Category: Therapeutic Issue

People seeking the help of a psychotherapist almost always do so after trying—and failing—to help themselves. Many have self-medicated, using everything from herbal remedies (e.g., St. John's Wort for depression) to alcohol or other drugs. Still others have tried to enact the psychological advice they sought from friends or family. But many turn to the products and services put forth by what we might call the self-help or self-improvement "industry." It is a large industry indeed. A 2004 study by Marketdata estimated that Americans spend $8.5 billion on self-improvement products and services annually, including over $600 million on self-help books alone.

The problem with the self-improvement industry is that it is better described as an unregulated "wild west" rather than staid science. Certainly much of what this industry offers is high quality, and is put forth by reputable psychologists. But in this article we'll focus on the seamier side of this industry, as we explore self-help snake oil and self-improvement urban legends. In particular, we'll focus on how professional psychologists can help the general public, and their clients in particular, separate the good this industry has to offer from the bad and the ugly. As we shall see, fruitful conversations with clients can result from discussing the misperceptions fostered by snake oil, and the deeper truths underlying many psychological urban legends.

Repeat after me: "Affirmations don't work. Affirmations don't work."

Many self-help books advocate the use of "incantations" or "affirmations." Simply repeat phrases such as "I like myself" over and over again, we are told, and soon we will experience an enhanced self-image and boosted self-esteem. This idea is not new. In the 1920s, French pharmacist Emile Coué created an international fad of "autosuggestion" by encouraging everyone to repeat the mantra: "Day by day, in every way, I am getting better and better." Repeating it aloud 20 times each morning and evening was supposed to result in health, wealth, and pretty much whatever else one wanted (it does, after all, specify improvement "in every way.")

This technique supposedly influenced the unconscious mind, and struck a chord amidst the growing popularization of Freudian psychology. But of course, if this technique worked as advertised, the vast majority of psychotherapists would immediately be out of business, today's epidemic of depression would be easily reversed, and everyone would walk around grinning like Stepford wives. Research clearly demonstrates the many psychological and physical benefits of optimism. The problem is "getting there from here," and affirmations are unlikely to foster an authentic and lasting change from a pessimistic style of thinking to a more optimistic one.

The same criticism could be made of Norman Vincent Peale's The Power of Positive Thinking, which had a record-setting run on best-seller lists in the 1950s and remains popular today. Few would argue with its basic premise, but today its techniques seem quaint and simplistic (For example, Peale recommended "mind clearing," which simply meant purging the mind of negative thoughts and replacing them with positive ones.). Many clients will express some familiarity with the concept of positive thinking, and perhaps some frustration with the ineffectiveness of techniques such as affirmations. Psychologists can use these occasions as segues to discussing the very real benefits of optimism, and the more potent techniques for achieving it such as reshaping one's attributional style, or the types of counter-arguing strategies offered by cognitive-behavioral therapy.

Subliminal self-help tapes: Just when you thought affirmations couldn't get easier

Self-help snake oil is typically sold with the promise of easy, effortless change. And perhaps the only thing easier than repeating affirmations is listening to someone else repeat them for you. That's the premise behind subliminal self-help tapes, a $50 million industry featuring products that promise to improve memory, enhance workplace performance, aid in weight loss, and make a host of other lifestyle changes.

These products are simply affirmations with a high-tech makeover and bigger marketing budgets, and every independent study has shown that these tapes don't work as advertised. In fact, they have only two reliable effects, with the first being removing money from the buyer's pocket and placing it into the seller's. The second, more psychologically interesting effect is what psychologist Anthony Pratkanis has called the illusory placebo effect.

Consider one of the studies conducted by Pratkanis and his colleagues. Participants took baseline tests of self-esteem and memory, and then listened to subliminal tapes purported to improve either self-esteem or memory. But here's the twist—half of the participants received tapes that were correctly labeled, while the other half were given mislabeled tapes. In other words, some purported self-esteem-enhancing tapes were labeled as memory improvers, while some tapes that promised to improve memory were labeled as self-esteem enhancers. Everyone was given instructions on how to use the tapes, and each participant was called weekly with encouragement to continue listening to the tapes. Five weeks later, the self-esteem and memory of all participants were measured again.¹

Consistent with other studies, these tapes did not deliver the benefits their manufacturers had promised, as there was no significant improvement in self-esteem or memory. Although the tapes themselves had no effect, the labels did. Those who listened to tapes labeled as self-esteem enhancers believed their self-esteem had improved (in fact, self-esteem remained stable). Similarly, those who listened to tapes labeled as memory enhancers believed their memory had improved (in fact, their memories had not improved). Thus the illusory placebo effect: Like a placebo, the tapes had an effect only because users expected them to have an effect, but the effect was illusory, not real.

This study and others like it not only debunk ineffective products, they reveal the insidious nature of self-help snake oil. When people mistakenly believe they have been helped, they fall short of their own potential, and unwittingly aid dubious companies by becoming loyal customers and persuading others to do the same. Nineteenth-century snake oils had similar effects. Many contained a mixture of alcohol and opium known as laudanum, and it pretty much doesn't matter what's wrong with you—taking alcohol and opium will make you feel better, even though the underlying medical conditions often become worse. It is an important message for psychologists and clients alike: Just because something makes you feel temporarily better doesn't mean it is safe, effective, or does what its proponents claim.

For psychotherapists whose clients have tried these products, an opportunity exists to discuss their misleading claims, and contrast them with how psychological change truly happens. A cognitive-behavioral therapist, for example, would likely dismiss the entire premise of reshaping the unconscious mind, choosing to focus instead on conscious thoughts and overt behaviors. In contrast, someone of a more psychoanalytic bent would likely explain that, although unconscious desires are important, psychological change begins with bringing those desires into conscious awareness, a process not facilitated by subliminal affirmations.

The Eat Popcorn/Drink Coke study: A fictitious study can't create an international uproar . . . can it?

How do marketers sell self-help snake oil? By using the "supporting" research from self-improvement urban legends. Subliminal self-help tapes are often sold on the basis of an infamous study conducted in the mind 1950s, in which advertising "expert" James Vicary supposedly exposed thousands of New Jersey movie-goers to the subliminal messages Eat Popcorn and Drink Coke. Vicary claimed dramatic results: an 18-percent increase in Coke sales and a 57.5-percent increase in popcorn sales.

Even more dramatic were the results outside the movie theater. After the study was publicized, several nations outlawed subliminal advertising, and the US Federal Communications Commission threatened to strip the broadcast license of anyone using it. In less than one year after the results were announced, nearly half of Americans had heard of subliminal advertising; by the 1980s, that figure had risen to nearly 80 percent, with two-thirds of those believing it could be effective in shaping behavior. By the mid-90s, subliminal advertising achieved a pop culture mainstream double-whammy—Saturday Night Live and beer commercials—with Kevin Nealon's character Subliminal Man. Today, an online search for "subliminal advertising" yields over 280,000 hits, with "eat popcorn drink coke" yielding over 60,000. And although the first few online results clearly debunk the study, many of these Internet sources present the study as valid evidence for the effectiveness of subliminal self-help products.

There are many "footnotes" to this study that never gained the notoriety of the original—particularly the fact that Vicary recanted. Sort of. In 1962, he admitted that the study wasn't quite as good as advertised (pun intended): "We hadn't done any research, except what was needed for filing for a patent. I had only a minor interest in the company and a small amount of data—too small to be meaningful. And what we had shouldn't have been used promotionally." This carefully worded "non-admission admission" stops short of acknowledging the study as an outright fraud, and opens a loophole that many snake-oil-peddling web sites use to question the sincerity of Vicary's recantation.

But even more damning have been the repeated failures to replicate Vicary's dramatic results. Precisely replicating Vicary's methodology wasn't easy, given that his study was never published in a scientific journal, and the most detailed description of its methodology was in a 1957 issue of Senior Scholastic—a magazine written for junior-high students. But that didn't stop researchers from conducting hundreds of similar studies, virtually all of which conclude that subliminal messages have no significant effect on behavior at all.

Although carefully controlled laboratory studies may be most persuasive to scientists, perhaps it is a pair of naturalistic field studies that best illustrate the point. In 1958, the Canadian Broadcasting Corporation subliminally flashed the message "Phone Now" 352 times during one of their programs. Not only was there no increase in calls, but when viewers were later asked to guess the message, most reported being hungry or thirsty. Apparently Vicary's subliminal messages of Eat Popcorn and Drink Coke shaped behavior after all—they created a placebo effect that was felt years later and a country away. Remarkably, police in Wichita, Kansas conducted an almost exact replica of this study 20 years later. Desperate for a break in the hunt for the publicity-hungry murderer known as the BTK Killer, police instructed a local television station to subliminally flash the message "Now Call the Chief" during a news broadcast. Unfortunately, no one called, and another 30 years passed before police made an arrest in the case.

Like all great urban legends, the story of the Eat Popcorn/Drink Coke study captured the public imagination despite the evidence largely because it conveyed a message that people were particularly ready to hear. The Zeitgeist of the late 1950s was characterized by Cold War paranoia and the fear that science was being used for negative purposes. Movies like The Manchurian Candidate depicted brainwashed assassins whose behavior was controlled by forces of which they weren't consciously aware. Books like Vance Packard's The Status Seekers revealed how marketers had shifted from overt messages such as Buy Product X to more subtle methods of capitalizing on consumers' fears and insecurities.

The Eat Popcorn/Drink Coke study was not the first—or the last—time that subliminal phenomena became a national fad because they meshed with what people wanted to hear. Consider that…

• In the early 1900s, psychology and advertising texts described potent subliminal effects, even though the evidence at the time was far from consistent. Not coincidentally, several popular spiritual and self-help movements of the day, such as Christian Science and the New Thought Movement, preached that the human mind had powerful but unconscious abilities to bring about health and happiness.

• In the 1970s, Wilson Bryan Key created a lucrative cottage industry for himself with a series of best-selling books claiming that subliminal messages were being widely used in print ads. Even today, many people remember his claim that sex is subtly written into ads for everything from alcohol to Ritz crackers, but they reached mainstream popularity during the me decade because they meshed with Americans' rising distrust of advertisers and general loosening of sexual mores.

• In the 1990s, Americans yearned for more self-help products as the "recovery movement" and "therapy culture" went mainstream. Little wonder they were so ready to believe the claims about subliminal self-help tapes.

Of course, this legend is not the only marketing weapon in the arsenal of snake oil salespeople. They are, for example, experts at making irrelevant research seem as if it supports their claims, and are skilled at blurring the lines between subliminal perception and subliminal persuasion. Research on subliminal perception has conclusively shown that, under highly controlled laboratory conditions, individuals can perceive images which are flashed very briefly, even without being consciously aware of having seen the images. But that does not translate to subliminal persuasion—there is no evidence that broad patterns of thought and behavior can be substantially influenced by subliminal messages. Yet many snake oil web sites deceptively cite studies of subliminal perception as if they are evidence for subliminal persuasion and, by extension, their snake oil products. But as selling tools these studies are not nearly as effective as the Eat Popcorn/Drink Coke study. The fact is that a single vivid study with name recognition is, for most people, far more persuasive than a dozen studies published in scientific journals.

Although professional psychologists are no doubt dismayed that a dubious study is being used to sell dubious products, this is not the only detrimental effect of subliminal myths they are likely to face. Recently a young man called my office seeking something to block subliminal messages because he was being "bombarded" with them. He had seen an article on my web site debunking the subliminal industry, and had clearly missed the point. The sad fact is that he was a troubled young man, and subliminal messages were the least of his problems. The myth of subliminal persuasion led him to misinterpret the psychological challenges facing him, and distracted him from exploring more relevant and effective psychological techniques.

The Yale Study of Goals: Tony Robbins, Brian Tracy and Zig Ziglar can't all be wrong . . . can they?

Unfortunately, the Eat Popcorn/Drink Coke study isn't the only urban legend used to sell less-than-effective self-improvement products. The "Yale Study of Goals," for example, has become a staple in the repertoire of motivational speakers and modern self-help writers. It has even been described in more than one best-selling book.² As typically described, there are three elements to the study:

• The 1953 graduating class at Yale was interviewed.
• 3 percent had written specific written goals for their futures.
• 20 years later, that 3 percent was found to be worth more financially than the other 97 percent combined.

This study would indeed be a dramatic illustration of the power of goal setting, except for one minor point: it was never conducted. There are literally hundreds of published studies on goals. I have read virtually all of them, and although I have read about the Yale Study of Goals in several popular self-help books, I have never seen a single reference to it in the research literature.

The Consulting Debunking Unit of Fast Company magazine deserves credit for unmasking this study as an urban legend that was passed uncritically via word of mouth until it was accepted as truth.³ When they approached Tony Robbins for documentation, a spokesperson explained that the background material for Robbins' 1986 best-seller Unlimited Power (which cites the study) "met a disastrous end," and suggested that self-help author Brian Tracy might know more. Tracy, in turn, explained how he often describes the study in his books and speeches, and that he learned of the study from motivational speaker and sales guru Zig Ziglar. When reached for comment, Ziglar was unable to locate the original study, suggesting, "Try Tony Robbins." The circle was complete. Yale gets numerous requests for information about this study and, despite extensive research, has never found any evidence that it was ever conducted. As one Yale spokesperson put it, "We are quite confident that the 'study' did not take place. We suspect it is a myth."

Urban legends typically get repeated because they convey a moral or have some deeper meaning, and there is considerable truth to the notion that goals can enhance performance. Although this urban legend is certainly not as misleading as the Eat Popcorn/Drink Coke study, it remains an excellent example of how a little knowledge can be a dangerous thing. For example, the research is clear that goals only enhance performance if they are set properly (in my work, I use the acronym SCAMPI to teach the elements of effective goals: Specific, Challenging, Approach, Measurable, Proximal, Inspirational). This urban legend fails to convey this important caveat, and doesn't teach these goal-setting principles. By coming across as "the whole story," this urban legend minimizes any motivation the reader might have to dig deeper and learn more about the true science of goal setting.

A Final Thought

A clinical psychologist's early sessions with a new client often focus largely on the history of the client's problems, including what has helped and what hasn't. An important component of such discussions are the client's history of less-than-successful attempts to solve their problems themselves. Therapists can better steer these conversations toward valuable insights and effective solutions if they are knowledgeable about the half-truths of self-improvement urban legends and the unkept promises of self-help snake oil.

Clearly, as psychologists, we have more than a therapeutic duty of helping clients solve problems—we have an educational duty as well. This obviously includes educating clients that "technique X doesn't work" or "study Y wasn't really conducted." But it should also include using this debunking as a springboard to educating clients about genuine processes for psychological change, which almost always involve thought, effort and action. The educational role that psychologists play will not only help clients solve problems in the short-term, it will help them evaluate "too good to be true" promises long after their psychotherapy sessions end. In short, it will give clients the skills to help them recognize and avoid self-help snake oil and focus on methods that work.

Notes

¹Anthony Pratkanis, a professor at the University of California at Santa Cruz, summarized this study and others in his article The Cargo-Cult Science of Subliminal Persuasion. Published in the Spring 1992 issue of the Skeptical Inquirer, it can be found online at www.csicop.org/si/9204/subliminal-persuasion.html. Interested readers may also want to check out Subliminal Perception: Facts and Fallacies by Timothy Moore (http://www.csicop.org/si/9204/subliminal-perception.html).

²For example, it can be found on page 200 of Anthony Robbins' (1986) best-seller Unlimited Power, and on page 26 of Bill Phillips' (1999) Body for Life (which even gets the legend wrong, describing it as being conducted at Harvard).

³See page 38 of their December, 1996 issue, or read it on the Internet at www.fastcompany.com/online/06/cdu.html. The quote from the Yale spokesperson at the end of the paragraph comes from that article as well.

For more about Dr. Kraus's science-based systems for success, visit his web site on Positive Psychology: The REAL Science of Success, or his Positive Psychology & Success Blog.

Note: This article was first published in the June 2005 issue of The San Francisco Psychologist (www.SFPA.net).

Unless we are treating medically ill or very elderly patients, we’re not likely to think of our patients as being at imminent risk of death, at least not while they are under our care. Patients leave therapy for any number of reasons, but few clinicians are prepared for the possibility that termination would take place because a patient has died. I had been worried about Jim* for months, urging him to see a physician for his deteriorating health, particularly his strained breathing. The fact that Jim was similar to me in age (early fifties) made the issue all the more personal for me. When I began seeing Jim as a psychotherapy patient some nine years earlier, our expectation was that we would meet for only a few months. Jim had grown increasingly concerned about troubles in his marriage, and he wanted to figure out what he was doing wrong. The story that unfolded during the subsequent years was tragic in so many ways. Oddly, as matters got worse in Jim’s life, the alliance between the two of us got stronger.

When I received the phone call from Peggy, one of Jim’s friends, I sensed that I should rush to the hospital. The fact that Jim had actually, finally, gone for medical help led me to believe that he must have been in desperate pain. As I arrived at his bedside, he gave me a wry smile, so common in our exchanges, so much like the amused look that he would give in our sessions when he said something completely outlandish about the state of affairs in our world or our town. It was evident to me that Jim was at the threshold of death, a hunch confirmed by the nurse who entered the room during our chat.

During dinner at home that evening Peggy called from the hospital to tell me that Jim had passed away. I excused myself from the table, and went to my study where I reflected with deep sadness about the loss of such a precious person. “A bit surprised by the depth of my grief, I felt caught off guard as I tried to discern the reasons that Jim had affected me so deeply.” I reflected with fondness on the years of our work together, but also questioned what I might have done to help him obtain medical help before the point at which his body began to surrender. Over the course of Jim’s nine-year therapy, Jim brought me some of the most difficult issues I had encountered in three decades of clinical work.

Soon after Jim had started therapy, his wife asked him for a divorce, causing him to become depressed and neglectful of his physical well-being. Jim began to drink heavily in his desperate attempts to alleviate the incapacitating emotions with which he struggled on a daily basis. In time, he lost his job as a salesman because of his increasing unreliability. Without work, Jim then was left without insurance coverage. His financial picture worsened on a daily basis, and he eventually became destitute as he found it necessary to allocate his minimal savings to cover the expenses of a protracted divorce and custody battle. As Jim’s psychological, financial, and medical problems intensified, I found myself juggling several roles in my work with him. In psychotherapy, we focused on his emotional well-being, with particular attention to his worsening problem with alcoholism. Although Jim was responsive to therapeutic work focusing on abstinence, he periodically relapsed in response to stressors in his life. In the financial realm, Jim was able to turn to close friends to help him procure the basics of life, but he had nothing more than what was needed to sustain himself.

As for his deteriorating medical condition, I helped Jim connect with a public health nurse who agreed to consult with him as well as facilitate the process by which he could obtain basic medical care for critical physical conditions. As the months and years flew by, Jim was looking sicker and sicker each time I saw him. In one medical consultation the nurse became deeply concerned about Jim’s strained breathing, and insisted that he proceed with her immediately to the emergency room so that he could be admitted to the hospital. The end would come only two days later, leaving me no time to process impending death with Jim, or for that matter gather my own thoughts in anticipation of the loss.

Responding to a patient’s death

Although I had seen hundreds of patients over the years, and had supervised or consulted on thousands of cases, I had not yet dealt with the death of one of my patients. I had no script but I had many questions. Should I attend the funeral? How will I identify myself? Do I send a sympathy card or flowers to Jim’s sister? If I attend the funeral, how should I interact with his son, or with his ex-wife who would probably accompany their son to the funeral? Jim’s ex-wife and I had met once, at the very beginning of my work with Jim, to discuss their marriage; presumably, she would remember me. Certainly, she had heard quite a bit about my involvement over the course of the nine years, particularly in the form of the reports I had written relevant to the custody evaluations. In addition to the pragmatic concerns, what about the emotional issues? How would I process my own grief? With whom could I consult to deal with my questions, my concerns, my sadness?

I was also unprepared for the ethical issues that emerged. When Peggy called to inform me of his passing, she said that she hoped that she and I would have the opportunity to process our feelings about Jim, and our reaction to the loss. On several occasions Jim had given me permission to speak with Peggy regarding my concerns about him. Jim knew that she and I shared a commitment to his well-being. However, would it be ethical to disclose anything about my therapeutic work with Jim? I thought not, although I did feel that it was permissible to concur with statements about what an impressive man Jim was, and how he had touched each of our lives.

The ethical quandaries continued when I received a call from Jim’s sister, who phoned to thank me for all that I had done for Jim and to invite me to the funeral, saying that she knew it would mean so very much to Jim if I were present. She had known that Jim had been unable to pay for his sessions during the past several years, and expressed her deep appreciation for my kindness in continuing to see her brother. Although she offered to pay his debt, I explained that I couldn’t accept the offer. I was well aware of the fact that his sister had minimal financial resources, and that there would certainly be no estate in Jim’s name.

Should I go?

Should I attend the funeral? How could I not go? After reflecting on the words of Jim’s sister about how much it would mean to him, the decision became clear that I should be present at the celebration of Jim’s life. As I pulled up in front of the stately church, I fretted about when I should enter and where I should sit. I sat inconspicuously in the middle of the congregation, attending to the eulogies, and quietly grieving the loss of such a special man. Following the ceremony, Jim was buried in an adjacent cemetery while additional prayers were read. To exit the burial area it was necessary to pass through a receiving line consisting of Jim’s sister, his son, and his ex-wife, all three of whom were aware of who I was and the nature of my relationship with Jim. I offered the customary expression of sympathy, all the while feeling constricted in terms of what or how much I could say.

Somehow I expected that the story of my relationship with Jim would not end on the day of his funeral. I anticipated a call from his sister, another from Peggy, perhaps from his ex-wife, and possibly from his son. I was relieved that I wasn’t contacted by any of these individuals, or anyone else for that matter. In the years since his passing, I’ve wondered why I had even anticipated such a contact. At the risk of sounding egocentric, I had come to realize that Jim’s son, his friend Peggy, and I—his psychotherapist—were the most important people in Jim’s life. Wouldn’t family members, or close friends, want to extend condolences to me? Obviously, such a wish had more to do with my needs than with the reality of the situation. However important the therapist may be, in the eyes of others, the therapist may or may not be all that different from the accountant, or even the auto mechanic, for that matter.

Many people might wonder why a therapist would experience grief at the loss of a patient. Unlike a planned termination with a long-term patient, Jim’s death left me feeling a sadness for a life cut short, frustration about clinical work abruptly terminated, and an aching feeling of emptiness resulting from the loss of someone I cherished. To process my grief, in the week following the funeral I turned to a colleague who guided me through a cathartic discussion about my reaction to the death of this special patient. “We spoke about the grief evoked by the death of Jim, and also about the reactivation of grief associated with previous losses of significant people in my life.” Specifically, I found myself becoming stirred by thoughts and memories pertaining to the death of my parents. In so many ways, memories of being nurtured by caring parents as a child evoked associations regarding the ways in which Jim relied on me for help, support, and kindness. The cycle of life and death continued.

Honoring . . . grieving

There’s no question in my mind that adhering to the highest standards of ethical and professional behavior is essential, irrespective of the situation. My patient’s privacy must be protected, dead or alive; the secrets I hold must go with me to my grave. At the same time, I cherish the wonderful relationships I have had with many of my patients. Just as I have become a compelling voice in their lives, they have also become part of me. Out of respect for this valued alliance, we need to grieve. We need to find ethically informed ways to participate in the rites of death and the process of mourning.

There are, however, circumstances in which attending a deceased patient’s funeral may not be appropriate. Many patients are not as open about being in therapy as Jim, who had talked to me often about his discussions of our clinical work with his sister, his friend, his son, and even his ex-wife. However, for patients who are secretive about their therapy, the presence of the clinician at a funeral, especially a small gathering, might be problematic because mourners might infer or ask about the relationship with the deceased. Risking such a confidentiality breach must be avoided, necessitating that the clinician grieve in private rather than at the funeral. Or, had there been ongoing legal problems or animosity involving relatives and significant others, the presence of the therapist at the funeral might be provocative, and therefore inadvisable. If and when such events recur, I will again consider the dilemmas, seek out consultation, and strive to make choices that are ethically and clinically grounded, yet informed by caring attitudes.

“I feel at peace regarding my choice to attend Jim’s funeral. I know that I would have felt terrible pangs had I chosen to stay away due to a rigid, unfeeling worry about professional boundaries.” The decision was less complicated due to the fact that Jim was so open about his therapy under my care, and also by the fact that the funeral was well publicized and drew a large crowd. I was touched by the fact that several people came up to me to say, “You must be the Richard” whom Jim so often mentioned. If I had not been a known character in the play, I still would have attended, but with the demeanor of a saddened distant acquaintance at a large ceremonial gathering, rather than as a person in whom Jim had invested the stories of his life.

I also felt that I had benefited in many ways by my relationship with Jim through the positive energy, the intelligent dialogue, and the profound humanity he brought to each of our interactions. Jim left me with intangible gifts that continue to enrich me professionally and personally in many ways. Honoring Jim, and grieving with others who cared deeply about him, felt important and right.

* Note: All names have been altered to pseudonyms.

I recently attended the 40th annual retreat conference sponsored by the Association of Family Therapists of Northern California (AFTNC), and this year's renowned speaker, Monica McGoldrick, showed many videotapes of her own work. Throughout the two-day conference, I was continually impressed by her ability to relate so very closely and easily with such a racially and culturally diverse group of clients. I also kept noticing how much of the connecting seemed to take place through nonverbal behaviors and tone of voice (conveying warmth, comfort, directness, engagement, confidence, being collaborative, and indicating genuine interest in the details of people's life histories). As president of AFTNC, I also received lots of spontaneous comments afterwards about Monica McGoldrick being such a "lovely person," a "great human being," so "down-to-earth," "easy to relate to," "willing to show her mistakes," and so on. At the same time, I heard many therapists in the audience make comments about how they work so very differently from McGoldrick in terms of not using extended family genograms as a main vehicle for connecting nor using traditional Bowen coaching methods with one family member. I also heard a few complaints that McGoldrick's presentation did not allow for easy note-taking in that it was not structured with specific teaching points or generalizable techniques one could use with almost every case.

The Therapeutic Alliance

The combination of these comments and my own reactions reminded me of that old Marshall McLuhan phrase, "the medium is the message." That is, the main message for me in McGoldrick's way of working was not about genograms, or Bowen theory, or coaching methods, or concepts and techniques that could be written down. The meta-message was that she modeled a way of relating to people of diverse backgrounds that is very rare among therapists of any theoretical orientation but lies at the heart of therapy. This way of close (but still professional) relating is extremely difficult to describe and teach in a didactic format. Partly, this is because the emotional aspects of the therapist/client relationship, which are so much anchored in nonverbal behavior, are hard to communicate in words. There are no simple directives one can give therapists for generating warmth toward or comfort with clients in general. Simply telling therapists to reflect feelings or give compliments can backfire if the nonverbal aspects of these communications are not congruent with the content of what is being said. “Telling therapists to "be warm" or "be genuine" simply puts them in a "be spontaneous" paradox because true warmth and genuineness must, by definition, be guileless and uncontrived.”

In fact, few contemporary publications in the field of couple and family therapy have focused in any depth on the process of alliance building, the most notable exceptions being Bill Pinsof (see Integrative Problem-Centered Therapy, 1995) and Sue Johnson (see The Practice of Emotionally-Focused Couple Therapy, 2nd Edition, 2004). Ironically, however, most clinical supervisors believe that therapist relationship skills, rather than techniques or theoretical orientations, are the more important aspects of effective treatment (Blow & Sprenkle, 2001). After 30-plus years in the field, I also have come to believe that each of the most popular family therapy orientations is too limited and too focused on specific change-oriented interventions, rather than on the vicissitudes of the therapeutic alliance. I don't think treatments succeed or fail based primarily on the particular theoretical orientation of the therapist. Rather, I believe that treatments succeed mainly on the therapist's ability to develop and maintain an emotionally positive therapeutic alliance with all members of the system in treatment.

A positive therapeutic alliance requires:

1. giving sufficient emotional validation and support to the individual or members of the couple/family,
2. successfully managing negative emotions within the couple/family so that members are not hurting each other in sessions, and
3. regulating the therapist's negative emotional reactions to couple/family members (i.e., managing "negative countertransference").

Too many of the current approaches to family therapy either take for granted or neglect to adequately address the importance of the emotional bond between therapist and clients. “No array of clever, change-oriented techniques is effective in the absence of a positive emotional connection between therapist and client.” First and foremost, clients need to feel that the therapist is caring, collaborative, trustworthy, fair, reliable, knowledgeable, and that she/he understands and appreciates their feelings. This is true regardless of the therapist's theoretical orientation. Within each theoretical orientation, there are therapists who are very skilled at forming close and collaborative relationships with clients and those whose relationship skills need improvement. Yet the majority of current family therapy theories and training programs deal with these common therapeutic factors in a cursory fashion if at all, preferring instead to focus on abstract theories and very specific change-oriented techniques.

When therapy breaks down, it almost always is because of some emotional rupture and failure to repair (or failure to establish in the first place) a positive therapeutic bond with family members. In fact, therapists' and clients' negative emotional reactions to each other, even when not directly expressed, are among the major factors predicting early termination or poor outcomes. These negative emotions tend to be expressed indirectly in terms of behaviors like the therapist not returning phone calls promptly; not inquiring how the client is reacting to interventions even when the therapist observes the client's disapproval; the absence of spontaneous mutual warmth, humor, and responsiveness between therapist and clients; therapist passivity in sessions; or the therapist's unequal responsiveness to family members in sessions.

Although it would be comforting to assume that all therapists are inherently capable of forming positively toned therapeutic relationships with all clients, there is an enormous range of skill among therapists in this respect. Also, certain kinds of clients (e.g., those traditionally and pejoratively labeled "borderline" or "narcissistic") can challenge any therapist's relationship skills. The very best therapists tend to be those who can easily establish and maintain positive therapeutic alliances with the widest range of clients, both in terms of clients' cultural diversity and in terms of managing negative emotionality.

Training to Become a Therapist

Given the above, “a major focus of training should be on how a particular trainee can use her/his emotions in forming therapeutic alliances and in preventing those alliances from breaking down.” This training focus should include the special issues in intercultural therapist/client matches (race, gender, social class, sexual orientation, age, religion, etc.), which are more likely to dissolve for lack of a strong positive emotional connection, or to be negatively tinged and lead to experiences of oppression for the client. In my view, a major focus of all training programs should be the development of therapist alliance-building skills, especially emphasizing cases in which the client displays a lot of negative emotionality and cases where the therapist and client are from different sociocultural groups.

Therapeutic relationship skills are best acquired through close observation of the therapist's behavior in role plays and in sessions (i.e., via live, videotape-, or audiotape-based case supervision). Such skills are not as easily learned—or maybe impossible to learn—through "delayed verbal report" supervision because the latter's effectiveness is constrained by what the therapist was aware of during the session, remembers after the fact, and can report in words to the supervisor. Verbal report supervision always loses emotionally relevant information because a lot of what transpires between therapist and clients is automatic and not necessarily within the therapist's awareness, especially when the therapeutic alliance is not functioning well. Paradoxically, the very areas where supervisees may need the most help are areas about which they are unaware and cannot articulate the relevant emotional information to their supervisors.

The analogy I like to use here is that learning to do therapy is like learning to swim. You could describe to your swimming coach, after the fact and in words, how you moved your arms and legs while in the pool. You could even demonstrate your movements while sitting in your chair or lying on a table. But to actually learn how to swim, it is far better to have your coach by your side, preferably in the water with you, watching you perform the new strokes, and giving you immediate feedback on your movements based on the coach's immediate observations rather than on a delayed report. The same is true of therapy. Describing a difficult session in words for one's supervisor will not convey the same information as having one's supervisor directly observe the "drowning" noises one makes in an actual failed session! Supervision based on delayed verbal reports limits the supervisor's ability to accurately visualize and give input about the therapist/client alliance.

There simply is no substitute for live supervision (or video- or audiotape-based supervision) in learning to become a therapist. In my opinion, the fact that many mental health professionals still become therapists never having had their work observed is a major shortcoming in our training programs. Just as one would not want to be under the care of a neurosurgeon whose work had never been observed by other neurosurgeons, we should require extensive observation-based supervision for all therapists in training. Only then can we be more certain that our trainees have learned to build and maintain effective therapeutic alliances with a wide array of clients.

Maintaining a Focus

Although I am emphasizing its centrality here, I think of a positive working alliance as a necessary but not sufficient condition for therapy to be effective. That is, I think of the relationship as a partial intervention in itself (a "corrective emotional experience") as well as being the necessary groundwork for other, more specifically change-oriented interventions to have an impact. The other main ingredient in effective therapy I would call "focus": successful therapy requires establishing relatively clear collaborative goals with clients and using interventions that are relevant to those therapeutic goals throughout. For example, in consultations for "stuck" cases, I frequently have found that a clear sense of direction was never established at the outset of a treatment; or, once having been established, the therapy conversations meandered or avoided dealing with the main presenting problems.

By using the word "goals" I don't mean to imply some superficial, limited purpose, but rather that the client and therapist should share the same vision of what a desirable outcome might be in terms of changed behaviors, affects, or cognitions, as well as the path for getting there. As the old aphorism holds: "If you don't know where you are going, you are not likely to get there." This also reminds me of something that a hapless character in a Lily Tomlin play once said: "I always wanted to be someone, but now I realize I should have been more specific."

In therapy, you can't get there with the client if you don't have a strong positive emotional relationship and if you haven't established together where you are going. I think that effective therapist/client systems have reasonably explicit and clear (albeit evolving) goals, and the conversations in the sessions are always brought back to those main foci. This point may seem obvious, but a lot of ineffective therapy sessions end up veering off into conversations relevant to the therapist's theoretical orientation or to the client's momentary preoccupations rather than to the clients' main presenting problems. Therapists need to keep their eye on the ball—the shared goals—and help their clients do likewise. This requires a client-specific formulation of the problem and goals, but it does not require that the therapist use only one particular theory.

I often feel that the specific interventions chosen by therapists (e.g., unique outcome questions, sandtrays, enactments, genograms, dream interpretations) are much less important than whether the interventions are explicitly related to the client's presenting problems and the established goals. That is, the client and therapist should readily understand what the connection is between the agreed-upon goals and what is happening in the sessions. Too often, clients seem not to understand that connection, and they are reluctant to ask for explanations, even when they think the therapy is not really addressing their main concerns and is going nowhere.

To summarize this viewpoint: therapy is effective to the extent that it is characterized by a strong positive emotional alliance, relatively clear goals, and conversations and tasks whose relevance to the goals is obvious to all parties. By contrast, therapy that does not consistently maintain a positive emotional alliance, has extremely vague goals, and consistently includes conversations and tasks that are tangential to the client's experience of the problem(s) is unlikely to be effective. I believe these statements hold true regardless of the therapist's preferred theoretical orientation.

Problem Formulations Rather than Theoretical Orientations

I question whether it is even necessary to have a specific theoretical orientation. Obviously, one cannot not have an idea about what is causing the client's problem, and one cannot not use techniques. Virtually anything a therapist says or does can be considered an aspect of technique that is based on some theoretical concept. But how much does a therapist need to adhere to a specific theoretical orientation in order for therapy to be successful? Or to put it differently, how eclectic can one be and still be effective?

I believe that successful therapy requires that the therapist have a workable problem formulation—a hypothesis about what is causing the problem in a given case—and a general treatment plan—an evolving path toward the goals in that case—in order for the therapist to select meaningful things to say and do in the sessions. The problem formulation and treatment plan should be explicit (able to be articulated verbally or in writing) and tailored to the client's and problem's uniqueness. However, I don't think a therapist's formulations and plans have to derive from a single theoretical orientation in order for that therapist to be effective. The formulation for a given problem will typically involve the relationships between two or more levels of functioning—biological, psychological, interpersonal, and/or sociocultural factors.

Without digressing too far, I'd like to suggest that given the enormous variety of client belief systems and presenting problems in the world, “each theoretical orientation may be best suited for certain kinds of clients and presenting problems and not as applicable to others.” It also seems that less experienced therapists may have a greater need to adhere to a single orientation in order not to lose their focus over the course of treatment, but I think they do so at the risk of reducing their flexibility to respond in the most helpful way.

The Integrative Therapist and Emergent Design

The task of the "eclectic" or "integrative" therapist is to co-develop with the client a set of achievable goals, a coherent problem formulation (an explanation for why the problem exists or what is causing it), and a treatment plan tailored to the client's specific problems and situation, all the while maintaining a positive therapist/client alliance. The process of therapist and client co-creating these therapeutic elements is what I once called an "emergent design" (Green & Herget, 1989b). No two therapists would be able to develop the same design with a client. The emergent design process can best be conceived as a mutually catalytic reaction between a particular therapist and a particular client evolving together at a particular point in time. In Darwinian fashion, if all goes well, the ideas and behavior patterns that "survive" over the course of therapy will have therapeutic utility whereas other ideas and behavior patterns will become "extinct." It is for this reason that some cases that start out, for example, in a seemingly psychodynamic mode may become increasingly behavioral over time, or some individual therapy cases may surprisingly turn into couple therapy cases by the end. If therapist and client are sufficiently flexible, this evolution happens more quickly and progress is likely to be quicker. If therapists adhere too closely to traditional theoretical orientations after the beginning phase of therapy, the essential evolutionary nature of the treatment relationship is more likely to be impeded and progress stalled.

For the therapist's part, after establishing a mutually acceptable formulation of the problem, the remaining therapeutic task involves improvising a treatment plan and techniques based on that formulation. The therapist as participant-observer in this process must be both emotionally engaged and purposeful in ensuring that a consistent focus is maintained during the sessions. Effective therapy, in this view, does not require that the therapist adhere to a single theoretical orientation with all cases or even across all problem areas within a given case. It does, however, require reasonable consistency and narrative coherence regarding each specific problem focus and formulation established with a given client.

This kind of meta-theoretical approach to therapy is not entirely new and is partially an outgrowth of comparative psychotherapy research and the movement toward psychotherapy integration. It constitutes a new kind of "theory of therapy," emphasizing the "common factors" that make the implementation of any therapy either effective or ineffective regardless of the "brand" of therapy practiced by a therapist (e.g., psychodynamic, cognitive-behavioral, or systems-interpersonal). Versions of this meta-theoretical approach were proposed in the 1970s by individual psychotherapy researchers such as Jerome Frank (1973), Edward Bordin (1979), and Hans Strupp (Strupp & Hadley, 1979); and by family therapy researchers in the 1980s such as Leslie Greenberg and William Pinsof (Greenberg & Pinsof, 1986). Mary Herget and I also used it to some extent at the Redwood Center in our small-sample research on Milan teams in the mid-1980s (Green, & Herget, 1989a, 1989b, 1991). Most recently, the meta-theoretical approach is best represented in books such as Psychotherapy Relationships That Work: Therapist contributions and responsiveness to patients (Norcross, 2002) and The Heart and Soul of Change: What works in therapy (Hubble, Duncan, & Miller, 1999).

Having participated in many of our field's fads and fancies since 1970, this meta-theoretical framework represents my current personal list of the "eternal verities of therapy"—the essential components of effective treatment. Although I will never use Bowenian techniques to the extent that Monica McGoldrick does, the AFTNC annual conference reminded me once again of the centrality of therapist relationship skills, which cannot be acquired through books and lectures. The indelible images of McGoldrick relating so closely, comfortably, and confidently in sessions—even with computer in hand and genograms as the focus—was the take-home message for me, and I hope for students learning the practice of therapy, as well.

References

Blow, A.J., & Sprenkle, D. (2001) Common factors across theories of marriage and family therapy: A modified Delphi study. Journal of Marital & Family Therapy, 27, 385-

Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16, 252-260.

Frank, J.S. (1973). Persuasion and healing (2nd ed.). Baltimore: Johns Hopkins University Press.

Greenberg, L.S., & Pinsof, W.M. (Eds.). (1986). The psychotherapeutic process: A research handbook. New York: Guilford Press.

Green, R.-J., & Herget, M. (1989a). Outcomes of systemic/strategic team consultation: I. Overview and one-month results. Family Process, 28, 37-58.

Green, R.-J., & Herget, M. (1989b). Outcomes of systemic/strategic team consultation: II. Three-year followup and a theory of "emergent design." Family Process, 28, 419-437.

Green, R.-J., & Herget, M. (1991). Outcomes of systemic/strategic team consultation: III. The importance of therapist warmth and active structuring. Family Process, 30, 321-336.

Hubble, M., Duncan, B. & Miller, S. (Eds.) (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association.

Johnson, S. (2004). The practice of emotionally focused couple therapy: Creating connection (2nd ed). New York: Brunner-Routledge (a division of Taylor & Francis Publishers).

Norcross, J. C. (Ed). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients.

Pinsof, W.M. (1995). Integrative problem-centered therapy. New York: Basic Books.

Strupp, H.H., & Hadley, S.W. (1979). Specific vs. non-specific factors in psychotherapy: A controlled study of outcome. Archives of General Psychiatry, 36, 1125-1136.

Note: An earlier version of this article appeared in the January 2004 issue of the Association of Family Therapists of Northern California Newsletter. For further information about AFTNC, you may visit its website at http://www.aftnc.com.

Published on Psychotherapy.net with written permission from the author.