Janet Hyde's recent article in the American Psychologist (The Gender Similarities Hypothesis). If you look at any kind of behavioral, psychological, or cognitive traits, what you will find is that there are only a handful of small mean differences, and you will find overlapping distributions. And you'll find within those distributions that, say, males are higher in this trait than females, and you'll find lots of females who are higher than lots of males. Imagine two bell curves with the means very close together, you can see that there's just lots of overlap. So Hyde says, "Let's talk about gender similarities," and that's really true.

But she's misusing the term "gender." It's really sex similarities. It's about biology. Males and females are not that different.

RW: Ok, how are you using gender?
RL: Gender is masculinity and femininity, actually, and in many ways they are like polar opposites. Masculinity and femininity are the ways in which we socialize boys and girls and the ways in which we relate to adult men and women that reinforce or punish certain behaviors. Masculinity is the antithesis of femininity. Whereas men are socialized to traditional masculinity, which would have men be tough and aggressive, women are expected to be nurturing and caring.

We have an ideology about gender that varies within subcultures and societies and is something that I've spent 15 years studying, actually, looking at masculinity ideology. And there tends to be a certain amount of adherence to what my colleagues and I define as traditional masculinity ideology, which is the notion that

men should avoid anything that hints of the feminine, restrict the expression of emotions, be aggressive and dominant, be extremely self-reliant, be studs and always be ready for sex.
men should avoid anything that hints of the feminine, restrict the expression of emotions, be aggressive and dominant, be extremely self-reliant, be studs and always be ready for sex.

RW: The strong cowboy and the Marlboro man.
RL: Yes. The traditional, macho version of masculinity is still adhered to in varying degrees within societies and subcultures. I developed the Male Role Norms Inventory when I was at Rutgers back in the late 80's. It measures seven norms of traditional masculinity ideology and nontraditional masculinity ideology. I used that to study African American males and females, European American males and females, and Latino males and females in this country and abroad. We looked at Russians versus Americans, Chinese twice, before and after the NGO Conference on Feminism in Beijing. And my collaborators have studied it in Japan, South Africa, and Pakistan. So we have quite a bit of data, and we've recently developed a parallel measure for women called Femininity Ideology, a scale which we're just now studying that looks at five norms of traditional femininity ideology.

So ideology or the belief about how men and women ought to behave is a very powerful construct. There are a number of masculinity constructs that have been derived from this paradigm. One is the endorsement of traditional masculinity ideology, the second is conformity to male norms, the third is gender role conflict, and the fourth is gender role stress. And these four constructs—all of which are measures developed by myself and my colleagues — have been used in hundreds of studies, and one of the things that you find is that the higher the level of masculinity, the more the problems.

RW: The more masculinity, the more the problems? Say more about that.
RL: In my scale, the greater the endorsement of traditional masculinity ideology, the more likely it is that the person is alexithymic, which means they have an inability to put emotions into words.

They are more likely to endorse coercive and harassment attitudes towards females. For boys, using a similar measure to mine, they're more likely to have drug and alcohol problems, have early sex and drop out of school. Using Jim O'Neill's measure, The General Conflict Scale, they're more likely to be depressed and have relationship issues.

The long and short of it is that traditional masculinity is hazardous to men's health.
The long and short of it is that traditional masculinity is hazardous to men's health.

RW: It’s not uncommon for a man to come into therapy and say something like, “I was taught not to show my feelings. I was taught to be tough, to ignore those things. I don’t really think I need to be here, therapy is not for me.”
RL: When a man comes into therapy that man could be anywhere on a scale from one to 100 in terms of where they are in their masculinity and I think one of the first messages I would say to clinicians is: think about that. A man is not a man is not a man, but a man may be hypo-masculine, hyper-masculine or somewhere in between, and that's going to be a big difference in how they're going to respond to therapy.

I've created an instrument, the Normative Male Alexithymia Scale, which is available free in the journal Psychology of Men and Masculinity. It's a 20-item scale that you could administer relatively easily to your clients that would give you an indication of whether or not they are likely to be alexithymic. It's a good instrument, only twenty items, with strong reliability and validity, so it's a fairly easy way to assess it.

The fact is, you can assess how traditional a man's view—your client's view—is of masculinity. That's going to make a big difference in how you're going to want to approach him.

RW: In your video, Effective Psychotherapy with Men, you assessed, in session, how your male client made sense of his emotions.
RL: You can probably get a good sense just from the initial encounter by how the man responds to questions, and you might ask him to describe how they felt in certain circumstances, to see whether they're capable of describing how they felt. And men do vary. Again, we have to think of masculinity, not men. There are some men who have not been reared to conform to traditional masculinity or have gotten over it and are fully capable of experiencing and expressing a wide range of emotions. There will also be men who are harshly socialized, maybe even punished for any deviations to the male code. They might have even been traumatized for showing non-stereotypical feelings and have a really hard time answering your questions and will feel ashamed of themselves for even trying to express vulnerability.

Mistakes Therapists Make Working with Men

RW: Let’s focus on that traditional man, because it is that man with traditional masculinity that’s difficult for many therapists. Therapists are used to clients that come in talking about their feelings. They want a verbal, expressive client.
RL: They want a client who's more like a stereotypical female. A man that exhibits the kind of openness to emotions that is ascribed for women and that's an essential core component of femininity. And some men are indeed like that.

But as you point out, you don't need a special training video to learn how to work with those men. You can apply what you already know, and it will work. But the man who doesn't want to be there — his wife forced him to be there. His boss said, "Look, if you don't do something about your lateness" or, "If you don't do something about your aggression." Or the man runs into a few DUIs and has a substance abuse problem and is forced in. Oftentimes, those men don't come voluntarily. They're forced in by circumstances. And so it's a very delicate act to get them engaged.

RW: Can you tell us some of the things you think about when trying to get these traditional men engaged?
RL: I want to connect with what brought them there. Their wife told them to come but they didn't have to come. Okay, you came. So therefore, you must want to preserve your marriage, and you probably want to figure out what you can do about it, right? So I try to start building the alliance with their motivation for being there. There's some motivation. Let's find out what it is. How can we build on it? I try to connect that to my assessment of where they are, if this man is also alexithymic, as I did in the video.
RW: And what if they are alexithymic?
RL: If the man is alexithymic, as Raymond is in the video, I will give a little introduction to masculine socialization: "We men were raised in such a way that we felt it was really inappropriate to express vulnerable emotions, to even dwell on them too much. But the fact is, for you to resolve these problems, you're going to have to learn a lot more about your emotions than you've ever known. The good news is there's a short way to get there. We have a structured method for teaching men how to learn to identify and process their emotions."

You'll encounter lots of resistance along the way. In the video, I am going over the emotional response log with the client and he says, "I can identify 10 emotions but I've still got a problem to deal with."

I came back and I said, "Well, yes, indeed. You do. But I think you're going to be in a much better position to deal with the problem if you kind of know what you're feeling and process that rather than stay stuck in being angry, say, at your shop for delaying the repair of your car."

RW: What kinds of reactions do you get from that, or what resistances emerge?
RL: They might come up with other kinds of resistance, like a common thing I've heard men say is that if they learn how to express their emotions they'll have no choice but to express them. And I say, "Well, actually no.
You're going to have more choices than you have now. You only have one choice now, which is not to express your emotions."
You're going to have more choices than you have now. You only have one choice now, which is not to express your emotions."

And in Raymond's case, to somaticize it, you get a headache or a stomachache. Or in some other man's case, to numb himself by drinking or chasing women, or whatever the maladaptive method that has evolved in that man's life for dealing with psychological distress. And so, "You really have limited choices now. If you can identify and think about your emotions, that is, route it through your cortex rather than simply have it go from your limbic system to your musculoskeletal system, you can choose."

RW: From your emotions to your body, use your mind in between.
RL: That's it. You said it more simply than I did. (laughter)
RW: Reframing.
RL: But that's exactly what it is. If you think about what happens in the socialization of boys, a lot of boys really are humiliated around the expression of vulnerable emotions. "Big boys don't cry," or worse, somebody teases them or picks on them and they show vulnerability and their friends laugh at them or beat up on them, depending on the kind of neighborhood they live in.
RW: What mistakes have you found that therapists commonly make in working with traditionally masculine men, and what can therapists do to work better with these men?
RL: The mistake both male and female therapists make is to really not be aware of how the differences in men and how masculinity affects men's functioning. I think that it's really a knowledge thing. Unless you've taken a course in gender issues in psychotherapy, you're probably not likely to know about this. So to not stop and think, "What kind of man am I dealing with? To what extent has he been affected by masculinity? How alexithymic is he? How am I going to work with him? How much shame does he have about just being here?" If he's very traditional, he's going to be feeling very ashamed. So just simply not knowing some of these front-end issues and that really have to factor into the very initial minutes of your meeting. I think that's one of the first things.
RW: Instead of, “This guy’s annoying. He doesn’t talk about his feelings, doesn’t say anything emotional or immediate, why is he here, what is his problem?”
RL: Exactly. Just like a lot of wives find men annoying and they think that they're just being obstinate:
"I told you I want to talk about your emotions. What's wrong with you? Please share your innermost feelings with me. What the heck's wrong with you? Why aren't you doing that?"
"I told you I want to talk about your emotions. What's wrong with you? Please share your innermost feelings with me. What the heck's wrong with you? Why aren't you doing that?"
RW: And do you find when you work with men that they can change on these things and are they grateful that they have?
RL: Yes, and I actually now have some hard data. I did a pilot study of a flexible, manualized treatment and we did a pilot study with a group that received that treatment and another group that did not. We used the Normative Male Alexithymia Scale and the Male Role Norms Inventory. We showed that after six sessions, we were able to significantly reduce the men's scores on alexithymia and on the endorsement of traditional ideology.

So not only do I have clinical, anecdotal case study evidence from treating dozens of such men when I had my practice in Boston, but now I actually have at least pilot study data—not a randomized clinical trial, just a comparison group—that show that this kind of treatment does help men reduce their alexithymia and reduce their adherence to strict male norms.

The Three-Legged Stool of Evidence-Based Practice

RW: To switch to another important part of your work as the President of the American Psychological Association in 2005, you were instrumental in creating the APA Presidential Task Force on Evidence-Based Practice in Psychology. Could you tell us how that all came to be?
RL: Sure. In 1995, APA Division 12, the Division of Clinical Psychology under the leadership of David Barlow, established a task force on empirically validated treatments, and took a rigorous scientific approach to practice focused on empirically validated treatment. The treatment had to be subjected to two randomized clinical trials using a manualized treatment, using measures that had good reliability and validity. They had a list of criteria, which would be considered the highest standard for experimental clinical research, and as a result of that, they generated 8 treatments, most of which were cognitive-behavioral or behavioral. This task force identified 18 specific disorders that met this criteria and could be treated with manualized treatments. And this was disseminated as a list of empirically validated treatments. It was updated a couple of times.

People had problems with that approach because those treatments were really validated on a narrow band of the clinical population. For one thing, the randomized clinical trials that they were based on largely excluded patients with two disorders, virtually excluded people of color, and thus were basically an artificial population. Like many clinicians, I have yet to see many patients who have only one diagnosis. I couldn't find an empirically validated treatment that had two randomized control trials that fit the population I treated, which was a combination of Axis I substance abuse and Axis II problems. And that's true for many clinicians, especially when you rule out co-morbidity.

RW: Then there is the question of using manualized treatments.
RL: Now there's a spectrum of views on manualized treatments. The most narrow view reduces the role of clinician to that of technician and allows very little deviation from the manual. The manuals that were personified in the Division 12 lists were the really rigid manuals. And then there are much more clinically sophisticated versions, like Steve Hollon's work that recognizes that therapy does have to be tailored to the needs of the person and that you do have to attend to the relationship.

So you know, it's not like a manual is always a manual.

RW: Not all manuals are created equally.
RL: So getting back to your question about why we set up the Presidential Task Force on Evidence-Based Practice. We did so because we felt we needed a much broader look at the role of evidence in practice, and we were inspired by the Institute of Medicine's approach to evidence-based medicine, which basically said that evidence-based medicine rests on a three legged stool. One leg is the research evidence, but we took a much broader approach to defining research evidence. We didn't say that only randomized clinical trials should be looked at. Certainly, they are the only way to determine causation, but they're not the only kind of research evidence. Correlational studies can help, too.

We said there's another variable, the second leg, that's ignored in the Division 12 approach, and that's the experience of the therapists. That was dismissed.

RW: Clinical judgment, clinical impressions.
RL: And clinical expertise. And it was dismissed because of the Kahneman and Tversky article about heuristics, essentially showing that clinicians could make errors. Well, guess what? Researchers make errors, too. We all make errors. Humans make errors, but that doesn't mean that there isn't data that supports the idea that there's such a thing as expertise. In fact, there is a lot of data that shows that expert clinicians behave differently than neophyte clinicians.

We said part of clinical expertise is really knowing the research literature enough to know how best to serve your patient.

RW: And then there is the patient and what they bring to the equation.
RL: Yes, the third leg of the stool is the patient because
psychotherapy is not an approach where a technician does something to a person and then they go off and essentially live with it.
psychotherapy is not an approach where a technician does something to a person and then they go off and essentially live with it. It's not like surgery. It's a collaborative process. The clinician and the patient work together. The patient has to participate. They have to bring in the material. They have to apply the techniques. Patients have preferences for how they'd like to work. They have values. Patients of different cultures have different cultural understandings of the word, of the concepts of healing.
RW: Alright, to go over my sense of this, the three legs are: one, the best research evidence on psychotherapy and assessment broadly defined, including randomized trials, the alliance, case studies and so on; two, clinician expertise including the use of the alliance and the interpersonal relationship, clinical judgment, self-reflection, understanding of culture, and so on; and three, patient characteristics, values, and context which takes into account patient motivation, support, readiness to change, preferences, culture, functioning level, presenting problem and so forth. The lists are longer but does that seems to be the gist?
RL: Yes, those are the basics. To see the details people can look at a recent article published in the American Psychologistin May-June, 2006 which focuses on evidence-based practice. We define that broadly to include all psychological practices; not simply treatment, but also assessment, consultation, prevention and a whole range of things. And we said that when psychologists practice, they really should take into account the research evidence, broadly conceived clinician judgment, and work to improve their own judgment and expertise.
RW: Including, it must be added, the importance of case studies, which was excluded in early versions of empirically-based work.
RL: Yes, that's very much a part of the research evidence. The Division 12 excluded everything except for randomized clinical trials.
RW: If medicine only included randomized clinical trial, we wouldn’t have much medicine, right?
RL: Quite correct. Certainly you have to assign relative weights to different kinds of evidence but if you were to simply follow the Division 12 approach, you'd probably have to turn away 68 percent of the people who came for your services because you wouldn't have randomized control trials to back-up an approach for them.
RW: How did all these researchers and psychotherapists from different positions work together?
RL: We tried to get people on all sides of the spectrum, drawing on the task force, to essentially debate and dialogue on a wide range of issues. I think it would be hard to find an issue that doesn't come up in our debates. Norcross, Beutler, and I brought out a book on evidence-based practice, (Evidence-Based Practices in Mental Health: Debate and Dialogue on the Fundamental Questions) which opens up the discussion.
RW: Now did the folks who were advocating for the earlier view of evidence-based therapy, stricter manualized treatments, and randomized trials, how did they participate in these task forces? Was there a meeting anywhere in the middle?
RL: Yes, they were invited and did participate, including Dave Barlow and Steve Hollon. Barlow is the one that created that Division 12 Task Force. And we had Drew Westen, John Norcross (see Norcross' Stages of Change for Addictions video), Bruce Wampold, and people from just a broad range of perspectives.
At the very first evidence-based practice meetings, we gave everybody an opportunity to put their stuff on the table with three PowerPoint slides. No more!
At the very first evidence-based practice meetings, we gave everybody an opportunity to put their stuff on the table with three PowerPoint slides. No more!
RW: I like that; a psychologist having to limit themselves to three slides and be very concise.
RL: What is the kernel? What is the essence of what you're about? Really forcing them to think about what's most important. Then we put them into breakout groups where we mixed them up. So we had people like Carol Goodheart and David Barlow in the same group.

Now these two individuals—Carol's a well-known clinician, David's a well-known researcher—normally wouldn't attend each other's convention programs. But here they're kind of forced to listen to each other's perspective. And so Carol had to really understand why David thought that randomized clinical trials was an adequate basis for this, and then David had to understand why Carol felt hamstrung by that because so few patients would fit into those narrow criteria. And they had to then address the middle ground in between them.
They had to address the vast unaddressed part, because what we were dealing with was extreme views. And that's really what the Evidence-Based Practice Report does—it sketches out the middle.
They had to address the vast unaddressed part, because what we were dealing with was extreme views. And that's really what the Evidence-Based Practice Report does—it sketches out the middle. The report is lengthy but basically says, "When you're a clinician and you're trying to provide services in good faith to your clients, here's a good way to use the evidence and where there is no evidence, here are other things you can do." Or, "Here is the best work to date on psychotherapy research, the contributions of the psychotherapist, and the contributions of the patient."
RW: This is a real contribution to the field, instead of succumbing to the pressure to get more narrow about practice, it was opened up to every meaningful avenue for the growth and value of psychotherapy. And I’m sure you heard, but for ground floor therapists and colleagues and professors, this has been something I think people can join with, psychologists and psychotherapists of different theoretical orientations, because it’s fairly comprehensive and it’s inclusive. And it values the relationship. It values randomized trials. It values what we’ve been doing to better the lives of people, so it really is a godsend. Of course, this is not the end, but it is a testament to brilliant people putting aside their differences, and making a meaningful contribution. People really rose above the typical turf battles, this time, at least.
RL: Well, we haven't solved all the problems, but we've created a different format for the debate. I don't think anybody would, at this point in time, think of just simply, "Let's get a group of people who only agree with us, and let's just talk amongst ourselves." We've also got to get practicing clinicians in on designing these studies if they're going to be useful to them.

And clinicians like Steve Ragusea have started to create these practice research networks among themselves, networking with scientists. So he was networking with some people at Penn who were advising him. He's not a researcher. He's a very good clinician. And he and his colleagues created a practice research network.

So I think what we've done is we've populated the middle ground and taken the emphasis away from the extreme positions. You know, you had your extreme positions 10 years ago: "Only randomized control trials" vs. "I want to do long-term psychoanalysis, and I don't care if there's any evidence."

RW: Psychoanalysis, my psychoanalyst friend Lee Rather used to say, is based on the “case study method, which is part of the scientific method.” It is systematic and it is the way analysts test hypothesis in clinical practice. And the CBT folks were saying, “Let’s do a pre-test, during-test, and post-test. Let’s do the Beck Inventory, let’s control client selection.” Luborksy and Strupp, of course, did some work on researching outcomes for psychodynamic therapy in a systematic way.
RL: Right. And when I mentioned that, I was not trying to mischaracterize people, but in '95, people thought it was legitimate to stay in your camp and I don't think any more people see that as legitimate. You have to address the middle ground and continue the dialogue in a way that includes both sides of practice.
RW: Well, that’s good, because that’s what psychologists have been preaching particularly in politics. Psychologists are always out there saying, “Why can’t people and countries make peace? Why can’t they talk? Why can’t they negotiate?” You always hear psychologists saying that in the press. But if we don’t talk to each other then our methods don’t amount to much.
RL: We need to apply it to ourselves.

What were we thinking?

RW: Let’s dig a bit into something you’ve emphasized, which is the importance of clinical judgment and the clinical relationship in outcomes research.
RL: Well, I think Norcross' book (Psychotherapy Relationships that Work: Therapist Contributions and Responsiveness to Patients, Edited by John Norcross), which is based on the Division of Psychotherapy 29th Task Force, did a great service. This preceded my presidential initiative but it was an important stepping stone, and it was after the Division 12 lists of empirically validated treatments. His book and his task force brought together—essentially assembled—all the evidence for the therapeutic relationship.

 

And the evidence that he assembled shows that the quality of the therapeutic relationship outweighs the influence of the model of therapy you're using. And the book went further to delineate and really look at specific evidence for different aspects of the relationship, from working alliance to empathy to some of the conditions that were described by Rogers back when he was doing research on empathy and conditional regard, and so on. It's hard to dispute that the therapeutic relationship accounts for a large percentage of the variance in therapeutic outcome, which can be viewed as part of clinician expertise. We really have to know a lot about how to build that relationship. We have to know about stages of change, the Prochaska model, and understand what stage our clients are in and tailor our interventions accordingly.

Also, there are important cultural variables. We have to become multi-culturally competent.

RW: Multiculturalism is clearly part of everything psychology does these days, and rightly so. APA considers it an important part of accreditation, and in practice and research. So psychotherapy, of course, requires attention to a client’s culture vs. one-size-fits-all therapy techniques.
RL: I don't know why our field got away with this for so long, but so much of our earlier clinical research virtually excluded people of color, and looking back on it now, I just have to scratch my head. What were they thinking? Are we not going to treat people of color? Are there not people of color who need our services? I mean, I just don't get it. But evidently, the zeitgeist of the time was that you could ignore that. Maybe the progress of civilization can be measured by the realization of the need for inclusiveness.
RW: Let’s hope we are headed in that inclusive direction for good. Thanks so much for taking the time to speak with us on these most important issues.
RL: Thank you.

Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy

Posted on by rezendevknowfully.com

The Interview

Chanda Rankin: I’m Chanda Rankin, and it’s a real pleasure to have you here for this interview today with Psychotherapy.net. Earlier you mentioned you were born in Vienna, Austria. I wanted to know how much sociocultural influences at that time affected and influenced you to go into the field of psychotherapy and analysis.
Otto Kernberg: To begin with, I left Austria when I was ten years old. My parents and I had to escape from the Nazi regime. We did so at the last moment and immigrated to Chile. I trained in psychiatry at the Chilean Psychoanalytic Society. I came to the States for the first time in 1959 on a Rockefeller Foundation fellowship to study research in psychotherapy with Jerry Frank at Johns Hopkins. Then in 1973 I moved to New York, where I was at Columbia. Now, I'm Director of the Personality Disorders Institute where we're carrying out the research of personality disorders.

Certainly my cultural influences are Austrian, German, and that has influenced me in many ways. But my psychiatric training was integration of classical descriptive German psychiatry and psychoanalytic psychiatry/psychodynamic psychiatry. Later I became immersed in ego-psychology and Klein's work. I also visited Chestnut Lodge where I became acquainted with the culturist orientation, Sullivanian, Frieda Fromm-Reichman as well as the ego/object relations psychologists, Edith Jacobsen and Margaret Mahler. So it was natural to try to synthesize an object relations approach between the great ego psychological Kleinian and so-called British 'middle group' or independent approaches. Then many years later, to this was added a certain influence from French psychoanalysis.

Kernberg’s Gold Mine

CR: I’ve always been very curious about what is it about working with personality disorders do you find so compelling that you’ve made this the focus of your life’s work?
OK: It was a combination of various influences. First of all, perhaps the most important one was that the psychotherapy research project at the Menninger Foundation that I joined and eventually directed consisted of the treatment of 42 patients—21 treated with various types of psychotherapy from a psychoanalytic basis, and 21 patients were treated with standard psychoanalysis. Now, it so happened that many of the patients sent to the Menninger Foundation suffered from severe borderline conditions. Severe personality disorders, right now called Borderline Personality Organization…the concept had originally been developed there by Robert Knight and his coworkers. Many patients with severe personality disorders were included in that project, and the diagnosis was made very, how shall I put it, tentatively or fleetingly. When the project started in 1954, there were no clear-cut criteria being used. It was very helpful because it turned out that half of the patient population on the therapy side, and half of the patient population on the psychoanalysis side suffered from severe borderline conditions.
CR: How fortunate for the researchers.
OK: Yes. And each of these cases had typed process notes of each session, of treatment over many years. Big fat books. So by the time I got there, I had 42 cases studied in detail, and it was just a gold mine! I noticed regularities about what happens in the treatment, what would have facilitated the diagnosis, so I combined my interest in object relations theory with the interest in clarifying this group, to develop some hypothesis about treatment. We then did the statistical and quantitative analysis of the project. It provided me with important confirmations and disconfirmations of the hypothesis.
CR: And this population was not well understood at the time.
OK: No, so I was very lucky to have this patient population. And when I started out, I wasn't aware myself that I was getting into a very interesting subject.
CR: How did you become involved with the study of narcissistic personality disorders?
OK: Just by chance. One of the patients who I saw in a controlled analysis while I was a student at the Psychoanalytic Institute in Santiago, Chile, had been diagnosed as an obsessive-compulsive personality. I was unable to help him—he didn't change one inch over years and his memory persecuted me. Then, I perceived that he was very much like other patients I saw at the Menninger Foundation. Hermann Van Der Waals, who had written an important article on the narcissistic personality told me, 'These are narcissistic personalities.' Nobody had described these characteristics in the literature well.

I then took another patient into analysis, exactly like my previous one, and on the basis of my then-developing psychoanalytic knowledge, I developed a particular thesis on how to treat that patient. And this is how I developed the treatment of narcissistic personality, the diagnostic observations, the differential diagnosis between narcissistic and borderline typology, the generalization of the concept of borderline personality organization. So it was a combination of luck and interest.

CR: A very rich time, and a confluence of things coming together to make that happen. What or who influenced your clinical style which seems to be neutral in many ways but not passive or impersonal?
OK: One individual who I have not yet mentioned, who is very little known at this point, although he was a leader of American psychiatry, is John White, the Chair of Public Psychiatry of Johns Hopkins when I was there. He developed a method for clinical interviewing that inspired me for developing structural interviewing. He was the best interviewer I've ever seen. He would start talking with the patient, and the interview would go on until he had a sense that he knew what he wanted to do. It went on for two or three hours. John White had a way of putting himself into the background, disappearing, so to speak. He was very direct, very honest, and understood something about people, in depth. No showmanship. Just raising questions that permitted the development of the patient. He had a tremendous capacity to permit the patient to develop his present personality, rather than asking what happened 50,000 years ago. That also influenced me in interviewing. Sharpened my approach to the study of the present personality.

But, perhaps also what has been very important to me is the excitement with the fact that there you have these patients with severe distortions, that ruin their lives. No doubt about it. This is not phony pathology for wealthy patients who have nothing to do but to go to a psychoanalyst. These people have not been able to maintain work, a profession, a love relation. And with the psychoanalytic psychotherapy and psychoanalysis you are able to change their personality, improve their lives. I think that is an extremely important contribution of psychoanalysis. And we need to do empirical research on this. One of the things that I have been very critical about is the lack of systematic and empirical research within the psychoanalytic world.

How People Change!

CR: Do you think that there’s any one specific thing, if at all, that contributes more than any other thing to change with a personality-disordered patient?
OK: People change in many ways with common sense, with friends, with help, with luck, with good experiences in life. I think that psychoanalytic psychotherapy and psychoanalysis are probably the methods that promote the best changes in case of severe personality disorders, through the mechanism of analyzing of the transference, the split off, dissociated, primitive object relations that determine and are an expression of identity-fusion, bringing about normalization of the patient's identity, integrating his self and concept of significant others. In that context, permitting the advance from primitive to advanced defense mechanisms, and strengthening of ego function in terms of increased impulse control, moderating affective responses, and facilitating sublimatory engagements.

So I think that's probably the best approach nowadays to bring about fundamental personality change. There are indications and contra-indications; not all patients can be helped. I think that the prognosis depends on the type of personality disorder, on intelligence, on secondary gain, on the severity of anti-social features, on the quality of object relations, on the extent to which some degree of freedom of the sexual life has developed or not. So there are many features that make indication, contra-indication and prognosis for the individual cases different. We are in the middle of trying to spin all of these out.

“Psychotherapy Training is Going Down the Drain”

CR: You often emphasize the importance of training, really making sure that the therapists know what they are doing and what they are dealing with in terms of the patient. Can you speak to that issue?
OK: First of all, yes, I am very critical of chaotic gimmickry in treating patients based upon chaotic theory. Each person who invents a treatment method invents his own ad hoc theory for treatment. I find that this damages the field, the treatment, the patients. It's bad science, on top of it. One thing I like about psychoanalysis is that it's an integrated theory of development, structure, psychopathology, that lends itself to develop a theory of technique of intervention. I'm not saying it's the only one, but that's one of its strengths.

I think that when people apply various techniques from different theoretical models, they cannot but end up in a chaotic situation in which transference and countertransference is going to drive the relationship in one direction or another. I'm not saying that you can't help patients with this. But you cannot learn how to develop a certain approach. I've seen so many bad consequences from that. Because then you don't match technique with the needs of the patient. And you don't give patients as much. So I prefer to have a cognitive-behavioral therapist, let's say, a well-integrated general theory that applies to his field, rather than one of these esoteric schools everybody has. In this field there is so much voodoo and so much fashion and quackery. It's paid for, and of course, it requires research. Now, unfortunately, most of the research that's been done on short-term psychotherapy done by non-therapists with non-patients in university settings, to grind out papers… so the real treatment that is done clinically has only been researched in a limited way… I think that's our major task. And I believe that we need to develop manualized treatments for long-term psychotherapists, whatever their background. And test them scientifically.

So, regarding training, I think that training should focus on theory of personality, personality change as a basis of technique. And then, apply it to clinical situations.

CR: What do you think of the impact of managed care on psychotherapy?
OK: Psychotherapy training is going down the drain in this country, under the corrupting effect of managed care, this terrible system for profit that goes under the mask of 'managed care,' but really it's managed cost. Under its pressure, long-term psychotherapy is now reserved for those who can pay for it privately. So we are depriving a significant segment of the population of treatment. I trust that that system is going to explode by its own corruptive effects and structure. This is already occurring. And that in the long run, our knowledge and our scientific development of psychotherapy will restore an optimal level of psychiatric practice and psychotherapeutic practice. I think that in the meantime we live in a happy-go-lucky, democratic fashion in which everything goes. Which creates distrust in the public, cynicism in the profession, and is not healthy to patients.
CR: Have you considered ways to reverse this trend?
OK: I think the solution is, in the long run, scientific research.

In my own Institute of Personality Disorder, we're trying to contribute in a modest way by carrying out empirical research. We have randomized three groups of 40 patients each, all of them with the diagnosis of Borderline Personality Disorder. One group to be treated with transference-focused psychotherapy, which is a psychoanalytic psychotherapy that we have developed and tested. The second group by DBT, Dialectical Behavioral Therapy, developed by Marsha Linehan for suicidal Borderline patients. And third, supportive psychotherapy based on psychoanalytic principles. We're going to compare these treatments, not simply in a kind of horserace, but we're trying to study what process mechanisms are connected with what mechanisms of change.

I don't believe that one treatment is 'better' than the others, but there are specific types of patients who respond better to one or another or that treatments may be equally good on the basis of different mechanisms of change. In this regard, I'm very critical of the assumption that non-specific aspects of psychotherapy are by far the overriding cause of its effectiveness. Because all the studies on which these conclusions are based are short-term psychotherapists of very questionable nature. Nobody has studied yet the comparison of long-term psychotherapists from the solid bases, as I have tried to define.

Critiquing the Media and Pop Culture

CR: To go back to something we were talking about earlier, I was wondering if you could say something about psychotherapists portrayal in the media? What are your thoughts on how psychotherapists are portrayed in movies and television? Along those same lines, you have noted how eclecticism in the field is leading to a diffusion and misrepresentation.
OK: In general, psychotherapists are portrayed in simplified and almost caricatured ways in movies. What is very fashionable in this country right now is the so-called intersubjectivist approach, in which the therapist lets 'everything hang out' and people are impressed with how real the therapists are. I think that reflects a dominant culture of doing things quickly, immediately, the culture of faith, good faith, warmth, belief in the human being helps everybody along. Which is different from the reality when we treat patients who suffer under severe regressive conflicts, whose major need is to destroy the therapeutic relationship, who envy the therapist's capacity to help them—those kinds of cases we don't see in the movies, except that by the time we see that kind of patient, they are shown as monsters and people get horrified. And there is a strong cultural critique of psychoanalysis that is not new, but now takes the form of "psychoanalysis is lengthy, expensive, hasn't demonstrated its efficacy and effectiveness, and patients can be helped by brief psychotherapists." Often they present psychotherapy as shamanism.

At the same time, the combination of the important development in biological psychiatry, the financial pressures reducing availability of psychotherapeutic treatment, the cultural critique of subjectivity and wish for quick solutions, adaptation—all that has tended to decrease the participation of psychodynamic psychiatry and psychodynamic psychotherapy and the training of psychiatrists. It has brought about the old-fashioned split between biological psychiatry (centering on basic research and psychopharmacological treatment) and psychotherapy (pushed off to other professions and being disconnected from medicine and psychiatry). I think that's unfortunate. That leads to a kind of mind/body divide when they should come together.

CR: Can you say more about this mind/body divide?
OK: The impact of the new neurosciences on psychotherapy is very misunderstood. I think there is a lot of premature, reductionist excitement with all these new findings. We have important new findings of the central nervous system, as an effect of psychotherapy, correlations between psychiatric disorders and brain functioning. But these new developments do not, as yet, have any practical implications in terms of both theory and technique, technical interventions, so we have to keep that in mind.
CR: How do you view issues of the mind/body applying in the clinical situation?
OK: Of course you could say that it applies insofar as psychopharmacological drugs derived from our better understanding of neurotransmitters. That is certainly true for the case of schizophrenia, major affective disorders, syndromes of depression and anxiety in general, but it's not true for personality disorders, the many sexual difficulties and inhibitions that go with them. And, to the contrary, there, medication has a very limited symptomatic effect on anxiety and depression, but not at all on the basic psychopathology. The illusion that eventually everything is going to be cured by a pill is an illusion that has existed for a long time, and I think that there are good theoretical as well as practical, clinical, reasons to question it.

The Question of Love

CR: I want to turn to a different interest of yours which you explore in your new book Love Relations: Normality and Pathology. I was very curious how that came about, and in the body of all your other work to be writing a book on love seemed like such a drastic change. What was the impetus for this book?
OK: As I mentioned in the Introduction to the book, I have been accused of being only concerned with hatred and aggression, so I thought it would be fun to write about love!
CR: Was it fun to research and write this book?
OK: It was fun, but it was also difficult, because when I got into the subject, I realized how complicated it is, and how I had to renounce exploring many areas that I would have loved to explore. So the book has important limitations. I observation that the degree of pathology of the personality disorder, of one or both participants of the couple, does not permit us to establish a prognosis of how the couple would do. Two perfectly healthy people get together and it's like hell on earth; two extremely troubled people get together and have a wonderful relationship! So that clinical observation created my curiosity, because of course it's a problem that borderline patients face—establishing couples, getting married.

I also became interested in the subject of sexual relations, because I found out there were two types of borderline patients—I'm using the term loosely to mean severe personality disorders. One with an extremely severe primary inhibition of all sexual capacity, no capacity for sensual activation or enjoyment, no sexual desire, no capacity for masturbation. These patients had a bad prognosis because in the treatment, as everything was consolidating, more repressive mechanisms inhibits that sexuality even further. On the other hand, you had those with wild promiscuous sexuality—polymorphous perverse, invert, pan-sexuality, with masochistic, sadistic, voyeuristic, exhibitionistic, fetishistic, homosexual, heterosexual, everything…those with such a chaotic sexual life seem to have a terrible prognosis, but the opposite was true. These patients did extremely well, once their personality was functioning better. So it raised my interest, why this extremely severe sexual inhibition, what could be done about this? And, also, a more basic question about how much a couple can contribute to inhibit each other or to help each other to free themselves sexually. That's it, in a nutshell.

What are Good Therapists and Analysts Made Of?

CR: Do you have any thoughts about personality characteristics that an analyst or a therapist needs to have in order to work with severe personality disorders, or even mild personality disorders?
OK: That's a good question. As I look at our experience, we've trained many therapists. We've had 20 years of training and supervision. I think that people with very different personalities can become very good therapists. I don't have anything deep or new to say about this that couldn't be said by anybody with some experience in this field. I think it's important, first of all, that the therapist be intelligent, it helps. Second, that they are emotionally open. That they be a personality that is sufficiently mature, on the one hand, and open to primitive experience, in contrast to someone who is extremely restricted. It helps not to be excessively paranoid, infantile, or obsessive-compulsive. Although, I'm saying excessive because we have all kinds of therapists—all basically, honest with themselves and others, with a willingness to learn. Therefore, it helps not to have too much pathological narcissism. If you are too narcissistic, you don't have the patience to work with very troubled patients, and your capacity for empathy is limited.
CR: But it also seems like you need a healthy dose of those things.
OK: Yeah, some of us are exploring that. I really don't have a good answer to that. But there are some people who have a talent for it, like people have talent for playing piano. I don't know whether experts would say, what personality does it take to play the piano? There are some people who have the talent. Some people are able to do it almost without any training. It's almost frightening that they know things before we teach them. It's bad for our self-esteem! I've had therapists with whom I've had a sense that there is such an inborn capacity that with little…they would flourish. And others who never learned, even though they were intelligent and hard-working. And I'm not able, at this point, to spin out what it is. But, we can discover it.

Very simply, we tell people who want to train, "Bring us a tape. The best tape you have, of any session that you are carrying out, a videotape with a patient in treatment." And we have developed methods of the psychotherapeutic interaction by which we can sort out who does have the talent for doing it. We can evaluate very quickly with manualized treatment whether the therapist is able to adhere and whether the therapist is competent. Competence is seen by the therapist talking, focusing on what is relevant, focusing on what is relevant with clarity, doing it relatively quickly and in depth. Relevance, clarity, speed, depth. The combination of them tell us who is a good therapist. It's terribly simple, and it works.

And I'll tell you, some experienced psychoanalysts are terrible; and some young trainees are very good. This creates the problem: does one have to be a psychoanalyst to do this kind of treatment? I would say it helps to have psychoanalytic training, but it's not indispensable. There are some people who have so much talent they can do it without psychoanalytic training, although, a personal psychotherapeutic experience always helps, particularly if people have a kind of "blind spot" in a certain area. Sometimes a psychoanalytic treatment or psychoanalytic psychotherapy helps.

CR: You have written about the importance of therapist safety. It really hit home with me, and I had not actually heard anyone articulate that clearly before. The ability to be able to sense when safety is an issue seems so primary. So all the things that you’re talking about—your own self-awareness, to be able to have the insight into these areas, to know when something is a problem. It’s very important for safety as a therapist and also the amount of safety you can provide for your patient.
OK: Exactly right. It permits you to maintain the frame of the treatment. It's absolutely essential. The therapist has to maintain the control over the therapeutic situation. The therapist has to be in charge. There is a realistic authority of the therapist that has to be differentiated from authoritarianism, namely, the abuse of that authority. There is kind of a cultural move toward "democratization" of the psychotherapeutic relationship. I think that's just silly. Because patients come to us because of a certain expertise, otherwise they wouldn't come to us, and they shouldn't. There's a difference between authority and authoritarianism. And part of the authority of the therapist depends on the therapist's being able to maintain the frame of the treatment. And our own safety is essential in this regard. When you treat severe personality disorders it becomes crucial…physical, psychological, legal safety, in this country which is so litigious. It's the most paranoid culture that I know within the civilized world. I've not been in the jungle…
CR: We might be close!
OK: Perhaps so, we live in a very paranoid culture.
CR: Thank you so much for your time.
OK: You're most welcome.

Susan Heitler on Couples Therapy

Posted on by rezendevknowfully.com

The Interview

Randall C. Wyatt: Dr. Heitler, it’s good to have you here. Let’s start with how you first got into conflict resolution and marital therapy work?
Susan Heitler: I think this is a profession I have been in since I was 3 or 4 years old. When I was just a child, my parents would battle and I would be the one that would step in and bring some calm or reason to the situation.
RW: Were your parents a high conflict couple?
SH: My father was a high conflict individual and my mother would react but was somewhat clueless about what to do.
RW: So what did you do? How did you intervene as a 3-year-old?
SH: I have a sense of myself as having my two hands up – one facing him, one facing her, standing in the middle like, "Cut it out." Cut it out would be too strong; "enough," "calm down," "Stop, listen, listen!" would have been more like it. (Laughter…)
RW: As you grew up did your parents listen to you much? Did you get them to stop or quit arguing so much?
SH: I think on the whole they did. It is a little bit amusing now that they are elderly, 91 and 86. And when my mother introduces me, she will typically say, "This is my daughter, but she thinks she is my mother." I must say, though, that she was a marvelous, marvelous mother.

RW: Wow! That’s pretty amazing. We have interviewed several master therapists of all stripes on Psychotherapy.net and that is the earliest beginning we have heard. What began to influence you to get into couples work?
SH: I don't recall a single course in couples work being offered at NYU graduate school ('75) nor at my internships, where I got otherwise excellent training. The phenomenon of couples work just didn't exist like it does now. I was fortunate to work with a doctoral fellow from Israel who was studying at Denver and he knew a lot about family therapy and the beginnings of couples work. He suggested readings and we did cases together. And then the rest of my training has been either from seminars and workshops or from listening very closely to couples. Also, conflict resolution theory and techniques have mainly originated in the realms of business negotiation, international relations, and legal mediation, which I have incorporated into my work.

Conflict Resolution and Marriage

RW: When did conflict resolution enter the picture?
SH: I had the notion that what I was doing seemed to be about helping people to resolve conflict, both intrapsychic and interpersonal.

Yet the only time I heard about it was from a one-hour lecture by an organizational psychologist who talked about the new literature on conflict resolution in the world of business. It stunned me that here we were helping people resolve their conflicts and yet not a single therapist that I had met seemed to know squat about conflict resolution. So I filed it in my mind that maybe, someday, I would learn all I could and one day write a book about it, which I did – From Conflict to Resolution.


RW: In the business world, conflict resolution and communication skills are much different then when people are in love or married. Lovers and married folks can be very touchy and can quickly regress, suddenly losing all the communication skills they have ever learned
SH: Yes, I think it's a sad state of affairs that most people behave far more maturely at work than they do at home. Now, the good news is that means most people are bilingual. They do know how to talk in a civil way and, even if they are beginning to get agitated, they will calm themselves down and resolve conflict in a fairly cooperative way. The bad news is how sad it is that we use a lesser language – the language of arguing – at home.
RW: Why do you think it is that lovers, married folks – who begin with such caring and consideration – find they can’t talk about hard things without arguing or withdrawing? They become their worst selves.
SH:
Why do people become more degenerate, more argumentative, more agitated, and more aggressive at home than at work?
Why do people become more degenerate, more argumentative, more agitated, and more aggressive at home than at work? Early on we see the difference. Many children fight a lot with their siblings and yet when they go to school virtually never have a fight with anybody. Even in abusive situations, many abusive spouses handle work conflict in a more collaborative way. There are three main realms where we learn the language of interaction: interacting with siblings and parents, and watching our parents interact. And, there are many more decisions that need to be made in a family.
RW: At home, it becomes a matter of the heart too and the stakes seem that much higher.
SH: Well, the stakes are higher and decisions need to be made about so much: money, whether to have kids, where to live, intimacy and sex, how to treat in-laws, how to treat children, how to spend leisure time, do we watch the football games on TV or do we have people over for dinner, or do we spend a lot of time going out together. Multiply that over and over again about all the decisions involved in making a life as a team, yoked together as partners. Those decisions are not only more quantitatively frequent but they are qualitatively different.

At work, you know for the most part who has power and what the expected roles are. At home, that needs to be negotiated. So, in families where everything becomes an issue, there are often underlying issues about how much power do I have, how much am I listened to? Or does he love me? Does she really care about me? We know that the more emotional intensity there is, the more likely people will regress in their collaborative dialogue skills.

RW: Clearly, as you point out, love is not enough since most couples love each other to begin with.
SH: Shall I give you the good news?
RW: Yes, the next question is: What can be done about that? What can you offer them?
SH: That's exactly what I was thinking about. I have come to see maturity as a function of skills. For example, as a tennis player, I have observed that there are plenty of people who just go out and play tennis. They never raise their skill level. There are others who go out and get some instruction or watch good players on TV or play with better players. Those people are definitely elevating their skills. It's much more fun for me to play tennis when I play better.

Living well as a couple means living with an excellent skill set – a skill set for dealing with conflicts, for dialoguing and sharing information effectively, for relaxing and enjoying life, and also skills for emotional self regulation. So, instead of getting agitated and angry, people stay calm and are able to use their skill sets to deal with difficult issues.

RW: It is nice when someone can communicate directly and calmly, but this seems unrealistic to expect people to just talk so directly and rationally. Some people tend to be more passionate, emotional, and some people are more private, more casual, shy, and some are super rational. People seem to have different ways of arguing and different ways of solving problems. Plus, there is a great deal of cultural variation in communication styles. How does your approach account for all these different ways since a lot of therapies want people to “speak directly, be clear, be rational,” yet that does not seem to fit everyone’s style so well.
SH: Right, there are certainly cultural variations, many of which are harmless. They are like the multiple flavors of ice cream. There are other cultural variations that have a major impact on how collaborative a couple is going to be or how likely they are going to be split off into separate realms. In some cultures, the roles between men and women are more defined and problems are dealt with indirectly instead of through direct communication. In most American couples, however, there is a lot of necessity for husband and wife to be able to make shared decisions, to function as a team. If the goal is to have a collaborative relationship, then there are certain principles of information flow.

I like to tell my patients I work on flow. A good analogy is traffic flow. Cars crash if the traffic is flowing too fast which is the equivalent to too much emotional intensity. Cars also crash if people don't follow simple traffic rules and guidelines.

RW: I have read that if traffic is going less than 30 mph there will be a traffic jam.
SH: This is exactly right. If you never get on the roads at all, you are not going to get where you want to go which is a mistake that many people make. They never even bring up the issues and talk about what is concerning them.
RW: Going another step: people seem to use communication skills and I-messages when they are calm but lose it when stressed out.
SH: The pivotal factor is that the more important the issue, the higher the level of agitation and emotional intensity, and the harder it is to have good communication.
It is just like driving a car, where speeding takes more driving skills but someone with excellent driving skills can still manage 90 mph. In terms of communication skills, most of us can go up to 30-40 mph with ease but we are in trouble when we go faster.
It is just like driving a car, where speeding takes more driving skills but someone with excellent driving skills can still manage 90 mph. In terms of communication skills, most of us can go up to 30-40 mph with ease but we are in trouble when we go faster.
RW: So what should we do when our emotional speed is too hot and we are traveling out of control?
SH: I teach couples that as soon as they are beginning to get out of their effective zone, just take a break and get a glass of water, learn to calm oneself, and then we go through this step by step. I teach each person this shared choreography so they don't feel like the other person is walking out on them. The agreement ahead of time helps monitor their emotional intensity. And, each person is responsible for calming themselves down and rejoining the discussion.

Heitler takes on Gottman’s Unresolvable Problems

RW: And what has your success been in working with couples to teach them these skills and resolve their problems?
SH: A significant proportion of my clients are referred by divorce lawyers. I also get newlyweds and people who are beginning to have some problems. I really like getting the 'last chance' cases. That's what I am known for in Denver, I am sort of the court of last resort. I would say, of those cases, the vast majorities end up with great marriages; they just never had the skill set.

What I hear over and over again is, "I wish someone had taught us these skills when we first got married. All those years and all that dreadful modeling we have done for our children wouldn't have happened. All those years of suffering, all those years of portraying how to make each other miserable wouldn't have happened if we had just known how to interact more maturely, more effectively."

Now does everybody do better? The reality is some people would rather stay how they are. My approach is a kind of a coaching approach to therapy and just like some people will prefer to stay beginners on the tennis court, some people aren't interested in learning in their marriages.

RW: So is learning the skills the whole of it for these couples?
SH: What you said earlier is very true. Once there are deeply felt issues, it evokes strong emotions even if people take breathers, that when they return they become so emotionally reactive on those issues or to each other that they will have a hard time using the skills. So a combination of skills training and therapy is really important.
RW: How and where does therapy enter into your couples work?
SH: In therapy, as people are getting hot, I would be more likely to help them see where their initial issue came from, their own marital issues or family issues from their past. I agree with the research that says skills alone won't work with difficult couples. First, the guidance of a coach who knows the skill set and, secondly, also knows traditional therapy skills of accessing family-of-origin material.
RW: You have questioned Gottman’s findings that often there are certain interpersonal problems couples have that will not be resolved, rather that over the years they will come to manage or work around these repetitive problems. How do you differ from this view?
SH: Yes, Gottman and I have had some dialogue in this regard and I have given him my books From Conflict to Resolution and The Power of Two. He has looked at them and said, "Yes, that's very interesting." I have been told by others that he refers to my work on conflict resolution in a positive way.
I have continued to hear Gottman say that some conflicts can't be resolved, that conflict resolution is an unrealistic goal. I take great exception to that.
I have continued to hear Gottman say that some conflicts can't be resolved, that conflict resolution is an unrealistic goal. I take great exception to that.
RW: Let’s hear it.
SH: Gottman and others have contributed excellent research on marital communication skills, but his writings do not include the advances in the conflict resolution theory that enable fights to transform into cooperative problem-solving and conclude with mutually satisfactory, win-win solutions – this is where my work is focused.

If there are conflicts between two people who have the cognitive flexibility to really listen to each other and work together till they can come out with win-win solutions, then those conflicts can be resolved. Of course, I would say that we all know some people aren't willing to learn the skills of win-win conflict resolution, but that is the exception. For example, I get conflicts about whether to have children or how many children to have. I have had a number of those cases in my practice and they have always come up with excellent win-win solutions. You would think either we are going to have a baby or not have a baby and that should be a zero-sum game, right? Wrong! It's how you decide to have a baby or if you decide not to have a baby. So even that is quite amenable to a win-win conflict resolution.

Hot Buttons: Geography and Religion

RW: You and Gottman seem to agree that some couples don’t solve their problems, but you emphasize that with the motivation to learn, most issues can be worked through. I would like to see this debated with Gottman, but, for now, what are the most difficult conflicts that you find couples having?
SH: There are some conflicts that are inherently more difficult, the two most difficult issues being geography and religion.
RW: I thought it was politics and religion.
SH: Right now, politics – I have found, that if people have very good skills, that most people can listen to the underlying concern and let it go after awhile.
RW: So then what about geography and religion?
SH: There are deep attachments that people often form not only to their family that might live in a certain area but also to the land. Now, I do think the more mature and more flexible people are, the easier it is.

I am thinking of one poignant couple, for instance, where she was rather a brittle person who felt very much of a New Englander. Now, myself coming from New England, I can identify with that. She grew up in an old small subculture there and she felt safe there, she felt she belonged. Unfortunately, her husband, a lovely fellow who had been very successful in business, went through 3 or 4 years where he was unemployed. It was terrifying for him since he wanted to support his family. Finally, he got a job in the Southwest and she tried to move with him but just couldn't do it. She wasn't able or willing to make new friends. She strongly missed being away from her parents and felt they needed her since she was the only child. It was multi-dimensional and a very difficult issue to find a middle ground on.

Now, remember conflict can be at a shared decision making or conflict resolution level. Shared decision making is what we call the process if it's going smoothly. We call it conflict resolution if the couple is getting oppositional. In this case, they were going beyond oppositional to desperate because they each felt so strongly wedded to their own concerns and unable to embrace it in a broader way to take into account the concerns of their partner.

RW: A very difficult situation, certainly. I saw a couple recently where the man felt strongly that they should move to the country so the kids could have a more peaceful life in a small community. And his wife felt they should stay in the suburbs near her friends and family. They both believed strongly that God was leading them to follow their own path in this matter and they went round and round on it.
SH: With religion too, that is double trouble.
RW: Since they were so adamant, I said, “Maybe God wants you to get divorced, the way things are going.”
SH: And then that would pose problems for me because I see myself very much as a pro-marriage therapist.
RW: My comment was tongue in cheek, said to make the point that they were falling into a trap of using God to support their personal preferences as a fixed solution that they had both become entrenched in; yet it was not merely an either-or solution.
SH: So this situation is extremely difficult.
RW: They actually share many of the same values and goals, but have different ideas about how to accomplish them. Understanding their shared values brought the conversation to a manageable level.
SH: Excellent! And again, if they are flexible, they would find some way to go to the country for the summers and live in the city during the school year.
RW: Yes, they are going in that direction for now at least – they live in the suburbs and go hiking and camping more often.
SH: And that takes both cognitive flexibility and financial flexibility that some people realistically just don't have. So, are there always options? Yes. Are they always within what the couple realistically can do? Once in a while, you find a real difficulty.
RW: Can you speak briefly on religion and marriage?
SH: Religion brings on non-negotiables. For instance, if you are an orthodox Jew, you just don't drive on Saturdays. You don't eat certain foods in certain places. You don't bring certain kinds of food into your home. As a reformed Jew, you can have greater flexibility in these matters. Basically the choices are doing things the more religious person's way, or finding someone whose lifestyle is more like your own. Now even that's not 100% true because there are plenty of orthodox Jews who think flexibly and creatively, who have married less observant spouses, and they find some way to accommodate each other's needs.

Changing the Argument Cycle

RW: You have done lots of consultations with therapists and trainings. What do you find are common mistakes therapists make in working with couples
SH: I see the same pattern everywhere. First, even experienced therapists are quite clueless about how to do conflict to resolution approaches. Second, virtually everyone takes too long to intervene with couples. So when I demo a case or when people watch my video that demos a case, one of the first comments I virtually always get is…
RW: I have seen the video, so it is striking to see how quickly you intervene and interrupt the arguing.
SH: If I am on my toes, they would never argue in my office because I intervene preemptively. Do you intervene after a car has rolled off a cliff or do you intervene when it begins to hit the soft shoulder? In fact, I intervene when they are just beginning to cross the line where there is still a little place before they go on the soft shoulder.

If a couple is accustomed to arguing, that means a lot of intervention. Intervention not just after they have argued but lots of setting them out to do it right. So, for instance, one person starts to says something… I can see the "b" of the word "but" forming on their mouth so I would interrupt them right there and offer alternatives.

RW: What is your thinking behind interrupting them and stopping their argument? Many couples therapists and writers will let them go on but try to help them argue better?
SH:
Well, I don't know what they mean by "argue better." It's an oxymoron from my point of view. Effective dialogue is almost always collaborative. Emotion and passion are fine but only up to a point.
Well, I don't know what they mean by "argue better." It's an oxymoron from my point of view. Effective dialogue is almost always collaborative. Emotion and passion are fine but only up to a point.

I am referring particularly to what I call crossovers when people are labeling others or speaking for the other person versus people speaking for themselves. Are they listening to take in information or they are listening like a hockey goalie to bat it away? Did they digest what the other person said out loud or do they just move on to their own thought? So there can be a perfectly civil collaborative tone but each person ignores what the other says rather than what I call breathing the dialogue. The couple needs to have a positive experience versus just repeating what goes on at home.

Also, many people don't know how to ask good questions. In other words, the alternative to you-messages is not just I-messages, it's good questions. Good questions almost always begin with "What?" or "How?" and many people don't know how to ask those questions. Lastly, many couples lock into a tug-of-war over "I want X," – "No, I want Y." Many people don't know how to switch levels to the underlying concerns that fuel such tensions.

Sharing Therapist Reactions in Couples Work

RW: Couples therapy involves the couple’s relationship and you have a relationship with them too. Are there times when you share your own reactions, personal feelings, your own life stories with clients?
SH: Well, I assume you might have noticed already I get tearful easily, so when I am touched, I am not going to fight it – it shows. And couples have often given me feedback later that my getting tearful in response was meaningful to them.
RW: What about anger coming out or other emotions that are not so tender?
SH: I do have anger. I am a human being and anger is very, very important as a feeling to know when something is wrong. So I use my feelings of anger to validate for myself when I feel that a couple or an individual is getting off track. For instance, I recently found myself getting very angry with a teenager in a family session with her parents. Did I act in an angry manner towards her? No! Did she hear some built-up tension and the firm manner of my voice? Yes! You could label her borderline or you could just say she had real difficulty self-soothing, very quickly misinterprets what is going on, and becomes angry and provocative; she had controlled her parents forever in this way.

So I used my anger in service of the work by allowing myself to feel my own anger and express my experience with her parents… that this girl evoked that response in me and does so with others as well, but the parents continued to enable this oppositional behavior. I essentially told them they needed to address it, talk quietly with her about this, and help her learn skills so she would not continue to be provocative in that way. But I showed them how anger could be used well instead of just going head-to-head with her.

RW: That is nice. It seems more and more therapists of various orientations are using their own reactions to bring about more immediacy in the session, which seems to lead to a more real and effective therapeutic engagement.
SH: That is a very good question for therapists: when and how do you share aspects of your life? The technique I most often use is if there is something in my own life that is relevant to them, I will talk about it in the third person or from a general perspective. At the same time, it's a little too complicated and risky to talk about oneself. But I don't have that as an ironclad rule. There are times when being able to share something about my own world facilitates the normalization of what they are experiencing. At the same time, it's their therapy, it's not my therapy. So that's got me wondering: do I not want to talk too much about myself?
RW: Too much or too little would be a problem.
SH: I think one can't err very often on the side of too little. If you never talk about yourself, I think that's fine. There are moments when something in my own experience could be very relevant and very helpful.

Saving Marriages

RW: Let’s go back to what you meant by pro-marriage. You said that you are pro-marriage and your website states that you specialize in saving marriages.
SH: Correct. Marriage happens to be good for people and there is very good research now out. For example, Linda Waite and Maggie Gallagher summarize the research very well. The research shows that people who are married are more fortunate than those who are not in terms of money, sex life, happiness, as well as physical and mental health. Now there are some exceptions to that. In general unmarried women do better than unmarried men. But, on the whole, marriage – particularly a good marriage – is a great blessing in people's lives. I think it's important to therapists to be unequivocal that marital health is good for people and marriage is a great blessing. And even the average kind of marriage seems to be far better for couples for the most part and particularly for men than a divorce.
RW: How does getting divorced or being single play into it?
SH: It's one thing to be single and it's another to be divorced. It turns out that people who have always been single adjust fairly well in life. More and more research is coming out showing not only negative consequences of divorce for the children, but also physical consequences for the couple as far as 20 years down the road. So, you can see why I am pro-marriage. 'Marriage friendly therapist' is the going term now. There is a new website at marriagefriendlytherapist.com.
RW: Marriage friendly therapist?
SH: Yes, my approach is friendly and supportive of marriage and I am dedicated to teaching people how to do it better. At the same time, nothing is simple. It is one thing to be rigidly against divorce and I certainly would not put myself in that category. There are definitely marriages that should be terminated. All people have the right to be safe in their marriage.
RW: So that’s what I was going to ask you, do you ever see couples and think, “Why did they even get married?” or “They should get a divorce.” What do you then?
SH: I lay it on the line to them. For instance, I remember one couple that I worked with over a period of months. She was a very fast-talking, highly energetic woman from New York, a very successful entrepreneur. He was a slow-moving guy, nice looking but kind of laidback Appalachian kid who had grown up in a dirt-poor environment. They had economic clashes plus educational, lifestyle and income differences. She was doing fabulously. He could barely hold a job. They used to argue a lot about everything since his way was radically different from her way.

Yet I was able to teach them some skills and help them to see their family of origin and cultural roots in context. But no real progress was made,
and at some point, I said to them, "I hate to admit this but I truthfully can't see how I can help you make a real marriage out of this. I can't see how to bring the two of you together. I see on each issue that we discussed such radical differences. I don't see how it can work."
and at some point, I said to them, "I hate to admit this but I truthfully can't see how I can help you make a real marriage out of this. I can't see how to bring the two of you together. I see on each issue that we discussed such radical differences. I don't see how it can work." I apologized to them.

To my surprise, they came back the next week and said, "Thank you so much. That was so helpful. We have stopped fighting." They came a few more times and I did not see them for years. I ran into her downtown one day and she told me an amazing story. She said that about three months after they finished therapy, she was diagnosed with breast cancer and he was an angel to her. His real mission in life… this story still makes me cry when I tell it now…was to care for her. And he was so loving, so marvelous. That's really why she made it through. It makes me tear up just to think of them.

RW: It seems you’re admitting how difficult their situation was and your sense of helplessness gave them a way to look at reality and do something about it. Plus, they rose to their life crisis in a way that transformed their lives.
SH: Absolutely. And this was maybe 10 years ago. I saw them recently and they said that they have continued to have a marriage where they both feel very blessed to have each other.
RW: What touched you so much about this couple?
SH: I think probably the limits of my own or of any therapist's ability to know what's good for another couple. They knew at a deep level that they were somehow meant to be together. So I could do what I could do, teach them a few skills, help them see the differences in their background and implications of that. I could go part of the journey with them and that was okay. And such a single limit of my… oh no I will start to get tearful again… of my ability to have to do more there, that there are bigger forces than therapists in the world and fortunately they take care of these things.

Now, at the same time, there are couples that the research would certainly say they ought to get divorced. If couples are fighting a lot, the research is unambiguous that it's better for the children for them to disengage; a climate of war in the house is not conducive to child rearing. Medved and Quayle partnered on a fine book called The Case Against Divorce where they outline 9 factors where divorce is indicated.

What to do with Secrets in Couples Work?

RW: What is your approach to seeing couples together and individually, and how do you deal with secrets?
SH: That's a very important question. I have written an article, Combined Individual/ Maritial Therapy: A Conflict Resolution Framework and Ethical Considerations, that sets me at odds from the conventional wisdom in the field. If a couple is in individual work with another therapist, I make it my policy not to see them in couples therapy unless the individual therapy is done with me. The individual and couples work needs to be under the guidance of one person or else it just doesn't work. If the therapy is split among therapists, they are almost inevitably going to have two different databases so that the therapist becomes a source of iatrogenic doctor-induced damage.
RW: I would think this is even more so with high conflict clients, though yes, it goes against the grain in the field.
SH: The therapist is unable to correct the distortions because they can't see for themselves what the other person is doing. The client in individual therapy presents as being so perfectly nice, very warm, very nurturing, very interested in changing… you see their healthiest side. Many times I saw this in working with just one person then was stunned to see what happens when they are interacting with their spouse.
RW: How do you set up who comes in to see you?
SH: If they are in a relationship or married, we encourage them to come in from the very first session as a couple. Then we will work out to what extent they do individual work, couples work, or some combination of both. Also, when you are stuck in the couples work, switch to individual and you will find out what the 'stuckness' is about. I recommend that they each do a similar number of individual sessions. The client is able to relax and speak more freely, take in new information, or experiment with new stances in a way they may not be allowing themselves to do while the other is watching. Then you have more leverage with that person when you return to the couples work. In real troubled couples, I will consistently see them both alone and together.
RW: What about keeping secrets and confidentiality in this flexible approach?
SH:

It is very important that a therapist have a policy and state it clearly in the first session. The prevailing policy seems to be that there are no secrets: if you tell me something in session, I have the option of disclosing it to the other.

I am truthfully horrified by this no-secrets perspective because it means that if one person really does have some information they don't want the other party to know about for whatever reason, they are not going to disclose it to me.
I am truthfully horrified by this no-secrets perspective because it means that if one person really does have some information they don't want the other party to know about for whatever reason, they are not going to disclose it to me.

After laying out the foundation of confidentiality, I turn to each of them and say, "When I work with either of you alone, the confidentiality that I am bound by limits keep me from saying to your spouse what we have talked about. Each of you can trust in that privacy." Then I explain that they are free to speak with each about their own therapy or to play the session tape because I audiotape every session and give them the tape so they can listen to it. I am the only one that's bound by confidentiality. The tape, by the way, radically increases a therapist's effectiveness since patients benefit greatly from listening to the session.

RW: Many experienced couples therapists I know take an approach that gives each person confidentiality in their own sessions. But I agree with you that the no-secrets approach seems to predominate in graduate training. New therapists are afraid of keeping any secrets for fear of becoming confused about who said what. My experience has been that people keep private things all the time in life and people appreciate it in therapy as well. You don’t necessarily tell one good friend what another friend said about them. With tact and permission, I find that most people want to bring out important issues in the couples session as well.
SH: Exactly. And people tell their spouse information and they don't expect them to tell others. Privacy and maintaining boundaries of privacy is an important maturity skill. I think I learned this lesson years ago when I saw one of my first couples and, sure enough, it was a situation where the man was having an affair. I don't know why it happened that he spoke alone with me at some point, but we had one session on the affair. Through that session, he realized, "I don't want to be having this affair. I want to get out but feel so stuck in it," which is so common. And so we role-played how you end such a relationship and he learned that skill set. He ended it and we subsequently went on to deal with their problems and concerns which we handled virtually immediately.

I saw them some 15 years later when I was downtown.
remember thinking, "Thank heavens I disobeyed the conventional wisdom of the time and did not insist that everything come out in the open."
remember thinking, "Thank heavens I disobeyed the conventional wisdom of the time and did not insist that everything come out in the open." My guess is he has never told her; it was one of those stupid mistakes people do. They have a wonderful relationship. They never wished for Humpty Dumpty to fall apart. And I at least have no responsibility for whether he told her or didn't tell her. I care that they have raised five wonderful children and have a great marriage.

Heitler’s Husband and Tennis Coach Teach Her Some Things

RW: On a different note, what have you learned from your own relationship and marriage to help you in being a couples therapist?
SH: A lot. If it doesn't work at home, I am surely not going to teach other people to do it. My husband has been my accomplice or coach in this whole practice of learning about what principles keep data flow moving comfortably, playfully, effectively. He's been wonderful about that.
RW: Do you have an example?
SH: There is the classic therapist dilemma which is when I know the rules and he doesn't in terms of effective dialogue. It's not going to work for me to coach him when we are in the middle of the discussion because that's what I call a crossover, telling him what to do. And what my husband taught me to do was use my own ideas with him. I can talk about myself or I can ask about him. But it's not for me to either examine his way of talking or tell him how to talk or what to feel or think. So all I can do is model it or ask "How?" and "What?" questions myself.
RW: What about for therapists who are married to one another; often people think they should have some perfect relationship…
SH: And they should.
RW: Really?
SH: If they can't do it at home, what are they doing talking to other people? Would you want a tennis coach who can't play tennis?
RW: We would want a tennis coach who can learn from his mistakes and could correct them, but I think therapists can overanalyze things to a point where it gets in the way of living life. Indeed, some coaches are so good at their sport that they become perfectionists and can’t coach beginners well. Some of the best coaches are just fair players.
SH: That would not be enough for me if he really wasn't good at the game. But yes, some great players have forgotten what beginners do. So I think one doesn't have to have a perfect relationship. One does have to have a good strong skill set, like my current tennis teacher, Charles, who I am very fond of.
RW: I can tell. What makes you so fond of him?
SH: He is a dear of a person, has a marvelous eye for what the next technique is that would move me to the next level of playing. And part of the fun is that although he is a good player, I can still win some points off him. He reminds me of what it is like to be a great therapist.
RW: Let’s hear more about that. What about his coaching is like being a therapist?
SH: As long as I feel like I am learning every single lesson from him, I feel like I still want to be taking lessons from him. He is actually a very unusual tennis coach in terms of where he came from in life. He is an African American fellow in his 20s who grew up in a very poor area where for years he was doing all the riskiest things in his life. But he has always been a very good athlete who had a great tennis coach. Eventually, the head coach at my tennis center found him and said, "Hey this guy is a gem," because he has strong skills and has an engaging charismatic, fun personality. Charles just lets himself be Charles out there. He is upbeat, full of enthusiasm when I do things well, like he really cares how I do. He's really in there, connected with me. So I think what I am saying is that therapy too should be skill-based work and fun.
RW: Good coaching and good therapy have lots in common. What other advice would you give for young to mid-ranged therapists?
SH: You can't coach if you have no skill sets, so a therapist has got to really be well-schooled in at least the main couples techniques that I set out in my book The Power of Two. To me, those are the skill sets that one needs to be a quality therapist.
RW: What about the ability to form a positive relationship or working alliance with couples, to be able to approach problems in a collaborative way?
SH: The ability to have an alliance with a couple is a function of therapist attunement to the couple. If you are only listening without also being a person there commenting on what you hear, then you don't have attunement or a relationship. So I spend very little time at the outset of therapy worrying about building a relationship. I build a relationship because I am an attuned and responsive human being as we talk about their problems. Within the first five minutes of seeing a new patient where we are interacting, I am in there with them.
RW: You are not building a therapeutic relationship, you are having one.
SH: I love that way of describing it.

Heitler's Hats
Coaching Hat: Teach people the skills that enable them to have successful relationships. These intrapsychic and interpersonal skills facilitate self acceptance, coping with stress, emotional self-soothing, and soothing of others. Couples can learn these skills, be prompted, and can reinstate them after failing to use them in a tense situation.
Healer Hat: Use traditional therapy skills to understand the patient's past, family-of-origins issues, understand depression, anxiety, anger, obsessive compulsive and addictive disorders and know how to reduce or eliminate the symptoms.
Mediator Hat: Walk people through their intrapsychic and interpersonal conflict. Help them to tolerate emotional exploration while using the dialogue and question skills that enable them to keep moving forward in the three steps of conflict resolution: express initial position, explore underlying concerns, and create mutually satisfactory solutions responsive to all the concerns of the participants.





Still Having Fun

RW:
SH: Obviously after more than 30 years in the field…
RW: Obviously you have kept your enthusiasm in the field and it shows. What is it that still excites you about the work?
SH: Like with my tennis coach, I enjoy my clients and the work. I am playful, we laugh a lot, we have a good time. I don't think therapy has to be this deeply serious thing all the time. Certainly, there are issues that carry more emotional weight and need to be given their due. Even more than that, when I think of all the next generations that are benefiting from their parent's growth, because the skill sets get passed on from generation to generation. We therapists are very, very fortunate to be able to have this kind of impact on our world and the generations to come. And it's also a great fortune to be able to spend one's life making other people's lives radically better.
RW: Thanks for sharing your work and yourself with us today. I agree it has been fun.
SH: I have enjoyed it as well, thank you.

John Gottman on Couples Therapy

Posted on by rezendevknowfully.com

The Interview

Randall C. Wyatt: Welcome, Dr. Gottman. Thank you for being with us today and sharing your insights and work with our readers at Psychotherapy.net. Many therapists are familiar with your couple’s and marital research, which you have written about extensively in several books and articles. Today I want to focus more on the therapist’s end of it as much as the couple’s end of it, because this is going to be going out to therapists of all stripes. You have often quoted Dan Wile, who said that when you choose a marriage partner, you choose a set of problems, a whole set of difficulties. That doesn’t sound very hopeful. Is that as pessimistic as it sounds?
John Gottman: Well, it's interesting. It changes the way you think about marital therapy.

When we brought couples back into the laboratory four years later to talk again about their major issue in their marriage,

69 percent of the time the couples had the same problems, same issues, and they were talking about them in exactly the same way
69 percent of the time the couples had the same problems, same issues, and they were talking about them in exactly the same way, so that the instability in the marital arrangement was enormous. Still, 31% of the problems had been solved.

When we looked at the masters in marriage, how did they go about solving these solvable problems? That's when we discovered this whole pattern of really being gentle in the way they approached solvable problems – a softened start-up, particularly guys accepting influence from women, but women also said things to men, it was a balance, they both were doing it. The ability – again as Dan Wile says – to have a recovery conversation after a fight. So it wasn't that we should admonish couples not to fight but that we should admonish them to be able to repair it and recover from it. That became a focus of the marital therapy that I designed.

In terms of the unsolvable or perpetual problems, we found two kinds of couples, and the optimistic part is we found a lot of couples who really had sort of adapted to their problems.

It's not that they liked it but they were coping with it and they were able to establish a dialogue with one another about it. Okay, you're not happy about it but you learn you can cope with it, have a sense of humor about it, and be affectionate even while you are disagreeing, and soothe one another, de-escalate the conflict. And then the other kind of couple who is really gridlocked on the problem. Every time they talked about it, it was this meeting of oppositional positions; there was no compromising.

The Myth of Active Listening

RW: Many couple’s therapists, as you know, recommend “active listening” and “I messages,” and that’s pretty much the bedrock or the history of couples therapy in this country. Satir and Rogers, among others, advocated these approaches yet you’re critical.
JG: Well, I used to recommend it. The history of where it came from is that Bernard Guerney took it from Carl Rogers' client-centered therapy. Most of the techniques of marital therapy have come from extrapolations from individual therapy. Carl Rogers would be accepting and understanding and genuine and the client theoretically would grow and develop and open up.
RW: So each member of the couple could then be a therapist to the other person?
JG: Yes, suggesting that the same thing could be applied to marriages is a big leap because, first of all, there's a hierarchical relationship between therapists and client. The client is paying, the therapist isn't paying. Usually the client is complaining about somebody else, so it's very easy for the therapist to say: "Oh, that's terrible what you have to put up with, your mother is awful, or your husband, or whatever it is. I really understand how you feel."

But in marriages, it's different because now you're the target, and your partner is saying: "You're terrible," and you're supposed to be able to empathize and be understanding. We found in our research that hardly anybody does that, even in great marriages. When somebody attacks you, you attack back.

RW: “I feel you’re a jerk,” instead of “You are a jerk,” so the I statements are covert attacks?
JG: But that wouldn't really put the kibosh on active listening, because even if people didn't do it naturally, you could train people to do that. In the Munich Marital Study, a well controlled study, Kurt Hahlweg did the crucial test and he found that the modal couple after intensive training in active listening were still distressed. And the ones who did show some improvement had relapsed after eight months. It was the worst intervention in the Munich Marital Study! I'm not against empathy,
I'm just thinking active listening is not a very good tool for accomplishing it.
I'm just thinking active listening is not a very good tool for accomplishing it.
RW: Tell me why, in particular?
JG: Well, it kind of makes sense. Let's say my wife is really angry with me because I repeatedly haven't balanced the checkbook and the checks bounce. I keep saying: "I'm sorry, and I'll try not to do it again." So finally she gets angry and confronts me in a therapy session. What would it accomplish if I say: "I hear what you're saying, you're really angry with me, and I can understand why you're angry with me because I'm not balancing the checkbook." That's not going to make her feel any better, I still haven't balanced the damned checkbook! So I've got to really change – real empathy comes from going: "You know, I understand how upset you are. It really hurts me that I'm messing up this way, and I've got take some action." Real empathy comes from feeling your partner's pain in a real way, and then doing something about it.
RW: Doing what you can do?
JG: Yes, doing what you can do.
RW: You may not be a good accountant but you can try.
JG: You can try, right. So I think it's really kind of artificial to just say: "I hear what you're saying, I can understand that, that makes sense to me, and then we switch back and forth." Have you really engaged in empathy?
RW: You might have to work a lot harder to show somebody you understand, that you know what they’re talking about, and that it matters.
JG: So here's what the secret is, I think here's what couples do who really are headed for divorce. They take the problem and they put it on their partner: "The problem is you, and your personality, your character; you're a screw-up." That's an attack, and that's the fundamental attribution error that everybody's making: "I'm okay, you're the problem, you're not okay." So then their partner responds defensively and denies responsibility and says: "You're the problem; I'm not the problem."

What the masters do is they have the problem and it's kind of like a soccer ball they're kicking around with each other. They say: "We've got this problem. Let's take a look at it, let's kick it around. How do you see it? I see it this way, and we kick it around." And all of a sudden I can have empathy for your position because you're telling me what you contribute to the problem.

RW: One person has to break the cycle and then –
JG: And move that from defense mode into a collaborative mode.
RW: So have you found that if one person does that, some momentum starts going and things start changing?
JG: Rarely. It usually has to be both people. So one person is admitting fault and saying "I'm sorry" all the time, the other person is saying:
"Yeah, you're a screw-up. No wonder you're apologizing, you need to apologize, you should get down on your knees and apologize."
"Yeah, you're a screw-up. No wonder you're apologizing, you need to apologize, you should get down on your knees and apologize." And then eventually that person who's saying I'm sorry all the time feels pretty angry and pretty much like it's not fair, it's not balanced. There has to be a real balance, I think, or has to be a perceived balance, it has to feel fair.

"Yes Dear" and What Men Can Learn from Bill Cosby.

RW: I remember Bill Cosby having a father-son talk on the old Cosby Show. His teenage son said: "My girlfriend is still mad at me, I screwed up! I said I was sorry, but she won't forgive me. What can I do, Dad? I want her back more than anything." And Cosby says in his Cosby voice: "Son, you're not done til' she says you are done." His son dejectedly says: "Well, how many times do I have to keep apologizing, Dad?" And Cosby says: "Until she begs you to stop." This sounds similar to what has been called your "Yes, Dear" approach, which has been lampooned on the Politically Incorrect TV show. It sounds cliche, but what are Cosby and you really getting at?
JG: There's this great Ogden Nash poem that I think gets Bill Cosby's point, and I'll paraphrase it:

To keep brimming the marital cup, 
when wrong admit it, 
when right shut up!

It's a great line. It's about respect, it's about honor, and the idea of giving in, of saying I'm sorry, that really honors both people. So what we find is that, first of all, just like Bill Cosby said, the husband is really critical in this equation because women are doing a lot of accepting influence in their interaction. That's what we find and it doesn't predict anything, because many women are doing it at such a high level. But there's more variability in guys. Some guys are really in there and these are the masters. They're not saying: "Yes, dear." What they're really saying is: "You know, I can see some points in what you're saying make sense to me. And there's other stuff you're saying I just don't agree with. Let's talk about it." Now that husband is a different husband from the husband who says: "No. I'm not buying any of this!" Then the husband becomes an obstacle.

If you don't accept some influence, then you become an obstacle and people find a way around you and you have no power. So the violent guys that Neil Jacobson and I studied, they're always saying: "No!" to offers to communicate better. No matter what was said, they would bat it back like baseball players at batting practice. Wham! And they turn out to be enormously powerless in their relationships. I think that's one of the reasons they resort to violence, because they have no influence in any of their personal relationships.

RW: And in couple’s therapy, oftentimes when dealing with the aggressor, they’re told to basically give up all their power, both illegitimate and legitimate, and so then they’re powerless again, and the cycle begins anew.
JG: That doesn't work either. Morihei Ueshiba, the Japanese genius who invented Aikido, had that very point, his whole approach to negotiating conflict, which is you need to yield to be powerful.
RW: When pushed, pull, when pulled, push, and roll.
JG: That's right. So it's not that the guys were saying: "Yes, dear," as the parody went, and, sure, "I'm sorry, I'm sorry, anything you say." They were saying: "I can see this point; let's kick this around. Here's my point of view. I accept some of what you're saying but not all of it." Usually the wives will be saying a similar thing. And then they really start persuading one another and compromising and coming up with a solution.
RW: You’ve used “masters” several times, by that you mean?
JG: I just mean people who stay married and kind of like each other. I have a low criterion for mastery, and I actually do have a lot of awe for these marriages. We've studied couples who have been together 50 years. We've looked at masters from the newlywed stage through the seventies, the transition to retirement people who are 70 and 80 years old now. When I say they're masters I really sit down and watch them, and my wife and I try to learn from what we've learned in the research and acquired in our own relationship.

What Gottman Learned from His Own Marriage

RW: I was curious about that. In your own relationships in marriage and life, have you applied what you have learned personally in working with couples, and vice versa?
JG: Absolutely. For example, when Julie and I do our workshops with couples, one of the main messages we give is that we've found that really good marriages, people who are really happy, have terrible fights, where they're thinking at the end of the fight: Why did I marry this person?
RW: Not right before the workshop, I hope?
JG: Well, sometimes we have. We've had a fight the morning of the workshop and we're not talking to each other before the workshop. So one thing we did in the workshop is we processed our earlier fight in front of the audience. One time I got up in the morning and my wife had had a really bad dream about me. I was a real rotten guy in her dream. She was mad at me! I was being really nice to her in real life but in her dream I was a rotten SOB. So I try to be real understanding but she is still mad. And then finally I said: "You know, this isn't really fair because I didn't do this stuff" and so I got angry with her. She went in the shower and she's crying, and so I got in the shower and tried to comfort her. She wouldn't be comforted by me because now, I'd really made her angry. We talked about this in front of the audience for the first time: "We've had this fight, and this is not unusual. Periodically we have disagreements, stuff like this happens, and here's how we talk about it."

My wife and I once had a disagreement that took five years to resolve. It started out as a perpetual problem, a real big difference between us that wasn't reconcilable. We worked on it and we talked about it every day and we finally made a compromise. But it still wasn't fully resolved and five years later we actually solved this perpetual problem. It stopped being a problem, which happens occasionally in our research, too. But most of the time they don't get resolved at all. And somebody in the audience said: "Well, that's amazing that it took you that long. You guys, you're teaching this workshop." And we said: "Well, this is the way it is in good relationships."

RW: Why did it take so long? You’re both smart people, I am sure.
JG:
But she's so stubborn. You don't know what I have to go through. And that's what she says about me. That's what people are really saying.
But she's so stubborn. You don't know what I have to go through. And that's what she says about me. That's what people are really saying.
RW: It seems there are three issues: prevention of fights when possible, how to argue when you do fight, and how to recover when it gets away from you.
JG: Exactly!

When Compromising Too Soon is a Problem

RW: You brought up the need to compromise. Dan Wile (see Couples Therapy: A Non-Traditional Approach) suggested that sometimes people compromise too soon even when they feel strongly about an issue. By the time they talk, neither one of them will compromise anymore. Each person has already compromised once, though their partner does not know that or appreciate it. And then both people come across as more stubborn then they actually are.
JG: Right, I think that's a very good point. I think Dan Wile is a very wise person, a wonderful therapist, and most of his insights are supported by the research I do. We have him come up to Washington every year and do a workshop for our therapists at our marriage clinic. I think one of the great things that Dan Wile said is people shouldn't compromise so much.
RW: Yes, that sometimes compromise is a solution that becomes a new problem.
JG: A lot of times they're giving up their ideals, they're giving up the romance and passion of their selves. They've giving up something really essential. That's what the secret is to ending the gridlock in these perpetual problems; to realize that there's a reason why people can't compromise. They have a personal philosophical ideal that they're holding on to and it's very essential to who they are as a person.

And

if you can make the marriage safe enough, you can take those fists and really open them up, and there's a dream inside of each fist, there's a life dream.
if you can make the marriage safe enough, you can take those fists and really open them up, and there's a dream inside of each fist, there's a life dream. When people see what the dream is and what the narrative story is, what Michael White would call the narrative behind it, the history of this life dream, usually both people want to honor their partner's dream.

RW: They may not be able to go along with it all, but honor is different than just kowtowing.
JG: Exactly. There are many ways of honoring someone's dream. You can support it, understand it, financially support it, or you can talk about it.
RW: Here’s another area where you go against the grain of couples’ therapy tradition. Often couples therapists begin their books criticizing romantic pop songs or idealistic romance movies or novels. You say “Don’t give up those dreams, don’t give up your fantasies, you may not get them all but don’t give them up.”
JG: I'm basing this a lot on the work of Don Baucom who has looked at this idea: Is it true that we have too high of standards and that's why we're unhappy and so should we lower our standards? He found just the opposite. He found people who have idealistic standards, who really want to be treated well and want romance and want passion, they get that, and the people who have low standards, they get that. It's better to really ask for what you want in a relationship and try to be treated the way you want to be treated.
RW: You’ve critiqued two pillars of the couple’s therapy accepted truths. Active listening is not the be-all/end all to accomplish empathy, and romance and hopes should not be cast aside as merely wishful thinking. So how do therapists respond to this? Are they shifting? What’s your perception?
JG: I think there's a certain kind of therapist that's real interested in what I have to say, those interested in scientific validation for ideas. Not every therapist finds it appealing. I've tried to create a psychology of marriage from the way real, everyday people go about the business of being married, instead of taking it from psychotherapy.

What Works in Couple’s Therapy?

RW: You’ve done in vivo research, looking at couples in their homes, in the lab. Now you are doing the outcome studies. How does it look?
JG: We're now doing the outcome studies to see whether it will work. What came out of this way of studying normal couples, everyday couples as well as the masters of marriage, was a theory, and I think that's what therapists find useful. Pieces of it have some evidence, but it still needs more confirmation. For example, if you know that the basis of being able to repair a conflict is the quality of the friendship in the marriage, then
you can individualize therapy for each couple and that's the task that every therapist is confronting.
you can individualize therapy for each couple and that's the task that every therapist is confronting. We confront it every day in our consulting rooms.

We look at three profiles in every marriage – the friendship profile, the conflict profile and the shared meanings profile – which is creating a sense of purpose and shared meaning together. Then on the basis of that we think: Well, they need this kind of intervention and that kind of intervention, but it really emerges from the process in the consulting hour from what the couple brings.

RW: Many therapists want more than a cookie cutter type of therapy? they want to individualize their work with couples vs. using only one theoretical model.
JG: That's right. The interesting thing to me is that my research supports a systems view, that really is husband affecting wife and wife affecting husband in a circle. The existential view is supported because you can't just look at what these gridlock conflicts are about; you have to look underneath at what the life dream is. Then these dreams have narratives, so narrative therapy is supported, and they usually go back to the person's childhood and they go back to have symbolic meanings about the way they've been traumatized in other situations, so a psychodynamic point of view is also supported. You get a behavioral view supported because you find when you look at the evidence that often the best way to effect change is changing the behavior rather than trying to change the perception of a person, and perception often follows behavior. So all these different kinds of therapies are supported by this research.
RW: There’s something for everybody to be happy with.
JG: You have to really take a little from everybody to do good couple's therapy.
RW: When you went into couple’s research, you had certain views of marriage and relationships. Which ones were debunked, and which ideas do you still hold on to, despite the research?
JG: Well, I went in with an open mind. When Bob Levenson and I started doing this research, we decided on a multi-method approach. We thought perception must be important, so we showed people their videotapes and interviewed them about what they saw on their tapes. We interviewed them more globally about the history of their families – multi-generational perspective must be important. Asked about their philosophy of marriage, how they thought about the conflict and what their worldviews were about their relationship, what their purposes were. And we thought emotion must be important, so we scored facial expressions and non-verbal behavior and voice tone. We tried to look at everything. We looked at couples in all these contexts, whether they were conflicting or talking about how their day went or a positive situation, with no instructions at all, and we tried to see what would emerge from the data.

I thought active listening would be powerful. People just didn't do it. For a long time I thought we were getting evidence that it was happening, but it wasn't until I started doing workshops with clinicians that I couldn't find any examples of it. I went to my observational coding team: "Help me find some examples," and they went: "Oh, God, we don't know how to break this to you but we haven't found any examples." And I said:

"Why didn't you tell me?" and they said: "Well, we didn't want to hurt your feelings." So I was blown away by it.
"Why didn't you tell me?" and they said: "Well, we didn't want to hurt your feelings." So I was blown away by it.

RW: Researcher and assistant bias?
JG: That's right. So my staff was really protecting me. I saw that I was wrong about this and had written about it in print. I really had to eat my words. I think it's important to do that, to find out these things. I also thought that what would really work in conflict is people being honest and direct. Confronting each other saying: "You know, you do this and it really makes me angry," and the other person would not get very defensive. Boy, that wasn't true. The masters were not doing a lot of this clashing and confronting stuff. They were softening the way they presented the issue and giving appreciations while they were disagreeing.
RW: They can also hear some feedback. They weren’t just closed to it.
JG: They weren't closed to it, because the partner was using humor: "I appreciated you taking that drive, it was so nice and I know you were tired." And the other person wouldn't see that as gratuitous flattery, and say: "Thank you very much," and really appreciate those comments.

Happy Marriages: What are They Made of?

RW: Is this something that is in these happily married people before they were married? Did they learn it? It is part of their family background?
JG: Well, we know a little bit. We know that personality, the enduring qualities that people bring to their relationships accounts for about 30 percent of it, how conversations begin could be a moodiness and so on.

But then there's the fit between two people. Let's say I select somebody to marry and she's kind of a moody person, but it doesn't really bother me that much, I don't take it personally and we fit in terms of this. If she had married somebody else and if she comes in moody and all of a sudden they take it personally, that doesn't work.

Nathan Ackerman talked about this a long time ago in the thirties, saying that two neurotics can have a happy marriage if they don't push each other's buttons and they're respectful about what Tom Bradbury calls enduring vulnerabilities.

That's one thing we do in our therapy is really try to find out what are the enduring vulnerabilities in these two people, how does the marriage respect that?
That's one thing we do in our therapy is really try to find out what are the enduring vulnerabilities in these two people, how does the marriage respect that? How can we, in this marriage, not trample on those sensitivities so that person doesn't go nuts?

RW: It sounds like there’s sensitivity to each person’s vulnerabilities and meanings and not just an open-ended kind of experiential therapy. In the same way, how can the therapist appreciate what works for the couple already? It reminds me of – it will sound far afield, but since you mentioned baseball, stay with me – the old Boston player Carl Yastremski used to have his bat way up there, and some coach tried to change it. Maybe he holds his bat funny but it works for him. For couples, I fear that sometimes therapists have a view of just how things should be. The couple’s doing fine, it’s not a problem for them, and yet we’re trying to fix it, the problem that doesn’t exist.
JG: I think that's true. I think a lot of us come in with a sort of model of what good communication or intimacy should be, and it doesn't fit what this couple wants or desires or needs. We have to be very flexible and be able to move from one system to the other, and really speak in their language as well.

Future Breakthroughs?

RW: What’s your next challenge in research? I see you have a book out on domestic violence and what works in couple’s therapy (When Men Batter Women: New Insights into Ending Abusive Relationships). What’s the next breakthrough on the horizon?
JG: The real challenge, I think, is to try to develop a therapy that fits certain kinds of people so that we're not doing the same thing for every couple. So we can do an assessment and say: "Oh, we need this kind of therapy for that couple, and this other couple doesn't need that, they need something quite different." We need to modify therapy to fit each particular couple.

And preventing relapse is the other challenge. We're trying to develop preventive approaches. We're doing things like arranging birth preparation classes to prepare people for what's going to happen for when the baby comes, because 70 percent of the time marital satisfaction goes down the tubes. We know marital conflict increases by a factor of nine.

Extra-marital affairs are another area where there hasn't been a single controlled outcome study, trying to help couples get over non-monogamy. At least if you're on the science bus you want more research-informed therapies. You can select from the clinical literature but it's hard to know which treatment approaches work best. Shirley Glass's is the one I really favor because it's based on more research. Another issue is co-existing problems like depression and marital trouble, or alcohol. O'Farrell and MacCready have approached alcoholism and marital distress and created an integrated program focusing on both issues in the same therapy; both were more effective.

RW: What is the most gratifying part of your work as a researcher, couple’s or marital therapist?
JG: I'm really in this for knowledge. The deal I made with God is that I wanted to understand things: how relationships work, how to make them work, and I'm hoping that eventually this knowledge becomes widespread and well known. Just like we don't know very much about the guy who invented Velcro, we just use it. One of the things that I've really learned in the past five years is to make research and therapy a two-way communication. That's what needs to happen because up until now therapists have been on the firing line – developing these ideas in isolation.
RW: One thing that people enjoy about your books and your work is that it does bring research from the ivory towers of academia to therapists, to other people, in an everyday language.
JG: I think it's absolutely true that if the people come alive from the theory, then you know that it makes some sense. If you can actually use the ideas and put them into practice, in some concrete way in your own relationships and in work with clients, then you know that maybe it makes some sense, it's useful.
RW: That would be a good thing. Thanks for taking the time to talk with us today.
JG: Thank you.

Nick Cummings on the Past and Future of Psychotherapy

Posted on by rezendevknowfully.com

A Psychotherapy for the People

Victor Yalom: Well, Nick, good to have you here at the Brief Therapy Conference in San Diego, 2008. I believe you’ve long been a proponent of brief therapy and intermittent therapy throughout the lifespan.
Nick Cummings: Correct. In fact, I started that in the 1950's.
VY: Really? Tell me about that.
NC: I was trained as a psychoanalyst and went into a psychoanalytic practice in San Francisco. I did this for a number of years and decided that if I were lucky—I had an epiphany one night—that by seeing patients four times a week for seven years, in my entire lifetime, if I live long enough, I might touch 70 lives. And it occurred to me that that's not why I became a psychologist.
VY: Now, for some people, touching 70 lives deeply would seem like a good thing.
NC: Well, in those days there was no prepayment, so it was essentially treating the diseases of the rich–people who could pay. And to pay for four sessions a week, you had to have some money. It occurred to me that there was a great need out there among working people that didn't have these services available.  If they had mental health issues—in those days all you had was psychoanalysis—they didn't go into it. Minority groups—for example, African-Americans—turned to religion when they had distress, because psychotherapy wasn't available to them. We were the first program to make it available to them for free. And the idea that African-Americans didn't go into psychotherapy turned out to be a myth, because when we provided it, we had many African-Americans in the late 1950's in our program in San Francisco. So after practicing psychoanalysis for a while, and butting up against the psychoreligion of the San Francisco Psychoanalytic Institute, which was absolutely rigid in those days, I decided this was not what I wanted to do, and I was wondering what I was going to do. 

My wife said to me one day, "Kaiser Permanente is looking for a chief psychologist." So I applied, found out there were some 56, 58 people that applied, and I made the final cut of half a dozen finalists. In my interview with the founders of Kaiser Permanente, which was very young in those days—Kaiser Permanente was formed post-World War II—they said to me, "If you take this job, you've got to agree that for the first six months we can fire you with no questions asked." I found out later I got the job because the other five finalists said, "No way," and they withdrew. To me, that was like waving a red flag in front of a bull.

VY: You liked the challenge.
NC: I loved the challenge. "I'm going to take this job and I'm going to show you that I can succeed." After I started, I found out why they had made this challenge: my predecessor had been Timothy Leary. Do you remember Timothy Leary, the High Priest of LSD? He was the chief psychologist of Kaiser Permanente before me.
VY: Wow, who would’ve thought that?
NC: This was before he went to Harvard and got into LSD and so forth. But he was so interested in doing research that they couldn't get him to send one of his people over to the hospital to do a bedside consult. So one day, Sidney Garfield told me—Dr. Garfield was the founder of Kaiser Permanente—he came to work and the second thing he did was hang up his coat. The first thing he did was pick up the phone and fire Tim Leary. And then he decided that he didn't want anything more to do with psychologists. They went for a couple of years without them, but then decided they couldn't get along without them. And Dr. Garfield, interestingly, although he was a physician, didn't want the department vested in psychiatry. He wanted psychologists doing the work, because Kaiser Permanente was beginning to realize that a lot of the so-called medical conditions were really emotional problems translated into physical symptoms. And they said, “A psychiatrist is ultimately a physician”–wearing white coats in those days—“and it's just going to ingrain in the patient that this is a physical issue.” So he wanted it done by psychologists. Two years later he decided he was going to try again; I was interviewed, and I stepped into that post.

Throwing out the Couches

VY: You’ve had obviously a long, illustrious, and sometimes controversial career; we could spend hours going through all of it. So to be brief, what were a few of the things you did at Kaiser that you thought were instrumental?
NC: The first thing: in those days, you never started therapy until you did a social worker intake. Then, after the social worker intake, you did a battery of tests. Those were absolutely mandatory before therapy could start.
VY: Was this just at Kaiser?
NC: No, this was the United States! And the battery of tests were the ubiquitous Wechlser Intelligence Scale, Rorschach, Thematic Apperception Test, the Bender Gestalt, and the Machover Draw-A-Person. You had to do those five tests—it was written in the bible of psychotherapy in those days.
VY: Wow. I had no idea.
NC: Before you did the battery of tests, you had a social worker do an intake interview. By the time the therapist saw the patient, the patient had told his or her story two other times. Now this was the third time. We eliminated the first two. Everybody said, "They're going to be sued up the kazoo. This will not work." We never got sued. The first person to see the patient was the therapist.
VY: Makes sense.
NC: Which is what we do now! That was radical in 1957. It worked. So that's one of the things we did.

I had the power to hire eleven psychologists, twelve of us in all. And I had my own psychoanalytic couch, being trained as a psychoanalyst, so I ordered eleven more psychoanalytic couches, all with nice tufted black leather, just like Freud's. We started seeing plumbers, carpenters, bus drivers, restaurant servers…
VY: How many times a week? Would you see them more than once a week?
NC: We insisted in the beginning we had to see them twice a week at least. And we'd ask them to lie on the couch, but they were uncomfortable. They'd want to get up off the couch. So I had another epiphany.

I saw a working class man that had back trouble. He’d exhausted all 33 orthopedic surgeons at San Francisco Kaiser, and they all decided, "This is all in your head; go see the shrink." I asked him to lie on the couch. He said, "Sure, Doc," and he lay on the couch face down. I said, "No, no, you don't understand. I want you to lie on your back." He turned over and said, "Sure, Doc, but how are you going to examine my back if I'm lying on it?" I said, "No, no, no, I'm not going to examine your back." He said, "What are you going to do, Doc?" I said, "We're going to talk." "Oh!" He jumped up off the couch, grabbed a chair, put it opposite me, sat down, and said, "OK, Doc, what do you want to talk about?"
It suddenly hit me that everybody in the world knows that when you talk to people, you talk face-to-face–except psychoanalysts.
It suddenly hit me that everybody in the world knows that when you talk to people, you talk face-to-face–except psychoanalysts. You have to sit behind the couch so the patient can't see you.

So we decided to get rid of the couches. We called up Goodwill and when they came out to pick them up they looked at them and said, "What are these? Nobody can sleep on them: they slope. You can't sit on them because they don't have a back. We don't want them." They refused 12 couches! So I called up the Salvation Army. They came out and they said the same thing: "These are ridiculous, what are we going to do with these?" So I called up St. Vincent de Paul. And I told them we had 12 nice black leather tufted couches that we wanted to give away. I got my staff—we were on the third floor—and I said, "We're going to take these couches and we're going to carry them in the elevator and stack them up on the street on the corner. And I'm going to stand out there." When the truck pulled up at the appointed time, they said, "We don't want these." I said, "They're yours. I'm going to walk away, and if I have to call the police that you're littering the sidewalk… Because they're yours, you agreed to take them." That's how we got rid of the couches! So we started seeing patients face-to-face. I was immediately declared a traitor from psychoanalysis.
VY: So your traitor status started early in your career.
NC: Very early in my career–actually much earlier, before I became a psychologist, but anyway, that's another story.

Your Therapist for Life

So we started seeing patients face-to-face, and instead of asking them to free-associate, which working people didn't know how to do… See, up until that time, the only people we treated were the educated class who had read about psychoanalysis and were eager to try it. So when you'd say, "Free-associate," they would do it. These people didn't know how to free-associate. They knew how to talk. We started listening to them and began to develop focused, targeted therapy addressing the problem. Do you remember a man named Michael Balint?
VY: Heard the name.
NC: Michael Balint helped found mental health in the British universal health system after World War II. In his 1950 book, The Doctor, the Patient, and the Illness, he said that physicians have to become more like psychologists, and psychologists have to become more like physicians. He said that the idea that a psychologist is going to treat a patient so that for the rest of his life he will never have another neurotic symptom is insane. It's crazy. Physicians don't practice that way. You come in, you have the flu, you're treated for the flu. After the flu is cured, you're dismissed. But two or three years later, you may come in with a leg injury, with a fall, with whatever. And you're treated for that. Psychologists should treat people for the condition that brings them in.
VY: There’s no magical, comprehensive cure.
NC: That's right. So we started doing that, and the hostility was enormous. We never terminated a patient. When we got to the place where the patient said, "Gee, Doc, I'm feeling great, do I have to come in?" I'd say, "No, we're going to interrupt our treatment. Just like you go to your doctor for your physical problems, you come here if you ever have another problem that you can't solve yourself."
VY: People don’t have the idea if the doctor cures an illness or a virus, that that’s the end of their relationship with the doctor.
NC: Exactly. We extrapolated that into psychotherapy. This was absolutely heresy in those days. I was attacked, not just by psychoanalysts, but by colleagues. And it worked because the patient could come in for life. We began calling itbrief intermittent psychotherapy throughout the life cycle. "I am your doctor for the rest of your life." And the interesting thing was we found out it was transferable—that patients who might not have come in for four years would start talking as if they'd been in last week.
VY: Kind of like old friends: if you don’t see a friend for a long time, you pick up where you left off.
NC: Exactly. I might not remember the last conversation that well, but they did. And it worked. Now, they didn't know that there were other forms of treatment, but for what we were doing, it worked. And Kaiser said, "How do we know that these people are doing well?"–because calling them up and asking them "How are you feeling?" is unreliable.

Kaiser got interested in psychotherapy because they found out that 60 to 70 percent of their physician visits in primary care had psychological, not medical, conditions. So we decided to follow these people the year after they'd been in, the second year after, the third year, and see what their overutilization of health care was, because they would be running to the doctor when they actually had psychological problems. We found that we were reducing medical overutilization by 65 percent within five years after the initial contact, with no further therapy. And that's how the medical cost offset attracted the National Institute of Mental Health, the Veterans Administration, and so forth. We started a series of research.

The acceptance in medicine was terrific. The acceptance from government in Washington was terrific.
The rejection from my colleagues was intense. I was accused of destroying psychotherapy singlehandedly.
The rejection from my colleagues was intense. I was accused of destroying psychotherapy singlehandedly. And I said, "Well, it's just a pleasure to learn I'm that powerful." But nonetheless, this is what I had to put up with. I contacted Michael Balint and asked if he could come to San Francisco and spend a week with us. And I wanted him to meet with our psychologists and physicians. He asked, "Can I bring Alice?"—his wife. Victor, we got both of them for one week and we would go from morning, have dinner, and go into the evening. We got him and Alice for one week, not counting airfare and hotel, for $1000. Both of them, in the late 1950's.

He convinced us that we were going in the right direction. A lot of my staff was beginning to chafe under the attacks, but all of this bolstered our resolve and we kept going, and we'd write about it and we'd publish. All of us became consultants in Washington, D.C. over this. For example, I became a consultant to Ted Kennedy when he was head of the Senate subcommittee on healthcare. At the same time, I was in private practice.

So this is how we developed the model of brief intermittent psychotherapy throughout the life cycle. Later we changed it to focused intermittent psychotherapy because our adversaries had made such a dirty word out of "brief." We decided to call it "focused" or "solution-based" or whatever.

Strange Bedfellows at the State Capital

VY: Now, how did you get from there to starting the California School of Professional Psychology, the first independent professional school?
NC: I found out, in talking to students in the late 1960's, that the same conditions were extant with them that were there when I went through a doctoral program. Clinicians were not allowed to join the faculty. They had to have lots of publications, etc. etc.—all things clinicians don't do, because clinicians are busy seeing patients. So I started working with the education and training board of the APA to try to change the rules of APA accreditation to allow clinical faculty to be brought on board with the same status as nonclinical faculty. I utterly failed. Finally, one night in the middle of the night, I couldn't sleep and I had another epiphany. I said, "I have to start our own school." I was president of the California Psychological Association at the time; Don Schultz was our executive officer. The next morning I could hardly wait to tell Don my idea. And Don started saying, "You know, Nick, you're working a little bit too hard. I think you should maybe take a rest." I suddenly realized Don was treating me like I was having a psychotic episode or something with my idea.
VY: It seems work is what drives you and keeps you alive.
NC: It's invigorating. Especially if it's innovative.
I have to change careers every seven years because once I succeed at something, administration bores the dickens out of me.
I have to change careers every seven years because once I succeed at something, administration bores the dickens out of me. I have to go out and create again. This is why we're forming this new program.
VY: We’ll get to that in a second.
NC: So anyway, Don says, "How are you going to pull this off?" Ronald Reagan was governor of California in those days. No friend of psychology. But Reagan was having a fight with the University of California on the Board of Regents. And I knew that he might listen to this idea, not because he liked psychology, but because he wanted to do something to the Board of Regents.
VY: They say politics makes strange bedfellows.
NC: Absolutely. He had an administrative assistant named Dr. Alex Shariffs who had been Dean of Students at Berkeley, and I knew Alex. So I called Alex up and said, "Can you give me an appointment with the governor?" "Oh, what's this about?" When I told him, he said, "Hey, that sounds like a great idea!" So he arranged it. When we walked in, the governor said, "Dr. Cummings, today is very busy." They were having the eruption on the San Francisco State College campus.
VY: Yeah, late 60’s.
NC: Yeah. "You've got 20 minutes." We were there for almost two hours. Once he heard it, he kept asking questions. Finally he said, "Dr. Cummings, I'll make a promise to you. You get a first-class faculty, a first-class library, you get an endowment and a curriculum that makes sense, and I will order the head of the department of education in the state of California to accredit you."
VY: That’s a dramatic story.
NC: I thought, "How do I get a first-class library? This takes millions of dollars." I discovered in my research that any Ph.D. in the state of California had complimentary access to the Berkeley and UCLA libraries. So I got a card and all of my students got duplicates. And they all used the University of California libraries, using my card.
VY: So they were all using Nick Cummings’s card!
NC: We got it later amended that any doctoral student could use the state facilities. When we got it changed, they had their own cards as bona fide doctoral students. So we solved the library problem. We got a first-class faculty because I got 200 psychologists to volunteer to teach for free for 18 months—they would all teach one course. And they loved it. And this was sort of like our endowment. Teaching free for 18 months launched us, because we didn't have the money up front.
VY: That’s a lot of free labor.
NC: A lot of free labor, but it was very productive free labor. They loved it, and they loved interacting with our students. And we had a very innovative program.

Originally we started with the San Francisco and Los Angeles campuses. The San Francisco campus was above a machine shop.
VY: I heard about that. I heard there were pillows on the floor and all the students had to be in group therapy.
NC: Yep, absolutely. But when the big machines were running on the first floor, the whole second floor would shake and vibrate. The Los Angeles campus was in a condemned Elks Lodge, and the building was right on MacArthur Park and was due to be torn down. We got it for nothing. But the problem was, right in the middle of class there could be plaster falling off the walls. But within a year we got enough money, got our own facilities, and moved out of these. And then we founded the San Diego and finally the Fresno campuses. And this launched the professional school movement in the United States. So today, even though the APA has accredited doctoral programs, there are clinician faculty members in universities.
VY: Before we get to the new program you’re launching, what are your thoughts on the status of professional school education now?
NC: It has failed.
VY: How so?
NC: I formed the National Council of Schools of Professional Psychology—NCSPP. And I had set it up with Washington, the department of education, that it would be the accrediting body for the professional schools. Remember that our first classes at CSPP were in the 1970's; I founded it in the '69-'70 school year. We held our first meeting, and I said, "I'm doing the last thing for the professional school movement." We had to ratify the articles of incorporation, etc., etc., and elect a president. They elected Gordon Derner, who was my mentor at Adelphi. Gordon had run three times for APA president and lost, and he wanted APA respectability. He talked the group into going for APA accreditation, which was the biggest mistake–they signed their death knell at that point because the APA made them hire full-time faculty. Now, I could get ten to 12 part-time faculty to teach 12 courses for the same cost of hiring one faculty member who taught two courses. So we had created the business basis for the professional schools to succeed even though they were tuition-dependent. But once they had to get full-time faculty, they couldn't make ends meet. What they're doing now, unfortunately, is turning out hoards of master's-level practitioners and PhDs. They're accepting 900 GRE scores—it used to be if you weren't 1600, you couldn't get in. And they're flooding the market because they need the tuition. In that sense, they've failed.
VY: You’re known for making strong statements, and to say “failed” seems… There are certainly lots of good programs, and lots of good psychologists coming from these programs.
NC: And there are lots of very poor psychologists coming from these programs.  I say about them that some of the best psychologists I've ever worked with came from the professional schools, and some of the worst have come from these same professional schools. The range of ability is incredibly large.  The old saying that you can't make a silk purse out of a sow's ear also applies that you can't make a sow's ear out of a silk purse. The bright students do well, and they flourish in the professional schools. And then there are students that limp through.

The New Behavioral Health Providers

VY: Jumping ahead, you’re starting a new program this coming fall: the Nicholas Cummings Doctorate in Behavioral Health. What’s the idea behind this?
NC: The idea behind this is we have launched a plethora of professions out there. We not only have psychologists; we have social workers, we have MFTs, and we have MA-level counselors. All of these organizations fight each other. And when the newer organizations are looking for licensure, the older organizations fight them, just like psychiatry tried to prevent psychology from getting licensure. We tried to prevent social work from getting licensure. We now try to prevent MFTs from getting licensure, master's-level counselors from getting licensure. So we have created a very antagonistic atmosphere with a profession called psychotherapy that is fractionated into organizations that are fighting each other.

Also, we have drifted so far away from health care that we have created two silos. We have a huge silo called health care, and it gets a trillion dollars a year. And over here we have a tiny silo called mental health that gets the crumbs. In the last ten years, where we've passed parity in 44 states, the portion of the budget that goes to mental health has dropped from 8 percent to 4.5 percent—almost half.
VY: Parity hasn’t helped.
NC: Parity has done nothing, because when you pass parity, the managed care companies either create more herculean hurdles for mental health and for physical health, or they drop mental health altogether from their package. So we have declined by almost 50 percent in funding; the mental health silo's getting smaller and smaller. The American people pay for health care. They do not pay for mental health care on federal funding. That is an afterthought; it's the crumbs.
Until we become an integral part of health care, we will always, always get the crumbs.
Until we become an integral part of health care, we will always, always get the crumbs.
VY: So how are we going to do that, and how is your program going to help with that?
NC: Our program trains master's-level psychotherapists who've been in the field for several years and are savvy. They've been up against the world of hard knocks; they know what it's like out there. They know that psychotherapy has declined by 40 percent in the last decade. They are ready to upgrade and learn a new profession called behavioral health provider, to work in medical settings side by side with primary care providers, with equal status. You can't work in a medical setting unless you're called "doctor"—there is that chauvinism.
VY: So how are they going to get equal status? Even psychologists don’t get equal status.
NC: Psychologists go into medical settings and they make fools of themselves. They don't know a type-II diabetic from a type I-diabetic. They make so many errors, they don't know what medical protocol is, and they don't know how the health system works–they've been isolated in this other silo. So they're not accepted. Then they become defensive. They see that medicine is relegating us to a lower status. When we integrate behavioral care providers into primary care settings on a ratio of one BCP to six PCPs—BCP being behavioral care provider, PCP being primary care physician…
VY: One behavioral care provider to six physicians?
NC: In some systems they've loved it so much they've upped it to three—twice as many as our original model.

You always have to have at least two BCPs in every medical setting, because one is doing the treatment while the other is doing what we call the “hallway handoff.” When a physician is seeing one of the 60 to 70 percent of her or his patients that have severe psychological issues, instead of writing out a prescription and getting the heck out of the office—because they've learned that if this patient opens up and collapses and cries, they're stuck there for the next hour, and they have a waiting room full of patients—they can say, "You know, Mr. Smith, Dr. Jones, my colleague down the hall, I think can help us with your case." And the physician walks Mr. Smith only a few steps down the hall to Dr. Jones's office. And Dr. Jones is a behavioral care provider. The physician introduces the patient to Dr. Jones, and they sit down–the primary care physician doesn't dump the patient–they sit down, but only for a couple of minutes. And then he excuses himself, goes back to his office. The BCP takes over and does a 15- to 20-minute interview. They have been trained to engage the patient in treatment.

Now, Victor, the amazing thing is, we've done this with the U.S. Air Force, we've done this with several VA centers, we've done it in TRICARE [U.S. Military Health Plan], with returning veterans, and in community health centers. I named it the hallway handoff and the term has stuck. Eighty-five to 90 percent of patients who experience the hallway handoff will follow up and get into treatment, whereas when the physicians makes a referral to an outside therapist…
VY: They’ve got to first have the courage to call the person, set up an appointment, go across town.
NC: Only 10 percent get there.
VY: Wow.
NC: Literally only 10 percent. So this increases our patient flow by 900 percent! It's amazing. And it's consistent. Cherokee Health System in Tennessee has adopted this model. It's going great guns. Native Americans are really getting engaged in treatment because there's no stigma. This is a seamless part of the health system. You're not being abandoned by your physician and thrown into a mental health system where, "Oh gosh, my doctor thinks there's something wrong with my head." Even if they know this is a behavioral care provider, they see it as part of the health system, and the stigma is gone. It solves access, for crying out loud. You know, I have decided that we perpetuate stigma and access in our current practice, inadvertently.
VY: How so?
NC: Patients have a hard time getting to us. They have to call, make an appointment, go across town, leave the health system, go into a mental health system. The stigma becomes an issue, so they deny their own access because they don't want the stigma. We make it harder for the patient to get to us because psychologists do not congregate in health centers. If you look, physicians are herd animals. Every community has a medical plaza.
VY: They have a hospital and a medical office building next to it, or in the hospital.
NC: That's where podiatrists practice; that's where optometrists practice. Psychologists are across town in a solo office.
VY: Well, a lot of psychologists don’t think that they’re medical providers. We’re having conversations, as you said, with people about life—about their relationships, about their family, about their work.
NC: That's why we get the crumbs: because the American financial system pays for health care; it doesn't pay for psychosocial care.
VY: You said earlier that when professional schools joined with APA, I forgot your wording, but it was something like they made a pact with the devil. Don’t you think that, by identifying ourselves as medical providers when we’re really not, in some sense we’re making a pact with the devil, despite the financial gains of it?
NC: You just mentioned the fallacy. You said, "Wouldn't we identify ourselves with medical care?" There's no such thing now. When you talk to a nurse, they're not in medical care. They're in health care. When you talk to a podiatrist, they're not in medical care. They're in health care. Every health care profession recognizes that: "Oh, no, we're apart. We're not going to be medical care." Psychology has not caught up to the fact that, in 1985, the Supreme Court ruled that health care was subject to the same anti-trust laws as every business, and medicine lost their stranglehold on health care. You have these independent professions. And you know who figured this out first?
VY: Who?
NC: Nurses. Nurses used to be the lapdog of physicians. They'd do all the scutwork. Nursing now has established nurse practitioners. Only two percent of physicians go into primary care because that's not where the money is. The money is in specialties. Within 10 to 15 years, the primary care physicians in the United States are going to be nurse practitioners. Nurses know this. So the 26 nurse practitioner programs and nursing schools in the country this fall, 2008, upgraded their nurse practitioner program from an MA to a doctorate, because they're getting ready to be the primary care physicians. They've already done that. They own emergent care. You go to a doc in a box, it's going to be a nurse. The nurses are going full-blast, because they say, "It's not the medical system anymore! It's the health care system, and we're going to lead the way in health care."

The Hallway Handoff and other How-tos

VY: Let’s get back to your program in behavioral health. What are people going to learn in this program, and how are you going to teach it?
NC: They're going to take survey courses in the basic sciences. They're going to learn chemistry, they're going to learn physics, they're going to learn biochemistry, they're going to learn organic chemistry—not to the extent that they’re proficient in these, but they have a working acquaintance.
VY: In a year and a half they’re going to learn chemistry, physics?
NC: The mission of this program is to train skilled practitioners who are intelligent consumers of science—the opposite of what the APA does.
The APA trains scientist-professionals. So while they're trying to do both, they end up with second-rate scientists and piss-poor professionals.
The APA trains scientist-professionals. So while they're trying to do both, they end up with second-rate scientists and piss-poor professionals.
VY: Don’t mince your words, here.
NC: I'm not! I'm not. You know that.
VY: Tell me how you really feel!
NC: So for once, we say, "Let's do what all the health care professions do." We train skilled professionals that are intelligent consumers of science. That's what medicine does, that's what nursing does, that's what podiatry does, that's what optometry does, that's what dentistry does. Psychology hasn't figured this out yet.
VY: OK. So they’re going to get some survey, some general understanding, and what else? What are they going to do with this?
NC: During those 18 months, you spend two days a week in a medical setting and you rotate from outpatient to hospitals to cancer clinics, on and on. You learn the lingo of health care. Psychologists do not know the lingo of health care, and this is why they're fish out of water when they try to work in medical settings. They're going to become proficient in working like physicians work, but on the psychological side.
VY: So you’re assuming that these people–they’re master’s-level therapists, they’ve had quite a bit of experience–they have good therapy skills already.
NC: Yes.
VY: So you’re not there to teach them more therapy skills.
NC: No, we are not.
VY: So they know something about science; they learn about the medical system.
NC: Yeah.
VY: What do they need to know that they don’t know already? In other words, how do you take your existing clinical skills and modify them so that they work? Because I assume they already know a lot.
NC: They don't know how to do the hallway handoff.
VY: So what are three keys to doing the hallway handoff?
NC: They're chained to the 50-minute hour. The managed care companies always pay us on what we do in a 50-minute hour. And the more they squeeze the fee on that 50-minute hour, the more they squeeze us. So number one: abandon the 50-minute hour. It is archaic. As I say in the foreword to my latest book, the 50-minute hour is outdated in our nanosecond generation.
VY: Well, I’d say in that kind of setting I can see the disadvantage. But for ongoing depth, life-changing therapy, it works pretty well. And a lot of people do still want that.
NC: Then we're going to do what David Barlow recommends: that we should have a health care when we're part of health care. And that's called behavioral care. Then we have something called psychotherapy that continues to do what it's doing. But it's going to have to figure out how it gets paid, because under health reform, medical necessity is going to prevail, not life change. Americans are not going to pay taxes to fund a life-change system.
VY: Makes sense to me. So back to the hallway handoff: break the 50-minute hour. What else? What are the other skills?
NC: Role modeling. When you start, you sit in and watch an experienced person do the hallway handoff.
VY: Right. So what does the experienced person do, what do they know, that therapists need to learn?
NC: It's a skill that's hard to describe in words.
VY: I’ve never seen you at a loss for words, so do your best.
NC: There's no word for it; you are actually role modeling. And by role modeling, you learn to zero in very rapidly on the patient's presenting problem, which is something physicians do routinely because they have seven minutes with a patient. The average PCP visit in America is seven minutes. And in that, they've got to make a diagnosis and a treatment plan and so forth. We're not asking students to do it in seven minutes. We're giving them 15 to 20. But they learn to do it. And third, you learn what physicians need to do their job. And that's when they become so dependent on us that we achieve equal status.
VY: Well, this sounds good. It sounds like there’s a need for that.
NC: We're trying to respond proactively to where we see health reform going.

The Pits

VY: You’ve been a visionary in our field, an innovator, so let’s get you on record here. Where do you see health reform going?
NC: I see that
psychotherapy's either going to have to become part of the health system or lose out entirely.
psychotherapy's either going to have to become part of the health system or lose out entirely. Medical necessity will prevail. Marriage and family therapy, marriage counseling, occupational counseling is out. Look at the federal parity law that was passed last month.
VY: What you’re saying is it’s out of being paid for by tax dollars.
NC: Yes. MFTs are out. As David Barlow has seen, he said there are going to be these two systems: the traditional system, which we'll call psychotherapy…
VY: So that’s going to continue.
NC: That's going to continue, but they're going to have to figure out how to fund it. And it'll have to be funded out of pocket because it's not going to be part of health care. So if you want a life change, pay for it. Now, if the American people want it badly enough, they'll pay for it out of pocket, just like they do for alternative medicine.
VY: And there will still be some form of community medicine and various nonprofit counseling centers.
NC: Absolutely. But it will not be the golden age of psychotherapy that we've had in the past.
VY: When was the golden age?
NC: I'd say the 1950's.
VY: Private insurance was paying for it then?
NC: No. Private insurance came later.
VY: So we’ll be going back to the golden age, then.
NC: In the golden age of psychotherapy, there was a tremendous shortage of psychotherapists. People would wait sometimes for weeks and months for an interview.
VY: A golden age for therapists! Not for the public.
NC: Not for the public, absolutely not. I'm thinking you're asking me, "What's the fate of psychotherapists in the future?" And I'm talking about how the golden age is over. The competition is fierce. We now have 700,000 licensed psychotherapists in the United States. We only have 750,000 physicians! So we have almost as many psychotherapists as we have physicians, and they're all competing for a declining number of patients.
VY: So, in economic terms, you think we have an oversupply?
NC: Terribly. I call it a glut. A glut is more than an oversupply. I talk to students nowadays; they graduate and they can't pay their student loans.
VY: Yeah, it’s tough. But you’ve made some dire predictions before. When I started graduate school, I heard you speak, and you said something to the effect of, “Private practice is dying.” And it doesn’t seem to be, although the economics is not as attractive as it used to be.
NC: Now what year would that have been, Victor?
VY: That was about 1984.
NC: Because the book I published–I'm trying to remember the name of it–but at any rate, it predicted the decline of solo practice and why we had to succeed in doing group practices, which we didn't succeed in. Consequently, we're working at the same fee scale that we had in 1980, 1990.
VY: Exactly. So in real dollars, fees are half what they used to be.
NC: So my prediction—OK, it didn't die, but it sure is limping. It's the walking wounded.
VY: Right. Now, as I said, you’ve been a visionary and you’ve started a lot of new things, but let me be devil’s advocate for a minute.
NC: Oh, you can't do that, Victor.
VY: Sounds like you made some great changes at Kaiser, but if you look at where Kaiser’s at now, they provide very limited mental health services.
NC: Absolutely.
VY: If people are suicidal, they can get in. If not, it will take a few weeks, and they may not get back in for a month. And they’ll get a few sessions in most places.
NC: Correct.
VY: I imagine that must be somewhat disappointing for you.
NC: Terribly. But we're now in the third generation from the founders of Kaiser, and each succeeding generation becomes less like the Kaiser Permanente vision and more like the managed care routine.
VY: All right. You started the professional schools and you’ve said they’re a failure.
NC: Yes.
VY: You started American Biodyne, which was an innovative managed care organization.
NC: It was the only managed care organization where it was completely run by psychologists.
VY: Right. And that was bought out by Magellan. And what’s the status of it now?
NC: It's the pits!
VY: It’s the pits. So, you started three great things with great promise, and they’re all the pits. What makes you keep going and trying something new?
NC: I'm very proud of the fact that clinicians can be on faculties in psychology. I'm very proud of that. Maybe the professional school movement went astray, but there were some gains there. Kaiser Permanente is in its third generation; it doesn't have the vigor and vitality of the founders. I mean, Sid Garfield and Morris Collen, those people were fantastic physicians who saw that psychology was more important than psychiatry, and so forth. Naming a psychologist chief of mental health for all of Northern California was unthinkable.
VY: Thanks for balancing out your record. You’ve had some lasting successes as well.
NC: Yeah. So at any rate, there have been great disappointments because people tend to—what should I say—return to the mean.

I Hate Golf so I Can’t Retire

VY: So you told me at the beginning that you’re 85 years old.
NC: Yes.
VY: You look fantastic.
NC: Well, thank you.
VY: You still have a great deal of energy.
NC: Thank you.
VY: What keeps you going?
NC: Productive work. I love it.
I hate golf, and when you hate golf, you're not allowed to retire, because all retirees have to move to Florida and play golf.
I hate golf, and when you hate golf, you're not allowed to retire, because all retirees have to move to Florida and play golf. I hate golf so I can't retire. But I joke about that. I really, really enjoy productive work. This month, my 47th book is coming out.
VY: Wow.
NC: All my books do well. Eleven Blunders That Cripple Psychotherapy in America: A Remedial Unblundering is shaking up the APA. People are reading it. I get invited all over to talk at meetings and state conventions and so forth on the subject. So maybe I was put on this earth to be an agent provocateur. I don't know. But nonetheless, I am proud of my profession. I love this profession. I have never left it. I want it to succeed. It dismays me that we've created a profession that is full of economic illiterates. They don't think that private practice is a business, yet they have a product called psychotherapy. They have a place of business called their office.
VY: A unique skill set.
NC: A unique skill set. They collect a fee. They pay taxes on that fee. It has all the attributes of a business but they say, "No, no, I'm not in business."
VY: I heard recently that a lot of psychotherapists are reluctant to accept credit cards because they feel they’re enabling their clients to get into debt, rather than use the preferred method of payment in this country.
NC: Hippocrates said it is the obligation of the physician to do no harm, and he lists a number of things that the physician has to do. Then he talked about the obligations of the patient, and the first one was to pay the fee. Now, that was Hippocrates in 300 B.C.! And psychologists haven't learned that. You go to a physician's office, and when you check out, you pay the fee. At many physicians’ offices now, you pay the fee when you check in. Psychologists haven't learned that, and they say, "I didn't become a therapist to make money."
When I ask them, "Did you become a therapist to lose money?" they don't know what to say.
When I ask them, "Did you become a therapist to lose money?" they don't know what to say.
VY: So what parting words of advice would you have for young psychologists, students wanting to get into the field, people in mid-career to ensure their continued success?
NC: Pick your graduate school carefully.
VY: OK. If you’re going to graduate school, pick it carefully
NC: Make sure that they are teaching business courses, teaching you where the profession is going and how you have to evolve to keep up—all the things that most ivy-covered professors have no idea about. And drop your anti-business bias. Drop your guru worship. We're at a conference right now that is founded on guru worship. There was a time when we worshiped our leaders because we had no evidence-based therapy. If you wanted to prove something, you'd say, "Well, Sigmund Freud said…" or "Anna Freud said…" or "Carl Jung said…" Now, under health reform, if you don't do evidence-based therapy, you won't get reimbursed. So pick your graduate program carefully. I would say most of them are worthless. Again, I'm mincing my words, I know.
VY: You mentioned evidence-based treatment. What’s your general thought about that, and manualized treatment as well?
NC: The problem with evidence-based treatment as it's going now—it's very recent—I refer to the three E's of psychotherapy. We need to do what the IOM has told medicine it has to do–we have to catch up to that.
VY: What’s IOM?
NC: The Institute of Medicine. Their "Closing the Quality Chasm," one of the greatest reports ever written about health care, alludes to this: that there's too much non-effective treatment going on out there. But at any rate, Chambliss has called our attention to the need for evidence-based, the first E. Barlow has come along and he said, "Now wait a minute, what often works in the laboratory doesn't work in the treatment room. So we also have to look ateffectiveness. Does the evidence-based that worked in the laboratory work now in real life?" That's the second E. And the third E was developed by some guy named Nick Cummings, and it stands for efficiency: that we not only need evidence and effectiveness, but we also need efficiency.

Let's take an example in medicine. There was a time when everybody got a coronary bypass: expensive, intrusive. It took months to recover. Now we find out that a lot of the people can be treated with a stent instead of a coronary bypass. That's efficiency. The coronary bypass was effective, but it wasn't efficient. Psychotherapy does not look to develop efficiency. And this is one of the things we're doing in this program: we're creating the kind of efficiency that goes from getting 10 percent of the patients referred to 90 percent. Those are the three E's that I use. Stopping at evidence-based would be a mistake. It has to be proven in the field.
VY: And what about manualized therapies that are being taught? How do you manualize a human relationship, especially given that everyone is different?
NC: At American Biodyne, we had 68 proven group interventions or therapies–all time-limited, manualized psychotherapy. And they were guidelines; they were not cookbooks.
Ultimately, therapist ingenuity, insight and decision trump the manual.
Ultimately, therapist ingenuity, insight and decision trump the manual.
VY: I’m glad to hear you say that.
NC: Too many manuals are considered sacrosanct. That's a mistake. The word "manualized" to me is a dirty word because it denotes, "Here's the bible that you can't deviate from." I don't believe in that. The guidelines we had for our programs were based on our research. For example, if I can give you one innovation that was just absolutely fantastic…
VY: Sure, why not?
NC: Borderline personality disorder—the scourge of all therapists. If you see borderlines, get ready—someday you're going to be sued, as Bryant Welch, who defends psychologists all over the country, said. We developed a program for treating borderlines. We created an esprit de corps where the borderlines would police each other, which a therapist can't do. And we created an atmosphere where, "If I can't do this, I'm not going to let you get away with it."
VY: These are in groups.
NC: These are in groups. And our research showed how effective this was.
VY: Was the group identified as being for borderlines?
NC: Yeah.
VY: So they accepted their diagnosis?
NC: "You're a borderline." The first such group we did we called the "last-chance group." We had a group of borderlines that, for one of the Blue Cross plans, were so egregious that Blue Cross was considering dropping their health insurance. And I said, "Give me one more chance." They were all borderline women. See, male borderlines are scarce in psychotherapy because they go into the criminal justice system. They do things that get themselves in jail. Female borderlines disrupt the mental health system, not the criminal system. So most of our borderlines were women. And we called this the "Losers Group." "If you flunk this therapy, you're out of the health plan. I have prevailed upon the heads of Blue Cross Blue Shield to give you one last chance. I want to let you know that I have a side bet that you're all going to flunk. It's a sizable bet and I don't think I'm going to lose, because I don't throw my money away." So they're motivated: "I'll show this SOB." But then you create an atmosphere where they police each other. And then from there—and we would only have 20 group sessions, two hours each—they start to be able to form boundaries for themselves for the first time. And then we allow them brief intermittent psychotherapy throughout the life cycle. "Whenever you can, come back." It works. My therapist said, "I'm terrified when I have one borderline in my office. You want me to have eight??"
VY: Well, that could get into a whole other discussion about why there’s so little group therapy going on when it’s such an effective mode of treatment. But before we wrap up, getting back to words of wisdom, one was for therapists to pick their grad schools carefully if they’re going; the second was, if they’re practicing, to think of themselves as businesspeople. Any more words of advice?
NC: Be flexible and innovative. Unfortunately, too much of psychotherapy has been carved in stone. It is turning itself into obsolescence. Patients are ultimately our customers. The main characteristic of a customer is if they don't like your product, they don't buy it. And that's what we are now. Patients have been misled into now saying psychotherapy takes too long. They accept medication.
VY: I don’t know that they’re not buying it. I think the demand is still there and probably stronger than ever. I think its more an oversupply, as you said.
NC: That's one. But the actual number of referrals for psychotherapy have declined by 40 percent. Let me give you a very concrete figure. In 1995, 92 percent of all patients discharged from a psychiatric hospital were referred for outpatient psychotherapy. In 2005, it dropped to 10 percent. Ten percent!
VY: They’re not being referred–not that they’re not wanting it.
NC: They're put on a medication regimen. They're not being referred, but… If a customer wants the iPod, they're going to get it. If they really wanted psychotherapy, they'd get it. They say they're satisfied with the medication. Psychotherapy is not in its golden era; we would see articles in 1950 that psychology was going to solve the world's ills.
VY: And in the 60’s, drugs were, and in the 70’s, encounter groups were; and then it was the decade of the brain. Hope springs eternal.
NC: Yeah. But if a product keeps up… Nobody is going to buy a 1980's Apple computer.
If Apple hadn't kept up, if they hadn’t made the iPod, etc., they would have gone out of business. We also have to innovate.
If Apple hadn't kept up, if they hadn’t made the iPod, etc., they would have gone out of business. We also have to innovate.
VY: You’ve certainly walked the walk in your life. It’s been a pleasure to review your lifetime of innovations, creativity and contributions, even if they occasionally disrupt things and annoy people. It’s been a great pleasure talking with you, so thank you very much.
NC: Thank you very much, Victor.

Larry Beutler on Science and Psychotherapy

Posted on by rezendevknowfully.com

The Making of a Psychologist

Hui Qi Tong: Good morning, Larry.
Larry Beutler: Good morning.
HT: So I’ve known you in different capacities for a couple of years, and I have to confess that it’s always been on my mind over these years that one day I might have the opportunity to just sit across from you and interview you.
LB: Well, I'm glad to get a chance, myself. It's nice to have you here.
HT: I’m always kind of intrigued with people’s passions–their choice of profession. How did you come to choose to be a psychologist?
LB: That's a good question. Subjectively, I'm not sure I chose. I think the profession kind of chose me. My first year in college, I had probably four different majors. I started out in chemistry because my cousin was in chemistry. And then in the middle of the quarter I think I switched to physics. I went through math. By my second year I think I'd been in art, I'd been in social science, I'd been in sociology, I'd been in pre-law. But I transferred from a junior college to a university, and on a whim, I'd taken one psychology course and I'd really enjoyed it, and they asked for my intended major and I wrote down "psychology." And I've never looked back.

But I'm sure that it's more complex than that. I think there are other some other hidden issues. I had struggled for a long time, as most adolescents do, trying to find a place for myself, and….

HT: To establish your identity.
LB: And a lot of my identity was built in regard to my family's very conservative values. And part of their conservative religious values put them at odds with what I came to be learning in high school and college, in particular, around the role of service. My family's values emphasized the role of service, but only within the confines of a religious organization. And it really had a very hierarchical kind of structure. And I became very concerned with what it did to disenfranchise certain people–people who were outsiders, people who by virtue of their skin color, by virtue of their ethnic background, by virtue of their gender, were given a different role within my family's value structure. And I struggled with that for many years and ultimately made some very significant changes. quote[:I made specific decisions about wanting to build into my life a view of people that was infused with more equality than I had seen.] I don't mean to say that my family wasn't respectful and interested in people's assets, but they regarded people only based on their religious beliefs, and infused in those religious beliefs were a lot of attitudes about gender and race. Within their religious view, for example, people whose skin was darker colored than Caucasians came from a place prior to their birth that was less righteous than those of us with white skin. And that was a real troubling aspect for me as I came into my early twenties, and became an organizing theme for what essentially became a break with my family and a break with my traditions.
HT: Have you had any opportunity to voice your own opinions within your family?
LB: Oh yeah, I did What it meant was that nobody in my family would talk to me for a number of years!
HT: That’s hard.
LB: When I was going through this struggle, we had strong words. I was not slow to voice my objections. And I did so in a very clumsy, awkward and hostile way. And what it did was disenfranchise me from my family, my sister, my father, and all my relatives that I'd been raised with. And some of those relationships have survived, some have healed at least partially, and some never healed. So I would have to say it was in some ways costly, but it was also freeing. I did become very much my own person in that regard, in how I set my values. But by the same token, what I set as a value, to live what I considered to be a good life, was very different from what I'd been raised with, and there have been periods in my life where I've had to struggle with, and really make sure I was doing what I had vowed myself to do. And you know, I haven't always been successful in that. I find little pieces of bigotry and rigidity and other kinds of things hidden in my persona that I have to expunge from time to time. It has been an organizing theme for me.
HT: What was your family’s religion?
LB: Our religion was Mormon. And the reason I guess that this comes up right now is I've just been in a conversation with a childhood friend that I have resurrected a relationship with. We haven't talked to each other for 50 years. But over the past year, we've developed a friendship again. And he has had a lot of similar experiences that I had in regard to family struggle, and now I'm in contact with his brother, and I've just gone through a week of revisiting some of these old issues. And resurrecting some of the feelings that occurred to me back when I was going through this in my twenties and thirties. So it's very raw to me right now. But I think that it was very pointedly involved in my decision, happenstantial as it might have been, to get into the helping fields, and ultimately to become a clinical scientist and practitioner in psychotherapy.
HT: So that’s really profound, your experience during adolescence and young adulthood, how you moved away from the old frame of view and broke some bonds to free yourself to establish your own identity. You mentioned that before you entered psychology, you were exposed to math, chemistry, physics. I also believe that no experience is wasted.
LB: Oh, no, I enjoyed it.
HT: And you’re such a hardcore scientist in the field of psychology. I just wonder whether the experience of being immersed in basic science had an impact on your research in psychology.
LB: I think so. I think I gained some appreciation for science in that process, although my original aims in psychology were to be a private practitioner. I didn't make the decision to be a scientist until I was well into my doctoral studies. But it occurs that that is a theme in my life: I wind up making decisions that, it feels to me, are really not made decisively. But as I look at my life it's almost as if I had planned it from the beginning.
HT: That’s a wonderful feeling.
LB: It's a curious phenomenon to observe that one does make something of their life, and sometimes their brain is the last part of them to know.

The Challenge of Training Psychologists

HT: You mentioned you started out wanting to be a practitioner, then later on became a researcher, a scientist-practitioner. I wonder–at our school (Palo Alto University) our training model is more practitioner-scientist–if you were to design a training program, how would you design it?
LB: Well, that too is a good point, because I struggle with that still. I struggle with it now as I teach my Introduction to Psychotherapy class, because I designed that as I have thought for years would be the best way to teach people how to be good psychotherapists. But I'm finding now that I may be wrong, that I have to relook at how I develop the steps to becoming a good scientist-practitioner, practitioner-scientist.

I wound up moving from being a clinical researcher with, as most psychologists want, a practice on the side. I've always had a practice, and sometimes it's been a very big part of my life, but other times it has not been. But always there since receiving my PhD, has been the clinical scientist. My practitioner world has been taking what I find in the laboratory and then trying it out. And there have been people who have talked about their research–good scientists like Hans Strupp, for example. He's a remarkable man. But he's always said that his research findings, his science, really never had any influence on his practice. And see, I find just the opposite–what I found in my research had a very direct impact on it. And that being the case, I see that what has occurred as I have thought about the third role, which is education, that I have changed a lot in how I think the concepts need to be given or provided for students. And I'm still changing, and I'm not certain about that right now. Because I'd say what I have been doing the past three or four years isn't working as well as I'd hoped it would.
HT: What have you been doing the past three years?
LB: I've been trying to teach the students from the beginning what the core basic concepts are in psychotherapy, independent of the theoretical model they apply. The core basic principles, the most fundamental ways of looking at an individual and constructing the interaction that will have a beneficial effect. This is what I've derived from my research, looking at others and so forth. The fundamental core principles of psychotherapy.
HT: Do you mean the principles of change or…
LB: The principles of change, the principles of how one person can interact in a closed environment with another person to facilitate change. And I put a lot of stock in those principles. And the more I find out about them, the more I find that there are more principles, but there are some really good ones. I just wish I could articulate them better. But I have been operating on the assumption that if I taught them the basic principles first, and then taught them their theoretical models, that then they would be better practitioners. But this is just the opposite of what I did for years at the University of California: we would teach the theoretical models first and then teach them how to integrate concepts out of those models and principles.
HT: So now you’re adopting an approach that is broader to start with–just lay the foundation, then later on students will study the specific models.
LB: That's the idea. And it sounds good. But it's not working. It's really not working.
HT: How can you tell it’s not working?
LB: My students tell me. I mean, I am going through a period where students, I am finding, are very resistant to the methods that I am applying. And so it makes me want to return to some of the ones that worked before, and to redo the educational process. So in answer to your question, I don't have a handle on how to go about teaching people at this point. I have little glimpses of how to teach people. The real problem that you have in trying to teach people psychotherapy is you can't just teach them about it–you have to expose them to it. And in the beginning processes, that is a very tender, fragile kind of interaction, to teach people to interact with a client. Because the therapist is afraid, the client is afraid, and bad things might happen. Good things might happen, and most of the time they do. But bad things might happen. So one has to be careful in that initial interaction. I haven't found a way to do that in a way that students feel safe enough to try it.

I don't like the way that psychotherapy is conventionally taught. I don't think it works well. I think out of it we have produced one third of therapists who are ineffective at best and maybe harmful. That's not a good track record. We have an article that just came out, for example, in one of the APS [American Psychological Society] journals from some old colleagues of mine,1
that most psychologists simply don't practice anything based upon any scientific evidence whatsoever.
that most psychologists simply don't practice anything based upon any scientific evidence whatsoever. And we know that. We've known that for years. And what they propose is that we begin to make our training programs reflect specifically how well students are able to incorporate scientific findings into what they do. I think it's important. But then, just this morning I was interacting, I'm a member of APA Council and I was interacting with people on the Web about this very article. And one of the very strong themes in that is, "These people are all wrong. Science doesn't matter to clinical practice." And these are very senior people. Some of the former APA presidents and leaders are saying this, that science doesn't really matter to practice. These people are all wrong.

Making Science Matter

HT: You have a paper just published this year about making science matter and redefining psychotherapy. What I see that’s interesting is that bidirectional communication is disconnected. Some clinicians do whatever they want, and disregard what scientific evidence is there. And some researchers actually don’t pay attention to what’s really going on in the room.
LB: They don't. They don't.
HT: They come up with narrow, rigid focuses of the scientific inquiry, as well as the way they design their research.
LB: That's very true. We have, I think, in the course of our experience as a budding science, defined ourselves almost out of… not out of existence, but out of value. We try to adopt, in the psychotherapy field, a model of research that was being used very successfully in psychopharmacology, was being used somewhat less successfully in medicine, but was highly advocated and highly regarded. And it was a model that to many people looked really good. It's the medical analogy that you consider the treatment to be like aspirin: we need to know the ingredients of it, and the person who gives it shouldn't matter. So we give cognitive therapy disembodied from the therapist. And we studied in a disembodied fashion. Now people are giving lip service, finally, to the inappropriateness of that, but they haven't changed the method. They still rely upon that narrow method that says we will train people to follow a prescription, we will train them to do it so it doesn't matter who is delivering it. And then we will study the outcome.

And the one thing that these people are wrong about is they make a big case out of the fact that they have discovered that cognitive therapy worked well with all of these groups. Now, they're right. But what they don't say is that they've discovered that cognitive therapy is better than something else. Because we haven't discovered that. What we've discovered is cognitive therapy works. But people hear the implication that it works better, and therefore we should be doing it. But that's only because we have in our research model excluded characteristics of the therapists, nondiagnostic characteristics of the patient, qualities of the context, and certainly qualities of the relationship. And so the paper you're talking about is one in which I try to make the argument that
psychotherapy is not just what the therapist does. It is, in fact, who the therapist is, how the therapist interacts, who the client is, how they interact, and the nature of the relationship.
psychotherapy is not just what the therapist does. It is, in fact, who the therapist is, how the therapist interacts, who the client is, how they interact, and the nature of the relationship. And all of those components can be scientifically studied. But they can't be studied using the research designs that we're currently using. Interestingly, out of that, I've gotten an invitation to present a paper at the SPR conference in June at Asilomar.
HT: What’s the SPR?
LB: It's the Society for Psychotherapy Research, an international society. I've been president of it. But it was the place in which Gerald Klerman, who was head of the National Institute of Mental Health, made his first pronouncement that we were going to study psychotherapy as if it were aspirin, and initiate the randomized clinical trials model for psychotherapy research. And at that point we began forgetting about therapists and patients and relationships.
HT: That reminds me of evidence-based practice in psychology–it’s really parallel with evidence-based practice in medicine.
LB: Well, that's what they try to make it.
HT: Tell me about your opinion of the EBPP [evidence based practice in psychology] movement. There are so many different terms coming out of that, and now there’s also research-informed practice. I’m a bit confused about all these forms.
LB: I'm confused too. I strongly believe that practice should be research based, and should certainly be more than research informed. "Research informed" is where the American Psychological Association has now taken this with their task force a few years ago. This was discussed just the other day in the council exchange that I was talking about a moment ago, where James Bray, who is currently the president of APA, tried to make the case that psychotherapy is not research based, and should not be. According to him, it should be based upon research knowledge, plus patient values, plus the personal impressions, feelings and judgment of the therapist. And that to me is a scary thought, but that's where we are in psychology.

It's the one thing that makes this whole thing into a soup rather than a science, because it says there are three equivalent ways of knowing something is true: one is through patient values, one is through the observations and judgment of the clinician, and the third is through science, and they are to be equal as they go into this soup. Well, to me that makes a soup that has no character. Because if we don't keep the research base–not just research informed, but research grounded–we are back to the point in our history that anything goes as long as you're sincere. The patient values guide us. Those values may be quite disturbing and distorted. Certainly we know that therapists' judgment is often very poor. If one third of therapists produce more patients that get worse than get better, well, I'm not sure I want to trust my children to those therapists. And that means that we need to do something to improve their judgment, and I don't know any better way to do it than through scientific grounding.
HT: It seems to me that all of these three components–the patient’s values and preferences, the clinician’s wisdom or experience, as well as the scientific evidence– should be integrated and tested.
LB: They should be integrated. If we could adopt research, plans, programs and methods that incorporated the investigation of how patient values affect clinical judgment and treatment procedures that would be psychotherapy. But as long as we are conceptualizing it as separate, it will stay separate and it will stay ineffective. The common finding is still that all therapies are the same. It doesn't matter too much whether it's therapy as usual or whether it's a therapy constructed out of the theoretical research model or what. They're all pretty much the same as long as all you do is study them in a disembodied way, separate and independent of the patient's values and of the therapist's judgment, experience, background, etc.
HT: That reminds me of the Dodo bird verdict2, that everything works.
LB: It is a Dodo bird verdict. All have won and all must have prizes. Everybody wins. The problem is also that everybody loses.
HT: Yeah. So if in the near future there would be a new research design which is not as narrow, incorporates every factor that is important, relevant…
LB: I'm cautiously optimistic. I want to be alive when it happens.
HT: But you’re doing it now.
LB: Well, I have tried very hard to make it happen. If I have a mission in the world, this is the mission I would like to accomplish.
HT: Can you state your mission so we capture it here clearly?
LB: To redefine what we are studying in psychotherapy, to be more inclusive rather than exclusive, to be inclusive of the common factors, to be inclusive of the therapist factors, patient factors, etc., that are not bound within these narrow definitions of diagnosis and treatment model. Now, it seems periodically that we have made some headway in doing that. People are interested in this paper I published3, they're citing it and so forth. But it's not the one that's getting on the front page of the New York Times. This is the one that's getting on the front page of the New York Times: Psychotherapists are not practicing scientific methods and they won't. And again, there are two things wrong with that. One is that that is a sad shame if it's true, and second is that our definition of psychotherapy almost makes it impossible for psychotherapists to do otherwise.
HT: So in this particular paper, “Making Science Matter,” you said something really salient. You said, “Despite all the evidence or lack of evidence that science matters so far, I still believe that scientific methods offer the best way of finding optimal and effective ways to intervene with behavioral health problems.”
LB: That's right. That takes me back to my chemistry and physics. There are connections between things, and the best way to find them is to control variables and allow other variables to vary, and systematically evaluate the outcome.

Matching Therapists, Treatment and Patients

HT: What are the variables you think are important to study in a more broad kind of approach?
LB: There are so many of them. I think, increasingly, the evidence as I read it says
the maximal amount of change that we'll be able to account for is going to be embodied in the way therapist characteristics, treatment, and patient characteristics interact
the maximal amount of change that we'll be able to account for is going to be embodied in the way therapist characteristics, treatment, and patient characteristics interact–algorithms, essentially, that bring those three things together. Those will be the strongest contributors. It will not be therapy procedures, it will not be patient diagnosis, it will not be these other isolated variables. It will be the interaction among them.

And so I am very tied to looking at ways to match patients to therapists and match patients to treatment. And those are two different things, but they have to be incorporated within the same research model. There are certain things we find very difficult to randomly assign. The gender of the therapist, you know, that's difficult. We can assign male and female therapists, but we can't assign to a therapist a different gender and separate out of that connection what the therapist is from the gender the therapist assigns. So we've got to find more flexible research models that don't throw away the randomized clinical trial but add to it more correlational kinds of variables to put into that mix and evaluate the outcomes. And that, I think, is where science needs to go to become really relevant.
HT: I’ve taken your course twice, and in the class we read your book Systematic Treatment Selection4. And that model is what you’re talking about: to try to capture the patient’s characteristics, the therapist’s characteristics, and to match them, and also looking at what kind of treatment approach will work best for a certain patient depending on the stage of their condition. Can you tell more about therapist and patient matching? What do you match them on?
LB: Well, again, the potential is limitless. But what we look at are four basic kinds of variables. And sometimes it's difficult to assign the ownership of those. Are they characteristics of the patient, the therapist, or the treatment? They should call it intervention, not treatment, because it describes what the therapist does, and we can only roughly categorize those into groups. Of the variables that we look at, the first one is really the impairment level of the patient. Now, the impairment level of the patient isn't just something owned by the patient. It's also owned by the context in which they live, the social environment, the culture, the value system that exists in that culture to define what is adaptable and not adaptable. So we can't just study functional impairment disembodied from the culture in which it lives.
HT: So it’s really beyond the DSM-IV.
LB: Oh, way beyond the DSM-IV. But we can take functional impairment and say, once you have defined it within a cultural context, then there are a couple of things we can clearly say we know about that; one of them is that the more impaired the person is, the more treatment they require, the more varied kind of treatment they need to get, and the more it needs to extend into the environment in which they live. There's some real implications with this. This means family treatments need to be involved based on the impairment level. That means groups–social groups, not just therapy groups but social groups–need to be involved, and that the intervention needs to be more life consuming the more impaired the person is. But you need to start with how you define the impairment in the culture in which it's done.
HT: By life consuming, you mean more sessions, longer sessions?
LB: More sessions, longer sessions, and sessions out there, not in the office.
We need to help take the person out into the world in which they live, and therapists are still reluctant to do that.
We need to help take the person out into the world in which they live, and therapists are still reluctant to do that. The second variable we look at is the patient's coping style, but that too is a culturally defined variable. It reflects what works within the culture that one lives. It's clear to us now that at least people in many Asian cultures, certainly Japan and probably China, tend to cope with things in a much more internalized and self-reflective fashion. And the concept of collectivism becomes very important in the whole concept of coping. So we need to understand coping within the context of the culture it occurs in.

But within that there is variability, and it varies along this dimension of how one copes, how one deals with the self versus others, how one accommodates to others versus defends against others. Once we know that, then it can tell us a little bit about how we need to intervene, what kind of focus we need to take. And again, the effect sizes of this cut across cultures pretty well right now. Compare the effect size of cognitive therapy to interpersonal therapy: the mean effect size is zero. But if you can compare what we call a good match between the focus and the coping style of the patient, and a poor match between the focus and the coping style of the patient, we get effect sizes on average of 0.6 to 0.7. That's good–those are high effect sizes. That means that we're having a much more significant effect upon that patient by taking into account coping style than we are by identifying their diagnosis.

Then we take the next variable, which is a patient's resistance. And this is where we get some real problems. We've always thought that if a therapist can identify and deal with how the patient wards off efforts to persuade them or change them, then the therapist can adapt to that. And we find, in fact, that this only works in some contexts. For example, we just did an analysis of the effect size related to coping style and directiveness of the therapist. We've always thought that if the patient was very resistant, then if the therapist was less directive and confrontive they would be able to persuade them. But that seems like it may only work in North America. And it may only work with relatively serious problems. People with less serious problems and people that are outside of the North American value system may not always relate to that. In fact, very resistant patients in some cultures may respond well to a very directive, authoritative therapist. We don't know yet. And we don't know whether the therapist is able to change their level of directiveness. We don't know if it's a characteristic of the therapist or a characteristic of the therapy, or if you can even make those distinctions.
HT: Yes, I can see that–even with different therapists the resistance level would be different.
LB: Then the final thing we look at is the distress level. This is an aspect of patient adjustment, obviously. It becomes a problem of separating that concept from functional impairment, because your distress level changes functional impairment. People can't function well if they're highly distressed. On the other hand, they don't get motivated very well if they don't have some distress. So the real clinical struggle is to find that window in which they are motivated for change, because they are uncomfortable and they want to become comfortable. They're motivated for change but they're still functional.
HT: Distressed but not overwhelmed.
LB: And then if you're successful in therapy and help them lower their distress, what does that do? Does it take away their motivation to continue to work? There are some interesting answers with this that we don't know, but what we do know is that motivation, as embodied in concepts of arousal, are important in trying to facilitate and negotiate this road of psychotherapy. There is something here about the management of patient emotions. Helping them manage their emotions so they stay within a window, an optimal range that is very important. And many therapies talk about that, but it's real hard to define what the window is.

Lessons from Horse Training

HT: At the VA (Veterans Administration) we often say it’s not only the distress but also the functional impairment that will bring the veterans in. So they will avoid seeking service until their relationship doesn’t work.
LB: Things crumble.
HT: Yeah. They lost their job. And of course they’re subjectively distressed, but they avoid that due to different reasons. But it’s not until they’re really impaired in their social or interpersonal occupational functions that they come in.
LB: Some people have a lot of tolerance for distress, and other people have very little tolerance for it. The levels of impairment and disruption in their lives become an additional factor in helping them. In fact, there's a principle in horse training that has been articulated by several different people in what's called the natural horsemanship movement. It says: Distress motivates, release teaches. But to take that analogy further–and I do find the analogy an interesting one–I got back into working with horses when I moved to California in about 1990. For the twenty years prior to that, I'd been flying airplanes and interested and enjoying airplanes, and then it just got too expensive to do, so I thought I'd get back into a cheaper kind of thing.
HT: And you didn’t find a good analogy.
LB: I didn't find a good analogy in flying airplanes. It's very interesting because I used the airplane functionally. I used it to go from Point A to Point B, and it was fun to do. I traveled all over Texas trying to recruit students to our graduate programs and talking to them about psychotherapy and so forth. But the plane was a way to get there and have fun while I was doing it.

When I got back into horses I discovered that there are so many parallels with psychotherapy. And it has changed so much–it gave me some hope for the field. When I was a kid doing horses, we broke them. We really tried to bend their wills, and we forced them into positions. It took a long time, and it was hard to do, and they were always resistant. As I got back into it, I discovered a whole new movement had occurred, in which what was important in horse training was the relationship you had with the horse, not the technology you used to make the horse do something.
When I got back into horses I discovered that there are so many parallels with psychotherapy. And it has changed so much–it gave me some hope for the field. When I was a kid doing horses, we broke them. We really tried to bend their wills, and we forced them into positions. It took a long time, and it was hard to do, and they were always resistant. As I got back into it, I discovered a whole new movement had occurred, in which what was important in horse training was the relationship you had with the horse, not the technology you used to make the horse do something. So it was the development of a relationship that became important and that gave you the avenues to do all kinds of other things. And I saw people doing some marvelous things with horses that I'd never thought we could do when I was 15 years old and trying to do these things. And I started to apply some of that to psychotherapy.
HT: Like what?
LB: Like this concept of managing their arousal level. For horses, that becomes a central component of any training experience–to be able to raise it up and be able to release it, to stop it. With horses that's relatively easy to do once you get the concept and the additional one that says, well, if it doesn't work in big steps, take small steps. If we could apply just those two concepts to psychotherapy, I think we'd have greater levels of effectiveness than we do now. But we don't; we couch them in all kinds of other things, and the human condition makes it harder to observe when a person is optimally aroused, and it also makes it more difficult for a therapist to relieve that arousal, because they're responding to so many things out there.

I began to note that in a small, enclosed area anybody can train a horse to come to you when you ask it to. All you have to do is control those two basic principles. You control their arousal and you break it down into small steps. I could teach anybody to do that. But then when I said, "Okay, generalize that principle, take it out of that small, enclosed area, and teach a horse to do the same thing out there in a hundred acres," some people could analyze it and decide how to do it, but most people could not. I began to observe how psychotherapists learn to do something. To most psychotherapists, they see it as a technique, but to some psychotherapists, they see it as a principle. And that means that they can change it and still be true to the principle and apply it in a new situation to a new patient in a new environment. The difference between a technician and a therapist, an artist, is not that they don't follow the same principles. It's that they are able to translate them into new settings, new environments, and new ways of operating. And that's where the real art and science of psychotherapy come together: to identify what the scientific principles are, and then learn to use them creatively in new environments with new people under new circumstances. It's happened in horse training.
HT: But the challenge is how to apply these principles to human behavior.
LB: If it can happen in horse training, it may be able to happen in psychotherapy. We've got bright people working in psychotherapy. Can't they just move beyond that narrow view to be able to see the creative way of applying scientific principles?

Therapy Research Across Cultures

HT: So we’ve come back to evidence and science. And I know you’ve been working in Argentina, Japan, China. Any findings from the STS (Systematic Treatment Selection) approach? Any preliminary data that shows that it’s a better alternative to the traditional “gold standard” of manualized treatment? What does the data say so far?
LB: The data is pretty clear, so far, that we can do a better job of predicting outcome and even controlling outcome by controlling things that include the context and the environment. I point to the coping style focus of therapy, for example. This seems to be a construct that does nicely moving across cultures. We don't know about all cultures, but many–we've tried in Northern Europe, we've tried in North and South America, we're beginning to try it in Asian countries. It's a general principle that cuts across culture, that
if you can identify variation in the coping style and then begin to fit the focus of therapy as either insight-focused or symptom-focused based upon that coping style, then we can facilitate change.
if you can identify variation in the coping style and then begin to fit the focus of therapy as either insight-focused or symptom-focused based upon that coping style, then we can facilitate change. Therapists seem to be able to change what they do, at least a little bit, to become more insight-focused or more symptom-focused. It is not a characteristic that's so closely bound to the therapist that they can't alter it.

The relationship between resistance and directiveness with therapy, that seems to be more difficult to generalize. That seems to be a characteristic that's very tied to the therapist–can they be both directive and non-directive? No. It's hard for them to do. The way that people resist and the way they respond to directiveness also varies across cultures.
HT: So you’re identifying that some principles are universal but some are more culturally bound.
LB: That's the important aspect of all of this: being able to define what is generalizable from one place to another, and what is not. And what makes it generalizable and what inhibits it from being generalizable. People talk to some degree about this model of mine, this STS model, as being a common factors model, because it looks at the same variables across all of treatment. But it doesn't apply them the same. It asks specifically for variation in what one does as a function of the patient characteristic. It's not common across and it doesn't fit all therapeutic models, it doesn't fit all cultures. But we don't know all of the limits yet, so that's really where we're going.
HT: One thing that occurred to me is I’ve heard over the years that therapy is about what, when, who. But what you’re talking about is the how. You’re not talking about therapy itself, but rather what you’re using with whom and when to use it. STS sounds to me like you’re figuring out how to take all these factors into consideration.
LB: Yeah, that's what we're trying to do. We're really still addressing Donald Kiesler's concern of 1967, that there is still the myth of homogeneity of therapists and patients and so forth. And a real central question that Kiesler raised at that point was what treatment works with what patient under what conditions by whom. And we're still trying to do that. What psychotherapy as a field has done is move away from everything but the what. We want to incorporate the what, but we want to keep the who there, and for whom, by whom, under what conditions.
HT: That’s amazing.
LB: It will be amazing if it works. Well, it does work. It will be amazing if it catches on. People, psychotherapists in particular, continue to look for something more simplistic than that.
HT: I’m thinking about China, where we have a limited number of therapists. It’s really hard to do this matching, because many of them were trained in one approach, for example, a more dynamic approach, and they use this approach with everybody. And some of them were trained in CBT and they do CBT with everybody. And I think in the beginning of this kind of developing stage, it’s almost inevitable.
LB: Yes, but the nice thing about the STS model that defines all of these principles is that you don't have to use all of them at once. If I could just give you one principle that could make a significant impact on your treatment that you could follow, for example, the fit of the impairment level of the patient to the intensity of treatment. The more impaired they are, the more they need a wide variety of different treatments, the more they need treatments that involve other people, the more they need treatments that involve the society out there. If I could just give you that principle, you could do substantial things to your effectiveness rates.

The other principle I could give you has to do with the coping style of the patient and the focus of treatment. If you could just change that–and you could do it within any model. I mean, Freud talked about symptom-focused kinds of interventions versus more insight-oriented interventions. The range of what the therapist does within a particular model is not as great as what they might do if they had a wider range of therapeutic models at their disposal. But they have some variability, and thus they have some choices, and could improve their effectiveness if they were just to apply one or two principles. I have no hope that people will apply more than five, because I don't think people can keep more than five in their head at once. The best thing we know, the closest thing to truth we have out of this whole field, is that they could make a very substantial difference in how effective they were in working with a wide range of the people by just taking one or two of the principles. You don't have to take the whole thing.
HT: But from an STS approach, the therapist needs to have expertise in more than one approach, right?
LB: Well, to be optimal, it would be nice. But it's not more than one approach. They have to have a toolbox that's filled with more things than screwdrivers. If you're going to do a job, you need to have a toolbox that's full of tools. So you don't just have reflection. You don't just have interpretation. Or you don't just have behavior reinforcement or contracting. You try to have a toolbox full of many of those things. And ideally you need to have a toolbox that's filled with individual interventions plus group and multi-person interventions. You need to have a toolbox that has in it both tools to increase distress and lower distress, that both focuses upon indirect change through insight versus direct change through behavioral reinforcement, and that gives you variation in being reflective versus being directive. If you have a toolbox that has some of those tools, you don't need the whole model. You don't need to buy psychoanalysis and have the whole training in psychoanalysis to do an interpretation. You have some tools to do it, and then what STS tells you is when you might optimally use each of those tools.
Don't use a hammer for every job you have. I mean, around the ranch I like to say, I can fix anything with a hammer. But you know, it's really not true.
Don't use a hammer for every job you have. I mean, around the ranch I like to say, I can fix anything with a hammer. But you know, it's really not true.

The Future of Psychotherapy

HT: So if I may, I have two more questions. One is more practical, and one is more broad and general. Let’s go with the more practical one. If you’re speaking to a group of entry-level therapists who are just starting their career in this business, what would you say to them about what they can do to be more effective therapists?
LB: The central theme: first is relationship. That's what I would tell the horse trainer, and that's what I would tell the psychotherapist. If I have one thing to tell them: learn to listen. And you'd be surprised at how difficult this is. But it's the one thing that they need to start with, the ability to sit and listen to another person without an agenda, without inserting some salesmanship, trying to sell a point or a point of view or a perspective. Don't sell a perspective. First, learn to listen. Now, for more advanced ones, then they can learn one principle at a time. The next principle I would say…
HT: How many do we have? How many principles do we have?
LB: We can have a hundred principles.
HT: Eighteen?
LB: Well, we've got 18 in STS, but we know there are more principles than that. But the ones that are going to have the most powerful impact are the principles having to do with the quality of the relationship, because most of the patients that you see will benefit just from that. They don't need anything else. So learn to listen. If you just learn to listen–I'm talking to you as everyone. You're a collectivist, right?
HT: I’m integrative.
LB: Integrative. All right. This perspective, if people could just learn to listen and to do it without inserting. It's called motivational interviewing, it's called client-centered therapy, it's called humanistic therapy. If you could learn that concept of listening, most people that you see would benefit from it without adding anything else.

And then if you were to add the principle of intensifying therapy with the level of impairment that a person has. Just those two concepts. If I could get that across to new therapists out there, they would make a huge difference. But they don't believe me. They say, "research be damned." They don't believe me.
HT: How many years did it take you to come up with these ideas?
LB: What am I? I'm almost 69.
HT: It’s 50 years of wisdom.
LB: At least.
HT: At least. No, every year counts–69 years. Okay, one last question–it’s kind of a broad one. What do you think of the future of psychotherapy, or the best possible approach to psychotherapy?
LB: Well, those are two different questions. My greatest fear is that psychotherapy will continue to persist in this fragmented way, and that we will see an increasing schism between the science of psychotherapy and its practice. And people will continue, as practitioners, to try to sell a point of view that is needed and will be valued, but which society will not ultimately support because society has a price tag attached to everything. And what the price tag is going to say is that you have to be able to prove what you do, and you have to be able to replicate it. That means we're going to have to move increasingly towards a broad view of science. Though I don't know, frankly. Back in 1970, George Albee, then president of APA, was asked to write an article on the future of psychotherapy. And I believe completely what he wrote, which was four blank pages. It has yet to be written.

I believe there will always be a place for people who can listen and who can provide, through whatever means they can, the experience of help to other people. There will always be a place for that. I don't think that we will continue to support it through health care indefinitely, because we will have to accept the fact that it is not health care–it is life care. Society is forcing us into that in part by credentialing all these other quasi-therapists–you know, life coaches, etc.–that have taken away the things that we used to call psychotherapy, and now they use them under a different label. And it tells us something: that our view has been too narrow. Within the narrow view that we use–psychotherapy to treat psychopathology–we're going to have all kinds of medical, biological, chemical treatments to do away with symptoms. What we won't be able to do is change a lot, through this chemical interjection, some of the basic angst that people experience in not being connected to other people, not being heard, not feeling relevant. Having another person, someone who is be trained to do something that is helpful and optimal, who will listen and care for them, is going to continue to be very important.
HT: Thank you so much, Larry. Thank you for your time and wisdom.
LB: Well, I don't know how wise it is, but you got it.
HT: Thank you.