© On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
INTRODUCTION
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading our program on The Therapeutic Relationship.
Throughout the years, On Good Authority has been presenting you with cutting edge information about therapeutic practices to enable you to become more informed, more learned, more effective. We have brought you interviews on psychotherapy ranging from the work of psychoanalytic practitioners, to short term time-limited practitioners, to cognitive behaviorists, to family therapists, to narrative constructivist therapists, to Jungian dream analysts, to bio-psychotropic medication providers, on ethical issues, and more -- all in the interest of giving you the widest possible range of thinking.
In this program, we bring you the latest thinking about the heart of therapeutic practice – the therapeutic relationship. We are going to look at many aspects of the constantly evolving therapeutic relationship, taking into account important new knowledge gained from neuroscience, infant research, theory about attachment, and the seismic changes in our culture which affect all aspects of our world view.
Decades of research indicate that the provision of therapy is an interpersonal process in which the main curative component is the nature of the therapeutic relationship. Probably the most significant change in the treatment process has come with the opening up of the therapeutic relationship. Once a stiff, one-person, ―blank screen‖ model, where the therapist was the all-knowing, powerful ―expert,‖ now psychotherapy is viewed by virtually all the varieties of ―talk therapy‖ as a collaborative process.
Also called ―the helping alliance,‖ ―the therapeutic alliance,‖ and ―the working alliance,‖ the therapeutic relationship refers to the relationship between a mental health professional and a patient or client. It is the means by which the professional hopes to engage with and effect change in a patient (we will be using the terms ―client‖ and ―patient‖ interchangeably throughout this program).
The therapeutic relationship has provided fuel and fodder for portrayal in the entertainment world. Some of the interviews in this series will make reference to the award winning, HBO television series, ―In Treatment.‖ But whether the brilliant sessions in ―In Treatment,‖ the comedic therapy sessions between Mike Nichols and Elaine May, Robert deNiro and Billy Crystal, Woody Allen with himself interminably, Dr Malfi and Tony Soprano, or thousands of cartoons, therapy has been celebrated, portrayed and pilloried for decades.
1 Still, with all the paradoxes, dilemmas, and devaluations of psychotherapy and the therapeutic relationship, would we rather stick our heads in an MRI machine, swallow a pill, confess on television, or instead, look for the deep meaning in our lives? Not that these things are mutually exclusive, but for the purpose of this program, we are going to focus on the experience of being listened to and understood. We are going to treasure those people who want to search for a truth about themselves that goes beyond symptom relief.
To begin our program, we will take a look at what makes one therapist ―better‖ than another. And yes, some therapists are better, as indicated by their higher scores on all sorts of performance measures. In our first interview, we‘ll see how we can, and must measure and evaluate our work.
Then we‘ll go through the treatment process itself. Using ―In Treatment‖ as a backdrop, we will look at the opening session. Then we‘ll see how attachment theory, combined with self psychology and intersubjectivity have given us powerful tools for therapeutic change. We‘ll see how understandings from neuroscience can help us in a non-verbal way, and we‘ll learn about the meaning of crying. One thing that can really interfere with our effectiveness is our lack of awareness of diversity issues, and we‘ll learn how to assess our biases, our ―isms‖ which, like it or not, we all have. In these times, the economy has had a great impact on our practice and on the therapeutic relationship, which raises the question of what we do about it, so we give you two interviews on the subject. Then, along with the opening up of the therapeutic relationship comes the inevitability of self disclosure, and we‘ll learn about a new paradigm for the use of ―deliberate self disclosure.‖ Finally, we will focus on the termination process, a highly important and understudied aspect of the therapeutic relationship.
So here goes. Now to our first interview.
2 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Super Shrinks”
SCOTT MILLER, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
SCOTT MILLER, Ph.D. Post Office Box 180147 Chicago, IL 60618-0573 Tel: (773) 404-5130 Fax: (847) 841-4874 cell (773) 454-8511 [email protected] www.scottdmiller.com.
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #1 of our program on The Therapeutic Relationship.
Therapists differ in their ability to affect change. We may not like to think it, but it is so. How many times have we heard someone referred to as ―a gifted therapist?‖ Is this some inborn talent, like musical talent or artistic talent or athletic ability? And if so, are the rest of us ―un-gifted‖ folks doomed to mediocre performance?
―Not so,‖ says Dr. Scott Miller, our first speaker and co-founder of the Center for Clinical Excellence. Citing research going back to 1974, Miller tells us that the evidence is incontrovertible: who provides the therapy is a much more important determinant of success than what treatment method is provided, and the key to superior performance simple as it may seem, involves constantly working harder evaluating and improving one‘s performance.
To do that, we first have to know our baseline performance, and then engage in more ―deliberate practice‖ to improve our work. This willingness to engage in deliberate practice is what makes some therapists, ―Super Shrinks,‖ and the rest, well, simply average. What‘s really scary is that we might not know which we are because, in the words of Sherlock Holmes, ―Mediocrity knows nothing higher than itself.‖ But we‘ll let Dr. Miller tell you about it.
3 Scott D. Miller, Ph.D. is a co-founder of the Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavior health. Dr. Miller conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of "invited faculty" whose work, thinking, and research is featured at the prestigious "Evolution of Psychotherapy Conference." His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery.
Scott is the author of numerous articles and books, among which are Psychotherapy with Impossible Cases: Efficient Treatment of Therapy Veterans (with Barry Duncan and Mark Hubble [Norton, 1997]), The Heart and Soul of Change (with Mark Hubble and Barry Duncan [APA Press, 1999] and Bruce Wampold [2nd Edition, 2009]); The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy (with Barry Duncan [Jossey-Bass, 2000], and Jacqueline Sparks [Revised, 2004]); and the forthcoming Achieving Clinical Excellence: Lessons from the Field’s Most Effective Practitioners.
ALEXANDER: Dr. Miller, you say that who provides the therapy is more important than what treatment is used. Is that really true?
MILLER: Well, I think the evidence is actually fairly convincing that the provider of services has a greater impact on the outcome that the particular treatment model employed when it comes to the provision of psychological services or behavioral healthcare services. I‘m certainly not against evidence; the question is what evidence we use to guide the services that we offer?
Right now, there is a very particular and I would even call ―peculiar‖ view of what constitutes evidence. Somewhere back in the eighties, our field decided it was going to ape medicine, and medicine, in what is now recognized as a fairly limited model, decided that the randomized clinical trial where you pit alternate treatments against one another, or even more often, you simply pit a treatment against no treatment at all, or a sham treatment was the best research design we could use to decide what would be the best treatment approaches.
So our field took that up. We‘ve been running randomized clinical trials and claiming that certain models are more effective than others when in fact, the evidence doesn‘t say this. We‘ve run very cutting edge, scientifically sound meta-analytic studies comparing treatments for a variety of conditions in children and adults, from depression to post- traumatic stress disorder, to alcohol abuse and dependence, and we find no difference in outcome between the treatment approaches that are intended to be helpful. You find a dramatic difference, of course, when you compare a treatment approach against no treatment, and some difference when you compare it against a sham treatment.
4 This leaves open the question then, ―Well, if there‘s no difference between treatment approaches, what treatment approach do you use?‖ If I‘m talking to consumers, what I say is, ―Choose your provider carefully,‖ because the amount of variability and outcomes directly attributable to the provider of services is eight to nine times greater than the variability attributable to the particular approach that provider happens to use!
So yes, it‘s absolutely true.
ALEXANDER: That‘s amazing because when you think of all the time that‘s spent in conferences, seminars, workshops, talking about this treatment method or that treatment method, it‘s very wonderful to hear something different; that it doesn‘t matter whether you make an interpretation here or there, it‘s more like who‘s doing it.
MILLER: Yes, I think that‘s part of it. More specifically, it doesn‘t matter so much if you apply a particular approach for a given diagnostic condition. It may matter a great deal to an individual client, but in general, when we compare treatments for very specific diagnoses, we don‘t see any difference at all. It really comes down to the abilities of that individual therapist to connect with the client, and I think this is the very good news. When you look at the factors that do predict outcome, the particular treatment approach predicts very little, if any.
Neither really does the diagnosis that a client gets predict the outcome, but rather who‘s providing that particular service and the kind of engagement that they‘re able to gain while working with that particular client, or what‘s often referred to as ―the alliance‖ -- that relationship and that particular therapist‘s ability to relate to and, as I said, ―engage‖ that client in alternate kinds of behavior, in alternate thinking, in alternate ways of dealing with and handling their emotions.
ALEXANDER: What makes one therapist better than another? What makes one person be the best rather than mediocre?
MILLER: That‘s the million dollar question and if that were the question our field were debating, then I would be a happy camper. Unfortunately, very little research has been done for reasons that you could probably imagine if you let your thoughts run wild for a minute.
The first study about this was done back in 1974, by a person named David F. Ricks, who was looking at adults who had been treated while adolescents in a state healthcare system. I believe it was in the state of New York, but don‘t hold me to that. His article is interesting and fascinating reading, and yet, virtually no one has heard of David F. Ricks. It was in a book called, The History of Research in Psychopathology.
In essence, what he did, again, was he looked at these adults who had been treated as kids, and he found some of them were living very productive lives. They had gone on with jobs and relationships, careers, kids, and families, and stayed out of the legal and the mental healthcare system. Other kids had struggled their entire lives, ended up in prison
5 settings or in mental health settings, and never seemed to thrive.
He wanted to look at what accounted for the difference, and he was very careful in this initial research to make sure that he was comparing apples to apples, that he was looking at kids who were matched for their family backgrounds, their history, the severity of problems, etc… and he found that none of those things really mattered that much. What mattered mostly was who treated the particular kid. Some of the kids had been treated by a particular therapist in his study who had far superior outcomes than other therapists in the study. He called that person a ―super-shrink.‖ That‘s his language, not mine, and he called the other therapist in the sample, who had very poor outcomes, a ―pseudo-shrink.‖
It was just a preliminary investigation; we‘re now just beginning to turn our attention and our sights to what leads some clinicians to be more effective than others. Of course, the first step in the process is to find out who is effective, and we can‘t wait, like David F. Ricks did, for twenty-five years, and measure these young children as adults, because it‘s going to take too long.
So what we‘ve done, as a group, has been promoting the use of outcome measures: clinicians pick up a scale; their clients fill that out; and they aggregate the data and they can get an idea about just how effective they are.
Again, this is very new, done within the last, really the last ten years that people are being encouraged to measure their outcomes, and that‘s the first step. If you want to be a better golfer or if you want to find out who the best golfer is, you should find out their score, for example, and so we‘ve done that. We‘ve identified people who consistently score in the top quartile of outcomes with regard to their peer group, or in regard to their geographic location, or just in the world, and we‘re trying to understand what is it that these people do that‘s different.
ALEXANDER: Any preliminary understandings? The article that was in the Psychotherapy Networker a year or so ago is stupendous in describing this.
MILLER: There are a couple of findings and I would say that this is very much, Barbara, the wet edge of the paint for us. We‘re learning. What I‘m saying now shouldn‘t be cast in stone. It‘s an exciting area of research simply because it‘s completely open; it‘s the Wild West.
One of the key things that these therapists do that is different from average therapists, and that‘s who we‘re comparing it to -- we‘re comparing the best to the rest, not the best to the worst here. These therapists, in general, seek, obtain, and maintain more consumer engagement than the average clinician does.
You may ask, ―How do they do that? How do they seek, obtain, and maintain more consumer engagement?‖
6 We‘ve noticed a very interesting pattern by using measures in following and tracking the outcomes of therapists. One of the interesting patterns we‘ve noticed is that the superior performing therapists often score lower in the beginning stages of providing a service to their clients, as compared to average therapists on measures of the therapeutic alliance.
ALEXANDER: I don‘t understand. How could that be?
MILLER: Yes, it puzzles most people because most people, of course, would associate better outcomes with higher scores on the measure that we use: the ―Session Rating Scale.‖ It‘s a very simple alliance tool. In essence, what it does is it gives a snapshot of the engagement level and activity, that bond between the client and the therapist. The superior performing therapist tends, on balance, to get lower scores in the beginning than their more average peers. Average peers tend to get higher scores in the beginning.
When we‘ve looked more carefully at this, we‘ve noticed that the ―super-shrinks‖ not only get lower scores in the beginning, but those scores tend to improve over time, whereas average therapists‘ scores tend to either start high and stay high, or start high and decrease over time.
What could account for this? What we‘ve come up with is that these therapists, in the work that they do with their clients, somehow manage to get more negative feedback about what they‘re providing to their client early in the treatment process.
ALEXANDER: By negative feedback, what do you mean?
MILLER: I mean that the therapist creates a culture, an environment in the session, where the clients can say, ―We‘re not doing what I‘d hoped to do here. You haven‘t understood me in a way that I believe I am, and the methods that we‘re using don‘t seem to fit me exactly.‖ They do this because they feel able to. They don‘t feel like there‘s going to be criticism, that the therapist will take umbrage at this, or punish them. So it‘s truly a collaborative partnership between the two: the therapist tries something; the client feels willing and able to say that it needs to be tweaked in this way; the therapist doesn‘t take that as a sign of the client‘s pathology, but instead takes that as a generous clue as to how to work more productively together. It creates a more virtuous, rather than a vicious cycle. These therapists are simply more inviting of that kind of negative feedback and they then adjust the services, which leads to improvements.
The average therapists, and again, remember, we‘re comparing them to their peers, and their more average peers in terms of outcome, tend to take, and I‘ll say this twice, ―They tend to take an absence of negative feedback as an endorsement of status quo.‖ Let me say it again, ―They tend to take the absence of negative feedback as an endorsement of the status quo.‖ In other words, ―Things must be ok because the client isn‘t complaining,‖ and therefore, they don‘t work very hard at getting that kind of information from their client that they could then use to improve the engagement levels of that particular client.
7
ALEXANDER: Well, you would think then that if the client keeps paying and keeps returning, that would lead the therapist to say, ―Ok, this is going alright.‖
MILLER: Yes, you would think that. Unfortunately, now you‘re pointing at the second largest finding that we have, and that is that the superior therapists are much more sensitive to the risk of dropout and deterioration or lack of change in the early phases of treatment. We think if the client is going to continue to come back, then that must mean something, but the truth is that a very large percentage of people don‘t come back after the first and second and third visits. They drop out.
We have protected ourselves in some ways and you can hear support here in what I was just arguing, by saying that, ―These particular clients didn‘t come back because A) they got what they wanted, or B) because they were too ill to appreciate what I was offering.‖ In either case, the therapist remains insulated and protected against this potentially negative feedback.
Now I‘m not suggesting that what the client is saying is correct or accurate, because I have no idea of a way of judging that. What I am saying is that the therapists are able to solicit more of this information and their attention to it creates stronger bonds, which result in better outcomes overall.
ALEXANDER: Well, you know I could be flip; this is a little bit flip, but maybe the average therapist who gets the higher ratings at the start should just do very, very brief treatment, and then the other people who are more able to let things develop and who encourage things to develop, might be better at the longer term treatment! Is that at all valid?
MILLER: I think in general, what happens in our field is that a significant percentage, estimates range up to forty-seven percent -- up to forty-seven percent of people in some studies drop out without experiencing a reliable improvement in their functioning, and they don‘t tell their therapist, which is even more troubling because then, the therapist is prevented from getting feedback.
The second, and I think more troubling finding, is that a very small percentage of people - both in psychological services and in healthcare in general - account for the lion‘s share of the expenses. So you can have people who continue to come to therapy week after week after week, and estimates are that between ten and twenty percent of people who start treatment end up accounting for sixty to seventy percent of the expenses by the end of it. So you‘ve got people who go for a long period of time and who don‘t get well, and you‘ve got people who go for a short period of time and don‘t get well.
Let me just say in defense of therapists and therapy that average therapists‘ outcomes are very good, but we‘re not here to talk about average therapists; we‘re talking about these superior therapists. When you look at average outcomes in psychological services in the U.S., dating back now thirty years -- you go all the way back thirty years -- the outcomes
8 have remained largely the same. The outcomes of psychological treatments are on par with coronary artery bypass surgery and treatments known for acute stroke, and myocardial infarction.
So our outcomes are really quite good, but that said -- that‘s the given; that‘s where we‘re starting -- the question really is, ―Why does that physician doing a coronary artery bypass graft do so much better than average?‖ And, we‘re saying the same thing about psychotherapists here. Some of them do slightly better, and it‘s in those small differences where we achieve gold medals.
So what is it that those people are doing? They‘re more attentive to that one out of ten or two out of ten clients who are not making progress. How do they do it? We can go into that in a minute. And, they are much more sensitive to dropout. They don‘t say to themselves that it‘s okay that clients drop out. They don‘t defend themselves.
In fact, in a very non-scientific finding that we published in the ―Super-Shrink‖ article, we found, at two locations, that the superior performing therapists also had the highest outgoing call logs of the therapists in the entire clinic, meaning that these therapists didn‘t settle after a first, second, and third visit. They would sometimes pick up the phone. or at least more significantly more often than their average peers, and call the client.
Again, this isn‘t scientific, but we talked to some of these people and asked them, ―Why are you calling?‖ The general gist of feedback we got from these superior performing therapists was, ―I was dying to know. I was dying to know, ―Did what I say help? Did it make a difference? Was I right about my diagnosis? Was this homework I gave engaging and interesting?‖
So it wasn‘t about checking in on the client in some dependent fashion, but rather about refining their skills. That feedback loop is really a huge part of what separates the good from the great.
ALEXANDER: I want to talk about how the feedback enhances the therapeutic relationship and what kind of feedback are we talking about?
MILLER: We don‘t really understand or know how the super-shrinks do this, naturally. We‘re in a bit of an empirical bind, as you may well imagine. There have always been, and people do believe that there are superior therapists. The only way we could find them, since most methods for identifying them, like peer nomination, are unreliable.
What we did is we asked all therapists in various agencies around the world to fill out outcome tools. Then we looked at therapists, again as I said in the beginning, who‘ve consistently scored very high in terms of their outcomes, so that‘s how we‘ve been measuring the outcomes.
9 With regard to the feedback piece, we‘ve watched how these therapists deal differently when they get information about their work. Now, how the individual therapists do this before we measure them, we don‘t know, but we do know that the superior performing therapists, for example, get lower SRS scores, which has led us to assume, once again, and consistent with other research on expertise, that these people won‘t settle. They are interested in knowing. They create an environment where people feel free to complain, and I mean complain in the most non-pejorative, whiney way. I mean it‘s simply that they say that ―It wasn‘t up to what I had hoped for,‖ which allows for process improvement.
ALEXANDER: SRS Score is what, please?
MILLER: The Session Rating Scale is our SRS Score. It‘s a very brief alliance tool, and if you go to my personal website, that‘s www.scottdmiller.com, go down to the tab that says ―performance metrics,‖ there, individual clinicians can download and use those scales for free. We have two: one is the outcome rating scale, which is a very brief way of measuring your outcomes. You can take that data, you can aggregate it and determine your effectiveness. The SRS is, again, that alliance measure. It tells us about the bond, the engagement level with the client.
ALEXANDER: What about the idea about the match or the fit between the therapist and the patient and their attachment styles and how everything blends together? Does this matter to the super-shrink?
MILLER: It matters to some and not to others. I haven‘t met any except unless, perhaps they are of a dynamic leaning, who would potentially bring that up, but what these therapists do is that they‘re ―dynamic‖ in interaction with the client. They‘re seeking and obtaining feedback. That feedback allows them to alter their style to better accommodate whatever it is their client is presenting with.
The funny thing about the way we do research in our field is that we hold variables constant, and then we try to treat. So if you give a dose of antibiotics, well then, you give the same dose; everybody doesn‘t get their own dose, even though they may need a very specific dose. Superior therapists use very careful observation, interaction, and engagement with the client to alter the dose, type, level and intensity of services they offer.
ALEXANDER: So let‘s go to an example of the feedback. I know that there‘s no standard rubber stamp kind of feedback questions to ask, but in the article, you gave the example of Dawn and how she responded to the person, the older person who…
MILLER: Yes, there was an elderly gentleman whose wife had passed away, and Dawn just had a sense that she hadn‘t engaged him completely. It‘s in the session and when you watch this kind of thing happen as a clinician, and the client then confirms – and all of us have had that experience where we say to the client something that nobody else would have potentially said and the client is shocked, and they‘re helped because of
10 it or they agree -- but the superior therapists do it better and more often.
So the question is how to help average therapists be able to emulate the behavior of super-shrinks, because as I said, before we did the project, none of the super-shrinks were using our measurement tools.
So here‘s what I usually say: ―Where birds can fly, the rest of us need an airplane!‖ Me, and the rest of the average therapists in the world -- we can listen to people who extol the virtues of listening carefully, and reflecting feelings, and attending to, and trying to create a culture of feedback. You can hear all that kind of stuff. The problem is we don‘t have the scaffolding and the structure to make that happen. So in other words, we need an airplane. The super-shrinks do it in diverse ways. There are a million different species of birds and they all fly in slightly different ways, their bone structure is slightly different, but we can copy that structure.
One thing average therapists could do right now, if they wanted to improve their outcomes, would be to begin to measure the outcomes on a regular basis at every single session. Now let me just say that if a therapist listening to this rolls their eyes and thinks, ―Oh my God, I‘m not going to do that.‖ Well, you know, there is good news and bad news. Either they‘re a super-shrink already, or they‘re average and they‘re not likely to improve.
So if you want to improve your outcomes, there‘s a very simple way to do it: measure the outcomes and then talk about them with the client at every single visit. You would expect the same dialogue with your physician if you were trying to get your blood pressure or blood sugar levels, blood glucose levels in balance. You‘d want them to measure every single time and if they weren‘t coming into balance in spite of this physician‘s treatments, you would want either a different kind of service or a different physician at some point.
It‘s the same thing here, measure and monitor your outcomes, and then at the end of each visit, measure and monitor the status of the alliance and discuss it with your client.
ALEXANDER: So you would say what, for example?
MILLER: In the beginning, I would say the following: I‘d say, ―You know, I work a little differently than you may be accustomed to. I know from the research literature that if I‘m going to be of help and service to you, you should start to see signs of improvement sooner rather than later, generally within five or six weeks. That may not mean that you‘re finished or done, but you should not have to wait months and months before you experience an effect of our work together. If you‘re not experiencing some kind of benefit, than you and I need to talk about what I can do differently, where else you can go, and ultimately, if I don‘t help you, I will help you get in touch with someone else that may be able to be of more help. The way we‘ll notice this is that I‘m going to ask you to fill out this simple scale, and you and I will talk about it every single time.‖
11 At the end of my visit, I‘m doing a similar repeat. I say again, ―Here‘s the last piece and I‘d like to hand out this brief tool, and it‘s like taking the temperature of our work together. Is it too hot, is it too cold, is it just right?‖ And I then add, ―You know, high scores mean very little to me here. I‘m not going to take what you say personally. I will take it seriously. What I want to know is how I can improve the service I‘m providing to you, and secretly, to everybody else who sits in your chair from hour to hour here. So really go through here, it doesn‘t have to be something egregious, large, it can be something that may, even in your mind, seem inconsequential as you fill out this measure about what‘s happened over this last hour.‖ Then I hand out the form.
ALEXANDER: Dr. Miller, let‘s say that you‘re in a session with someone who‘s been talking about some very upsetting material. They‘re crying, they‘re very emotional…or another example-- perhaps the person is very angry, or it‘s a couple and they‘re very upset and emotional, or it‘s a person with a borderline personality disorder, and you know it‘s not going to be easy to end this session either for the person or for you. So then how do you give that person outcome questions to answer? It would seem to me that it would be sort of out of nowhere, or not empathic.
MILLER: Well let‘s take a look. The first thing is, as we talked about, you‘re going to start the conversation you have with clients by reintroducing at each visit and trying to create a culture of feedback. That culture of feedback states that, ―I work a little differently, that I‘m interested in hearing how you‘re doing between sessions and how you experience this particular visit. So at the end of each visit, each time that we meet, I‘m going to be asking you for feedback because I don‘t know if the session was too hot, too cold, or just right. That involves filling out a very brief survey, it takes usually about a minute and then I look at it and see if we should talk about it.‖
A lot of these kinds of questions can be dealt with by insuring that you‘ve created the culture of feedback in the beginning. That‘s the first answer.
The second answer is: the clients are very upset and it‘s going to be hard to end the session anyway. I think the use of the SRS, the session rating scale or any alliance tool that you want to use, that‘s the perfect time to do it when actually you may end up with some feedback that says to you that the way you did the session today that led to whatever emotions are being experienced, was too much, or in fact if it‘s just right.
If you‘re concerned about that, and people express concerns about this both at the beginning and the end of the visit, frankly, Barbara. What they‘ll say is, ―Sometimes I‘ll have a client who comes in and cries they‘re so upset, and I‘m supposed to hand them this form to fill out? That seems kind of rude.‖
I always use an example from a television show from the 1980s, and this will show you just how kitschy I am, that was called ―Rescue 911,‖ with William Shattner. Whether you liked the show or not, what was always impressive to me about these 911 operators… and think about that, there‘s probably a no more stressful job than people fielding phone calls from people who are in an automobile accident, whose child has just
12 drowned, who‘ve cut off their arm with a band saw out in their yard, and here‘s this 911 operator. Now what does this operator do? They don‘t say, ―Well let‘s not talk about it.‖ In fact, they get an incredible amount of detailed information from people at the moment of crisis: their name; their age; a description of the situation; their address. My sense is that if therapists are committed to getting feedback this would be exactly the time that you either (A) want to measure the client‘s baseline, or (B) get feedback about what they‘ve just experienced the last hour.
ALEXANDER: Do you think it‘s ok to let patients leave their sessions angry or upset? Or do they always have to feel kind of resolved in some way?
MILLER: Do I think it‘s ok? I think it‘s going to happen and we need to be able to deal with that eventuality. Clients will be upset and giving the SRS gives me a critical opportunity to discuss that and to perhaps ensure that the client doesn‘t take whatever they felt during the session, and because I didn‘t address it, not come back an additional time.
Dropout, remember, following the first visit, is the single largest threat to outcome that we know about. Studies indicate that nearly half of the people who start treatment in the United States drop out after a single visit, and it‘s high at the second visit. So that‘s the key. I want to be able to ask for feedback and make sure.
Now, what happens if the client gives me low marks? Well, we kind of talked about this, but in essence, that usually says that either I didn‘t understand etc… I usually do one of two or three things: if I‘m right up against the end of the hour and the client doesn‘t seem too upset about this, but they do say, ―Yes, I didn‘t feel like you heard,‖ or ―We didn‘t really talk about what I wanted to talk about,‖ or ―Your approach, I‘m not sure about a good fit,‖ I say one of two things: number one, ―Would it be ok if we talk about this at the beginning of your very next session because it‘s exactly what I should have been on top of and I‘m sorry we missed it.‖
If I get any sort of hesitation at all, and I‘ve got somebody else in the waiting room, then I say, ―Would it be ok if I called you at the end of the day and followed up and heard more of what you had to say?‖
You would expect this in a restaurant, in a hotel. Why wouldn‘t you expect this from the person treating you, a mental health professional? If the client is not too upset and they say, ―Yes, that‘d be ok and we can take this up at the beginning of the next visit,‖ I always ask at the end then, ―Is there anything in what we‘ve talked about today that would prevent you from attending the next appointment? If they say ―no,‖ I say, ―If something comes up, will you call me and let me know?‖ All I‘m doing is trying to use that measure as a shoe horn to slip that client back into the seat to give me one more chance to engage them.
ALEXANDER: That‘s very helpful, very helpful.
13 MILLER: Thanks. My sense is that therapists‘ reticence about using the scales has more to do with their lack of familiarity with it. All of us need some sort of hooks, some language hooks, to sort of be able to approach clients when these situations come up. But I‘ve been watching therapists do this now for close to nine years and I‘m amazed at how therapists can ask for feedback, especially at those particular times where they seem most needed.
ALEXANDER: You‘re right about ―Language Hooks‖—especially for a new skill or introducing a new procedure. You really do need to have some language hooks. That‘s a great way of putting it.
Now, what if the person you‘re seeing has a big need to please you or to not show anger, or not be critical, and what if, simultaneously, you as a therapist, want to be seen as very helpful and very good, so you don‘t want to hear anything much negative. So you‘ve got a person who can‘t express anything too negative, and the person who can‘t listen to anything too negative, so then where are you?
MILLER: There are a couple of things. Let‘s start with the latter instance before I start talking about the therapist. The best way to get better outcomes is, in fact, to be open to negative feedback. The best way to ensure mediocrity and average outcomes is to get no feedback about your performance, which is exactly what the research literature says happens to most therapists. Their outcomes improve for about six to eight weeks of starting, and then they level off and they don‘t get any better.
At the same time, confidence levels go up. Think about that. You have therapists feeling more and more confident despite the fact that their outcomes are remaining relatively average. So the first thing you could do if you want to improve is to get some feedback about the areas where you could change something.
Now, let‘s go back to the first example with regard to the client who has a need to -- now I‘m always puzzled by this comment, although I hear it fairly often. First off, who gets to decide whether the client is that way or not, that is, shy, or prone not to disclose? Who gets to decide that? Usually the therapist who‘s sitting opposite that client, who may have engendered that very behavior.
This idea is supported by our research which shows that variability in the alliance and feedback is not attributable to the client; it‘s attributable to the therapist. In other words, some therapists create a culture in which clients, regardless of how they present, are more likely to disclose. Other therapists, more average therapists, create an environment in which clients are less likely. So I would say the fickle finger of responsibility points back at us.
Now, that can create monumental amounts of frustration because the truth is, most of us average clinicians - me included -- have no idea about how to ―language‖ things -- the scaffolding and the structure -- in order to get that kind of negative feedback. In fact, we do things and we scaffold, and we talk, and we create an environment in which it‘s
14 virtually guaranteed that the client won‘t.
Let me give you an example: I‘ve already said that the superior performing therapists are much more likely to have contact with their clients between visits. Whenever I make this statement at a workshop, somebody invariably raises their hand and says, ―Won‘t that create dependency?‖ And another one raises their hand and says, ―What about boundary issues?‖
We are well defended against this idea when all I‘m recommending is that when you give an assignment, maybe you should follow up and find out between visits. These people, the superior performing clinicians and in fact, physicians, radiologists, chess players, pianists, they share the same quality: they are dying to know, ―Did it work?‖
ALEXANDER: Years back, I saw a patient who said to me that I was a B+ therapist, she said, ―You‘re a B+ therapist, but I want an A+.‖ And I asked her what would make me be an A+ and she really didn‘t know, and she really couldn‘t say, but she kept coming back and she kept complaining about me. I never could get quite at what it was she wanted. I just couldn‘t get at what she wanted me to be, what she wanted me to be doing differently. So I tried, maybe I didn‘t try hard enough, or didn‘t pursue…..
MILLER: Well, there‘s two things, and this kind of points into the last and the third item that is on our list of what the superior performing therapists do. So the person says, ―You‘re a B+ therapist,‖ and they‘ve given you no really useful information, as you were pointing out, about how you can change your behavior. We find, for the most part, that clients are often unable to give you specific direct instructions for how to change the treatment in order to improve their experience of it.
So what can you do? The first thing you could do is you could use this alliance tool that I‘m telling you about because it‘s going to give you four very specific pieces of feedback at the end of each visit, just like that. You can go in and you‘ll be able to see where the client is saying things are not just right. That‘s the first step.
The second step relates to the third point and difference that we‘ve noticed about superior performing clinicians and that is that they‘re constantly pushing their realm of reliable performance. The problem in our field and in every field where average is, in fact, the average, is that people‘s outcomes level off at an average level and they stop getting feedback, and in fact, they begin to explain and understand their average outcomes. At the same time, their confidence level increases.
What happens to make that happen, researchers call, ―automaticity.‖ We stop thinking about our work. We say things like, ―I‘ve seen this before.‖ Now, automaticity isn‘t bad in and of itself. You have to have automaticity in order to walk, otherwise you‘d never get up from a crawling position. Some things have to become automatic. At the same time, most of us are no better at walking than we were when we were three because we‘re not thinking about it anymore, and the way to think about it is to engage in a process called, ―deliberate practice.‖
15 Deliberate practice is not a concept that I invented. It really owes its entire existence to a phenomenal psychologist and researcher by the name of K. Anders Ericsson. Ericsson is the one whose research has really opened my eyes, at least, in terms of understanding the difference between average and superior by noting that these people engage in deliberate efforts to improve target performance.
So here‘s the key. First, you have to know that your performance is either average or less than average. That can help you engage and develop a plan of deliberate practice for improving those outcomes. Then you have to set some very specific target behaviors that you want to change, and you have to develop a very detailed plan about how you‘re going to approach that.
In your example, your client says that you‘re a B+ therapist. What I would be doing after the session, what superior performers do is video tape or audio tape that session, sit down and think about what‘s going on in the session that may be contributing to an okay performance, not great, not perfect, but okay. You then develop a plan with very specific targets in terms of process: what you‘re going to say and what you‘re going to do, because the truth is that most of us do this on the fly, or, when we‘re not doing it on the fly, it‘s become automatic.
This means when you‘re sitting down, developing a step-by-step plan, and in your step- by-step plan, you don‘t just have one direction, you consider permutations. So you might say to a client who says, ―You did really good today,‖ you might say something like, ―I‘m very happy to hear that. What would have made it better?‖ If the client says, ―Nothing could have made it better,‖ you would need to consider two or three alternate ways to ask that same question to get information. You‘d have a very deliberate plan. You then go back the next time and you try out your plan. At the end of that visit, you look back at, ―Did your plan work to achieve the target process objective? Did you miss any steps in the plan?‖ If it didn‘t work, you‘re thinking again.
This seems to be what leads to superior performance, say, in chess. In contrast to popular myth, chess players do not have superior memories. They don‘t have a superior I.Q. What they have are more lateral moves at every point along the chess board. Unlike me, I have two or three ways I play chess. For them, for each move on the chess board, there are multiple permutations from that particular point. They‘ve gotten this by rehearsing and practicing those steps one by one, before and after they play. That‘s the process of deliberate practice. It is very intense and it is why most people settle for average.
ALEXANDER: There‘s a lot in the theory that kind of makes it -- well, in the psychodynamic theory -- that makes that not so easy to do because of the multi-layered aspects of it, perhaps, but also because, for instance Winnicott, a developmental child psychiatrist had the concept of ―the good enough mother‖ and so you think, ―Well I‘ve done a good enough job with this person; it‘s a good enough job, it‘s not the greatest, it‘s not the best, but it‘s good enough.‖ And so you don‘t grow then. Yes? No?
16 MILLER: Right and you know what? Good is good. We‘re talking about average vs. superior. The question is whether or not you want to be a superior performer or not, and you know what‘s amazing about this, and this isn‘t my idea, this is an author whose work I also admire named Geoff Colvin. He‘s written a phenomenal book called Talent is Overrated. He says, ―Think about the people around you and the work that they do.‖ Most of us, and this includes me, go to work everyday and we work at the same thing everyday and we‘re good at what we do. But isn‘t it interesting how very few of us our actually great at what we do?
What he asks is, ―Why is it?‖ He says there are two primary reasons: first, people believe that greatness is due to an innate inborn talent for which Ericsson says there‘s absolutely no proof, and secondly, he says, ―Even if there is such a thing as native, inborn, genetic talent, it doesn‘t seem to matter, because, for example, there are chess grand masters who have below average I.Q.s.‖
I agree with you. For most of us, it‘s ok to be good and there‘s nothing wrong with that, but if you want to improve your performance, there are some very specific steps you can take, but it is hard work.
ALEXANDER: Well, the hard work would reflect in an improvement in the relationship, wouldn‘t it? The patient or the client would see that, ―Gee, this person is really trying hard, really wants me to be better, really wants me to grow. This person really wants to help me.‖
MILLER: I‘m not sure the clients are going to notice that.
ALEXANDER: Really?
MILLER: I don‘t know. No primary research has really been done on the subject but I wish instead that therapists had that idea, that, ―I really want to grow, I really want get better.‖ What happens typically is that our confidence grows and our outcomes remain flat, and by flat, I mean average. The best physics instructors and professors and thinkers may experience decline in virtually every other aspect of their functioning but they don‘t experience it in the realm in which they deliberately practice. So for me, it‘s very good news: you can not only maintain your skill level but you can improve your skills and your outcomes virtually until your death, but it does require effort.
I think it‘s important to note that again, we‘re just learning about this and bringing these ideas to the field of therapy. They‘ve been in operation in sports and in music and other areas, business, for a long time, but they‘re just now coming to the field of therapy, so I think it‘s critical, number one, that you‘ve given exposure to them in general.
I hope that when I present the ideas, that my commentary about where the field is at and where we need to go isn‘t discouraging, but instead gives, as you say, which I think is the best feedback you could give me, some very specific concrete steps people can take in order to improve their performance. Otherwise, we just feel like it‘s all futile and it is
17 definitely not futile.
Download and use the scales, talk about them with your client, begin to record some of your sessions that you feel like you‘re struggling with, develop a plan of deliberate practice, and get a coach whose work you admire to learn a very specific skill and have them listen and comment about your plan. These are all things you can do to improve your performance, and they will pay off in terms of outcome.
ALEXANDER: Dr. Miller, thank you. I want to say again that your article in Psychotherapy Networker is a feast, and it should be read by every therapist.
MILLER: Thanks very much.
ALEXANDER: Really, because people don‘t realize how, what‘s the word for it? -- sanguine they get about how they‘re doing, how complacent, and it‘s so important. I loved the article and I‘m very happy that you gave us the time today to speak with you.
MILLER: My pleasure and you can download that article and all the scales and everything else from my website. Again, it‘s www.scottdmiller.com. There is a link there that says ―Scholarly Publications and Handouts,‖ and you can download it there.
Barbara, I respond to all of my email. Sometimes it takes me a day or two but everybody gets a response, and if you don‘t get a response within three days, it means I haven‘t gotten your email, so you should send it again. I love the subject and I love talking to clinicians. I‘m very hopeful about us as a group. We‘re resourceful and I think once the information is available, we‘ll suck it up.
ALEXANDER: Okay, Dr. Miller. Thank you very much.
MILLER: You‘re welcome.
This concludes our interview with Dr. Scott Miller. We hope you learned from this interview and that you enjoyed it.
To order Dr. Miller‘s publications, view his workshop calendar, download his evaluation forms, and to contact him, visit his website: www.scottdmiller.com.
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
18 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“The First Session, as seen in „In Treatment‟”
ARTHUR NIELSEN, M.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
ARTHUR NIELSEN, M.D. 333 E. Ontario #4209B Chicago, IL 60611 Tel: (312) 649-0579 Email: [email protected]
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #2 in our program on The Therapeutic Relationship.
The true core of all psychotherapy is always the intimate relationship that forms between therapist and patient, containing emotion and drama. The first session in any therapy presents a unique opportunity which has been recognized by experts for decades, even being referred to as having ―a sacred nature.‖ Everything the therapist says and does in this first session conveys his or her concern, competence, and interest in helping the patient and evokes intense feelings in both patient and therapist.
From the first minutes of the first session, the therapist declares and demonstrates, verbally and non-verbally, that he or she wishes to relate to the patient. By focusing on the patient‘s feelings, asking for specifics, and responding empathically and emotionally, the therapist activates the patient‘s complex feelings about intimacy and closeness. In this way, the therapist offers the patient a therapeutic alliance, a partnership designed to resolve emotional problems. It is a truly unique experience and a singular interaction, with the main goal of the therapist to create a sound therapeutic alliance.
This relationship is brilliantly portrayed in ―In Treatment,‖ a compelling, award winning HBO television series that looks at a fictional, psychodynamic psychotherapist named Paul, his patients, his life, and his own therapy and supervision. In ―In Treatment‘s‖ first week of episodes, Paul has first sessions with 2 new patients. These first sessions do precisely what first sessions are always supposed to do: just as in first sessions between
19 new patient and therapist, the program‘s viewer is drawn into the drama, with all the curiosity and intensity of first sessions in real life therapy.
As a sidebar, you‘ll note if you watch ―In Treatment,‖ that the therapist doesn't go over some of the basic ―real relationship‖ aspects one might expect in a first session, particularly informed consent, which would outline expectations regarding confidentiality and duty to warn, etc. but without spoiling the plot, I can tell you that these elements are woven into very dramatic moments in the program.
Our next speaker, Dr. Arthur Nielsen will talk to us about both the program and first sessions. In his view, the most fundamental thing in the first session is having the patient feel that he takes very seriously why they‘re there. So, as you listen to this interview, you‘ll notice that Dr. Nielsen does what Scott Miller says ―Super Shrinks‖ do: he asks for feedback from his patients as to whether they feel he understands what their problem is and what they want help with.
Arthur Nielsen, MD has a full-time practice of psychiatry, psychoanalysis, and couples therapy. He is a faculty member at the Chicago Institute for Psychoanalysis, a Clinical Associate Professor of Psychiatry at Northwestern University‘s Feinberg School of Medicine, and a faculty member at Northwestern's Family Institute. For many years at Northwestern, he taught the psychiatry residents‘ journal club and a course on research methodology in psychiatry, and for the past nine years he has taught a course at the Psychoanalytic Institute titled, ―The Underlying Logic of Clinical Psychoanalysis.‖
ALEXANDER: Dr. Nielsen, I‘m so pleased that we‘re able to talk to you today about your thoughts about the therapeutic relationship as it begins in the opening session in treatment, and as that is exemplified in the wonderful HBO television series called ―In Treatment.‖ So let‘s begin by talking about some of your thoughts about the program, about the ―In Treatment‖ program.
NIELSEN: Thanks Barbara. I really enjoy the opportunity to talk about it because I found myself riveted by that series, although sometimes it was a bit of a busman‘s holiday because Paul has a very stressful time of it.
When I was a candidate at the Institute for Psychoanalysis, sometimes I would contemplate if a person could do a good fictional job about a patient or a therapy, and I would think it was impossible. The reason I used to think it was impossible was based on my process notes. I would look at them and see how many layers there were and how many references to things that had happened in the past, or in the patient‘s past, or associations that I had about memories from my childhood, and things with other patients. It‘s just so multilayered and multifaceted that I thought it would be impossible to do. But I think that actually, this show pretty much delivers on that score because it has this beautiful format of the multiple patients that are on his mind, his own therapy, his own family. Then of course each of the patients is portrayed in great depth and has lots to say about their past and their thoughts about him. So you get, I think, one of the most
20 realistic portrayals in that sense of the protean nature of psychotherapy and depth psychology.
I think it‘s also terrific because it really does a good job showing the great contributions, I think, of psychoanalysis to human psychology, and as an analyst, of course, I like that. I think it shows us unconscious motivation, it shows us transferences, it shows us all sorts of defenses that the patients erect. You see all of these patients wanting to talk and then simultaneously not wanting to face certain aspects of themselves. You see the shadow of the past that entraps people and also motivates them, so it‘s just really wonderful.
I think another thing you see that is rare in T.V. therapists, although I think, Dr. Malfi on ―The Sopranos,‖ you got some with her: the strain on the therapist, I think is palpable and you don‘t have the idea that this is an easy job, and of course at the end of the first week of the therapy, Paul doesn‘t think so either. He goes for help which I think was a good idea.
ALEXANDER: It doesn‘t just happen on television, you know. It‘s tough on television because it‘s tough in life.
NIELSEN: I think actually one of the really good things about ―In Treatment‖ is that it shows how hard it is on the therapist, I mean you can definitely see that and how it isn‘t a simple job of just listening to people. You know that‘s not, it‘s a major challenge and so I think, yeah I just had that experience.
Having said all of that, I think ―In Treatment‖ is a little like therapy on steroids. It‘s a little over the top, or sometimes a lot over the top, and this kind of treatment is to real psychotherapy like I think cop shows and doctor shows are to real life. It‘s too full of stuff per minute compared to the reality, but I guess that makes for great theater and certainly over the course of a lifetime, I have experienced many of the things that Paul encounters. So I think for the audience, it‘s great, but actually as total truth, there‘s too much per minute, I guess is what I‘d say.
ALEXANDER: But even yet as a therapist watching the program, you can‘t help but think, ―Well, how I would react to what this person is bringing in?‖
NIELSEN: I think for a therapist to watch this show or to use it for teaching is great because in fact, it has all of those moments where you‘re wondering, ―What would I say?‖ Then you see what Paul says, you see what happens and a lot of what he says is somewhat different from what we might say, and other times it‘s the same.
I think the writers, who apparently have all been in therapy, have really given a lot of thought and a lot of loving attention to the interventions and psychology of the patients. So yes, it is really interesting to think of what you would do.
ALEXANDER: Let‘s talk about the therapeutic alliance concept
21 NIELSEN: Yes, well, let me say a couple things about that. I think that will help us when we get to the specifics. The therapeutic alliance concept, I think, is a particularly useful one. Historically, it evolves partly because of Freud‘s discovery that when he had these great insights to give to people about their unconscious motivation and how they were sabotaging themselves, they weren‘t always so keen on hearing it and on changing. So he coined the term ―resistance‖ to deal with that. What subsequent people saw was that patients were ambivalent about change, and that that was a tremendously valuable idea, but also, they were ambivalent about the therapy, so that sometimes they seemed to be collaborating well with the therapist, and other times fighting them.
Actually, one of the classic papers in the thirties is by a guy named Sterba, where he talked about the optimal kind of therapy, which is somewhat similar to what you see often with Paul. Patients would be doing their maladaptive dance, their neurotic stuff, they would be having transference enactments in the room. But then optimally, they were also capable of observing that, so he thought there was what he called, ―a ―therapeutic split.‖ There was an observing ego that the therapist ought to be talking to. So the idea was that you would have this reenactment or revisiting the transference and it would happen in the room with the patient, but that you would ally yourself with this observing ego.
Now subsequently, people came along -- Ralph Greenson and Elizabeth Zetzel are two of the ones usually historically mentioned -- who noted that there were patients who regressed, but there didn‘t seem to be much ego to work with, or they didn‘t seem to be taking on the idea that they were supposed to help with the therapy. They became too passive or it was just an inactive experience, and in that sense, these authors and others took up the idea of a working alliance or a therapeutic alliance: what should the therapist do to engage the patient maybe more explicitly in the collaborative process?
So then having said that, Wilfred Bion took that idea and applied it to groups and made a nice distinction between groups that were working on task that he called the ―work groups,‖ or groups that were in the throws of some other human motivation and he called those ―basic assumption groups.‖ I think as a person either working in groups or working with an individual, it‘s a useful distinction. However you conceptualize what the problems are or what the solutions are, it‘s a useful distinction to see if a group is working on task or is the group somehow colluding and getting off and enacting something that really has little to do with what they set out to do.
In terms of the therapeutic alliance, I think it usually develops often over time so it‘s not something you have from the get-go as opposed to, say, an internist meeting with a patient. Ideally the patient would tell you their story and give you sufficient information to work with them. This is definitely not the case with most patients where there is some reluctance to fully reveal themselves. More about that later.
So anyway, I think that ―alliance‖ is something that develops over time. It‘s dependent on trust, trusting another person. Some people are more capable of that upfront; with other people, it develops. I think trust itself is not simply a monolithic concept; it‘s also
22 based on actual experience of helpfulness and success. So as a therapist, one of the things I notice that really makes a therapeutic alliance get better is literally helping the patient with what they‘re complaining about at a particular moment, so that the alliance is a function of actual success. It‘s also dependent on the patient feeling understood, that the therapist empathizes with them as opposed to feeling criticized or whatever other negative expectations the patient might have.
The alliance also develops as a function of working out things that would interfere with it, especially what therapists would call, ―transference resistances,‖ or ―negative expectations,‖ or ―unrealistic wishes.‖ Here‘s where an analytic therapist has an advantage over your boss, who might be puzzled as to why things aren‘t working collaboratively in a meeting. The analytic therapist has, in his or her armamentarium, the use of interpretations, the idea being that you try to uncover what the potential reasons might be for the lack of collaboration and try to bring them out and expose them. When we get to ―In Treatment,‖ we‘ll see examples of that.
Therapeutic alliances are also helped by what‘s often referred to as ―the frame,‖ or the ―therapeutic set up.‖ This definitely allows for greater trust and for collaboration. One of the elements that‘s pretty obvious but worth stating is the therapist‘s not really being a part of the patient‘s life. They‘re not the boss or the spouse so they don‘t have a hidden agenda. There‘s also confidentiality such that the patient can feel safe about revealing things that might get them into trouble or be difficult for them outside of therapy. There‘s also a manifest tilt of concern towards a patient who‘s the focus. The therapist‘s needs are not supposed to be of concern. Then there‘s the basic concept of ―therapeutic neutrality‖ which I think is important in that patients often come with concerns about life decisions, as we‘ll see with Alex, as to how they should proceed. Therapists over time have learned how to be careful about not making quick judgments or to take one side or another in what often is a conflicted decision that the patient is trying to work out.
Having said all of that, there are lots of studies in the psychotherapy literature that show that the quality of the therapeutic alliance, or the working alliance correlates highly with successful outcomes. That means that it‘s really important and I guess that grounds why this is a significant discussion that we‘re having here.
But some authors have said, ―Well look, if that‘s the case, isn‘t really the development of the therapeutic alliance almost the same as the treatment, and is it really a superfluous concept?‖ Charles Brenner, one of the more famous ego psychologists/ psychoanalysts in the U.S. argued that it really was a concept that didn‘t add anything because really, the ultimate goal of therapy was to help the patient become capable of collaborating, and clearing away all the things that interfere with that is the therapy. To help the person become capable of intimacy and differentiation, for instance, was the therapy and so it didn‘t add anything.
With that in mind, a couple of other thoughts that have been advanced about the therapeutic alliance subsequent to Brenner and Greenson and Zetzel: the contributions of self-psychology, I think, have been really important in that there are moments in therapy
23 where there‘s a disruption, where things are not going well. The self-psychologist would say that there was a disruption in the self/ self-object bond between the patient and the analyst or therapist. What the self-psychologists put on the board was that working on the repairing of the relationship, then, is something that strengthens the alliance and actually strengthens the patient. It strengthens the patient‘s trust that if you have a falling out with somebody, you can talk about it, you can work it out, and most of our patients did not have that experience with their caretakers. If they were upset, let‘s say with a parent, that was just too bad. They didn‘t have a chance to try to understand it and work it through, even have the parent or the caretaker apologize for the state of affairs.
Another school of psychoanalysis comes from California, San Francisco, Weiss and Sampson‘s concept… Mount Zion hospital is where they were. This is the idea that patients are often testing their therapist to see if their fears or their hopes are going to be met. They are hoping for a better relationship than they had in the past. I think in that sense, the therapeutic alliance grows out of many of these tests: whether the therapist can handle it if the patient is angry or sad; or whatever it is that the patient is in doubt about. Ideally then, the way that therapy works is that to the extent a therapist can provide a different or new experience, the patient will then take that on the road and try it out with other people, and that will then lead to healthier behavior.
The last thing I have to say about the therapeutic alliance in the history of psychoanalysis and psychotherapy is that people have been aware from the beginning that it can be interfered with, not just from the side of the patient, but also from the side of the therapist. Therapists can have countertransference problems or personal issues that interfere.
In this series, the most obvious thing that runs through the whole series is Paul‘s problem with erotic counter-transference through the patient Laura, who has a transference to him, and how that interferes with his ability to work with her. Now of course, counter- transference feelings can also be useful in that they point you to what‘s going on, but to the extent that the therapist isn‘t in control of himself/herself and their own needs, of course then, the patients‘ needs may get lost sight of.
There‘s other things, other limitations that come from the side of the therapist, which often have to do with lack of experience or education, and that‘s why it‘s useful for therapists to continue their education, to be educated, to talk to colleagues if they get in a situation they‘ve never seen before.
Mainly in this series, we‘re dealing with a very experienced therapist whose problems aren‘t so much with lack of experience or education as that his own personal life is in disarray. His wife is threatening divorce and, we see later, having an affair, and he doesn‘t appear to have many friends, if any, and is somewhat estranged from his kids. So there are troubles likely on the horizon for him based on his failure to manage his own private life. So that‘s sort of a whirlwind tour through the concept of therapeutic alliance.
24 ALEXANDER: Let‘s talk about how the opening session is used to begin to set that up. Would you say there are general goals for the opening session?
NIELSEN: I think that‘s a really good question. I think that the characteristic mistake that I see psychiatric residents or beginners make more often than not, in answer to that question, is what they‘re trying to do is get a history, and often, these days, to try to make a DSM diagnosis. So with that in mind, they‘re asking lots of questions and as soon as they think they have the answer, they move on to the next thing. There‘s a lot of research, and my approach to the first sessions with people is to put less of the weight on getting a comprehensive history and more of the weight on finding out what is really bothering that person. Why did they come? Why did they come now?
The thing that‘s going to help the therapeutic alliance most is not getting a comprehensive history and being able to come up with a DSM number, but having the patient feel that I take very seriously why they‘re here, that I have some sense of it in- depth, and I think, an additional thing -- that I have some experience with that particular problem. I try to convey that, often indirectly as I talk to people, but I‘d say that‘s the most fundamental thing in the first session with somebody.
In addition to that -- it sort of goes hand-in-hand -- is if you can uncover particular fears that they have about what you‘re going to do -- you‘re going to tell them what to do, that you‘re going to side with the parent, that you‘re going to be critical of them, whatever it is -- if you can discern what that is and comment on it or act counter projectively to that, then I think that also goes a long way to having people settle into therapy.
ALEXANDER: I always thought that a person would decide in a very short time in the first session whether they could work with that therapist or not -- the patient or client could -- and so I always wondered about people who shopped around, who would have interviews with maybe two or three different therapists, sort of checking them out. Along that line, somewhere along the road, I learned that you should try in the first session to make some one comment that shows that you really have the capacity to be ―into‖ that person or to understand that person. Would you say that‘s so?
NIELSEN: Yes, actually that‘s what I was trying to say earlier. It‘s not just that you find out what their problem is. Lazare has a famous paper on the psychiatric patient as customer. This was a paper from the 60‘s where they basically were going to give everybody psychotherapy and they were trying not to get the DSM diagnosis, but they were trying to come up with, ―Is this a candidate for psychotherapy or not?‖
But the failure in there was, again, not just to find out what the patient wanted. The paper is beautiful because it gives all the different kinds of things that people can want. But your point is that you need to convey to the person that you understood what they wanted. If they wanted you to help them deal with guilt, then you would try to convey that you‘ve got it, even if you couldn‘t help them completely in that session with whatever it was. If they wanted to know what to do with their mother-in-law, then you‘d say, ―I think you‘re really puzzling over this particular life issue.‖ You‘ve got to not just
25 sit there and write it down in your notes, but I think you have to verbalize it.
One other thing that occurred to me that I was thinking about a minute ago is in terms of shopping around and people checking out the therapist. I think clearly my experience is that when people are doing that, they‘re usually more skeptical than average. Most people, for some reason, don‘t do that. I don‘t know if that‘s necessarily a good idea but that‘s the norm, so I think when I hear that somebody is shopping around, I really want to be even more explicit about what they‘re looking for and what are they afraid of?
One intervention that I would highly recommend to therapists that I use in the end of first sessions and that I got from my own analyst years ago, because he did it with me and it seemed like it was a good thing so I identified with that, was that at the end of the hour, I ask the people if this is what they are expecting. Was this how they thought the first meeting would go, and if so great and if not what was missing? Then, if they think they can work with me is a related question. If so, why or why not?
Then the last one is did I say anything or do anything that really rubbed them the wrong way or upset them? What that does, even if there‘s nothing -- like assume that there is nothing and you were really hitting if off with someone, which is often the case -- is it gives the person the experience of your openness to that sort of thing, to hearing about the relationship and what their expectations are and what their hopes for and so in and of itself, it‘s a relationship improving intervention.
Also, the other thing it does is it encourages people to be thinking, reflecting on the relationship and so in the second interview, the move that I always make, which assumes they come back which most people do, is I always ask people what their reaction was to their first session? What stood out, what do they remember? There‘s tremendous data in that, but if nothing else, again, it‘s encouraging the person to comment on the quality of the relationship with the therapist and what they‘re learning and to be a joint explorer of themselves. So that‘s another intervention that I‘d recommend to your listeners.
ALEXANDER: As we talk about therapy, about the opening session with the patient Alex, in ―In Treatment,‖ we should come back to those things because I don‘t think any of that happened.
NIELSEN: Yes, that‘s true, but again, there‘s more than one way to deal with different people. Should we just talk about Alex?
ALEXANDER: I want to ask you one thing first: the concept of educating the patient about what therapy is going to be about.
NIELSEN: Yes, I definitely do that and I don‘t usually do that in the first session unless they ask me about it, or if they seem unclear about it. Again, you get people of all levels of sophistication and prior experience with therapy, so you have to individualize it. But after one or three sessions or so with people, I usually tell them that I‘ve got a sufficient amount of information and this is what I think the issues are. I don‘t want them
26 to think that the diagnostic phase goes forever but I do say that I have enough information to work on now, not that I know everything because I clearly feel that I don‘t and we‘re going to learn more, but I then say what I think they need to know to work in this kind of therapy.
Again, the kind of therapy depends. I do lots of couples‘ therapy so I‘m going to set that aside; I have somewhat different recommendations at the beginning of that. But for the typical individual, insight-oriented, psychoanalytically oriented psychotherapy, I‘ll tell people that what‘s important for them is that they essentially start the hour and they talk about something that is upsetting them or really on their mind, and I tell them why. It‘s not that I don‘t have questions or thoughts or my own ideas about how things could go, but that I don‘t know, on a given day, what might be uppermost on their minds and that‘s where I think we can get the most mileage. I say that if there is something though that I feel we should talk about, of course I will bring it up, so I don‘t make myself out to be just totally passive but primarily responsive to their talking.
Then I encourage them, as per Freud, to be as honest as they can and to not filter out things that they might think of as irrelevant. In particular, I say that it‘s important that they might be able to talk about their relationship with me, and we can use that as a laboratory for understanding their relationships with other people. If they‘ve mentioned who those other people are, who they‘re having trouble with, whether it‘s a boss, or a spouse, or a kid or something, I‘d say, ―Some of those problems may come up with me and that, as opposed to with your internist -- say you saw an internist and you thought that he had a funny looking tie, or why was he in a bad mood today or something like that, politeness would dictate that you didn‘t comment on those things.‖ I‘d say that, ―In this relationship, that could be really important to do and would be useful,‖ so I‘m trying to encourage them to be able to look at our relationship, so that‘s one thing.
Then I also say, because some people don‘t know this, that I feel that dreams are often important. It‘s not always a royal road to the unconscious, but dreams are a way to know what‘s really on somebody‘s mind, so I encourage people if they have a dream or if they had one in the past that they would bring that in also.
These are relatively minor sorts of an introduction to educating the patient about therapy, but I say that as we go along, there may be things that come up and if they have questions about how the therapy‘s going, please feel free to ask that.
Really what I‘m trying to is give them a general sense of how it‘s going to go and that I‘m going to collaborate with them, but that we‘re embarking on a journey that‘s just beginning and we‘ll see where it goes.
One other thing -- I don‘t know why I don‘t do it anymore but I think it‘s fine to do -- is I use Freud‘s image of the train. He said, ―It‘s like we‘re going on a journey, the two of us, and you‘re looking out the window essentially into your mind, and you‘re going to tell me what you see. What‘s important is don‘t leave too much out, and try to be as honest as you can, even if it‘s embarrassing, and then I will try to help you make sense of
27 that. That‘s my role.‖ I think that‘s not bad, that‘s not a bad image: ―I‘m here to assist you in self-exploration.‖
I think the reason that I don‘t use that one anymore, or I haven‘t in a while, is that I also want to have the other possibility that they‘re on a train with me and they‘re having trouble with me, the guy sitting next to them. They‘re having the same troubles with me as they‘re having somewhere else and I want them to be able to talk to me. Freud‘s image of the train is more of you as the helpful disinterested person, but I‘m sure that your listeners also have their own favorite metaphors that they might use for inducting people into therapy.
ALEXANDER: Well, another metaphor of Freud‘s was that he said therapy was like archeology, and so we wonder where to make the metaphorical first dig. And so Alex, to move to Alex, he doesn‘t give Paul, the therapist, a chance to make the first move. He comes in very arrogant, haughty, and he walks around the room and he examines everything with his nose a little out of joint and looking down on everything. Paul‘s sort of sitting there and then, as I recall it, what Alex says first is, ―Do you recognize me?‖ or ―Do you know who I am?‖ which is sort of stunning because it‘s not as if he were…
NIELSEN: That works on so many levels. It‘s one of the beauties of the show. Of course, we‘re going to find out who Alex is and who does Alex think he is, and also there‘s this arrogance of, ―I‘m a cool guy, I‘m a fighter pilot, top gun guy,‖ that he says later. But also, his worry that comes up later and is, I think, one of the central things is that he is the Madrassa murderer who‘s been in the papers. His picture is has been in the papers as this guy who accidentally bombed this Madrassa and caused the death of innocent people, including children.
I think the thing about Paul -- first of all, in facing this guy who is so clearly anxious but wanting to talk - the main thing is he doesn‘t have to do very much. This isn‘t a very reticent person where you‘ve got to coax it out of them to talk to you about what they see out the window. This is a guy who‘s almost on a rampage and I think Paul did the right thing by essentially letting him go, and you‘ll see this, I think, through the sessions.
This guy, like so many of the patients in the first year in the series: they‘re all really action-oriented, they‘re all on the move. This guy is a pilot but I suppose he could have been a prototypical surgeon. He‘s an action-oriented guy and so to help him get in touch with his feelings, his motives, and to sort of slow him down would be the goal of most therapists. But right now, he‘s talking and he‘s definitely saying a lot in terms of his emotional life. Even though he‘s intellectualized and he‘s controlling and he‘s telling Paul what the questions ought to be, as a listener, I thought the questions he was asking Paul to ask him: ―Do you know who I am?‖ I don‘t see as resistance so much.
People used to say, ―Why doesn‘t the therapist say anything?‖ The classic analyst answer is, ―Only when work isn‘t being done, when the patient isn‘t really getting anywhere and there isn‘t new material coming does the therapist say something.‖ I disagree with that. I think there are other times for a therapist to say things, but in this
28 case, that‘s not a bad rule. What‘s coming out is actually highly informative.
The one other thing I wanted to say about the alliance with Alex, this action-oriented guy, is that Paul manages to position himself so that he‘s neither being totally domineering, he‘s not a pushover, and he isn‘t himself domineering. I think this is the issue of the powerful father in Alex‘s past. Alex is this military guy whom people would command to do stuff like bomb places.
I think that the therapist is trying hard not to be on either end of that. He has to allow a certain amount of it. Later, you‘ll see that Alex brings him a coffee machine and insists on installing it and he‘s got all sorts of other controlling things that he does. The therapist kind of plays along, he lets him do some of it, he challenges other things, but he‘s trying hard to be on the side of the action, commenting on it, not just being totally railroaded by it. You‘ll see that he‘s willing to make some interpretations about what he thinks is going on, but also he‘s not letting himself get inducted into, ―Hey, you can‘t tell me what to do! I‘m the boss here. Who‘s the commandant in this administration, this base?‖ In that sense, I think he has a chance with Alex.
ALEXANDER: There was a lot I didn‘t understand in that session: the issue of the presenting problem, and the surprises, and the hidden agendas. So he never said to Alex, ―What is it that you want help with?‖ or ―What is it that brings you here?‖ or ―What made you pick up the phone?‖ – You know, any of the usual questions.
NIELSEN: In some ways, that‘s a problem because at the end of the session, you get a sense of what Alex‘s agenda was.
ALEXANDER: Right!
NIELSEN: I think Alex‘s manifest agenda is to get the therapist to agree that it‘s a good idea for him to go to visit the scene of the crime, so to speak. That‘s his goal. He actually goes so far, even though the therapist does not agree that that‘s a good plan, and had questioned it, he goes ahead and he locates the responsibility for that decision in the therapist!
There‘s this great parallel with Paul‘s therapist later. One of the things that comes out in his so-called ―therapy‖ with Gina is that in one session, his agenda isn‘t clear. She‘s focusing very hard on his agenda, which is to get her to agree that it‘s ok for him to sleep with a patient and his idea is that he‘s going to interrogate her and if she can‘t come up with a reason why not to -- he knows that she‘s a tough critic -- then he‘s going to go ahead with it. So he has this hidden agenda, just like Alex does.
I think the reason that it worked for me and I didn‘t find myself wondering why doesn‘t he ask that question is partly because Alex tells him the history leading up to coming to see him. I think it was recommended by the people on his military base who put him on leave after he had this heart attack, which Alex does tell us about. He gives us so much information that in a way, as an analytic listener, you‘re coming up with your own
29 formulation about why the person is there, and it may be a better one than the patient thinks of. Even though you want to get the patient as ―customer,‖ you know, you want to hear their manifest reason, the beauty of the show is that you‘re also hearing all these other themes below the surface as to what might be other reasons why Alex is coming for therapy.
There are people who debate how much history you should take from people, and the reason the people who say, ―Nah, you don‘t need to take much,‖ is basically that they think it will emerge anyway, it will come out. I want to have a general sense of the territory so I would take more of the history, I think, than Paul does with this guy, maybe not in the first session. But what they have in mind is actually the idea that patients aren‘t necessarily good at telling you why they‘re there.
Drew Westin is a famous analytic researcher and he‘s got a couple papers where he takes some of these paper and pencil personality tests to task with the idea that they‘re expecting too much of patients. They‘re expecting patients to be able to answer what they‘re like, when really, that‘s not the way analytic therapists operate. We operate on a basis that we experience the person, we hear what they‘re saying, we see what they do and then we come up with our own ideas about how they defend themselves and what their big issues are.
If you just ask many patients straight out, ―Why do you work so hard at your job?‖ or ―What are you so afraid of in relationships?‖ if you ask them that stuff straight, the answer they would come up with might not be particularly revealing. So this is more like Alex, with this tremendous pressure to get stuff off his chest, which is, I think actually, another of his agendas -- the therapist goes along with it. Judging from the fact that the patient keeps coming, it‘s not such a bad way to start.
ALEXANDER: I was bothered by Paul‘s assumption that Alex would have guilt about this. Well, I mean it would seem obvious that he would, but it bothered me…
NIELSEN: That he thought that was the main thing?
ALEXANDER: Yes, that he moved in with that so fast.
NIELSEN: You know it‘s been a while since I saw it. I think there is evidence that that is a strong theme and let me tell you what it is. I can‘t remember exactly when he tried that out on Alex, and Alex definitely disagreed with him.
ALEXANDER: It was right away.
NIELSEN: Yes, so it was right early in the session.
ALEXANDER: Yes it was very early in the session.
NIELSEN: This gets to a separate issues from the therapeutic alliance: how do you
30 judge data, or the validity of interpretations, or the validity of a particular motivational system? I teach a course at the Institute for Psychoanalysis on this topic so I guess I‘m reacting to it.
Freud said there was this criticism of psychoanalysis that if you make an interpretation and the patient agrees with you then you‘re right, and if they disagree with you, you‘re right because they disagreed with you. He actually quotes it in English, ―Heads I win, tails you lose.‖ Now that actually isn‘t right but there are certain ways in which, when people disagree, analysts actually think that their initial hypothesis is more confirmed than not. I think that Alex tells about this bombing and then he protests so much that he‘s not responsible. ―After all,‖ he says, ―This was a mission and I did the mission.‖ He goes on and on about this. One has a sense of, ―Well, if he doesn‘t feel guilty why is he going on and on about it?‖ And of course, later in the session we go, ―Why is he going back there?‖ What is he trying to check out?‖
Actually, Paul has another idea, which is not just that he feels guilty, but the possibility is that he wants to atone or punish himself, and the data for that, again, is not in what the patient said, but in the idea that he knows that it‘s a very a dangerous thing, and his face has been in the papers – your earlier comment alluded to that - and he is worried, so that it would be a realistic thing to go to this place and then come to some violence against him. The other data for the guilt has to do with his dad, but some of this we don‘t know until later.
There are two other things that have to do with the guilt. One of them is that he says, in a very revealing way, that the death of his mother was the most traumatic event of his life, so we wonder a lot about that. That comes out. What he said next was that he was distressed that his father remarried so soon, seemingly without much sense of loss. So you get a sense that there was this death, like the bombing victims, and then there‘s this guy who doesn‘t seem to react very much to it, and if anything, it distresses Alex. So there‘s this pattern, again, of something bad happened and shouldn‘t somebody feel a little bit worse about it?
Later we hear this tremendously emotional event where the father was in the house surrounded by the KKK, and they‘re all hiding down in the basement worrying that these people are going to somehow burn their house down or come in and find them. During that time, their grandfather apparently had, I‘ve forgotten what exactly he had, I think he had some sort of lung disease and he‘s coughing or whatever, asthma, and the father is trying to keep him quiet and puts his hand over the grandfather‘s face, and as a result of this stifling the grandfather‘s breathing, the grandfather dies. So it‘s not just that, but the father then is manifestly a lot like Alex, saying that he doesn‘t feel guilty about this. He doesn‘t feel guilty. Again, it‘s like a wartime experience, right? The Klan is there and so he‘s not feeling guilty. He says, ―Only white people are entitled to feel guilt. I don‘t feel any guilt; it was the KKK guys.‖ But this whole theme of a person doing things, not feeling good about them, and then denying the guilt is -- I mean clearly again, this is fiction so you may not be convinced. We won‘t do the fast forward but I can tell you that there is even more evidence for this interpretation.
31 The other one that came out in the session that‘s really interesting is that Alex relates this incident of running with his friend, with his gay friend, and you get a sense of hyper- masculinity defended. You know, he‘s got to always be tough, the tough guy, so he‘s running with this guy whom he normally ran with and Alex pushes it. Even though he‘s feeling really tired, he ignores his pain, which is what Alex does. He ignores his emotional pain, he‘s on the move, he‘s this action-oriented guy. He‘s running and he causes himself to have a heart attack. He runs beyond what he should have done and has a heart attack.
Now, one could wonder at that point whether this is, again, an expression of unconscious guilt, that he had some sense that this would be the outcome, that he‘s punishing himself. Probably it‘s both. The other possibility is that he just is having to prove himself, this hyper-masculine guy, maybe again, as it relates to this incident where he felt guilty or he felt like he screwed up. I think that‘s further evidence that he has potential guilt around the bombing and the session ends with him wanting to go back there.
I think the other interesting thing is how this session, like so many of the sessions in ―In Treatment‖ shows, again, one of the great principles of this kind of therapy: when patients are talking about something outside the therapy, it can be seen as an allusion to what‘s going on in the therapy, or just as parallel, or as similar. It has a similar pattern or format. I think that Alex in this session is running faster than the therapist wants to. It‘s the same sort of hyper-intense, hyper-masculine, pull out the stops, we‘re going to go off to wherever that bombing was, and the therapist is sort of along for the ride.
I found that again, it‘s very typical. It helps you make a diagnosis of this person, separate from if you just asked them, ―Why are you here?‖ You‘d say, ―Well, he‘s showing you. He‘s showing you. This is the kind of guy he is. He‘s busy running.‖
Later we find out about his marriage. It has a similar pattern to it where his wife is a high achiever and they don‘t really ever talk about feelings, like with his dad, and he doesn‘t much have time for that side of life.
Remember Sterba said, ―The people are doing it with the therapist,‖ but then, a la Greenson and Zetzel, can they reflect on it? That is really the challenge for the therapist with Alex: can he be brought to question, to interrogate himself and wonder about himself, rather than just be madly on the move?
ALEXANDER: Dr. Nielsen, we‘re getting close to being out of time and there‘s just so much wonderful stuff to talk about, as you said, ―Very multi-layered,‖ and I hope this gives the listeners an idea about how much depth and how much material can be presented in a first session, how much you can really know about a person, even when they‘re trying not to tell you.
NIELSEN: Yes. that‘s very well put.
ALEXANDER: So is there anything else you‘d like to add before we close?
32 NIELSEN: Well I think that the listener, if they haven‘t watched the series, they should go watch it because the other patients are terrific. There‘s Sophie, who is this adolescent gymnast who, interestingly, may also have enacted a guilty wish to hurt herself. We had a couple debating whether to stay married and whether to have a kid. We have Laura with the erotic transference and his countertransference, and then his own therapy, and just a wealth of interesting stuff. I hope we‘ve peaked their interest, not just in the therapeutic alliance but in this show, and how deep it is.
Actually, I now know one thing I wanted to say before I stop. I had some thoughts about Paul‘s interventions across sessions and how that works in terms of the therapeutic alliance. The main thing is that contrary to some of the possibilities that one could do to build an alliance, the main way he does it with these really action-oriented people is he survives their attacks and he isn‘t defensive and he meets them, I think, with what is a kind of admirable, firm ―curiosity,‖ is a word I would use to describe it. It‘s what Russ Schaeffer called ―the analytic attitude,‖ but in him, it‘s a kind of a soft toughness. He‘s hanging in, he doesn‘t respond much to the provocations. He keeps his eye on the ball in terms of looking at what they‘re really suffering, what the deeper issues are. He avoids giving negative judgments or simple sympathy or simplistic suggestions, so that‘s how he does it mostly in these sessions.
The other thing that he does is he makes interpretations of unconscious motivation. I think when he does this, to my ear, he‘s a little too much, ―Gotcha,‖ when he makes these comments, rather than conveying the idea that he does in his other interventions that, ―This is going to be helpful,‖ that his uncovering of unconscious material would be of great value for people, rather than that they‘re going to reject it. Of course, his patients are busy rejecting it so it‘s an uphill battle for him, but this sort of ―Gotcha‖ attitude is very similar -- listeners who watch the supervision with his therapist or his supervisor will see that she does that too. This was, I think, the prototypical analyst of the fifties, or the classical analyst who would sort of sit and wait and then zap you with some deep interpretation of your unconscious mind, rather than using you as a collaborator. I think that‘s another mistake that did not foster the therapeutic alliance. What it tended to foster was its overly dependent or compliant patient, or one who just plain got angry and quit, rather than a real collaborator.
Paul is a little too much like that, but generally speaking, he‘s pretty good. The glaring exception is the therapy with Laura where he‘s so caught in it, but with Alex he does some good stuff, and we‘ll let people watch it for themselves.
ALEXANDER: Let me just add one more thing: I was so startled at what a different person he was when he was seeing his own therapist. I really liked him as a therapist, and really did not like him as a person.
NIELSEN: Yes, I think everybody that watches this, one of their questions is, ―How can he be so screwed up as a person and so good as a therapist?‖ Of course, partly he actually isn‘t that good as a therapist at times, especially with Laura, but he has compartmentalized it. There are therapists who are capable of loving their work and their
33 patients and putting themselves in the background in their offices, better than they are in their life. If anything, maybe because he‘s so devoted as a therapist, it may mean that he‘s neglecting his own needs for intimacy and connection outside the office. I mean, his office is in his home and later he‘s actually sleeping in his office and it‘s sort of like you get the sense that he lives in his office.
The specifics of why this guy is unlikable when he goes to see Gina, we can get into them, but there‘s a way in which he is too much ―the therapist‖ to the exclusion of other stuff, and then that creates a number of the problems that you see when he is with Gina. It‘s very unclear what she is. She was the supervisor. I think she may have also been a therapist, and in the next season, she‘s now a therapist for him, but I think the quality of the sessions is that mainly, for him, they are kind of his personal therapy.
But I‘d agree with you. I think he‘s singularly blind to stuff and very defended, and I guess again, he gets into the category -- there‘s a whole list of therapists in movies who are more screwed up than their patients, and he almost gets there. Even though we, as therapists are rooting for him and like him -- many of his interventions are really good – but I think it may be that the public also wants to see therapists with feet of clay
ALEXANDER: Well, Dr. Nielsen, thank you so much for this interview and this time. It was fun, it was great fun.
NIELSEN: Thank you, Barbara. It was a lot of fun for me. You asked great questions and it was a great occasion to think about the thing in greater depth.
This concludes our interview with Dr. Arthur Nielsen. We hope you learned from this interview and that you enjoyed it. You may contact Dr. Nielsen at (312) 649-0579; Email: [email protected]
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
34 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Attachment-Oriented Psychotherapy”
DAVID J. WALLIN, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
DAVID J. WALLIN, Ph.D. 902 Curtis Street Albany, CA 94706 Tel: (510) 527-6048 Email: [email protected] http://www.davidjwallin.com Author of Attachment in Psychotherapy
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #3 in our program on The Therapeutic Relationship.
Perhaps the most significant development in contemporary psychoanalytic thought has been attachment theory. John Bowlby is considered ―the father‖ of attachment theory. His work began in the late 1940s, when he was studying the impact of separations on post World War 2 children in England. His core contribution was to recognize that ―the attachment behavioral system‖ in humans is inborn and instinctive. Further, he came to believe that the manifestations of the biologically driven need to attach are significant across the entire lifespan, that the ongoing, everyday interactions of children and their parents shape psychological development.
Our next speaker, Dr. David Wallin, translates attachment theory and research into a framework that integrates key attachment principles with psychopathology, with neuroscience, with relational and intersubjective psychotherapeutic approaches, with mentalization, and with mindfulness. In his thinking, patients in psychotherapy change and find a kind of healing potential in a relationship at a time specifically when they feel frightened, or in psychological or emotional pain.
Just as infants are primed to turn to parents for help, Dr. Wallin thinks there‘s a way in which patients are primed to turn to therapists for help. For him, the implication of this for psychotherapy is that because so much of our experience is shaped by influences that occur very early in life prior to the acquisition of language, in order for therapists to get
35 to the emotional core of their patients‘ experience, they need to get beneath their patients‘ words. So, the techniques that have been developed by Relational and Intersubjective therapists can be very, very useful because they get to the nonverbal dimension of experience.
David Wallin, Ph.D. is a clinical psychologist in private practice in Albany, CA and Mill Valley, CA. A magna cum laude graduate of Harvard College who received his doctorate from the Wright Institute, he has been practicing, teaching and writing about psychotherapy for nearly three decades. He is the author of Attachment in Psychotherapy (Guilford, 2007) and coauthor (with Stephen Goldbart) of Mapping the Terrain of the Heart: Passion, Tenderness, and the Capacity to Love (Jason Aronson, 1996). He has lectured on attachment and psychotherapy throughout the United States and taught for The Wright Institute, the Northern California Society for Psychoanalytic Psychology, and the extension programs of the University of California and the California School of Professional Psychology.
ALEXANDER: Dr. Wallin, I‘d like to begin by asking you the sixty-four million dollar question, which is: in your thinking, and in your scholarship and everything you‘ve done, what is ―therapeutic‖ in the therapeutic relationship? I‘d like to begin with this and by telling how really impressed I was with how you reported on attachment theory and how you put it together with intersubjectivity.
WALLIN: Right, that‘s what I described in the book as, ―A conceptual marriage made in heaven between Attachment Theory and Intersubjectivity Theory. I think each theory, in a sense, completes the other, but maybe that‘s something we can talk about more as we move along here.
ALEXANDER: Alright.
WALLIN: But you know, in regard to the question, ―What‘s therapeutic about the therapeutic relationship?‖ for me, a big part of that goes back to the whole idea of attachment, which is a very, very specific idea. In Bowlby‘s thinking, we‘re designed by evolution to attach, that is to turn to what Bowlby called ―stronger and/or wiser others‖ when we feel in pain, when we feel frightened, when we experience ourselves in situations of danger. So the idea is that patients in psychotherapy change, find a kind of healing potential in a relationship at a time specifically when they feel frightened, or in psychological or emotional pain. There‘s a way in which we‘re programmed by evolution to turn to stronger and/or wiser others, like therapists, for comfort, for support, for reassurance. There‘s a way in which the psychotherapy relationship is one that we are primed for. Just as infants are primed to turn to parents for help, I think there‘s a way in which patients are primed to turn to therapists for help.
I think a number of things happen in the context of that helping relationship. There‘s a way in which, when we are in need of help, we are opened up, as it were, to the influence of the other. A big part of the influence and the helpful or healing impact of the
36 relationship of the ―therapeutic other,‖ just as is true of the ―parenting other,‖ has to do with the way in which the parent or the therapist, the stronger and/or wiser other, is hopefully capable of helping the developmentally disadvantaged individual: the infant, the small child, or the patient in trouble, helping the developmentally disadvantaged individual to manage, to contend more effectively with difficult emotional experience.
The parent helps the baby manage what would be for the baby impossibly difficult emotional experiences of need, of anxiety, of hunger, of anger. I think the therapist, a good therapist, helps patients manage, helps them to tolerate, helps them to bear difficult emotional experience. I think experience that can be borne, experience that can be tolerated with help of the therapist in psychotherapy, is often experience that the person has had no help, or very inadequate help, managing when he or she was originally developing in the relationship with the parent. So when the therapist in the therapeutic relationship helps the patient to bear difficult feelings, it‘s often the case that not only are those difficult feelings being managed, being tolerated, being regulated in the moment, but additionally, what‘s happening is that old, unfinished, psychological business, experience that may have had to be defensively disowned or dissociated, is being tolerated and then, in the process, is beginning to be integrated. So I think the therapeutic relationship is therapeutic to the extent that it helps patients to manage difficult feelings. Managing and accessing difficult feelings, I think, can be a pre-condition for integrating old, unfinished, dissociated experiences from the past, basically.
ALEXANDER: Let‘s talk about the things that can go awry in early childhood with the, a brief review of the attachment styles as described by Bowlby, and Main, and Ainsworth.
WALLIN: Ok. You know, I said a second ago that the therapeutic relationship heals in a couple of different ways, helps people manage difficult feelings, helps them integrate previously dissociated experience. An additional piece of that, which ties into this question about attachment styles and security and insecurity and so forth, is that the parent, or the therapist for that matter, who is successful at helping infants or later helping patients to manage difficult feelings, to put it in a sort of fanciful way, is the parent who can read the baby‘s mind, or the therapist who can read the patient‘s mind. In other words, this is the parent or the therapist who can see beneath the surface of the patient‘s behavior to get at what underlies that behavior: what are the feelings, the beliefs, the desires that are the context for the baby‘s behavior, the baby‘s tantrum, the patient‘s behavior? An example of this would be the patient staying a million miles away from his or her feelings.
So I think that the varieties of security and insecurity that Bowlby and Ainsworth, his student and colleague, and Mary Main, who was Ainsworth‘s student and then later colleague are basically variations on the theme of how successful is the parent, or later, how successful is the therapist is in, you might say, ―reading the baby‘s mind?‖ in other words, the parent who can foster security.
By the way, Ainsworth and Bowlby talked about security, on one hand, as a kind of
37 balanced capacity to depend, to find security, to find comfort in the consolation of closeness, and on the other hand, the ability to explore, to function autonomously. That balance between attachment and exploration is the hallmark of security.
Parents who are able to engender security in their babies and in their small children are parents who are able, again I‘ll use that colloquial expression, ―to read the baby‘s mind,‖ to know, for example, that the baby is having a tantrum not because the baby is just obnoxious or difficult or presenting the parent with a task, but maybe because the baby is cold or is hungry, or the baby needs his diaper changed, or whatever. In other words, the parent sees what‘s motivating the baby. The parent see beneath the surface and that gives the parent the information to make decisions about whether to pick up and hold the baby, to comfort the baby, to change the baby, to feed the baby, or just to let the baby play, or to put down the baby who‘s being held and let that baby play. That‘s what allows the baby to develop this balanced capacity for attachment and exploration.
In normal populations that have been studied, something like fifty-five, sixty percent or a little more of babies are ―secure.‖ But Ainsworth, who‘s seen sometimes as the one who validated Bowlby‘s theories through her research, discovered two varieties of insecure attachment which she called ―avoidant attachment‖ and ―ambivalent attachment.‖
Avoidant attachment involves babies with a skew away from attachment and toward exploration. Rather than seek out the comfort of a connection to the parent when they feel badly, these are babies who actually avoid the parent, try to absorb themselves in activities, in play. They try to distract themselves. These are babies who not only avoid the mother, but who tend to avoid their own internal experience because paying attention to their internal experience is going to have them seeking the consolation of connection with mother. So these avoidant babies avoid others in their sense in which they avoid themselves; they avoid their own internal experience.
The other variation on this theme of insecurity is ambivalent babies, who, rather than tuning out the signals from inside and turning away from mother, seem to tune in so much to the emotional and physical whereabouts of mother, tune in so much to their own signals of distress that they have a very difficult time exploring or playing; they‘re preoccupied with attachment.
The shorthand here would be to say that secure babies have parents who are predictably responsive. Avoidant babies, with that skew away from attachment and toward exploration, have parents who are predictably unresponsive, and ambivalent babies, who‘ve got the skew away from exploration towards attachment, are babies who have parents who are unpredictably responsive.
The idea is that secure babies hue to the biologically ingrained, genetically programmed strategy which is to turn to stronger and/or wiser others when you‘re freaked out. The avoidant babies have a de-activating strategy. They tune out the signals that would have them seeking connection to attachment figures, and the ambivalent babies have a hyper- activating strategy, so they‘re acutely vigilant for external and internal cues that might
38 have them seeking connection to attachment figures.
So there‘s secure attachment, there‘s avoidant attachment, ambivalent attachment, and finally Mary Main and her colleagues discovered a fourth category of infant attachment which was described as disorganized, or disoriented attachment. The biologically engrained strategy: turn to others when you‘re freaked out -- that‘s an organized strategy. Avoid others when you‘re freaked out, that‘s an organized strategy, making the best of a not so good situation. Hyperactivate the attachment behavioral system so you‘re making a big emotional noise to heighten the probability that you‘re going to get the attention of the unpredictably responsive attachment figure, that‘s an organized strategy.
But what Main discovered is that kids who have parents who are not merely unresponsive, or unpredictably responsive, or unpredictably sensitive, but babies who have parents who are actually frightening to them, maybe because the parents are abusive or whatever, are babies who lack, much of the time anyway, an organized attachment strategy. Instead what you see is disorganization. When these kids are freaked out, rather than turning to the attachment figure or avoiding the attachment figure, or making a big emotional noise to get the attachment figure‘s attention, instead what we see in these babies is a collapse of an organized strategy. These are babies who, when they feel freaked out, might space out, or they might freeze in place, or they might just kind of collapse to the floor.
What Main and her colleagues observed was that these disorganized infants displayed behavior which was bizarre, or incomprehensible, or contradictory. The contradiction in the behavior makes sense if you understand that these are babies who, like all of us, are designed by evolution to approach attachment figures when they feel in danger, but these are babies for whom the frightening parents are themselves frequently the source of danger. These are babies who‘ve been placed in a kind of untenable situation. It‘s a biological paradox; a situation without solution where they are programmed by evolution to approach the safe-haven of the parent, but the parent is anything but safe. The parent is the source of danger so they‘re inclined to avoid, so that approach/avoidance dilemma may have them freezing or dissociating or collapsing. Those are the four varieties of security, insecurity, of attachment in infancy.
Main discovered four corresponding states of mind with respect to attachment in adults What was very, very striking was that adults who are secure tend to raise secure babies; maybe this isn‘t very surprising. Adults who themselves have an avoidant style or what Mary Main calls ―a dismissing style‖ raise and they also resemble avoidant infants. Parents who are preoccupied with their own attachment experiences tend to raise ambivalent infants who are preoccupied with attachment. Finally parents who are unresolved with respect to their own experiences of trauma behave in such a way with their kids that their kids wind up with this kind of disorganized attachment style that I was describing a moment ago.
ALEXANDER: In your book, you made some links or parallels between the attachment styles and different kinds of personality disorders. Can you review those for us?
39
WALLIN: Yes. In a nutshell, you might say that the de-activating strategy, the avoidant strategy which involves a kind of remoteness from other people and a remoteness from oneself, a remoteness from one‘s own internal experience -- I think that way of being in the world is one that I associate with a continuum of conventional diagnostic categories. I‘m thinking about a continuum where, at the healthy end you might find obsessives, at the very problematic end, schizoid personalities, and narcissists in between, because these are all folks who tune out the internal world of feelings, and tend to maintain a certain distance from other people.
Then there‘s a second continuum which I associate with the hyper-activating style of the preoccupied adult, or the ambivalent infant. These are adults who are gripped by very, very, very strong emotions and who can seem to be hyper-dependent rather than counter- dependent. These preoccupied adults, for whom the prototype, you might say, is the ambivalent infant, can be seen to fall in a continuum where at the healthy end are hysterics, at the more problematic end are borderlines, because again, hysterics and borderlines have in common: A) a tendency to be gripped or overwhelmed by strong feelings, and B) a tendency to be very, very preoccupied with the emotional whereabouts of other people. Specifically, they are preoccupied with the threat of abandonment by other people.
I guess the last thing I would say is that the disorganized infant and the adult equivalent, the disorganized adult unresolved with respect to trauma, are adults who have diagnoses that are often associated with histories of trauma, so these are diagnoses of PTSD, borderline personality disorder, possibly major depression.
ALEXANDER: It‘s so sad to think of tiny babies and tiny small children already so affected by and shaped by these early experiences that later in life they repeat them over and over again.
WALLIN: Yes. I understand what you‘re saying, however, what I would want to emphasize is that the experiences we have as infants and small children are not a life sentence. I think on the one hand, it‘s true that our early experiences predispose us to a certain trajectory in life. Early experiences of security make it more likely that we‘re going to experience security as adults and be able to raise secure children.
On the other hand, experiences of insecurity or even trauma and disorganization in infancy -- you could look at them as ―risk factors,‖ but they don‘t necessarily mean that we‘re going to be entrenched for life in the most serious kinds of psychopathology. These early problematic experiences are risk factors. That‘s the best way to look at them, and I think those risk factors can be trumped by the development of skills which Mary Main talked about in terms of things like meta-cognition: the ability to think about our thinking; or ―mentalizing,‖ which Peter Fonagy talks about: our ability to take a step back from our experience in order to make sense of it in terms of underlying mental states.
40 I think those capacities for meta-cognition, mentalizing, or reflection, to put it a little more colloquially, are capacities that tend to inoculate us from the worst impacts of childhood trauma. Even the most horrendous experiences early in our lives can be -- we have the potential to transcend those experiences. Largely what allows us to transcend them are our relationships, whether these are marriages, or therapy relationships, in which we experience some of the sensitive responsiveness that our original caregivers may not have been able to provide for us.
ALEXANDER: How much is temperament a factor and also the match, the temperamental fit between parent and child?
WALLIN: That‘s a really interesting question because it‘s one to which the research provides some, well, you might say, ―counter-intuitive‖ sort of answers. The attachment research, strangely, because this flies in the face common sense understanding of these matters, suggests that when it comes to determining security and insecurity, the temperament of the child is not highly significant. The evidence for this includes things like the fact that a baby who at three months is assessed to have an easy temperament, if that baby has difficult experiences with the parents, then by nine months, that baby can be assessed to have a difficult temperament. The reverse is also true: you‘ve got a baby with a difficult temperament at three months but then the parents learn some parenting skills or whatever, then that baby, at nine months, may be assessed to have an easy temperament. So the impacts of temperament seem to be, in some ways, subservient to the impact of experience, of parenting. The attachment research would suggest that nurture can trump nature!
On the other hand, what you‘re saying about ―fit‖ -- it seems to me just intuitively that it has to be true that because of the fact that their temperaments somehow fit with those of the parents, some infants are going to make it easier for that parent to provide a secure relationship of attachment for that child, whereas if there‘s a mismatch of temperaments, it feels to me like there‘s going to be a relationship in which it‘s going to be more difficult to provide the sort of sensitive responsiveness that results in security.
ALEXANDER: Thank you for answering that question. It‘s been on my mind and perhaps also on the mind of our listeners.
I‘d like to move to the subject of therapy now and, with teeth gritted, to approach the subject of Intersubjectivity. I grit my teeth about it because it‘s a lot of words to explain something that shouldn‘t need so many words, and I‘m hoping you can….
WALLIN: … boil it down, or make it accessible. So you‘re thinking specifically about the relationship between what‘s called ―Intersubjectivity,‖ on the one hand, and ―attachment‖ on the other.
ALEXANDER: Right, and how therapists can use attachment theory in their work. If you would explain to us the shift. I‘ve done this in other interviews, but it bears repeating over and over again to undo -- perhaps for the newer people in the field, it‘s
41 more obvious than for those of us who had it kind of ―trained‖ out of us.
WALLIN: Yes, I think I know where you‘re going with this question. There was, for many years, the idea among psychotherapists, which I think probably had its origins in Freud‘s personality and certainly in Freud‘s theory of therapy, that the therapist could and should remain ―neutral,‖ that the therapist could and should somehow eliminate the impact of his or her own subjectivity, the impact of his or her own personality on the therapeutic relationship and on the patient. The idea was that the therapist could subtract, somehow, the influence of his or her personality in order to provide a kind of objective, neutral response. This had its most extreme expression in the notion that the therapist should be ―a blank screen‖ upon whom the patient‘s wishes, hopes, fantasies, could be projected.
What‘s come to be understood in the last twenty or thirty years is that that whole notion is very misguided, that A) it‘s probably impossible for us to subtract the influence of our own subjectivity; and B) it‘s probably undesirable for us to attempt to subtract the impact of our own subjectivity for a whole variety of reasons.
In theories that have come to be called ―Intersubjective,‖ or ―Relational‖ theories of psychotherapy, both the impossibility and the undesirability of this effort to make ourselves invisible are highlighted. It‘s proposed in this re-thinking of the therapeutic relationship that it‘s undesirable to attempt the impossible and that there‘s no way -- I mean if you think about the attachment research which highlights the importance of the parents‘ ability to read the baby‘s nonverbal cues, which by implication highlights the importance of the therapist‘s ability to read the patient‘s non-verbal cues -- well, part of what that research really hints at is the way in which human beings are constantly reading and responding to each others‘ nonverbal cues.
So part of the re-thinking in the Relational and Intersubjective approaches of this whole matter of neutrality and anonymity has to do with the idea that patients and therapists alike are constantly reading nonverbal cues, making and drawing conscious and unconscious conclusions about the meaning of other peoples‘ behavior. This is nonverbal behavior or para-verbal behavior that‘s expressed in things like tone of voice, facial expression, body language, and so forth.
So the idea here is that a big part of what patients learn about their therapist is not communicated in their therapist‘s words alone. Similarly, what therapists learn about patients is not learned exclusively or even primarily from what our patients tell us in words. What gets understood is based largely on what other people show us nonverbally, not necessarily what they tell us in words.
The implication of this for psychotherapy is, as I‘ve been suggesting earlier in this interview, that because so much of our experience is shaped by influences that occur very early in life prior to the acquisition of language, if therapists are going to get to the emotional core of their patients‘ experience, they need to get beneath their patients‘ words. The techniques that have been developed by Relational and Intersubjective
42 therapists can be very, very useful because they get to the nonverbal dimension of experience.
This is also often the realm of dissociated experience: what we have not been able to integrate; what we‘ve not been able to own as part of ourselves. That stuff doesn‘t generally get expressed verbally but it can get expressed nonverbally, and the formula that I‘ve suggested is this: what patients and therapists and what all human beings can‘t put into words, we tend to evoke in others, we tend to enact with others, or we tend to embody. So the techniques of working with transference and countertransference that have been elaborated by Relational and Intersubjective thinkers have a very, very big place in an attachment-oriented psychotherapy, which is largely a therapy oriented around what happens in the relationship, a therapy oriented around getting at nonverbal experience as well as making sense of what people are able to put into words.
Paying attention to what‘s evoked, enacted, and embodied means, in practice, that therapists need to tune in to their own subjective experience as we sit with our patients. What do we find ourselves feeling, what do we find ourselves imagining, what do we find ourselves thinking, what are we experiencing subjectively as we sit with our patients?
The idea there is that much of what our patients can‘t put into words, they nonetheless will communicate, want to communicate, often, and they will do it by evoking in us what they can‘t tolerate in themselves. So we need to pay attention to what‘s evoked in us. We also need to pay attention to what we enact with our patients because the idea here is that often, what can‘t be expressed verbally will nonetheless be played out in the form of what have been called, ―transference/countertransference enactments.‖ These are the sort of ongoing scenarios, mini-dramas that are played out between patients and therapists. These are enactments that might involve issues of control, issues of desire, issues of connection, disconnection, so we need to be paying attention to what are we doing with our patients, what are we enacting with our patients, what are our patients doing with us.
Finally, the notion of ―embodiment‖ has to do with the fact that the body remembers. We can think in terms of the body as a kind of text, a text without words that can, nonetheless, be read like any other text. We need to pay attention to and enquire about what‘s going on in the patient‘s body and what‘s going on in our own bodies.
One of the things that we‘ve learned from neuroscience researchers is that all of us have in our brains a so-called ―mirror neuron system.‖ They are brain cells which essentially simulate in our own experience the experience we observe in other people. To put it in shorthand, you might say, ―We become what we behold.‖ Therapists simulate, not only in their own brains, but in their bodies and on their faces, the experiences that they observe on their patients‘ faces. Through the mirror neuron system, they resonate with what‘s going on in the internal world of the person that they‘re observing. The idea here is that we need to pay attention not only to the patient‘s body, but what‘s going on in our body because our body is going to be resonating in some ways with the often unspoken, but nonetheless emotionally experienced feelings of the patient.
43 ALEXANDER: Dr. Wallin, I was going to ask if we can have some clinical examples of this in the time that we have left. One situation that I was thinking about in particular, and you had an example in your book, was the therapist getting sleepy, and I think for many therapists that that‘s a real fear, that, ―Oh my God, I‘m going to fall asleep in this interview, this patient is just…‖ So if you could…
WALLIN: Let me give you an example. I think this is an experience I had which I write about in the book; I‘ve certainly talked about it in a lot of teaching. I became aware with one patient in particular that I was talking very loudly and talking very fast. When I asked myself what was the motivation, what was going on inside me talking so loudly and so quickly, what I became aware of was that I was trying to keep from falling asleep It was if I were aware that if I didn‘t stimulate myself through a lot of loud, fast talking, I might very well fall asleep.
So as I‘m sitting there with the patient and becoming aware of this, I‘m trying to make sense of it, but as is often the case, I think it‘s hard to make sense of our own experience without, you might say, ―consulting the patient.‖ Ideally, it seems to me, at times you might have, let‘s say, ―a conversation‖ with the patient, the focus of which is the conversation between the patient and the therapist. So we‘re having a conversation where I‘m speaking very loud and very fast, and I‘m trying to make sense of it, so what I said to the patient was, ―You know, I‘ve just become aware of the fact that I‘ve been talking very, very loudly and very quickly and I have a sense of what that might be about, and I‘m not sure if this has to do entirely with me or maybe it has something to do with you, or maybe it has to do with what‘s going on between the two of us, but I think maybe I‘m talking so loudly and so quickly to stimulate myself because if I don‘t, I have a sense I might start getting a little drowsy.‖
So the patient said to me, ―You‘ve not only been talking really loud and really fast, you‘ve been determining what we talk about, and I‘m aware that your chair is much too close to me for comfort and I don‘t like it.‖
Then the patient went on to say that he thought that he was himself -- and this helped him understand why I was getting drowsy -- he was himself aware of getting a little drowsy. What he had come to understand about himself was that he tended to ―space out,‖ or in the clinical language, he tended to dissociate when he was upset. So he was getting upset with me for talking so loudly and talking so much, and controlling the conversation, and sitting too close. He was getting upset with me and the way that he was dealing with that was by getting drowsy, by dissociating.
This part of our conversation opened up a whole vital area of the therapy which had to do with his difficulty establishing boundaries, his difficulty managing strong, so-called ―negative‖ feelings, like anger -- he was angry at me but didn‘t quite know how to express that or deal with that -- and in fact, it opened up an even more subtle area which was: how could he stay connected to his own thoughts while also being open to the thoughts of another person? Anyway, that‘s an example, I think, that illustrates how this therapist, in particular, used an attention to what was being evoked and enacted in order
44 to open up an area of therapeutic exploration with the patient.
ALEXANDER: That‘s a great example. What about an opposite reaction, an opposite experience with an opposite kind of person? So you would say that would have been perhaps a person who had an avoidant kind of attachment style?
WALLIN: Yes, very precisely, that tendency to dissociate, to ―turn down the volume‖ on internal experience, that‘s the de-activating attachment style that we associate with avoidant infants or dismissing adults. So you‘re asking, ―Let‘s have a clinical example in which we illustrate something about the interaction with a preoccupied patient, or an unresolved patient who tends to be flooded with feeling.‖ Is that what you‘re kind of looking for?
ALEXANDER: Exactly.
WALLIN: Here‘s an example. I‘m thinking about a woman patient with whom I had an experience that I think is very, very characteristic of the experience that we often have, certainly not always, but that we often have with patients in a preoccupied state of mind with respect to attachment.
You may remember from what I said earlier in the interview, or from your reading of the book, that ambivalent infants and the adult correlate of ambivalent infants known as ―preoccupied adults‖ are individuals with a hyper-activating attachment strategy, meaning that their emotions can be very strong and also that they can be very, very preoccupied with the emotional whereabouts of other people upon whom they might depend. They can be quite preoccupied with the threat that those other people upon whom they might depend might well abandon them.
These preoccupied individuals often deal with that threat of abandonment -- think of the so-called hysteric patient in psychotherapy who is well known for being melodramatic, sometimes charming, sometimes seductive, and, I would add, often helpless. So I think these sometimes seductive, sometimes charming, sometimes helpless patients, are all patients who are attempting to diminish the threat that they‘re going to be abandoned.
With this particular woman patient whom I mentioned a second ago, I found myself becoming aware that I was tuning into what was my experience as I sat with the patient. The first thing I became aware of was that I felt very, very comfortable. I felt unusually comfortable, I felt unusually good. As I thought about it, what occurred to me was that with this patient, I felt like an exceptionally good therapist and I felt like she was a really good patient. As I thought about that a little bit more, what occurred to me was that she was relating to me in such a way that I had every reason to feel like a really good therapist, whether I was actually functioning as a really good therapist or not, because she was communicating to me that I was very, very helpful, that I meant a lot to her, and she was lucky to have found me. What I realized was that in a way, this apparently very ―good‖ patient, was actually a very, you might say, ―compliant‖ patient, a very admiring patient.
45 So what I said to her during this hour, as I was becoming more and more aware of my experience, I phrased as a question. I said, ―You know, I wonder if you have the sense that part of what you need to do here is to help me feel good, help me feel good about myself, help me feel good about myself as a therapist?‖ That wound up opening up a whole area in which she talked about how a big part of how she conducted herself, in her relationships with men in particular, but a way in which she also conducted herself with both her parents, was to make sure that the other person felt good, felt needed, because to the extent that the other person, whether it was the husband, or her mother, or her father, felt good, felt needed, then that diminished for her the scary sense that maybe she wasn‘t going to be good enough for them, they weren‘t really going to be interested in her. So she had to make herself interesting and she had to make the other person feel good, and that‘s what she was doing with me.
As we clarified that, what it really eventually made room for was more, you might say, of her real feelings: her fears; her fear of being abandoned; her anger about always having to be such a good girl, so pleasing, so charming, so accommodating. It also made room for her gradual awareness of her real needs, her ambitions, what she wanted for herself quite independent of what somebody wanted from her.
ALEXANDER: Great example, Dr. Wallin. I‘m so frustrated that time is ever pressing.
WALLIN: Yes, indeed.
ALEXANDER: So with the few minutes that we have left, is there anything that you‘d like to say before we finish?
WALLIN: Well, I guess maybe what I‘ll say is this: I‘m going to talk for just a moment about a theme that is alluded to in the book, but which I‘ve been developing increasingly since I wrote the book. That theme has to do with the impact of the therapist‘s own attachment history: the therapist‘s own states of mind with respect to attachment on his or her capacity to be helpful as a therapist. This is because increasingly, it has seemed to me that not only is the therapist‘s subjectivity a kind of a constant factor, both productive and unproductive in the therapeutic relationship, but that the therapist‘s history, the therapist‘s personality may well be the most significant factor in determining our capacity to be of help to our patients.
It seems to me that our states of mind, our attachment histories determine so much about how we think. Our relationship to our own feelings, our relationship to our thoughts, our relationship to ourselves, our relationship to other people -- our attachment histories are so enormously influential that they may in some way -- I mean, this is something that I‘d have to go on for quite sometime about, but I‘ll just give you the headlines. It seems to me that our states of mind with respect to attachment are both our greatest resource when it comes to understanding our patient, and potentially the greatest source of impasses in our work with our patients.
So more and more, I am more impressed with paying attention to in myself and
46 counseling other therapists to pay attention to the impact of their own attachment histories, their own states of mind with respect to attachment on the work they do with their patients.
ALEXANDER: We have to come back to this as you develop your thinking about it.
WALLIN: I‘d be happy to, I‘d be happy to.
ALEXANDER: Great. Dr. Wallin, I‘m very happy with this interview and this conversation and I‘m going to just have to say, ―To be continued…‖
WALLIN: Ok, I‘ve enjoyed it. Thanks, Barbara.
This concludes our interview with Dr. David Wallin. We hope you learned from this interview and that you enjoyed it. You may contact Dr. Wallin at (312) 649-0579; Email: [email protected]. His book, Attachment in Psychotherapy, may be purchased from any major book dealer.
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
47 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Self-Psychology and Neuroscience”
JUDITH RUSTIN, LCSW
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
JUDITH RUSTIN, LCSW 26 West 9th Street, Suite 8E New York, NY 10011 Tel: (212) 620-3077 Email: [email protected]
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #4 in our program on ―The Therapeutic Relationship.‖
In her brilliant article ―The Interface of Self Psychology, Infant Research, and Neuroscience in Clinical Practice,‖ our next speaker, Judith Rustin, LCSW, writes that infant research and neuroscience add additional ways to understand and interact with patients in the clinical encounter, and offer specificity and nuance to basic self- psychological concepts. Findings from infant research delineate the nature of attunement both in early mother-infant and therapist-patient interactions, while neuroscientific research reveals how early mother-infant experiences are encoded in implicit memory and profoundly impact affects and feelings.
Describing herself as ―a self-psychologically informed analyst who integrates neuroscience and clinical practice,‖ she draws on infant research and memory research. Of particular importance in her work is the concept of ―implicit memory,‖ defined as unspoken aspects of communication and interaction formed in infancy and early childhood. To Ms. Rustin, this is a major contributor to therapeutic action, a powerful tool enabling the therapist to ―know‖ the patient more fully. In her work, she pays particular attention and brings a heightened consciousness to body language, that is, bodily based emotional experiences, as these are pathways for unpacking complex intrapsychic themes.
Judith Rustin, LCSW is a supervisor and training analyst at the Psychoanalytic Psychotherapy Study Center and the Institute for the Psychoanalytic Study of
48 Subjectivity, where she received her Psychoanalytic Certificate. A prolific writer on Intersubjective theory and infant research, her most recent publication, entitled ―The Interface of Self Psychology, Infant Research and Neuroscience,‖ appears in the 2009 edition of Self and Systems, Annals of the New York Academy of Sciences. Most relevant to this interview, her article ―From the Neuroscience of Memory to Psychoanalytic Interaction: Clinical Implications,‖ appears in volume 21 of Psychoanalytic Psychology. In 2009, she presented in Sydney, Australia and Duniden, New Zealand on the subject of ―The Interface of Self Psychology, Infant Research and Neuroscience.‖ She is in private practice in New York City.
ALEXANDER: Ms. Rustin, I‘d like to have you talk to us about how your use of self- psychology has been influenced by what you‘ve been learning from neuroscience and infant research. I realize it‘s a humungous topic so I‘d like to ask you first how it was that you got interested in the more research-y and neuroscience aspects of things?
RUSTIN: Ok. Actually, my interest really stems from a lifelong interest in basically, clinical theory and specifically, in the therapeutic action of clinical theory: what are the things that constitute the engine that facilitates change?
In the first hundred years of psychoanalysis, the pendulum always swung back and forth between: is it the relationship; is it interpretation; is it some combination of the two? But those two basic large concepts were the only shows in town. I certainly always believed it was a combination of both, but that there was a lot more to it, and this was always in the back of my mind as I worked clinically. So I was always asking myself what was that ―more‖ than just relationship and interpretation and some combination of the two?
Towards the end of the Twentieth Century, really specifically somewhere in the 1980s, the findings of infant research slowly, slowly, slowly began to infiltrate some of the clinical theory in psychoanalysis. I personally was profoundly influenced by Daniel Stern‘s book, The Interpersonal World of the Infant. This book came out at the very beginning of 1985, three months after my daughter was born, so I had the opportunity to watch a newborn develop while reading his book.
This changed my thinking radically in terms of how psychic development really proceeds. Certainly what I was both viewing and what came out of his book was that infants come into the world with many capacities: to organize data; to seek out experience; but most importantly, to be active participants in regulating the exchange between himself and the primary caregiver.
When my daughter began school at the age of five, I decided it was time for me to go back to school and learn more about this. I was very specifically interested in the integration of infant research in psychoanalysis and I was very fortunate to find an institute that privileged infant research and at the time was integrating it with Kohut‘s Self Psychology. That really started me on the pathway and I learned the two in tandem. I learned a lot about infant research, the infant-mother exchange, and I also learned about
49 self-psychology.
Kohut‘s view of derailed development was, from his perspective, located in the early caregiver/infant-child bond in which the child‘s need for mirroring and attunement was thwarted and it resulted in structural defects, underlying depression, and narcissistic rage. Kohut located the cure, and the therapeutic action for him was in building new psychic structure and helping the self to consolidate through the interaction between patient and therapist.
ALEXANDER: So in other words, there was a parallel between infant and caregiver and patient and therapist.
RUSTIN: Exactly, exactly. I mean it‘s very important to understand that it‘s not linear. It‘s not a one-to-one linear parallel, but rather, what you‘re looking at is the way two people who have an intimate, important relationship interact with each other. In other words, it‘s really more a theory of interaction in an intimate, important relationship.
ALEXANDER: How would building a greater knowledge of these ideas help a therapist become more excellent? How would it improve the therapeutic work?
RUSTIN: You mean, understanding more about the nature of the interaction?
ALEXANDER: Yes.
RUSTIN: Well, I think the more one can understand the nature of the interaction, the more expanded view one has of the interaction between patient and therapist. In other words, what are its early historical underpinnings? As far as I‘m concerned, it just expands a way of thinking about how somebody developed than why they do or behave or suffer in some of the ways that they do today -- that essentially, the past influences the present.
Of course, Kohut talked about it in terms of a listening stance of empathic immersion: that if you immerse yourself in the patient‘s experience, that would be a way of understanding the intrapsychic emotional logic of the patient‘s defenses, experiences, behavior, etc. This kind of listening stance of really knowing the patient from within not only expands your knowledge but it also sets the stage for the beginning of the reparative emotional experience between the patient and the analyst, or the patient and the therapist because it sets the stage for a repair of what he thought of as derailed development.
ALEXANDER: Can we move to some clinical examples, because you have some very unique ways of listening and observing that I would like to be able to have you share with the people who are listening to this program.
RUSTIN: Let me first segue into the neuroscience part. Integrating all three is the way that I begin to think about how I apply it clinically. As I really started to understand more about the infant-caregiver interaction and that that, in some way, serves as an
50 enduring template for self with other, I also began to realize that infants don‘t have memory. I mean, they don‘t have memory in the way we usually think about memory. It just doesn‘t exist.
It‘s controversial: when does memory, as we think about memory, really come into being? Some people say it begins at one year; others say it really doesn‘t happen until about age three, but the fact is there‘s so much happening in that first year or two that somehow becomes part of an individual‘s experience. So it was really in trying to learn more about memory that I started to segue into neuroscience.
Let me go back for a minute. Terminology regarding memory is often redundant and confusing. There are many kinds of memories, but basically, memory falls into two basic categories: explicit memory and implicit memory. The formation of implicit memory requires the development of the hippocampus, which is part of the cerebral cortex or the higher parts of the brain. Procedural memories really use many of the sub-cortical brain systems, so they are in place from birth on. Therefore those early memories that use the sub-cortical system are the parts of memory that are implicit; they are never available to conscious awareness. We don‘t call them ―unconscious;‖ we really call them ―nonconscious,‖ because they are formed before the capacity for symbolic thinking, and in order to have an explicit memory, even if it‘s repressed, you have to have symbolic thinking.
So, the infant is capable of forming both motor and emotional memories although they lack the symbolic representational capacity, but they hold these memories in motoric and interactive experiences that get encoded basically as ―patterns and procedures:‖ how I am; how I move; how I manage my states of arousal when I‘m with another person. Individuals hold these encoded, implicit, procedural memories throughout life, and they are both observable in close, metaphorically observable. One can see and one can hear them if one learns to listen for them.
The other thing about early memories is that those memories, the implicitly encoded ones, are state dependent. For example, an infant who is very aroused because he‘s upset about something and then he is responded to in a particular way when he is upset, throughout his life, that sense of arousal and feeling upset will trigger an expectation of the same early interactive sequence that occurred when he had that level of upset. In other words, these implicit, procedural memories are very, very state dependent and they really effect an individual‘s expectations of how significant others will or will not respond to him.
So, as I began to broaden my view of how early experiences of infant and mother become held in memory, I began to experiment with trying to find different ways to bring it into the clinical exchange and in a sense, de-emphasize some of the explicit, some of the verbal exchange, and pay more attention to patients‘ states and how they interacted with me in particular states and in their motor responses.
For example, Barbara, you asked me how I work with it and I‘ll give you several clinical
51 examples. These are examples where the motor behavior was very prominent. I worked with a woman, a very tall woman, who, early on in the treatment -- this is a patient I saw two or three times a week – would come into the room, sit in the chair opposite me and somehow manage to get herself into a position both with her legs and her arms so that no matter how hard I tried, I couldn‘t see her. I couldn‘t see her face, I couldn‘t see her facial expression. I have two exactly equal chairs, the same chairs, the same foot stool. I found myself constantly moving around trying to get a glimpse of the face and after about a month of doing this early on in the treatment, it finally dawned on me: this patient is giving me a powerful communication that she doesn‘t want to be seen. It was really remarkable the way she was able to hold her body in such a way that I couldn‘t see anything. So I began to accept that that was the communication: she didn‘t want to be seen; she didn‘t want to be known. She was essentially hiding.
As her history unfolded, I learned, over time, that her mother, very young when she had her, was also very ambitious and was working her way up the corporate ladder. She was planning to be president of the company, so she turned this child, my patient, over to her older sister to take care of everyday. It turned out her sister was a profoundly disturbed, bipolar, possibly paranoid schizophrenic woman, in and out of hospitals, very, very easily agitated, anxious, upset. To this patient, it seemed to come out of nowhere. This woman learned to try and hide all of her reactions or all of her experiences, feelings, thoughts, etc…, to just be as careful as possible in order to not set off some very extreme, affective, agitated, upset reaction.
Slowly over time, as we both talked about this, but also as I was able to accept that the hiding was essentially what this patient had learned in order to survive with this probably psychotic-like aunt, the patient slowly, slowly, slowly began to feel more comfortable, more trusting with me. It was so interesting that the whole sitting behavior in the chair changed. I remember somewhere about two years into treatment, she walked in and sat down and put her feet up on the foot stool for the first time, and I thought, ―Finally we can really begin.‖
What was really interesting in this treatment was that when something had happened, outside of what was going on with us, but when something had happened that was very upsetting to the patient and she couldn‘t quite organize her feelings, she would come in and sit in the old way, again, hiding. It always became a cue for me of where the transference was: that she was afraid, that she needed to hide, something bad had happened.
ALEXANDER: Was she aware of this? Was this something you pointed out, let‘s say, after the first month or so? Did you say something like, ―Are you aware that you are doing this?‖
RUSTIN: No, no. I used it as a communication. Now sometimes I do. I‘ll give you another example where I did use it - a very similar thing and I did use it with the patient, but with this patient, I chose not to because I felt that drawing attention to it would be much too shaming. We talked a lot about how this woman learned to hide all
52 of her feelings, her thoughts, her creativity, many, many aspects of her internal experience because she was always so uncertain about what might set off the aunt. I mean, it was so unpredictable. This was a very young child who learned that hiding was better than showing, but I never made the connection between the body posture and the dynamic understanding of her interaction with her aunt. It didn‘t really seem necessary. When she was feeling more comfortable, it just receded, and when she wasn‘t so comfortable, it was prominent, but then, I knew in what domain to enquire. I would say, ―I can tell from the way you are here with me, that something just happened that‘s upsetting to you,‖ and we would go from there.
ALEXANDER: I like that: ―the way you are here with me,‖ as opposed to ―the way you‘re all curled up in that chair and hiding.‖ That was very kind.
RUSTIN: Right. With somebody who has had that kind of unpredictable upbringing and who has learned really to manage and is really quite sensitive to everybody else‘s reaction to her, I think you really have to go overboard to avoid drawing too much attention to behavior that would then become self-conscious.
ALEXANDER: I‘d like to talk about ―mirror neurons‖ because I wonder if something didn‘t get activated. Can you explain to us what mirror neurons are and how they can help us in our work?
RUSTIN: I can explain what they are. How they help us in our work, I think, is still very, very controversial. I know that it‘s very controversial.
ALEXANDER: See, Kohut talked about mirroring a lot, right?
RUSTIN: He did, but he meant something really quite different. What he meant by ―mirroring‖ is mirroring the positive affect, the positive attunement, the mirroring of the patient‘s experience. I think he meant it more in a conceptual way than what neuroscientists are now describing as ―mirror neurons.‖
First of all, it‘s very new. It was discovered serendipitously in Italy in the mid-nineties. The original research on mirror neurons took place with Macaque monkeys. It basically demonstrated that when a monkey watches another primate involved in an action such as grasping a peanut or eating an apple, the motor neuron in the observing monkey fires as if he, the observer, is using the same neuropathways to perform the same action. That was the beginning of the concept or the phenomena of mirror neurons.
In the mid-nineties, Fadiga and his colleagues documented the same potential in humans by imaging motor-evoked potential, in other words, a signal that a particular muscle is ready to move. Now it‘s been broadened. Some of the people in California are doing it with emotions, where if somebody is watching a film of an actress showing disgust in the facial movements through FMRI scanning, the same motor neurons that would show disgust in the face of the observer begins to fire and swell.
53 I think the best that we can say, or at least that I would be willing to say at this point is that there are many way that people communicate other than verbally and they don‘t know that they‘re communicating in this way.
What I find most interesting about the mirroring neuron part is not so much that I might be resonating with a patient in my mirror neuron system, but that the patient is simultaneously reading me so that I might be showing things that I‘m not aware of that the patient is then picking up in his or her mirror neuron system! So it makes it much more difficult to dismiss when a patient says, ―You‘re disgusted with me. I can tell you‘re disgusted with me.‖ It makes it much more difficult to dismiss it as a transference issue. I mean, at least my own feeling is that I really should pay attention to what this patient is saying to me. In many ways, it really equalizes the relationship.
I think Irwin Hoffman wrote a paper about this, at least two decades ago I think called, ―The Patient as Interpreter of the Analyst‘s Experience.‖ I take that very seriously. It is truly a two-way street. It‘s bi- directional but not symmetrical.
ALEXANDER: Your clinical vignette that appears in your article in the Annals of the New York Academy of Science, the example of Jack, where you matched his -- he was silent, he was really quite nonverbal, right?
RUSTIN: Right, exactly.
ALEXANDER: I mean, this is very frustrating because we‘re in this world of words, you know, but yet you managed to connect with him by sort of matching his breathing. You toned yourself down to match his quietness. Am I understanding that correctly?
RUSTIN: That‘s exactly right and again, as I said earlier, one of the things in early infant memory is that it‘s state dependent, and Jack had two really psychotic parents. The particular nature of the psychosis I never fully understood, but one assumes, being raised with two psychotic parents, that there‘s a tremendous amount of agitation, and distress, and affect, and arousal all over the place. So, anything that in any way was too much, too loud, too affectively alive resonated with those very early experiences of growing up in a very agitated household.
When you say it was very frustrating, you know, so many people have said that to me and I didn‘t find it so frustrating. It was difficult because I‘m a very affectively alive person, so it was difficult for me to dampen myself down, but it wasn‘t frustrating once I had this whole body of knowledge behind me. I felt I was doing what needed to be done, and again, this is how the infant research and the neuroscience have really helped to shape my clinical practice. I felt this is what this patient needs. Too much arousal is not arousal -- it‘s agitation, psychosis, perhaps rage. I couldn‘t tell what was just too much of anything. So to me, although it was personally a little bit difficult for me to dampen myself down, I didn‘t find it terribly frustrating.
54 ALEXANDER: How did you know these things about him? Was this something that you knew at the beginning, that you took a history early on? Was he able to tell you about his parents so that then it became more understandable why his affect was the way it was, why his presentation was the way it was?
RUSTIN: Yes. It came out as a narrative. Not as a very coherent narrative, but it was definitely a narrative. It was recited. He was giving me the data in bits and pieces, in spurts. His basic bodily posture was one of quietness, speaking very low, holding his head down, sort of tucked into his arm, not looking at me. It was like a recitation. So I had the information and I saw the body language and the very, very quiet state of arousal, a very dampened down of any kind of affective response. In general, as he talked about his history, it seemed really quite dissociated. The affect just seemed to be absent, it was dissociated. So I had the information and I had the physical, the body posture, and I had what I would call ―the timing‖ of how the story unfolded; it came out in bits and pieces. There were lots of gaps in between. I would sort of have to sew it all together, but I had enough information to know, at that point, that I needed to be as non-intrusive, non- present as I possibly could.
ALEXANDER: What do you think made him get better? Was it years of this different kind of experience with you?
RUSTIN: Yes, and that‘s where Kohut talks about ―empathic immersion.‖ I immersed myself in his experience and his experience was that anything too loud, too much, too present, too pushy, too co-opting would get amalgamed with the psychotic parents, and that would not be good. What I think helped him was my being able to immerse myself in his experience and over time, things certainly improved there: he had more affect; there was more eye contact; there was less sitting in such an impassive, stony way; and as the years went on we had much more of a dialogue.
This is one of the first patients where I really used all of this newer information more completely and so I felt very rewarded. I felt very affirmed. Again, it was a bidirectional process in his response to the way that I was working with him, and I was thinking, ―Wow, this is really good. This is really working! This is really helping me to become -- you know, I joke about it -- this is really helping me become ―a self-psychologically informed analyst who integrates neuroscience and clinical practice!‖ It is a two way street and I really developed a particular, for lack of a better word, ―special place‖ in my heart for him in that he was affirming me: he was developing as a person and I was developing as a different kind of analyst.
ALEXANDER: Can you imagine that this work with him could have been done in a shorter period of time?
RUSTIN: Could I imagine it? No.
(laughter)
55 I mean I couldn‘t imagine it because I did the best I could. Is it possible? I suppose. You know, it‘s ―Can you turn back the tape and try it the other way and see if it would have worked?‖ Possibly. Maybe so. Maybe today, were I to do it again, would I be better at it, be able to do it more quickly? I don‘t know. I think that‘s a really good question.
ALEXANDER: Some things, I guess, need to be lived out, and then that‘s what I think what happened with him. You were giving him something that rebuilt something.
RUSTIN: I think that what happened with him was that he developed something he had never really had before, but because of the terror of any kind of attachment or connection, to get to the point of being able to take in what he never had before also took a certain amount of time and work. There was a lot of was profound defensiveness against attachment and connection. The two sort of had to go in tandem, both working on the fear and trying to convey a sense of trust and attunement that would reduce the fear.
I did not, in this particular instance, do a lot of resistance analysis. I just felt that that would be experienced as harsh and critical and perhaps too intrusive.
ALEXANDER: The ability, I think, to be able to discern how you should be with each person takes a lot of work , or takes a lot of self-awareness on your part.
RUSTIN: You know at this point, I think that‘s true. At this point, I do it intuitively and actually, you just reminded me… There are some people I work with much more from the perspective of empathic immersion: less is more; using the state of arousal; the body postures; the non-conscious kind of communication. But even when I think about people in my current practice whom I work with in that way, there comes a moment -- it comes from chaos theory, those emergent moments, where something happens. The Relational people call it ―enactment.‖ Something happens that you don‘t think about but you just say it. Something that you wouldn‘t have done six months ago, or something you haven‘t done in four years of treatment just comes out of your mouth.
Again, I believe that there‘s some kind of non-conscious communication going on that says that the patient is ready to do something different or to make space for something different, or to have a different experience. If it doesn‘t work, if it‘s a rupture, then you work with trying to heal the rupture but in many instances, I have found, in those sort of spontaneous moments which the Boston Study Group calls, ―the present moment,‖ that there‘s some non-conscious communication going on that says that the patient is ready for something else. It usually moves the treatment to a different plateau, a different level, a different dialogue.
ALEXANDER: This is really fascinating. As I said, it‘s such a vast topic of new under- standing and really burgeoning awareness that I think will change how people work.
RUSTIN: Well, it certainly changed the way I worked in the last twenty years. There‘s no question about it.
56 ALEXANDER: It‘s not verbal. It‘s not like you have to be a real ―smarty.‖ You don‘t have to be coming up with a ―correct‖ thing to say. You are just ―being‖ with a person.
RUSTIN: That‘s exactly right, and I tell you it‘s a great relief. I remember the days when I used to practice from a much more ego-psychological perspective because I was originally trained in that way, and I remember those days when I would struggle to find the exact way of making an interpretation that would both be heard, absorbed, and not resisted. It was a lot of effort, it was a lot of work.
This is much more -- I mean I suppose I think much more of Winnicott‘s concept of ―The Good-Enough Mother.‖ This is more ―the good enough analyst or therapist,‖ as long as you‘re attuned to the fact that you may try something and it doesn‘t work. Sometimes you can try something and it may actually be accurate but the patient isn‘t ready to hear it and so it creates a rupture. Then you repair rupture and you go on from there and maybe, a year later, the person is in a different place and is able to hear it.
ALEXANDER: A few years ago I interviewed Dr. Barry Magid from New York. He is very absorbed in Zen and mediation and he talked about ―sitting,‖ how you sit with a person and you sit, and it‘s a very Zen kind thing that you are doing. I don‘t want to trivialize it in any way or make it into a package that it isn‘t, but it interests me; it‘s very interesting.
RUSTIN: Well you know, Daniel Siegel from California, the latest book of his that I have is called, The Mindful Brain, and he‘s gotten much more into, I don‘t know if he calls it ―Buddhism,‖ but he calls it much more, ―the meditative state.‖ He works with people both helping them to get into a meditative state and he gets into it himself. He talks about it as ―the mindful brain.‖
ALEXANDER: When you were with this patient, were ―thinking‖ on a verbal level, or were you more ―being‖ with him?
RUSTIN: I was more ―being.‖ I was definitely more ―being‖ and in fact, I am not a mediator and I am not a Buddhist; I am a thinker. But that‘s a very good question because I would develop mantras. I didn‘t ―think.‖ I was looking, I was watching, I was breathing, and I would be talking to myself through various mantras like, ―Less is more here. Less is more.‖
(laughter)
I would repeat that mantra to myself over and over again because by that time, I had been doing that work for already quite a while and it was always about thinking and trying to figure out and so I had to retrain myself in that way and those were the kinds of things I would say to myself.
I was very vigilant with my eyes to notice changes, particularly more positive, and when I say, ―more positive changes,‖ I mean more ―alive‖ changes, even if they were very
57 subtle: more of the picking up of the head; more of the looking at me; more of a sort of affective response in the face. I wouldn‘t necessarily say it. Like with the other patient. I tried not to draw attention to it but I would use it within myself, again, to affirm. I needed to affirm to myself what I was doing. I would say, ―This is good, I‘m getting a good response here. Something good is starting to happen,‖ and so it would spur me on.
ALEXANDER: This is very good, but our time is running out. Is there anything you would like to add about this before we finish up?
RUSTIN: Well, there‘s one other patient and I think it is important that we add this. This was a patient who was very verbal and very affectively alive who for the first several years of treatment, sat with his face averted from mine at a ninety degree angle so it was as if his right cheek was talking to my right cheek, and he rarely if ever looked at me.
In that instance, the posture and the facial aversion came into the treatment and it was something we worked on directly because he brought it up. He brought it up as an issue; it was the only complaint all of his bosses ever had about him. He was really an unusually successful person, but in all of his reviews and evaluations, that was the thing that was said, ―You never look at anybody, you don‘t look at anybody in the eye.‖ The patient was very concerned about it because he knew he didn‘t do it and he wanted to be able to do it and really couldn‘t figure out why he wasn‘t able to do it. So he brought it into the treatment which was great because it did give us a way of trying to understand what his head aversion was all about.
It turned out it had many different meanings. He had a bipolar mother who was very affectively alive both in the manic state and the depressed state where she was very irritable. It was literally a way of keeping his mother ―out of his face.‖ That was one the meanings it had. As time went on and we began to understand that together, it then evolved into his fear of looking the other person in the eye out of fear of, on the one hand, wanting to be affirmed desperately and yet expecting to be criticized. So over several years as we unpacked these different layers, he was able to finally look at me and I assumed that went on outside of the consulting room as well.
ALEXANDER: This case sounds more traditional in a way.
RUSTIN: Yes.
ALEXANDER: It doesn‘t sound like it involved the kind of immersing yourself that the other ones did, did it?
RUSTIN: No, you‘re absolutely right, but when you asked me if I ever make the connection between the body posture, I said, ―Not in these instances.‖ It would have been too shaming and I think the patient would have experienced it has really just more reason to hide. But with this last patient, it did come into the treatment because he brought it in. I don‘t want to leave you with the idea that you never work with the body
58 posture or the state of arousal directly. It‘s like everything else in this business: it depends!
ALEXANDER: It depends! Ms. Rustin, thank you so very much. I‘m inspired to learn more and I hope that our listeners will too.
RUSTIN: I hope so too.
This concludes our interview with Judith Rustin. We hope you learned from this interview and that you enjoyed it. You may contact Ms. Rustin at (212) 620-3077; email: [email protected]
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
59 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Cultural Complexities”
PAMELA HAYS, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
PAMELA HAYS, Ph.D. 174 E. Redoubt Ave. Soldotna, AK Tel: (907) 262-4403 e-mail through her website: www.drpamelahays.com. Author: Addressing Cultural Complexities in Practice
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #5 in our program on ―The Therapeutic Relationship.‖
Since the turbulence of the 1960s and 1970s, brought on by the war in Vietnam, the Women‘s movement, and the end of the Cold War, our culture has shifted towards a less authoritarian, less formalistic, and more confrontational style of relatedness between persons. Individualism has become both aggrandized and devalued, and every group has its own terms for self-identification. Political events, population shifts and migration of new populations into what have been predominantly white, European societies has brought about a new sensitivity to diverse perspectives and backgrounds beyond the mainstream.
According to our next speaker, Dr. Pamela Hays, all these diverse cultural influences have required contemporary therapists to modify their worldviews. Although human beings like to think of themselves as complex, they often regard others as one dimensional, relying on others‘ most visible characteristics as the explanation for everything they say, believe and do
Dr Hays points out that although we may like to think that we are blind to ―isms,‖ such as racism, sexism, ageism, etc., as therapists, we are not immune. We do not have the option of ignoring cultural influences or the conflicts these influences may engender in ourselves. If we are to work effectively with people of diverse identities, we must learn to deal with difference and conflict in ways that do not simply reinforce dominant power structures, but rather empower and show respect for one another.
60 Moving beyond one-dimensional conceptualizations of identity to an understanding of the complex, overlapping cultural influences that drive each of us, Dr. Hays urges us that recognizing this complexity and recognizing our own tendencies to think, act, or feel certain ways about people can lead therapists to a much deeper understanding of our clients and ourselves.
Dr. Pamela Hays is a psychologist who works in rural Alaska with the Alaska Native Nakenu Family Center and Peninsula Community Health Services as a clinician and supervisor. She is author of the book Addressing Cultural Complexities in Practice, and co-editor of Culturally Responsive Cognitive-Behavioral Therapy. Her research has included work with Vietnamese, Lao, and Cambodian people in New York, and Arab Muslim women in North Africa. She has been a faculty member of Antioch University Seattle for 20 years and a presenter of workshops internationally.
ALEXANDER: Dr. Hays, I‘m very pleased that you can join me today to talk about the impact of cultural awareness and competence on the therapeutic relationship. I want to start by making a little confession to the world here, and that is this: when I realized I would be developing this program on the therapeutic relationship and that aspects of cultural diversity might be important, I really had no idea what I was talking about or even thinking about. It really wasn‘t until I read your book and the other materials that you had sent me that I realized what an important thing this is, and about the sort of unawareness of our own cultural assumptions that we have. As therapists we‘re trained to try to be aware of our own resistances, countertransferences and our own personal issues, but I don‘t really think that we are aware that even the way we think about doing therapy reflects a bias.
So what I want to start out by asking you is this: what have you learned about cultural differences and issues that affect the therapeutic relationship?
HAYS: Well, first let me thank you for telling me the book was helpful. I‘m glad. I think your experience is a common one of not recognizing the centrality of culture in the therapeutic endeavor until one is really in that situation, either through personal experience or in suddenly having a new client come in who‘s of a cultural background that is different from yours.
I think that cultural awareness, knowledge and skill – I group those together because in the counseling field, those have been found to be central in therapeutic relationships --are important for a number of reasons. One is that they guide the therapist in asking questions, so they help the therapist to figure out what‘s important to ask, and they can also keep the therapist from asking questions that might be offensive, and using language that might be offensive which then would stop the relationship. I use the concept of ―spiraling down‖ when I talk about interactions where we do or say something that creates defensiveness in the other person or in ourselves. Often then, the relationship begins to spiral down and unless we know particular things we can say or do to pull it back out, the relationship will generally break off, or the person won‘t come back, or
61 therapy won‘t be effective. So the ―knowledge, skills, and awareness‖ are helpful in guiding us towards the right questions.
They also help us to be more efficient because, for example, if you have someone come in of, let‘s say the person is of Arab / Muslim background from another country, if you have a high level of knowledge related to their particular culture, you‘ll be able to ask questions that are much closer to their reality than you would if you didn‘t have any knowledge or experience at all with that culture. It will hone your questions in so you don‘t have to spend a lot of time asking things that are generalities.
The other way that this ―knowledge, skills, and awareness‖ can be helpful is in increasing the therapist‘s self-confidence so that when you have somebody come in from another culture, even if you don‘t know the particulars about their culture, if you have done the personal work, and then also the interpersonal work on learning, you‘ll have some self- confidence about how to approach this and acknowledge the areas where you don‘t know enough and need to learn more.
Then finally, it can help a lot with credibility. Derald and David Sue are cross-cultural psychologists who have written about the importance of establishing credibility when you are working cross-culturally because the client‘s initial assumption will often be that if you‘re of another culture, your values and beliefs and attitudes are going to reflect the dominant culture, and why wouldn‘t they assume that? So you need to be able to use language and engaging behaviors that demonstrate that you are able to work with them more effectively and that you don‘t make those assumptions.
ALEXANDER: I had always thought that the person you‘re seeing, either your client or your patient, would themselves tell you about the ways in which they are different or the ways in which they view things differently, and from what I understand from your work, you say that it‘s not up to them to educate us.
HAYS: Right. I feel really strongly about this. I think it‘s the therapist‘s responsibility. We have to educate ourselves about clients‘ cultures.
Now that‘s not the same as learning about the client‘s personal experience of their culture. There are two pieces here: we have to do the background learning about the client‘s culture, but then we never want to assume that we understand the client‘s individual experience of their culture. That‘s the part that they‘ll tell us. But the more that we know about the culture in general, the better we‘ll be able to understand their individual experience.
I use this analogy: if you have any never seen anybody with a dissociative disorder before and you get your first client who has a dissociative disorder, you wouldn‘t expect them to educate you about dissociative disorder. You would go do your homework to learn about dissociative disorder in general and then you would ask the client questions to understand their particular experience of it.
62 ALEXANDER: The example that you have in your book about the Cambodian lady who comes with her translator to a counselor, is a great example, and in this example -- well, why don‘t you tell us about the example and what happened?
HAYS: The example is of an older Cambodian women who comes to therapy to see this middle-aged European-American psychologist who is very well intentioned. I call her ―Elaine‖ in the chapter. The Cambodian woman comes with her interpreter and they begin therapy right away. The psychologist has not worked much with interpreters and has never worked with anybody who‘s Cambodian -- or ―Khmer,‖ is the ethnic term. She begins to ask questions and as she asks questions about the Cambodian woman, whom I call, ―Mrs. Sok,‖ -- I try to use ―names.‖ Although they‘re made up names, I use ―names‖ that are real for that ethnic group because I think that‘s a part of cultural learning too – to learn to recognize what ethnic group names commonly belong to; it‘s just additional multi-cultural knowledge.
So anyway, this therapist, Elaine, asks Mrs. Sok lots of questions and very quickly learns that she has had a traumatic background with multiple deaths in her family and Elaine focuses almost exclusively on these experiences related to trauma. The time goes on and at one point Elaine is realizing the interpreter is taking a very long time to interpret some short questions that she‘s asking. She stops and turns to the interpreter and asks her in a very firm tone to please just interpret exactly what she‘s saying. The interpreter‘s demeanor then changes and she becomes a little more subdued and does that. So they run over time and Elaine asks the client to come back and she and the interpreter agree they‘ll come back, and the next week they don‘t come back.
I use the example because I think it‘s a good illustration of how the therapist can be doing everything right from her perspective: she‘s trying to be open-minded; she goes into overtime to understand the person‘s problems and focuses in on trauma because she believes she needs to learn more about how that will affect the woman. But the woman‘s original complaint was that her apartment building was being demolished. She had lived there for several years next to another Cambodian family. This was her community and she was sick that she was going to have to move. That was her presenting complaint and she came because the interpreter told her that the therapist might be able to help her.
Well, Elaine clearly tried to be helpful but she was helpful from her own framework which was, ―Oh, okay, this person has trauma in her background; I need to figure out how that‘s affected her.‖ But it didn‘t address the problem that Mrs. Sok brought in at all.
Elaine also made a big mistake when she corrected the interpreter in the middle of the session, and she hadn‘t established a good relationship with the interpreter to begin with. She should have held a meeting at the beginning with the interpreter, just the two of them, to talk about the interpretation process and get to know each other, get comfortable with each other, and then had the therapy session, so that if there were any discrepancies the interpreter wouldn‘t feel criticized or embarrassed.
63 Elaine also didn‘t recognize the expertise that the interpreter had regarding Cambodian culture. Elaine should have had a debriefing with the interpreter afterwards. It‘s always better to do these pre-meetings and debrief meetings with the interpreter when the client‘s not around because otherwise the client thinks that you‘re talking about them and wonders. They don‘t know what you‘re talking about and that could be upsetting to them.
So there are all these different things that Elaine could have done to make this more successful, but it wasn‘t within her repertoire. If you would have asked her, she would have said, ―Oh, I knocked myself out to help this person. I went over time, I really tried to be helpful, I gave suggestions about following up with the psychiatrist for medications, but I don‘t know why they didn‘t come back.‖
ALEXANDER: Well, this is an example that in our culture or in American therapy, Western European influenced, we value ―rapport,‖ right? Establishing rapport? And that‘s not a universal value in a helping relationship.
HAYS: You know, when I talk about values, I think it‘s more helpful to think in terms of priorities that cultures put on values. I talk a lot about respect and how important it is in many minority cultures, and I use the word, ―minority‖ in relation to the U.S. For example, among African Americans, respect is a very important concept because African Americans have been so disrespected by the dominant culture. Similarly, in Asian cultures, respect -- respect for authorities, respect for your elders -- is a very important concept. It‘s similarly important among Arab Americans. It‘s very important in Native cultures too, respect for all living things.
In contrast, in European American culture, in the counseling literature, the concept of rapport has been emphasized and I think that‘s because the dominant American culture highly values egalitarian relationships. So there‘s been a lot of research put into building rapport with your client, a peer-like relationship. That‘s not to say that African- American, Arab, and Native cultures don‘t value rapport; certainly they do. It‘s just that respect tends to receive a higher priority than rapport in an initial professional relationship like the therapy relationship.
In contrast, in European-American cultures, it doesn‘t mean that respect is not valued. It just means that rapport will be more commonly valued, will receive a higher priority than respect in most relationships.
You can tell as I speak, I use the terms, ―many,‖ and ―most,‖ and ―often,‖ because we have to be careful when we make generalizations. I think of generalization and specificity as on a continuum and if we go too far either way -- if we go too far towards generalization, it‘s not helpful, we end up stereotyping, and if we go too far towards specificity, we can‘t say anything about any group because every person is an individual.
What we‘re shooting for here is a middle ground where we recognize that there are some things we can say about cultures‘ particular beliefs and values and behaviors that are
64 common enough that if we keep them in mind, they‘ll help us in our relationships with people of those cultures, and at the same time, recognizing that there is tremendous variability within individuals and families within those cultures.
ALEXANDER: Do you think that people can be treating and working with clients of a different cultural background, or is it like only an addict can treat another addict; only a cancer patient can understand another cancer patient? Do you think that only a Cambodian should treat or work with another Cambodian? How much do we have to know that‘s really specific?
HAYS: Well, it‘s hard to say, ―You have to know this and this and this and if you don‘t, then you can‘t work effectively.‖ I‘m a psychologist in a small town in rural Alaska. I‘m very practically oriented. If I have someone come to me -- for example, I recently had someone who was a Pacific Islander and if I would have had a Pacific Islander therapist here, I would have asked him how he felt about working with me and let him know there was another option, a Pacific Islander therapist, if he would feel more comfortable working with the other therapist. But I work in a small town; it isn‘t an option.
As a general rule, as a practitioner I try to help the client the best I can, and then there are some things I do to increase my effectiveness if it‘s a client of a culture that I‘m not familiar with. For example, I consult. I‘ll call somebody that I know who is a therapist of that culture, or even if they‘re not a therapist, and talk with them a little bit, preserving confidentiality of course, about my thinking, and ask questions to get a feeling for whether I might be missing something or misunderstanding something.
I think one also has to consider the client and their experiences with the dominant culture, so if you‘re a therapist of a dominant culture and you have, say, an African American client come in, you have to consider whether that client wants to work with you. Nancy Boyd Franklyn has written about this in her book on working with Black families. She suggests asking a family, ―How do you feel about working with a White therapist?‖ At the same time, she says, ―If you ask this, you need to be prepared for the answer too, that you can handle the answer and figure out a solution with the clients, whether it‘s continuing to see you or seeing someone else.‖
Another piece to this is the research. There is research showing that when you ask people if they want to see someone of the same ethnic or cultural background, they‘ll usually say yes, but if you ask them to choose from a whole number of variables like age, gender, similar age, similar gender, similar sexual orientation, similar ethnicity and so on, ethnicity is not always the highest ranked variable. What is more important to people are similar values. That finding illustrates the point that you can have people of the same culture who may be very dissimilar in their values, so the match doesn‘t work at all.
ALEXANDER: That‘s really interesting. Do you think we can ever turn off our perceptions about groups of people, our biases? I mean, they may be just so hidden and out of our awareness that we don‘t even know about it.
65 HAYS: I think we have to continually recognize that we are biased human beings, all of us. We live in a society that reinforces biases everyday and in fact, cognitive psychologists have found that human beings seem to be hard-wired for making categorizations out of our experience and then generalizing those categories. This helps us organize our world. It makes us more efficient, but it can also cause problems, so we have to continually be aware that we could have biases and engage in learning that pushes us to recognize those biases.
I divide this work into two main categories. I divide it into the first category of the personal work that we as therapists need to do on ourselves, and then the interpersonal work that we do regarding the cultures of our clients. I see the personal work that we do on ourselves as an ongoing, lifelong process and if one is engaged in that process, you‘ll do okay generally with people of diverse backgrounds because you‘ll be continually wanting to learn about the cultures of your clients. But if you try to do cross-cultural work with clients without that personal work, it can backfire.
ALEXANDER: I was just thinking about an attorney that I know who had told me about negotiating a contract in Japan and that the Japanese business people on the other side, as he was speaking, would be nodding their heads like ―Yes, yes, yes,‖ and the attorney thought that they had the deal all settled. And it wasn‘t in the slightest bit settled. When they were saying ―yes, yes, yes,‖ it just meant that they were saying that they understood what the attorney was saying, not that they agreed with it. I guess there have been many, many lawsuits about this based on that kind of an assumption.
HAYS: Yes, the hard thing about learning about our lack of awareness is that if you‘re not aware of biases, how can you do anything about them?
ALEXANDER: That‘s right, that‘s right.
HAYS: This is why I emphasize the importance of a commitment to this ongoing learning. If you keep looking for and pushing yourself to expand in this way, that‘s about the best you can do. At the same time, if you start to do this work, in my experience, it‘s very exciting and interesting and so rewarding.
There‘s another piece I‘d like to add here though, that we haven‘t touched on: in the past, there‘s been an approach, often in business organizations that I call, ―the happy diversity approach,‖ which is recognizing that we are all different and we just need to recognize our differences, be aware of the differences, recognize them and just get along.
But there‘s another piece to this multicultural knowledge that I think is essential and that is yes, we all have biases, but we don‘t all belong to a dominant culture. When you pair biases with privilege, the privileges that come along with the dominant cultural identity, you get the development of ―isms.‖ When you pair racial bias with power and privilege, you get the system of ―racism.‖ When you pair gender bias with power and privilege, you get ―sexism‖ -- a whole system of discrimination against women. Similarly, with regard to sexual orientation, when you pair bias with power, you get homophobia and
66 ―heterosexism.‖ So these ―isms‖ are pervasive throughout society and they affect all of us: they affect members of the dominant group and they also affect members of the minority group.
One of the difficult things that people of minority groups deal with is internalized racism, sexism, heterosexism. So I always emphasize that we‘re not just talking about being aware of the differences and then being accepting. It‘s also recognizing this privilege piece that dominant cultural groups have privilege that minorities groups don‘t have. And privilege hurts all of us. It hurts members of the minority group, obviously, but for therapists of the dominant cultural group, it‘s also very harmful because what it does is it cuts therapists off from information about their clients that could help them understand their clients more effectively.
For example, if you‘re a White therapist, let‘s say a White lesbian therapist, and you have a Latina lesbian client, you might think, ―Oh, because we‘re both lesbians, I can understand my client better.‖ But if you don‘t have knowledge of the client‘s ethnic culture, and you don‘t understand how it is for her to be a lesbian in her culture, you will have to do a lot of background work to understand what that‘s like for her. It won‘t be information that you‘ll just be able to find by picking up a newspaper or magazine, or a book, or talking to a friend, unless the friend is Latina and lesbian, or Latina. So therapists need to recognize how privilege cuts them off from information that‘s important about their clients‘ cultures.
ALEXANDER: Let‘s talk about the paradigm you‘ve developed called, ―ADDRESSING,‖ as a way of helping us become more aware of ourselves and the cultural issues with our clients.
HAYS: Well, when I began teaching multicultural classes, the first thing that struck me was the separation of the literature. There was a strong multi-cultural counseling literature on people of color -- therapists and clients, and there was a separate literature in gero-psychology on working with older adults. There was a separate literature on working with gay and lesbian clients, and there was a separate literature on working with people with disabilities -- all these very disparate bodies of research, but the researchers didn‘t seem to be talking with each other. Within each one, the clients that were discussed, or the case examples that were given were typically mono-cultural.
So for example, in the multicultural counseling literature, an example of an African American client would apparently be presumed to be heterosexual, young to middle- aged, without disability, middle class. Similarly in the gay and lesbian literature, the client was gay but assumed to be White. So people didn‘t think about the ways in which people, in reality, hold very complex cultural identities.
None of us identify ourselves by one particular factor. We usually see ourselves as very complex beings, but it‘s easy to see other people as ―singular,‖ as if one characteristic of that person or one cultural influence on that person affects everything they think, feel and do.
67 So I tried to develop a framework, a starting point for helping people recognize that culture is very complex. With the help of a couple of colleagues, I came up with an acronym to summarize the major cultural influences that the American Psychological Association, the American Counseling Association, and the National Association of Social Workers have all said in their guidelines are important and have been relatively neglected within the field.
This acronym spells the word ―ADDRESSING,‖ and it stands for the following:
A stands for Age and generational influences. By generational influences, I don‘t just mean the person‘s chronological age but also, whether there are generational cohort influences. For example, people born during the Depression are a particular age cohort. Also it can include generational roles that are important, for example the role of an auntie in a family. The next influence is the acronym DD, Disability, which stands for developmental and acquired disabilities. Each of these influences has a minority group associated with them, so to back up a minute with regard to age and generational influences, the minority groups there are children and older adults. With regard to developmental and acquired disabilities, the minority groups there are people who have been born with disabilities and also people who have acquired disabilities later in life, for example, through an accident or a stroke or disease. I separate those out because when people who are born with a disability come to see a therapist for a problem, they often present very differently than people who come to therapy for help with a disability that they recently acquired. The next letter in the acronym, R, stands for Religion and spiritual orientation, and there, the minority groups are Muslims, Buddhists, Jews, and Hindus. The next letter, E, stands for Ethnic and racial identity, and the four largest ethnic and racial minority groups in the U.S. are African Americans, Asian Americans, Latino Americans, and Native people. In addition, I add Arab and Middle-Eastern people here because they are certainly a minority and are experiencing a great deal of racism and prejudice. The S stands for Socioeconomic status, and the minority groups are people living in poverty. Let me back up. Socio-economic status is commonly defined by occupation, education, or income, and in addition, I add rural or urban habitat, people who are living in poverty, or inner city, or rural areas. The next S stands for Sexual orientation and the minority groups are gay, lesbian, and bisexual people. The I stands for Indigenous heritage. I separate this from ―ethnic‖ to make the point that in many countries, Indigenous or Native people consider their concerns and issues to be very separate from ethnic minority groups. In fact in Canada, Native peoples are not described as ―ethnic minority cultures‖ because the Native peoples are seen as the ―First Nations‖ who were there originally. The ―Second Nations‖ are the French and English who came as colonizers, whereas all the other individuals who came via immigration are considered the ―Third Nations‖ and ethnic minority groups.
ALEXANDER: That‘s very interesting.
68 HAYS: Yes, so Native people wouldn‘t call themselves ―ethnic minorities‖ in Canada, and there‘s a growing global movement of Indigenous people in places like New Zealand and Australia and Canada, and the U.S.
The N stands for National origin, and this includes people who are immigrants, refugees, or international students. Finally, the G stands for Gender and that includes women and transgender people.
ALEXANDER: The difference between the gender factor and the sexual identity factor? They seem like they‘d be close.
HAYS: There are overlapping issues, yes. One other thing I‘d like to add about the ADDRESSING framework is that it‘s not just an acronym; it is a whole framework for approaching cross-cultural work, but the acronym is just a starting point to get people to recognize how complex culture is.
One exercise I use with people in workshops is to have them write down the ADDRESSING acronym on the left side of the page with a blank space next to each line, next to each influence, and then go in and fill in: what are the influences on you in relation to each of those areas? For example, what are the generational age and cohort and role experiences that you‘ve had, whether you belong to the dominant culture in that area or to the minority group? Then similarly, with regard to disability: do you have a disability, have you been a caregiver for a person with a disability? Then religion: what was your religious upbringing or spiritual orientation growing up, and what is it now?
As people do this on themselves, they come to recognize how much culture has influenced them. I should say, ―cultures‖ have influenced them, and how complex it is. In some of these areas, we may have an identity now that we didn‘t grow up with, and vice versa. Someone may be middle class now, in fact most therapists are middle-class by virtue of their education and occupation, but they may not have grown up middle-class at all, so they have a complexity of influences there in relation to that identity. Recognizing these influences on ourselves then helps us to understand the biases that we‘ve formed in relation to these influences, and to see the complexity or recognize that there is complexity in other people
ALEXANDER: Well, the work is just so complex! I mean we have to think about so many things. Just if you use an example and you‘re working with an African American client and you‘re a White therapist and you say, ―Well it‘s very simple, it‘s black and white.‖ And then they get offended because you‘ve said something. It‘s like, ―Oh my goodness, it‘s not only that I have to think about the meaning of this and the meaning of that relationship, and that dream and that statement. You also have to think -- I mean, it gets very busy up in your head, I think, a lot of traffic!
(Laughter)
69 HAYS: I do have to say though, I am of European American background and of a Christian background growing up, and my experience with people of minority groups has been that of people being so gracious to me. I think what members of the dominant culture have to watch out for is this defensive reaction that‘s common, that ―Oh well, what can I say that won‘t offend someone? Why even bother?‖
Well, as a therapist, you have a lot to gain by engaging with this learning and chances are if you engage with this learning and really try, people will be very gracious and forgiving. That‘s certainly my experience.
ALEXANDER: And that can only enhance the relationship.
HAYS: Yes, and it enhances your life. I mean it‘s not just about therapy; it‘s about becoming a better human being, really.
ALEXANDER: Absolutely. I have another question to ask you, and I want to give you an example about this. There was a situation some years back in the psychiatric hospital where I had done some work, some training. There was a patient who had been a Holocaust survivor. This was in the late sixties, so it was just not that long after World War II, and she kept breaking down all the time. The resident who was treating her was really fascinated by her and got extremely over-involved, took her to his home for religious holidays, and his whole family became involved with this patient, who had clearly suffered many losses in her life. Then the residency for that person was over, and she got transferred to somebody else who was not fascinated by her experiences, put her on medication and kept her in strict boundaries, and she got better! She got a lot better, better than she had gotten when she was being seen by these people who were so overly- involved and overly-sympathetic. Even though this was many years ago, I have remained amazed by that example, which I found very instructive.
So the question then, of course, is: can we become so fascinated by what we‘re learning, like Elaine and Mrs. Sok. Maybe she was more fascinated by the traumas of this woman than she was by the fact that she was being displaced from her house. I mean, isn‘t it possible that we do these things and we‘re not really paying attention to what the person needs and what they‘ve come for?
HAYS: Well, in the case of Elaine, I think the problem was that she was focusing on trauma because she‘d been taught that trauma can result in psychopathology, so she believed she needed to learn as much as possible about how that trauma had affected the client.
But in response to your question about can we become too fascinated by the backgrounds of our clients, I would say one red flag for that is if you find yourself asking a lot of questions about the client‘s culture which are not specific to the client‘s experience and the presenting problem.
ALEXANDER: That‘s exactly what I wanted to know about. That‘s exactly the point
70 that has concerned me and that‘s a great red flag. That‘s a great signal.
Is there anything else that you would like to talk about before we close that you think would be important for us to know, among the millions of things that are important for us to know on this topic?
HAYS: One of the most helpful things to me was finding a book called, The World‘s Religions, by Huston Smith, in which he talks about three qualities or abilities that the world‘s major religions agree are important for a wise person, and I draw an analogy between a wise person and a good therapist. The three abilities or qualities are:
One: humility. We have to be humble in this cross-cultural work that we do with clients. Two: compassion. He uses the word ‗charity,‘ I use the word ‗compassion.‘ Third is what he calls ‗veracity,‖ and for therapists‘ purposes, veracity means seeing things as they truly are, letting go of illusions.
For therapists‘ purposes, I think of this as, ―critical thinking skills.‖ We have to be able to see not just two sides of everything but we have to see multiple sides of things. We have to be able to see complexities of problems, and although we have to make judgments sometimes, the more we can stay away from being judgmental, the more effective we will be.
ALEXANDER: Dr. Hays, your work is really very fine, and your book is very fine. I‘m very grateful for your interview and what I personally have learned. I feel like I‘m only in first grade on the subject. I have a lot of catching up to do. Thank you so much.
HAYS: Well, thank you!
This concludes our interview with Dr. Pamela Hays. We hope you learned from this interview and that you enjoyed it. You may contact Dr. Hays at (907) 262-4403, and you may e-mail through her web site www.drpamelahays.com. Her book, Addressing Cultural Complexities in Practice, is available through all major book sellers.
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
71 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Crying in Psychotherapy”
JUDITH NELSON, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
JUDITH NELSON, Ph.D. 2110 6th Street Berkeley, CA 94710 Tel: (510) 540-7315 Email: [email protected] Author: Seeing Through Tears: Crying and Attachment
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview #6 in our program on The Therapeutic Relationship.
Few people encounter tears in a professional setting as often as psychotherapists, counselors, and others in the field of mental health. In her research on crying, Dr. Judith Nelson has studied forms of crying and crying situations, from children to adults, client to therapist, in-session and out-of-session.
What she has learned is that the default reason for crying is separation. This comes from the original studies that Bowlby did looking at infants who were separated from their caregivers in the nurseries in England during World War II, when children were taken outside the cities and kept with strangers for safekeeping. Bowlby delineated three phases of crying: protest; despair; and finally detachment. The same biological, psychobiological behavior that occurs in infants to bring about reunion with the caregiver also occurs at the death of a close loved one, and Dr. Nelson has translated this into an understanding of crying in psychotherapy.
Judith Kay Nelson, MCSW, Ph.D. is on the faculty of The Sanville Institute for Clinical Social Work and Psychotherapy, a Ph.D. program in California, and she maintains a private practice in Berkeley, CA. She has spent many years studying, writing and presenting throughout the United States and Europe on topics related to crying, laughter and attachment. She is the author of Seeing Through Tears: Crying and Attachment published by Routledge in 2005, and numerous articles and chapters on crying, laughter,
72 and attachment. She is currently working on a new book, What made Freud laugh? An Attachment Perspective on Laughter.
ALEXANDER: Dr. Nelson, the subject of crying is really very interesting and I‘d like to begin by asking you how you happened to get involved in your research on it?
NELSON: Well, it was more decades ago than I like to remember, but I was a recent graduate from social work school working in an outpatient psychiatric clinic at a university hospital and I had a patient with an unusual way of crying. So I went, as many recent students do, to the library to check and see what I could find out, and guess what I found? Absolutely nothing! I was stunned. These were the days before computer searching; I was in the card catalogue and nothing turned up. So that sort of stuck in my mind for the first ten years of my work, and then when I went back for my Ph.D. in social work, I decided to begin to do some serious research on the topic.
ALEXANDER: Did you find anything? Well, obviously you found a lot…
NELSON: When I really got into it, I sort of had to develop a literature out of bits and pieces that I found. In traditional psychoanalytic theory, crying is mentioned only briefly and glancingly, but from early days of psychoanalytic affect theory, when the idea was that emotion is quantitative, the idea has always been that it‘s a form of discharge. Negative would build up and needed to be discharged or symptoms would develop.
Of course, that idea has long since gone by the wayside in terms of psychoanalytic theory, but in terms of crying, it hasn‘t. We still hear in popular psychology the idea that having a ―good cry‖ will make you feel better. I started looking at that and various other ideas about crying here and there, and ultimately just found myself in a lot of dead ends and cul-de-sacs and unable to really come up with a theory that would explain crying throughout life.
I started back in looking at crying in infancy. There was a little bit of infant research by then, but the bulk of what I found to be helpful was in attachment theory. John Bowlby‘s early works were coming out in the sixties. I was doing this work in the late seventies and so I had access to all three volumes of Bowlby, as well as his work on separation behaviors on infants. So that‘s where I began to understand the idea that crying is an attachment behavior. It‘s inborn, it‘s universal, it‘s designed for bringing about proximity between the infant and the caregiver. That was the seed of the theory that then grew to be the central core principal of the theory that I now use about crying as an attachment behavior throughout life.
ALEXANDER: In your paper in the New Directions in Psychotherapy and Relational Psychoanalysis, you say that the default reason for crying throughout life is separation.
NELSON: Yes. That comes from the original studies that Bowlby did looking at infants who were separated from their caregivers in the nurseries in England during
73 World War II, when children were taken outside the cities and kept for safekeeping. What Bowlby noticed was that the infants, when first separated from their caregivers or parents, would go into what he called ―protest,‖ which is a very intense kind of crying and it‘s designed as an emergency signal to bring the caregiver right back. Then if there was no reunion, as there weren‘t with these longer term separations, then the protest crying would diminish and the children would go into what he called a stage of ―despair.‖ In that phase they were not crying loudly but rather, just an occasional low wail and kind of that universal, slumped posture of despair and giving up. Then if there was still not reunion and there was no reconnection with another permanent substitute caregiver, the children could then go into what he called ―detachment,‖ in which they would shut down. They were silent and that ultimately can, as we know now, be life threatening.
Bowlby wasn‘t interested in crying; he was interested in the attachment bond and what happens when there‘s a rupture, but he did, for my purposes, fortunately mention the type of crying and from that I was able to build and come to understand that crying is a separation or grief reaction throughout life.
The second article that Bowlby wrote, also in the sixties, was called, ―Looking at Adult Grief Reactions.‖ If we look at the prototype of infant crying and separation from the caregiver, the prototype of adult crying, as I determined in my research eventually, is loss of a close loved one, usually by death. So the death of a close loved one, universally in cultures around the world, even where it‘s forbidden, does induce crying in the bereaved. It‘s not in every person in every culture, but there is no culture where that is unknown and it is indeed a very common response. So this same biological, psychobiological behavior that occurs in infants to bring about reunion with the caregiver also occurs at the death of a close loved one. The idea is to bring about reunion, but of course when reunion isn‘t possible, there‘s a permanent separation and then there‘s the grief reaction.
So from the building my theory, I was looking at the parallels between crying, classifying different types for crying, and different stages of the grief reaction. So I came to determine that about 95% of crying is some kind of response to separation or grief. And of course in adult life, you begin to expand the definition of separation to include real separations, threatened separations, symbolic separations, large and small: we can be separated from a loved one; we can also be separated from a possession or from a dream. There are numerous types of losses that occur throughout the lifespan that can induce crying. The different types of crying would then be based on whether or not this was a protest reaction, or a reaction of despair, or shutting down, so that crying is inhibited, as with detachment.
ALEXANDER: Well, let‘s translate that into psychotherapy -- the kind of crying that takes place in therapy and how that expands your model.
NELSON: Yes, well I think the model actually is very applicable to psychotherapy. What you would be looking at in psychotherapy, or in casework, or in other relationship- based kinds of interventions is that when people cry or don‘t cry, there are a number of factors to look at. But what you‘re basically looking at most of the time, as I said, about
74 95% of the time, is some kind of a grief reaction. There‘s some reaction to some loss.
There can be protest crying, and protest crying as in infancy is an intense signal designed to bring about a quick and speedy reunion, or rather, if we were talking about a less intense loss, to undo a loss, to avoid its happening. So let‘s say someone is, let‘s say a couple has an anniversary and the husband announces to the wife that he‘s planned a motorcycle trip for the day of their anniversary and won‘t be able to make special plans with her, and she begins to cry and says things like, ―Well, you‘re always putting yourself first. You don‘t care about the relationship.‖ So she‘s basically indicating that she‘s threatened by his behavior, that the relationship to her feels threatened, and she begins protesting. The purpose of protest crying is to get him to stay home, to get him not to do what he‘s doing, as with the infant: to get that parent right back now. So it‘s an attempt to not accept a loss but rather, to avoid a loss.
As such, it often backfires. It makes the recipient or the caregiver feel guilty, feel blamed, accused, irritated, apathetic, annoyed. That‘s the kind of crying, really, that gives crying a bad name. So when you get protest crying it‘s the type of grief that really can‘t be worked through. It‘s designed to confront and avoid rather than to process a loss.
Then the second type of crying, crying in despair, is an altogether different experience. Remember the infants, when they are left without a reunion with the caregiver, go into this more quiet type of wailing. It‘s closer to what we would call ―weeping‖ in adults, and the weeping is of a different order. It‘s quiet, it‘s often silent in adults - tearful but silent - and is received by caregivers almost universally with empathy and sympathy and a wish to do something comforting.
Again, with attachment behavior, we‘re always looking at the parallel care giving behavior. These two operate in tandem: attachment behaviors and care giving behaviors. I look at crying as always being a relationship behavior, so that when a person is crying in despair in the presence of a caregiver, the idea is that if that caregiver is responsive and are themselves securely attached, then we have a situation where there is an internal desire on the part of the caregiver to comfort. So with protest crying, you either feel accused, or blamed, or irritated; with crying in despair, you feel much more empathic and have a wish to respond in a comforting and care giving way. That‘s the kind of grief that can be processed and worked through to what Bowlby then would call, ―reorganization,‖ where the grief is transformed. Not that it‘s lost or goes away, but rather that it‘s transformed into something that can be utilized to form new attachments or to change behavior or ideas in such a way that the person can move forward with more positive energy than when you‘re caught up in grief.
ALEXANDER: When a patient in therapy cries, is there a multi-dimensional aspect to it, that the crying may be related to the content of what the person is talking about, but the crying may also be intended to get the therapist to respond in a particular way?
75 NELSON: Yes. I think the interesting and valuable part of looking at crying as attachment behavior and in the therapeutic relationship in particular, is that not only are you seeing, in your own presence, the historical meaning of crying in the caregiver/ infant past of this person, you‘re also seeing an example of what may happen in the present in attachment relationships of the adult or the child that you‘re working with. Also in the therapeutic relationship, there is an attachment behavior designed to appeal to the professional caregiver, here the therapist, to respond in some way. So, that is another clue in terms of what‘s happening for the patient, that there are multi-layers of grief and loss. The fact that crying is occurring in a very alive and present moment in the therapeutic relationship is highly significant and is an important measure of the current quality of the therapeutic relationship.
ALEXANDER: Do particular patients have particular patterns of crying in therapy, would you say?
NELSON: Yes, and this is again why I‘m leaning on attachment theory and research heavily, and the research here is the research about attachment styles in infancy, and states of mind regarding attachment in adults. Many listeners will be familiar with ―the strange situation,‖ which is the protocol developed by Mary Ainsworth for looking at attachment style in infancy. She identified Secure, Anxious/ ambivalent resistance, and Avoidant attachment as three different attachment styles in infancy. Later Mary Main identified a fourth, which is Disorganized.
Then Mary Main also developed a way of looking at the states of mind regarding attachment in adults which parallel these three, using Secure/autonomous, Anxious/ambivalent which is Preoccupied, and then Avoidant, which is Dismissing/ Disoriented. So it‘s a lot to take in, although many people may be already familiar with these terms, but crying is an attachment behavior and since there are particular patterns of affect expression and affect regulation that go with all of these attachment styles, it‘s also very important to keep in mind and to observe and assess what the attachment style of the person that you‘re working with in therapy will be.
Because I‘m sure that‘s a lot to take in, maybe it would help if I gave an example?
ALEXANDER: Great.
NELSON: Ok, well let‘s start with a person who‘s securely attached in infancy or in adult life. This is a person who‘s able to rely on the accessibility and availability of a caregiver, who misses the caregiver on separation, but if they do get distressed, will go to the caregiver and be soothed. So these are people who are able to cry and able to be soothed. That‘s the person that will be the most comfortable in therapy and the most comfortable for the therapist to work with. That means that they will cry appropriately when talking about losses and will be open to the kind of verbal comforting that can be given, verbal and to a certain extent kind of kinesthetic: gaze and body posture and those kinds of extensions of sympathy and empathy that take place in therapy. That would be a successful and comfortable exchange in a therapeutic situation.
76 If you have a person who is, for example, more dismissing or avoidant -- a child or an adult -- their attachment systems, as part of this attachment style, become deactivated due either to neglect or to early independence training. They were left to their own devices and had to soothe and regulate their own affect, so they very quickly learned to shut down their attachment systems and do not show any signs of distress upon separation. In infancy, by twelve or eighteen months, you see the infants who look very unbothered when their parents come and go. I say ―look unbothered‖ because when the children are actually wired up and measured, they do show anxiety internally, but to look at them, they look very self-possessed and comfortable with the whole thing.
So you see by the time the person is an adult that they are not crying. This is a person who is not comfortable with crying, who doesn‘t want to cry, who, if they do have a loss that kind of breaks through their defensive structure, will get very upset if they cry. So that‘s another pattern: someone whose attachment system is deactivated and who‘s not open to receiving care and usually is not very good at giving it.
Then the third pattern would be the preoccupied person where that attachment system is hyper-activated, and they cry very easily, present in a very needy way. The hallmark is that their negative affect comes about very easily, is readily shown, but they‘re very difficult to soothe. That starts right back in infancy with the babies at twelve to eighteen months in the strange situation. When the mother leaves the room, the baby becomes very, very disturbed, but when the mother comes back, they will go to her and then they will become elbows and knees and arch away and keep crying, whereas securely attached babies may be crying but they settle within a few seconds. These children will keep crying for minutes and will be very difficult to soothe. So that‘s the third pattern that you see: the adult with the hyper-activated attachment system that‘s very difficult to soothe.
ALEXANDER: Talking about the ―deactivated‖ brings me to the question about men and crying. It‘s kind of cultural, but how do men learn not to cry? I mean they‘re told not to cry? Their crying is not responded to?
NELSON: Well in fact, I did delve into that very deeply. We have a lot of mixed messages related to gender. It‘s true that the stereotype or the myth is that little boys are taught not to cry and little girls are supposedly okay to cry. But there are multiple, multiple, multiple examples where in fact, crying in young boys and in men is much more tolerated than crying by girls. Crying by girls is often criticized, it‘s demeaned, it‘s seen as weak, and girls are often socialized to be caregivers.
So when I was trying to get to the bottom of this, I thought to myself, ―Well how am I going to figure this out?‖ So I thought that maybe if I can figure out the age at which the difference in crying frequency between men and women occurs, that will tell me something. First of all, I had to determine that there indeed is a frequency difference and the average in western culture is about 5.3 times per month crying for women, and about 1.4 times per month for men. So there‘s a considerable difference in crying frequency.
However, when I began to look at the research in children, and there isn‘t much, but what
77 I did find showed that boys and girls were crying the same amount and in some instances, from very early on, boys were actually crying more until puberty. When I discovered that, I thought, ―Uh oh, maybe what we‘re looking at here is a biological difference rather than a purely socialization, socio-cultural difference.‖
The more I looked and the more I studied and the more I began to deeply appreciate the biological aspects of attachment behavior and how the one difference that we know of between men and women is that our hormone and endocrine and reproductive systems are different, I thought that perhaps differences in crying frequency could best be explained by a biological difference that emerges at puberty.
In fact, the levels of the hormone, Prolactin, which has to do with lactation and also is believed to be involved with crying, are the same in boys and girls until puberty, at which time the levels in boys go way down. So, perhaps we‘re looking at nature‘s way of preparing women who become pregnant, deliver, lactate for that kind of much more visceral communication between mother and infant that takes place early in life, so that would explain the increase in crying. It‘s all speculative but it explained it to me better than anything I could find that made sense culturally.
ALEXANDER: You mentioned the phrase, ―inappropriate crying.‖ What do you mean by that? When is crying inappropriate?
NELSON: Well, it‘s inappropriate in the sense that it is excessive for the loss. I mean, if someone cries because they‘ve lost a loved one or they‘re going through a divorce, that‘s one thing. If they cry because they drop their earring in the sink, that may be understandable depending on the earring, or if they‘re crying because they got a B- instead of an A on a test… I mean obviously this is all relative and has to be looked at in terms of the symbolic layers beneath these losses as well, not just on the surface -- trying to look at the level of grief response as it relates to what the precipitant is, including the unconscious ones as well. So you‘re looking at that.
Another thing is that protest crying is often not well received. I have many examples from newspapers where politicians or other people might be crying because they‘re angry about something, like crying in anger. That kind of protest crying makes people feel blamed and irritated and they feel ―manipulated‖ by this crying. It‘s usually around protest crying that you get into what might be called ―inappropriate crying.‖ It‘s socially uncomfortable and interpersonally uncomfortable, and doesn‘t really help to further the working through of the relationship or of the grief, whereas crying in despair usually has the opposite affect. It‘s a bonding behavior. It brings people together. It has a whole different feel about it that is much more healing and comforting than it is off-putting.
ALEXANDER: For instance, decades ago, it cost Senator Muskie the Democratic Presidential nomination when he cried in a press conference, because the reporters had been criticizing his wife, or something like that. He was then viewed as being unstable. But whatever the view of it was, is that kind of crying protest crying or is that crying in frustration?
78 NELSON: I‘ve never seen tapes of him doing it. Patricia Schroeder also cried when she dropped out of the Presidential race and was roundly criticized by feminists and by men for doing it.
But I think we have a number of problems going on: it can be protest crying. But I also think we‘re looking at national leaders who, in a sense, are highly symbolic, powerful caregivers to our culture -- we need a leader that we can depend on, almost like you could say ―a symbolic parent figure,‖ someone who‘s strong and capable. So when a leader ―breaks down,‖ I think it creates disturbance in people because they need to feel more secure and that kind of undoes it. It gets all caught up in the gender based ideas of crying.
Now, Bill Clinton, on the other hand, could cry at every press conference he ever had and everybody thought it was sweet. I mean, he had a very different way about him that didn‘t unnerve people at all. It seemed like it was part of his care giving style that people used to joke about, that he could ―feel your pain,‖ as he was always saying. So there was a sweet kind of connected way about his crying that was different.
Of course again, it goes back to that myth that it‘s ok for women to cry but not men, but in fact, in the research, it shows just the opposite. Very often, male crying is better received than female, although, as you point out, Muskie‘s crying, in that situation was seized upon as a sign that he was quite unstable and should not become president, which of course, he did not.
ALEXANDER: Well, the kind of crying that makes you want to laugh at a person?
NELSON: The comedic aspect of crying you mean… ?
ALEXANDER: Well, no -- when somebody is crying and your response is to not feel any empathy for them but to feel like they‘re ridiculous. It evokes a totally different, weird kind of response.
NELSON: Yes, it does. That doesn‘t usually happen in therapeutic relationships but it‘s a vehicle often used in situation comedies. Lucille Ball, for example, was often bursting into tears, making everybody laugh. So it‘s a comedic, kind of iconic way of appearing ridiculous, which says something about us as a culture as well as about the type of crying that‘s going on. It‘s usually protest crying and it‘s usually somewhat ridiculous.
In general, women and men alike are better served using their words when they‘re angry and protesting than they are by using tears because it does confuse the relationship message. So to the extent that any this can be taught to children, if a child is crying because they are offered an apple instead of a cookie and the parents get irritated, the tendency is to send them to their room and tell them to be quiet. But in fact, I think a better message is to say, ―When you‘re angry like this, you need use your words. Crying is for when your hamster dies and your leg hurts.‖ You‘re kind of consciously teaching
79 that there is a difference: that protest can be done verbally, whereas despair is appropriately expressed in tears.
ALEXANDER: Crying when a person is criticized -- I wonder if that isn‘t somewhat sado-masochistic, that the crier provokes an increasingly attacking response from the critic.
NELSON: Yes, that‘s a very complex, intersubjective experience. It‘s a relational experience you‘re describing: you have to have a critic as well as a criticized person, so you have two people there. It‘s Intersubjective. We look at three things: we look at affect arousal; affect attunement, and affect regulation. In this case, we have the affect arousal being intersubjectively accomplished, so the one person is actually ―making‖ another person cry, and so you have a very complex dynamic. There may be a punitive aspect in that person that they want to bring out pain in the other person. There may be, as you say, a sort of self-punishing aspect in the other one. The crier themselves may be wanting to punish the criticizer because that protest crying is aimed to make the other person feel bad as well. So it‘s a very complex, interconnected, and good example, of how that‘s true, really, with all crying.
All crying is relational. It‘s not the older idea of ―discharging bad feelings.‖ It‘s not about that. Rather, it‘s about the interconnection between people so that affect arousal, attunement, and regulation are happening in the intersubjective field.
Of course, that raises the question of solitary crying, which is an offshoot of what I‘m saying. There are internalized objects, or as in attachment language you could say ―internal working models‖ of our relationships that are built into us. These can become evoked, both in positive and negative ways, when we‘re alone as well. It‘s not necessary that the caregiver relationship be alive and present in the room, but rather that it can be an internal process that‘s going on in the crier. Solitary crying is also relational but it‘s internalized relationships rather than the external, visible ones.
ALEXANDER: To go more specifically to the intersubjective field between patient and therapist, when a patient is crying, how do you know what type of crying it is? How do you tell the difference, let‘s say, between nervous crying, grief crying, or angry crying?
NELSON: All I‘m suggesting that one needs to do is to know the difference between the stages of grief: protest, despair, and detachment. Those are the three types of crying, because 95% of crying that you‘re going to see in the clinical situation is going to be a grief reaction to something, or multiple things. The hallmarks of protest crying are that it has a more urgent, a demanding/accusatory feel, like, ―Do something about this. Can‘t you fix this? I‘m mad that this is happening to me.‖ In the counter- transference, it makes the other person, the therapist, feel sometimes accused, sometimes uncomfortable, sometimes apathetic, sometimes irritated… it‘s not a comfortable series of feelings for most of us.
80 Occasionally, if someone‘s just had a recent loss and they‘re grieving in protest, I mean if they just heard one of their parents died or something and they‘re crying in protest, ―No this can‘t be, not this can‘t be,‖ that‘s a very normal human reaction and we can all empathize with that. But when it gets caught up in the therapeutic relationship, the protest crying has a completely different feel. I have multiple examples in my book and also in the clinical literature.
As you‘re reading or thinking about one‘s own cases, you can think of the times when it seemed like this crying isn‘t going anywhere: ―Nothing I say is working. The person wants something from me and I can‘t figure out what it is, I can‘t give it to them,‖… you know, that kind of feeling. So, you have a person that‘s easily aroused, difficult to see, there‘s an angry accusatory quality, and a wish to undo a loss rather than to work it through. That‘s the hallmark of protest crying.
Then you have the crying of despair which is the much quieter weeping where almost universally, you feel empathic toward the crier.
Then the detached, depressive, inhibited crying where the person shuts down -- again when you feel very shut down, shut off - that‘s a very kind of depressive silence that leaves the care giver feeling helpless, sometimes even blamed: ―What did I do, why can‘t I fix this, why won‘t you let me help you?‖ That kind of feeling.
So it‘s really just those three things that you need to distinguish and then those also are typically related to the attachment style of the crier, too. Crying tells you something about the attachment style of the person, and the attachment style of the person tells you something about how their crying will be and how receptive they will be to therapeutic care giving.
ALEXANDER: When the patient says something to the therapist that‘s terribly sad, and the therapist begins to cry… let‘s talk about that. I know of a situation where a brilliant woman told her therapist that she had an eminent death diagnosis, and the therapist burst into tears and the patient didn‘t. I wonder…
NELSON: Do you know what the outcome was for the patient? I mean that can have both positive and negative outcomes depending on the attachment style and the state of the therapeutic relationship in the moment.
ALEXANDER: I don‘t think there was any particular outcome that I know about, anyway.
NELSON: Because there‘s been almost nothing written about this, I did do some research, just survey research on a couple of listservs that I belong to, asking experienced therapists to let me know their own patterns or their experiences of crying as a therapist. I have about equal numbers of positive and negative stories. Sometimes it works out really well; sometimes it causes a lot of difficulty, particularly earlier in a relationship when there hasn‘t been a longer term relationship.
81 For example, this is actually when I was out doing a reading, and this woman told me a story about herself as a patient. She had been seeing this therapist for about a year and she was telling this therapist a sad story and the therapist started to cry, and the patient said she couldn‘t wait to get out of there and never went back. Now the problem is that if it‘s too soon in a relationship and the therapist crying causes a break in empathy for the patient, and it can‘t be repaired, then the problem is for many people who have had to be caregivers to their own parents -- you know, the sort of compulsive care-giving that Bowlby talked about -- they see this as an appeal, that their therapist is making an expression for the patient to take care of them. So it can be very counter-productive.
On the other hand, most therapists see this and feel this as a real care giving behavior, that the crying is an empathic response, a deep empathic response to what they‘ve just heard from the patient. In the case that you just described, it sounds like that‘s what the therapist was feeling. So the therapist may feel one way about it and the patient may feel a different way. If they both are on the same page, it‘s fine.
Another example I have from the research I did: a therapist said he‘d been seeing this man for about ten years and the man was talking to him about his relationships with various men in his life, older men, father figures… and some of the pain he expressed, and as he was talking about this, the male therapist began to cry. The patient looked at him and said, ―Hey! Isn‘t this supposed to be about me?‖ But because he asked, and because they had a long term relationship, the therapist was able to say, ―Well yes, this is about you, but you know, what you were describing is such a common experience for so many of us men, and you did such a poignant job of describing your feelings, that it touched something deeply in me, as well as my thoughts and feelings for what was happening with you.‖ So in that case, they were able to repair it and move on.
ALEXANDER: What a great recovery!
NELSON: Yes, it really was. I have other examples of that too where therapists… there‘s another example of a woman who had just lost her husband and she was just back in the office and her patient had lost his father, and I think maybe the patient was like her son‘s age or something, so there were parallel, age generational kinds of issues here. As he was describing his loss of his father, she was identifying with her own son‘s loss of his father and began to cry. So she had to then share maybe more than she would have otherwise about what was touched in her and why. And while crying women were not normally a comfortable experience for this man, because she was able to process it with him, it was then able to be used to work through the relationship breakdown rather than to cause a permanent rupture.
ALEXANDER: It is a form of self-disclosure. It‘s very powerful.
NELSON: It is. To a certain extent, many people, many therapists, make efforts to control crying at various times or all the time, in some instances. But there are times when you can‘t control it like the example you gave where the person was just distraught to hear about the fact that the patient would be dying. Again, we talk about that
82 biological part of ourselves: this isn‘t a decision we make to cry. It‘s something that comes over us, just like it does over an infant, particularly around these kinds of intense losses.
I have lots of examples of crying at terminations. There is both some positive and some negative.
ALEXANDER: You mean for the therapist crying?
NELSON: Yes, terminating of the patient, either a premature termination or termination after a long term experience: some instances where this was a really positive expression of the sadness at the end of the relationship, and other times where it really complicated the letting go process.
ALEXANDER: What about when the patient is criticizing the therapist? The therapist has made a terrible mistake and done something that caused a tremendous rupture, and the patient is berating the therapist for this, and the therapist starts to cry?
NELSON: I only have one example of that and it was very disruptive, I mean it destroyed the relationship. It was actually a couple and they were seeing a couple‘s therapist. She had made an intervention in the previous hour that the two of them were uncomfortable with. When they came back and tried to talk to her about it, she burst into tears. It was the same thing, they never went back.
I knew the situation from various angles, and I happened to know that that therapist had recently lost her husband and had gone back to work without a very long interval, I‘m going to say a couple of weeks. And so I knew, but they didn‘t know that she was going through an intense grief reaction. So it‘s a very complex form of self-disclosure and has to be handled very carefully, but I think it really speaks to the need for therapists to be self-caring, and to make sure that we don‘t stretch ourselves and push ourselves, and end up burdening our patients when we‘re stressed or grieving. If we do, I think we need to be a little bit more forthcoming about the fact that we might be more vulnerable. For example, that therapist could have said, ―You know, this isn‘t really like me. I appreciate what you‘re saying, I want to understand what made you unhappy, but I‘ve just had a serious loss in my family and I‘m really not at my most able to be present and I apologize.‖ You know, that kind of thing, where you could really be a little bit more self- disclosing about what‘s going on in order not to burden the patient with your attachment needs, really.
ALEXANDER: I have one little detail to ask you about and that has to do with Kleenex.
(laughter)
I always made it a practice, if someone was crying and I had Kleenex that I would pass the box. I would hand them a tissue or I would hand them the Kleenex box. I don‘t know whether that was appropriate or not, but frankly, it bothers me when people cry and
83 the tears are running down their face, and they‘re not taking care of themselves by… I don‘t know, it bothers me.
NELSON: Well, I know. You might need to look at whether it‘s protest crying and they‘re really trying to get your attention in that way, but there are endless debates about the Kleenex box. The more sort of traditional people never would offer the Kleenex; sometimes they don‘t even have Kleenex. It‘s considered to be sort of a seductive thing to have a box of Kleenex in there. So there are endless debates about Kleenex.
However, what I would say as general rule is that offering something like that is a very powerful symbolic form of care giving and for many people, that‘s really what‘s called for. Because we don‘t have touch in psychotherapy, I like to say that‘s it‘s really like we‘re working with both hands tied behind our backs, because touch is one of the primary, biologically sound ways of soothing negative affect from infancy on. So since we work without that medium, we are dependent on symbolic gestures and words and tone of voice and body posture and gaze to transmit our care giving, so offering a box of Kleenex is a possible way to do that.
Now you would want to do that to someone who‘s securely attached. That would be good. Probably with someone who is, as you say, ―getting on your nerves because they‘re not taking care of themselves,‖ you‘d be looking at somebody more in the preoccupied, anxious/ ambivalent kind of attachment style where having prominent neediness is part of their presenting picture: wanting to be soothed; being difficult to be soothed; all those things. So again, giving them Kleenex is fine. That‘s part of what they‘re pulling for, although it probably won‘t do much good.
But with the avoidant person, the less attention called to this, the better. So for them, they‘re so terrified of crying and so wanting to shut it down that a therapist making a gesture of offering something like that could be over-stimulating and could make them feel much more shamed than they already do. Of course this would be early in the relationship. Later, you might like to see things move along a bit, but early on, looking at the different attachment styles helps you to then determine what kind of interventions to make, even with something as seemingly simple as offering a Kleenex.
ALEXANDER: A patient is always crying, chronically weeping, the slightest thing triggers their crying response, and they say to you, ―Don‘t pay any attention to this.‖ They say, ―I cry all the time. Don‘t even listen to it. Don‘t pay any attention to it.‖ I mean that really ties your hands.
NELSON: Yes, except there are a couple things to look at there. One is that certainly you‘re thinking about the mixed messages of people who have highly activated attachment systems and are telling you to ignore it, which is obviously a contradiction in terms. You can‘t ignore it. We‘re not built to ignore it; it‘s not meant to be ignored. So that‘s one big contradiction going on.
It doesn‘t go without mentioning -- remember I said that 95% of crying is a grief
84 reaction? Within that other five percent are two kinds: one are somatic tears, which are linked to physiological disorders, so that some crying, post-stroke, multiple sclerosis, thyroid cancers, thyroid disorders, endocrine disorders of various kinds, there are a whole list of people who cry without emotional content, based on physical things. Those people should be evaluated by a physician. So if someone‘s crying all the time and says, ―Don‘t pay attention to it; it doesn‘t mean anything,‖ there could be a psychological explanation but there also could be a physiological one that needs to be tended to. I recently had a patient - they were a couple - and I had seen them earlier and they came back in and the wife was crying all the time and she was upset all the time, and her husband joked and said, ―I think her medications aren‘t working; I can‘t figure it out.‖ Anyway she ended up having a pituitary tumor which was responsible for this crying.
So, you have to consider that there may be a somatic condition underlying the kind of chronic crying that you‘re talking about. There may not be. It may be that hyper- activated attachment system that the person‘s trying to cover up, but it may also be that there‘s something that needs to be treated. So I think that‘s a good reminder for people who are thinking psychologically not to dismiss the fact that crying is a physiological bodily act that involves numerous systems of the body that can be responsible for increased tears.
ALEXANDER: Your knowledge of this is really encyclopedic!
NELSON: I have to agree with you, but it represents many, many decades of work and study and focus, so I have, I think, pretty much soaked up what there is to know about crying at this point.
ALEXANDER: Is there anything else you‘d like to share with us or any points you‘d like to make before we have to stop, or before I have to cry because we‘re stopping?
(Laughter)
NELSON: Well, I‘ve appreciated being able to speak with you and I know it‘s a lot to take in but the theory that I use is heavily based on attachment theory, so the more you know about attachment theory and research, the more sense this will make.
We haven‘t touched at all on the neurobiological aspects of any of this, which is certainly understandable in the amount of time we have, but just to say that increasingly in the last ten to fifteen years, there‘s a lot of neurobiological evidence to support all of the attachment research and all of the looking at affect arousal, attunement, and regulation and the importance of that from early in life, and the importance of understanding the infant/ caregiver relationship and the responsiveness and regulation of affect early in life and how that impacts us throughout life. So that‘s another whole layer of work and research that we haven‘t touched on which I would encourage people to read and study as well.
85 ALEXANDER: Can I tell you a funny story? I‘m sure everybody tells you stories…
NELSON: Sure.
ALEXANDER: Our daughter got married and there‘s the whole thing how you cry at your daughter‘s wedding, whatever. So no tears, no nothing. It was just kind of all process. Well anyway, then my husband and I were driving somewhere and we saw this big cathedral, it was really a basilica church in Chicago. We had never really gone into it. It was on a Saturday so… ―Let‘s go see it.‖ At any rate, we are sitting in the back of a church and it‘s a wedding. Both of us started crying hysterically. The bride and the groom, you know, when they come back down the aisle, they see these two people. I‘m sure he thought it was her relative, and she thought it was his side.
NELSON: That is so cute.
ALEXANDER: It really was quite amazing.
NELSON: It makes me think. My sister said when she went to see, I think it was a Steve Martin movie, ―Father of the Bride,‖ which is a comedy you know, and she said she had never heard so much crying in a theatre. Men were crying, women were crying. I mean, she said it was unbelievable, and that‘s a comedy about weddings. Not even your own wedding. So, something about that. When we think of weddings, we think -- I didn‘t get a chance to talk about joyful weeping, because people usually ask about grief.
People often ask that if crying is a grief reaction, what does that mean when you‘re weeping for joy, like at a wedding? And I think it‘s clear at a wedding that it is a joyful moment but it‘s also a culmination and a moment of loss. It‘s the loss of childhood, the loss of the family ties as they had been in childhood, it‘s a huge kind of milestone in terms of transition from one phase of life to another, from one way of relating to family to another way of relating to family, and I think that‘s often true of joy.
There did turn out to be a couple of psychoanalytic articles about weeping at the happy ending, crying at the happy ending that talk about how that can often be a delayed grief reaction, or a mixed grief reaction. For example, if the parents of a kidnapped baby cry at the time the baby‘s found as opposed to the time when the baby‘s missing, you see that it‘s all the outcomes that were avoided that they can then feel safe enough and secure enough to grieve and process and work through. Or when the Olympic champion cries at winning the championship, it‘s also that they didn‘t lose, and that all the other people around them that they could so easily identify with and so easily be, did lose. So, there‘s always loss in those moments of joy, or almost always.
Then in the moments when the crying is purely joyous connection, attachment, like aesthetic experiences or seeing the sunset, or a beautiful ballet, or something like that, that falls within that 5% of non-grief crying that I would call, ―transcendent crying.‖ It transcends personal loss and actually moves into the realm of attachment and connection. It‘s about crying about universal connection as opposed to loss. It a rare but highly
86 evolved and beautiful experience for the people who have it. It can be part of religious and mystical experiences as well. So that would be pure joyful crying, which would be transcendent crying.
ALEXANDER: Dr. Nelson thank you very, very much for all this wonderful information and the need to learn so much more about it. I very much appreciate your time. I very much appreciate your knowledge.
NELSON: Thank you so much, and I appreciate you inviting me to share it with you and your listeners.
This concludes our interview with Dr. Judith Nelson. We hope you learned from this interview and that you enjoyed it. You may contact Dr. Nelson at (510) 540-7315; Email: [email protected]. Her book, Seeing Through Tears: Crying and Attachment, is available through all major book sellers.
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
87 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“The Impact of the Economy,” part 1
FRANK SUMMERS, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
FRANK SUMMERS, Ph.D. 333 E. Ontario, Suite 4509B Chicago, Illinois 60611 Tel: (312) 266-8230 Email: [email protected] Author: Object Relations Theories and Psychopathology
Welcome to On Good Authority. I‘m Barbara Alexander. You are listening to or reading interview #7, which is the first of two interviews on the subject of the impact of the economy on the therapeutic relationship.
The experience of psychotherapy can feel both to the patient/client and to the therapist as if, for those 45 minutes or an hour, they are in a world of their own, on a private island, much like being in the fictional, ―Brigadoon,‖ a world floating and unconnected to time and external reality.
Lovely thought and lovely experience. Real for those 45-60 minutes, but not real, not exactly. Once the patient is out the door of the therapist‘s office, the external world is restored and the patient returns to the context in which he or she lives his or her life.
We are embedded in our world, in our context. For better or for worse, that includes the economic world. The economy goes up and the economy goes down. When it‘s down, people lose jobs, they lose their incomes, savings become depleted. Then they have to make some tough decisions about what is most important to them.
These events make an impact on the therapeutic relationship. Do we reduce our fees or not? Do we cut back on the frequency of sessions? How do we explore the meaning of this with our patient, who may be in reduced circumstances, but who also may have other issues about this decision specifically related to their therapy?
88 In these two interviews, we will hear two somewhat different opinions on this subject. Upon what does this decision to change the structure of the therapy depend? Do we hold fast to ―the therapeutic frame?‖ Or can we be somewhat more flexible?
Our first speaker, Dr. Frank Summers, takes the more flexible position. He views this recession as more serious than any that he has ever seen, and therefore he feels that his job as a therapist is to take the reality seriously, to see if he can judge whether there is a reality there based on the situation that the patient is in, and not try to force the issue one way or the other. He says that it‘s a very delicate issue. You don‘t always judge correctly but you try to investigate both sides of it, always: where‘s the anxiety and where‘s the reality?
Frank Summers, Ph.D., is an Associate Professor of Psychiatry and the Behavioral Sciences at Northwestern University and holds faculty positions both at the Chicago Institute for Psychoanalysis and the Chicago Center for Psychoanalysis. His previous book, Object Relations Theories and Psychopathology has been hailed as the best available survey of contemporary psychoanalytic theory and technique. In his current book, Transcending the Self, Dr Summers provides case discussions demonstrating how psychoanalytic therapy informed by an object relations model can effect radical personality change. Dr Summers maintains a private practice in psychoanalysis and psychoanalytic psychotherapy in Chicago.
ALEXANDER: Dr. Summers, I‘d like to discuss what the impact of the economy has been on people‘s psychotherapy practices: the impact on their clients and the impact on the therapists themselves, so if you have any overall impressions, then we can get into a little more detail, please.
SUMMERS: My overall impressions are that every time there‘s an economic downturn, there‘s an impact on practice on a couple of different levels. This time I see more impact than I have in the past. Sometimes psychotherapeutic practices, at least mine from my perspective, are not terribly affected by what goes on in the economy because you‘re dealing with a certain limited number of people, and if it doesn‘t happen to impact them, it doesn‘t impact the practice that significantly.
This time I see a difference, I see various kinds of issues that are coming up at different levels. First there is the level of patients‘ ability to come and get the help they need, and second, the issues of the kind of psychological impact the economy has on people, which is also highly significant, and that second part is something I‘ve seen much more this time than I‘ve seen in previous recessions.
First of all, with regard to the first area, just like with any recession, it will affect some people and they will feel either they can no longer afford psychotherapy, or that they have to cut down on the frequency of sessions. In the past, I have seen that to some degree but never enough to significantly enough to impact my practice. This time I‘ve had people who have lost their jobs and therefore had to quit summarily in the middle of
89 treatment, and of course number one, that is a problem for anybody in psychotherapy. Having to leave is one problem, but then having to leave when it‘s out of your control and suddenly, without even any ability to be able to say goodbye to the therapist, makes the problem even worse. That‘s much more difficult and what it does is it adds a trauma at a time when people can least afford it, so they‘re already traumatized by loss of job or loss of income such that they have to cut out therapy, and then that they to have do it suddenly adds to the significance of their woes. So those are the kinds of things that I see going on this time that I haven‘t seen in previous recessions.
Something I have done, I‘m starting to do that I‘ve never done before is if somebody -- and I‘ve had this with a couple of people -- calls me and says, ―I just lost my job, I can‘t come in anymore,‖ I will say, ―Come in for a free session at least to say ‗goodbye,‘‖ because at least I want them to have the opportunity to talk about what‘s happened. So that‘s a kind of adaptation I‘ve made that I‘ve never felt the need to make before because in the past, people have usually been able to come in once or twice at the end. They‘ve gotten some notice and so they‘ve at least been able to come and say goodbye and at least, work out the leaving and the loss.
This leads me to the second arena, which is an area that I have seen this time that I have never really experienced, at least certainly nowhere near this degree in the past. Even when people do come in and let‘s say they still have a job, they are very, very anxious about job security, about economic security, about being able to afford their bills. And so of course, the anxiety is going up so they need more help than they did before. So despite the anxiety, they don‘t want to leave but now they have a new conflict because they‘re afraid that they might lose their job and if they continue with their therapy, they now have an increased anxiety because they‘re afraid they should be saving that money that they‘re spending.
Number two, they may decide therefore that they just don‘t feel like they can come so that increases the anxiety of problems they already have. So the economy is having a significant impact on people even if they‘re not affected in the sense of actually losing their job or having a direct, significant loss of income.
The other thing I see is that there are people who may be making the same amount of money or relatively close to what they were making before, but they‘re losing in terms of their portfolio. They‘re losing their retirement savings. This is something I have never heard discussed before in other recessions. It was always about, ―Am I making as much money? Am I going to have a job?‖ This time you have people who still may be working but they‘re watching their portfolios be dramatically reduced and so they‘re getting anxious about their future. Are they going to be able to retire? Should they cut down on their expenses now? What should they do? So there are a variety of levels in which the anxieties about our economy are infiltrating into the psyches of the American people. And again, unlike other recessions, I have this with just about every patient I see. There is a significant sense of concern that the economy is going downhill. They see their savings disintegrating. It‘s making them very anxious. If they have a job, they‘re not sure they‘re going to continue to have it. Even if they do, they may be making less
90 money. If they‘re not on salary, if they‘re doing something like sales, they‘re watching their sales go down. So there are levels.
I‘ll give you an example: I have a patient whom I was seeing once a week. She came in for a session and she said, ―The good news is I still have a job; the bad news is on Friday, half of our company got cut.‖ So she felt what she had to do was cut down to every other week, which you really can‘t afford to do psychologically, but she felt she had to do it financially because she‘s not sure if her company is going to make it. They may wind up closing their doors, so she feels she needs to save every penny she possibly can. Also, the savings she does have, of course, is significantly reduced because of the drop in the stock market. So she‘s really making the same amount of money, but the anxiety is such that she can‘t get the help she needs and of course, it‘s at a time when she feels worse than she did before, and she needs more help.
The other very interesting and also distressing part of this economic downturn compared to others is this: I see people from all over the economic spectrum. I see people who live from fairly marginally or modest incomes to people who do not have to worry about money. In the past, that latter group has not really been affected significantly, in fact, not really affected at all by recessions. But this time, because of the loss of investment income, I have some extremely wealthy people who never thought they would have to worry about money, who are very worried about it and are having to cut down their psychotherapy.
Here‘s what‘s happening. This is what‘s different to me than in the previous recessions. I have people who have a great deal of money, who are retired. I‘ll give you an example, I have this man in treatment who is retired but who has substantial wealth. He never thought he‘d have to worry about money. He put a lot of his money into a spectacular real estate house/ land, complex where he lives and has another huge piece of land. Now, he‘s lost a great deal in the stock market. On paper, he‘s extremely wealthy but because he lives on investment income, his income is significantly reduced. He‘s living in what appears to be a spectacular lifestyle, but he can‘t sell either of his pieces of property. There are no buyers. If he could sell, it would be way below his mortgage so he would take a big loss. So he‘s cutting down on his psychotherapy. Even though on paper he‘s worth a tremendous amount of money, he‘s really not because he can‘t get rid of a lot of his wealth, so his day to day income has been significantly reduced. That‘s the kind of the thing I‘m seeing in this economic downturn that I have not seen before.
ALEXANDER: So at a psychotherapeutic level, where do you move with this? Do you move with the reality of it? How do you know there‘s not a certain level of resistance? Let‘s say they‘re at a dicey part of their treatment and this is a way out. How do you differentiate these things?
SUMMERS: That‘s a really good question and under normal circumstances, I look at these kinds of issues, or tend to look at them more as resistances, especially if people are getting into, as you call it, ―a dicey part of their treatment.‖ You think, ―Well this is a way out confronting and dealing with things that they don‘t want to deal with.‖
91
We have a saying in the field: ―Reality is always the best defense,‖ right? If you don‘t want to deal with something, you try to put it on something real like loss of income or anxiety about income. But in this situation, I find myself operating differently because there is just too much reality there that people have to confront.
So, what do you do as a therapist? Well, number one, you have acknowledge that there is a reality, and then it depends on your knowledge of the patient, their history, and what aspect, what part of the treatment they‘re in. If you have people who are in a particular part of their treatment that isn‘t the most difficult -- they‘ve dealt with other more difficult issues than they‘re dealing with now -- and they suddenly say, ―Half my company has been decimated and I‘m worried about having a job,‖ you try to investigate, well, what is the reality of that? What‘s going on? What‘s the company‘s situation? And you find out now, more than I used to, that there is a reality in the facts and figures and the numbers. I feel like myself as a therapist, I have to acknowledge that reality, at the same time addressing the person‘s anxieties, their issues, their need to not deal with things, so you kind of deal with it at both levels.
I feel like my job as a therapist is to take seriously the reality, see if I can judge whether there is a reality there based on the situation that they‘re in, and then address both and not try to force the issue one way or the other but say, ―Look, okay, this is going on. On the other hand, you‘re highly anxious about the things that we‘ve been talking about. We know that you‘ve tended to avoid those in the past. Can this be another instance of that?‖ And then you go from there, depending on what their response is.
But when you have people who aren‘t in a particularly anxious situation, like the one example I gave you of the woman whose company was cut in half, she has dealt with far more difficult issues than we‘re dealing with now. She‘s not at a particularly, as you call it, ―dicey‖ part of the treatment, so I‘m tending to go weighted more on the side of reality.
The bottom line to it is that there is always both, and as a therapist you have to be aware of both. I would say that in the past, I tended to look more at the psychology of issues that came up, psychology of economics, and I still do, of course, but I‘m giving more weight to the reality of this very severe recession that we‘re in. I look much more carefully at what is the reality there. But there‘s always a psychological component. Both are there. I‘m always looking at raising the issue of, ―Are there things that are avoided by having to cut down or having to cut out their therapy right now?‖
But when somebody loses a job, like I had one guy who was a recent arrival to Chicago. He had just gotten a job with a firm. He was the last person hired so when they made cuts, he was in the first group of cuts to go. He was living paycheck to paycheck. With him, we hadn‘t gotten far enough yet. We had only met a few times. I didn‘t feel like we could talk about it. There‘s always anxiety for anybody in psychotherapy, but I think it‘s clear that he would have been in therapy if he still had a job. He would have been anxious about it, there would be defenses, but he would be there. You can‘t very well, I
92 don‘t think, expect people to choose between therapy and eating and paying the rent, which was his situation.
So, it depends on the situation, it depends on how long they‘ve been in treatment, it depends on the phase they are in treatment, it depends more than anything else on what‘s been coming up, what issues have been there. It‘s a very delicate issue. You don‘t always judge correctly but you try to investigate both sides of it, always: where‘s the anxiety and where‘s the reality?
ALEXANDER: Let‘s say that you say to somebody, ―Well, I understand your reality and I can see that this is difficult, but at the same time, is there any other reason why you might want to be leaving?‖ And the person explodes at you and they say, ―What‘s the matter with you? Why don‘t you understand what I‘m saying?‖ So then where do you go with that and how do you understand that?
SUMMERS: Where you go with that is you say, ―I do understand what you‘re saying,‖ and you show them you understand. ―I understand that there is this reality,‖ and I will show them that I understand what they‘re saying, and then I say, ―I understand that, but I also know that there could be more reasons for anything. And I know that‘s a reality, and that causes you great concern and would cause anyone great concern, but my role as your therapist, my professional responsibility is to wonder if there is anything in addition to that.‖
I think where you get into trouble would be if I were to say, ―Well it‘s not really the job situation, it‘s really your anxiety about what‘s been coming up in therapy,‖ and I think that dismisses people‘s experience. What I try to do is not dismiss people‘s experience and say, ―I understand that and I think that is real and I get that, but that is a reason, it may not be the only reason. There may be other things and it‘s my job to ask if that‘s the case, if we can look at something beyond that that might be going on, something that might have been going on here,‖ and I might mention specific things that came up in the previous session.
Now, if they continue to explode and say, you know, ―You‘re crazy. Don‘t you understand? I can‘t afford this!‖ Ok, you know, that‘s fine. It‘s my job to ask the question anyway, I‘m not going to not ask it because somebody may be offended by it as long as asking it is in the context of showing that I understand their experience. I think that if you understand people‘s experience, then they tend not to explode, and if they do, it‘s not in the context that you‘re not getting what they‘re saying because you are getting what they‘re saying, but they don‘t want to deal with anything beyond that.
Then of course, you wonder. That usually is an indication of resistance and that there is defensiveness there, because the people who are concerned about their therapy, who may have to diminish it or cut it out completely for economic concerns are not the ones who are going to explode if you say, ―Well I get that. I see what‘s going on here and I understand your anxiety and is it possible there are other reasons?‖ The ones for whom it is the economy don‘t explode. They tend to say, ―Well, there‘s nothing I‘m aware of,‖
93 and they tend to be more open about it, and they usually do say, ―Well, not that I‘m aware of,‖ but you know, ―maybe there‘s something else going on and we‘ll explore it together.‖ If somebody explodes, it‘s usually an indication you‘ve hit a sensitive nerve there, and of course it may not always be that it‘s a defense or resistance, but it usually is. Not always.
ALEXANDER: Because after all, people don‘t need permission to leave treatment. I mean, all they have to is just say, ―I‘m not coming in anymore.‖
SUMMERS: Right, and that‘s, of course, what some people do. Those are usually the extreme cases where somebody just says, ―I‘m not coming in anymore.‖ That‘s like my example of the young man who lost his job. He just said, ―I just can‘t do this. I don‘t have a job, I don‘t have savings. I don‘t know how I‘m going to pay the rent, I don‘t know how I‘m going to eat, I don‘t know what I‘m going to do.‖ And he really appreciated the fact that I said, ―You‘ve got to eat first. Therapy is very important. I think you need it, but you‘ve got to eat first.‖ There is a hierarchy of needs in people, but that‘s an extreme situation.
Usually people come in and they talk about it, and you have a chance to explore it. Sometimes some people are unconsciously asking for my approval, my endorsement of their leaving, and then that‘s something that we talk about. Then I‘ll say, ―Well, it seems like you want to know if I agree with this,‖ or ―You want me to approve of your leaving.‖ Then often they‘ll say, ―Well yeah, you know, I don‘t want to feel like I‘m doing this against your wishes.‖ Whatever it is, it becomes a significant issue then, their need for my approval because, like you say, obviously they don‘t have to have my approval.
Other people are not looking for my approval. They‘ll come in and they‘ll just say, ―I think I have to do this. I‘ve thought about it and I just don‘t think I have any choice.‖ So yes, if somebody really wants to leave, they can, of course.
But a lot of people want to feel like I understand, and many people really would like to continue. Of course, we‘re talking about extreme cases that quit. I haven‘t had that many people who have out and out quit. More frequently it‘s, ―I want to cut down to save money,‖ and then of course we‘ll explore that.
Then sometimes, and this I‘ve seen in every economic downturn, what will happen is they will cut down because again, if people say, ―Look, this is all I can afford,‖ even though you explore it, that may be what they‘ll do. It isn‘t up to me; ultimately it‘s their decision. We‘ll cut down. I see them less frequently and then as we begin to explore things, things come up and it‘s become clear that they wanted to cut down because there is something very difficult for them that they could feel was coming up and they wanted to avoid, and they could avoid it better if they came in less frequently. So that will usually come up. We usually see that if that‘s what happens.
94 The fact that they cut down, if they‘re still coming, doesn‘t mean that‘s the end of the story. There‘s always the opportunity to explore things and find out and often, they will then return to coming more frequently, but a lot of times it‘s much more complex than that. It‘s, ―Yeah, it was a relief to cut down because I didn‘t want to have to deal with my anger,‖ or ―I didn‘t want to tell you that I have been gambling my money away, and I could avoid it better if I didn‘t come in, and here I am in the middle of a recession. I‘ve lost this money and now I‘m in a pickle. I didn‘t want to have to deal with that.‖ Those kinds of things will come up, but there‘s also the reality that they are in an economic pickle. These things are often not simplistic explanations that it‘s either a defense or it‘s some realistic economic concern. More frequently than not, it‘s both.
ALEXANDER: How do you deal with, or do you get requests to reduce your fee?
SUMMERS: Sometimes I do but most people will not do that. They will assume that my fee is my fee and they have to cut down. Sometimes I‘ll even raise it with them. I‘ll say, ―Well, what is the situation? What can you afford?‖ and I‘ll suggest a fee reduction. It may be temporary. It may be just while they‘re in a difficult situation or until they find a job or something like that, and then it would go up to the normal fee.
It‘s not too frequently that people will ask for a fee reduction once they‘re in therapy. When they start, a lot of people will say, ―Well, do you reduce your fees, or do you slide?‖ or something like that. My response to that is that I may do that if there is a need, and then I ask them to tell me about their financial situation, because if they‘re asking for something, then they have an obligation to tell me what the real situation is. If they‘re unwilling to do that, then they just pay the regular fee. But of course, usually they are. They‘ll say things like, ―Here‘s what I‘ve lost, here‘s what I have, here are my concerns,‖ and so on. And then you get a sense of where there‘s a need, and very frequently I‘ll say, ―Yeah, I can see you‘ve lost some income, or I can see you‘re anxious about it, but as far as my fee is concerned, you‘re not in that group of people where I would feel like I have to reduce it. I still feel like there‘s money there to afford my fee.‖
It‘s a question of how you allocate it, because a lot of people they want you to reduce their fee so that they can use the money for something else, right? So it‘s a question of priorities and there‘s an implied denigration of psychotherapy in that – ―I‘d rather have money for other things, for more entertainment and less for therapy,‖ They‘re devaluing the therapy by that. It‘s something you have to be very, very careful by that.
On the other hand, there are people for whom it is just a reality. They are paying me a significant percentage of their take home pay to be able to see me as frequently as they do, and for those people, if they‘re going to pay me a significant percentage of how much money they make, then I‘m going to be willing to reduce my fee so they can continue to come frequently. And some of those people are coming four to five times a week.
ALEXANDER: Would there ever be a situation that you could imagine where somebody would say that they would want to cut back, and you would say, ―That would absolutely not be in your best interest. I think you would be better served if we were to stop?‖
95 SUMMERS: I‘ve never said that. In some cases, I have said to some people in some cases who say they want to come, let‘s say, once a week, ―I cannot treat you once a week. I just don‘t think it‘s possible, I can‘t find a way.‖ I will repeat to them, I will say to them, ―With this, this, and this, these are the things that we‘re dealing with and that you need help with. I can‘t see any way we can do that once a week.‖ I‘ll leave it at that. I won‘t say, ―You‘re better served if you don‘t come.‖ I‘ll just say that it‘s not possible, and then it‘s back on the patient and then they have to struggle with that.
Sometimes they‘ll say, ―Well why not?‖ and I‘ll say, ―Look, here‘s all the things that we‘re dealing with. Here‘s all the things that have come up or that you say you want help with and I don‘t see any way I can do that.‖
I‘ve done that with a number of people because I feel there‘s a kind of fraudulence. If I don‘t believe I can treat them once a week, it‘s fraudulent of me to go ahead once a week. Now I‘m not a genius. I don‘t know exactly how many times. I can‘t say I would ever say, ―Well, it has to be three times a week or four times a week,‖ or some significant, some amount because I don‘t know that. But I can make a judgment. I feel I‘ve got enough experience to say, ―Once a week is not going to work.‖ You know, it might be two or three times a week, or four times a week. I may not know the exact number, but I know that it‘s got to have more continuity than that.
I‘m always surprised; I shouldn‘t be anymore. It‘s a very common experience for me to have people who are surprised because they‘re assuming they‘re going to come once a week. That‘s something a lot people, for some reason, just assume that that‘s what they‘re going to do. And I say, ―You haven‘t thought about more frequently. There‘s no rule that says it‘s got to be once a week,‖ and we talk about, and I tell them why I think it‘s better because, ―You need more continuity, you need to have the material more fresh, and at once a week, there‘s a long time that passes.‖ I always find it geometrically better to see people twice a week versus once. Almost anybody.
Let‘s put it this way, it‘s a common experience of mine to have people say, ―Oh, now I see why it‘s important to come more than once a week. I never did this before.‖ They see the continuity. They come Monday and Wednesday -- that Wednesday session is so much more meaningful because they‘re connecting much more with what happened. They feel the sense of continuity. Therapy is much more a part of their lives. It‘s not peripheral and they can‘t defend as easily as they could once a week and it‘s very common for people to say, ―Now I get it. Now I see.‖ They have to actually do it and try it.
ALEXANDER: Well, very helpful, Dr. Summers. Any other thoughts you have on this subject?
SUMMERS: I guess the one thing I would say, and I alluded to this before, but I think it‘s important for people to understand that at least in my experience, I mean I‘ve been around a while. I‘ve been through a few recessions. I‘ve never seen so many people across the board no matter where they are in the economic spectrum, have so much
96 anxiety, feel so uncertain about their present and their future, and have their economic concerns be so much at the forefront of their anxiety.
While as therapists we can say, ―Well, for some people, that‘s an easy out, a defense against other things that are more difficult for them,‖ for a lot of people, it is a central anxiety. It‘s actually much harder for them than a lot of other things that they may have felt or dealt with in the past. I mean, to be worried about if you‘re going to be able to survive financially creates a tremendous amount of anxiety for people and I‘ve never seen it so pervasive. There is a kind of anxiety throughout the country in the last, I would say, year and a half or so that I‘ve never seen before.
ALEXANDER: Well, as I was listening to you and finding myself becoming a whole lot more anxious …
(laughter)
SUMMERS: Well, I‘m sorry—sorry about that!
ALEXANDER: it made me wonder how you are managing your anxiety, if you have any, about this?
SUMMERS: Well I do, sure I do, and I‘m trying to manage it as best I can. Luckily, I happen to be in a position that‘s a little better than a lot of people: our house is paid off, which is a big source of relief; the money for our kid‘s college education has been saved in a safe way where it‘s not going to be affected by the stock market. So we do have certain basic things that are taken care of, and I try to remind myself of that.
Like everyone else, I‘ve watched my portfolio go down and that does create anxiety, but I try to balance that with my relative position. When you think of all the horrors going on in the world, it‘s really hard for me to feel sorry for myself and luckily, I still have a decent income and so I just feel like I‘m far more fortunate than a lot of people, and so I don‘t let myself get too anxious about it.
The other thing is I‘ve lived through a lot of these economic downturns, and they go down and they come up. It‘s just part of a capitalist economy. You‘ve got to ride them out. It‘s something I try to remind myself of.
ALEXANDER: Good, I‘m glad. I will remember those things too. Thank you.
SUMMERS: Alright, Barbara, thank you so much. It was great talking to you.
This concludes our interview with Dr. Frank Summers. We hope you learned from this interview and that you enjoyed it. You may contact him at (312) 266-8230; email: [email protected]. To order Dr. Summer's book, Object Relations Theories and Psychopathology, call the Analytic Press (800)-926.6579, or any major book seller.
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I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
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© On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“The Impact of the Economy,” part 2
KARLA CLARK, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
KARLA CLARK, Ph.D. 1330 Lincoln Avenue San Rafael, Ca. 94901 Tel: (415) 456-3138 Email: [email protected]
Welcome to On Good Authority. I‘m Barbara Alexander. You are listening to or reading interview #8, a continuation of our two interviews on the impact of the economy on the Therapeutic Relationship.
Unlike Frank Summers, who has perhaps a more flexible view of what is referred to as ―the therapeutic frame,‖ when it comes to situations where the patient in economic trouble needs to change the structure of the therapeutic relationship, Dr. Karla Clark says that the decision to reduce the fee or the number of sessions depends on the internal structure and diagnosis of the patient. Fewer sessions might not be in the best interest of the patient; such a change could rupture the self-regulation that‘s happening and the patient could go into a decline.
When in doubt, she relies on ―the therapeutic frame,‖ that basic real world agreement between patient and therapist. The contract has to be non-exploitive on both sides, fees have to be reasonable and the patient has to agree to pay them because those are the ground rules of a relationship that will work on any level, but most particularly, in psychotherapy, that‘s the ground work on which basic trust can be formed.
Dr. Karla Clark, received her PhD from the California Institute for Clinical Social Work. Following that, she spent several years in advanced post doctoral training in Psychotherapy of Disorders of the Self at the Masterson Institute, where she was a faculty member for nearly 10 years. She is a very popular speaker and has written several
99 papers on work with patients having disorders of the self, from a developmental, self and object relations perspective.
ALEXANDER: Dr. Clark, let me pose a hypothetical question to you: the economy is in terrible shape right now; many people are unemployed or in difficult straits or their portfolios have tanked …
CLARK: When does the hypothetical part start?
(laughter)
ALEXANDER: Anyway, you‘re a therapist and a patient comes to you, somebody you‘ve been seeing -- let‘s say you‘ve been seeing him or her long term for a couple of years, twice a week, let‘s say. And they say, ―Look, I can‘t afford to do this anymore. Maybe I can come once a month for a touch up.‖
The overall questions are these: how do you understand this? Are there variables within the person that you would need to explore? Do you take it at face value? and How do you manage the feelings that you have about it? So there are a lot of very interesting questions that come up about this situation.
CLARK: There sure are, Barbara, and of course, as you well know, this is not hypothetical at all. This is something that is confronting me and everybody I know every day now, and the complexities in it are enormous.
So let‘s start with this: ―a patient‖ is a very abstract term, right?
ALEXANDER: Right.
CLARK: An individual person is not abstract at all. So the first and the most obvious thing is that there is no general answer to this, but there are general guidelines that you can use to sort of wend your way through the problem.
The first guideline is this: do you have a therapeutic alliance with the patient? Some- times you can see somebody for five, six, seven, ten years, and they‘re happy to be with you, but they‘re not doing the introspective work of psychotherapy. They‘re using you for self-regulation, they‘re using you for self-esteem, they‘re using you for all kinds of reasons, but not for a depth therapy.
So the very first question you have to ask yourself is, ―What is the nature of the contract this particular patient has with you at this moment?‖ and ―Is it a stable contract? Are you trying to work towards something?‖
In other words, the patient might be seeing you because in their mind, they get a lot of soothing from feeling as though you and they are much alike and they feel understood.
100 They feel calmed and settled and soothed by the fact that they feel as though you are very much in sync.
Well, as you know, that kind of patient is going to stabilize if you see them a couple of times a week, and they may do pretty well with it. In fact, they may do very well in their lives. But it‘s very dependent on the regularity of the contact, and the patient is not actually making progress in managing their feelings about not having a like mind to others, if you follow me.
So with that patient, you have a very serious set of problems that have to do with that. This patient is using you for self-regulation and merger. The patient doesn‘t know they are; they have no interest at all in being any different from this. They are just using you that way and feeling fine.
Well, if that patient wants to cut back, it could rupture the self-regulation that‘s happening and the patient could go into a decline. So if that‘s going to happen, or if that might happen, what you‘d have to say to the patient about it is that you can try going down to once a week. I think it should be obvious to you why you wouldn‘t say any less than that because that patient simply couldn‘t manage it. That patient would be better off stopping all together rather than trying to maintain a merger-transference on a less than weekly basis. They just can‘t do it. So you might want to recommend that that person stop altogether. But let‘s say they want to cut back to once a week. You could say, ―We can try that.‖ Don‘t rupture the merger at the moment. Let it be. ―We will see how it goes, we will evaluate it together.‖
I‘m going to stop for a minute before I go on to give you examples of different kinds of patients who you don‘t have think about that way to say this: one of the things which is a tremendous pressure on therapists and patients at times like this is confusion about what therapy is and isn‘t, whether it‘s friendship and relationship, or what its parameters are. Patients are almost always confused about that: they see you as a friend; they see you as a mother; they see you as an enemy; they see you as a lot of things, but very rarely do they see you neutrally as somebody who‘s trying to help them within a rather formal dance, within a rather formal arrangement.
You, on the other hand, if you have your counter-transference under control, which all of us do only part of the time, remember that this is a very bound relationship with certain conventions which cannot be violated. So for example, a patient might plead with you to go down to once a month because they can‘t afford to see you more often than that. But you would know that at once a month, with very, very few exceptions, nothing is going to happen. In fact, it might encourage a kind of regression in the patient rather than anything helpful.
So, as a human being you might think it‘s perfectly reasonable to be flexible, to go down to once a month to try to maintain whatever relationship you can with the person, but the kind of underlying structure and rules of our profession will suggest to you that that would not be a good idea, that in fact it might do harm.
101 ALEXANDER: Well, would the person experience that as a rejection?
CLARK: They might, they might, and that‘s very sad and it‘s very difficult, but we can‘t control everything in the world and reality is one of the things we can‘t control. If once a month therapy would do harm, in our best view, or be a waste of the patient‘s money in our best view, then even if they‘re hurt, even if they feel very wounded by it, we still have to say, ―No.‖ We have ethics and we have standards of professional conduct which would limit our ability to be nice guys.
We have to control our worry about people not being happy with us or feeling like we‘re inflexible or mean or whatever, because reality is reality. If you go to a doctor and you ask for a prescription and he prescribes a medication for you, and you say, ―Well, I can‘t afford it. Can I take one quarter of a dose?‖ You have to say, ―No.‖ You may sympathize with how expensive the medication is. You may worry for the poor person about what‘s going to happen to them in the absence of the medication. But the reality is that if you don‘t take the full dose, it‘s going to do you harm rather than good.
There is an analogy in psychotherapy. Now there are exceptions to that, so that‘s why I‘m trying to walk this through, not in terms of huge, broad generalizations, but you have to hold on to the other sort of framework and net which holds us all as psychoanalytic therapists as a sort of starting place as you think things through. Worrying about whether the patient is going to like you or not, really, usually is a sign of countertransference.
Now this happens to me all the time. I want you to know that, so it‘s not like I‘m talking from a distance about a state of affairs I don‘t understand. But it‘s good to keep your eyes on that, and that your own worry about hurting your patient or about their not understanding, past a certain point, it doesn‘t matter. You can‘t force understanding and you can‘t change reality.
ALEXANDER: Well, do you say to the person, ―It would not be good for you‖? Do you just come flat out and say, ―Look, this would not be good for you and your growth and in your life to just see me once a month; it would be better for you not to see me at all.‖ Are you that upfront about it?
CLARK: I would be with certain people. What I would try to do, rather than say something that sounds so holier than thou is make it very concrete for the person. I‘m in that situation with a patient now, although it doesn‘t have anything to do with the economy going under. Basically, she‘s wanted to see me three times a week but she‘s wanted to see me on her terms, which means sometimes on the phone, and sometimes for shorter sessions, and sometimes she skips them because she‘s got other things to do and all the rest of that stuff. She‘s very narcissistic.
I didn‘t want to stress her too much at the beginning of our work so for a while, I kind of moved with her demands. Then she started to make noise about, ―I don‘t like the phone sessions; I can‘t tell what you‘re thinking.‖ ―Aha,‖ said I, now I have a hand-hold, so I could talk to her at that point and say, ―You‘re right. This is not working. We tried it
102 (merger), we tried it and you made some progress but you feel stalled and I agree, and this is one of the reasons why: you need more regularity, you need more predictability here, and what we need to do to go forward is to have you come regularly, see me in person, and commit to being at a number of sessions a week that you can manage regularly. Otherwise I would recommend that you stop.‖ And because she had tried it the other way, this particular patient could see it.
Now other people couldn‘t. If I said that to them, they‘d be out the door in a minute because I wasn‘t omniscient. I tried something that didn‘t work. So you have to tailor these things to your understanding of the particular person and their vulnerabilities. But what you can‘t do is accede. You can‘t give in and do what they want you to do when you know that clinically it‘s the wrong thing to do. It‘s unethical, and it may even be actionable. So you‘ve got to be careful, not only for your patient‘s sake, but for yourself.
Fortunately in this case, I don‘t see any conflict between what a board might say if a case came up before it, and what you would say as a clinician. You kind of know what‘s realistic and what isn‘t. See, one of the things about patients, for the most part, is that their sense of reality is, to some degree, distorted. Of course, all of our senses of reality are to some degree distorted, but one hopes that we have a firmer toe on the ground than do most of the people we see. So for their sake as well as our own, we have to keep reminding them not of what we wish could happen, but what is possible.
ALEXANDER: With this kind of a stance, could you be called up on, say, patient abandonment? The patient says, ―I can‘t afford to see you more,‖ and you don‘t take that literally, or you do take it literally?
CLARK: Well, I know what you‘re saying, and I find this a completely confusing emotional morass, so I‘m not going to give you any kind of clear, definitive answer. What I have taken to doing lately in situations like that is number one, consult with another therapist to cover my own back, in essence, in terms of abandonment issues. And number two, make every effort I can to help a person who cannot see me make other arrangements. Now that‘s getting harder and harder because all of the agencies are also stressed and the availability of lowered fee therapy is less and less all the time. So I think we‘ve got a lot of hard work ahead of us. I have no answers to this question. I just know it has to be very, very carefully evaluated.
I think you, I, all of us are free to try lowering our fees. The caveat there, again, is who you‘re dealing with? Is it going to reinforce this patient‘s feelings of specialness? Are they going to use it as a signal that you‘re going to do all the work and they don‘t have to do anything, or is this really going to be a helping hand for the person? For some, it will be a piece of acting out. For others, it‘s the right thing to do. You have to evaluate any frame alteration that you make in terms of your best understanding of the patient that you have in front of you, so this answer could be very different for twenty different people.
ALEXANDER: Well, let‘s talk about some different kinds of people then.
103 CLARK: Okay, we talked about one, the narcissist who‘s fusing with you.
ALEXANDER: Right, so what about the schizoid?
CLARK: Okay. See, schizoid people have an in-out relationship with you at best. The nature of the schizoid attachment is ambivalent. That‘s its core. They both want to be with you and don‘t. They both long for and fear closeness, usually in a very, very finely balanced pirouette. Because of that, they often are not patients who come for many sessions a week because for many of them, it puts too much pressure on the anxiety about being overwhelmed and devoured that they feel when they‘re in close. So they mostly are going to opt for a more distanced relationship anyway, and be able to do well with it because they feel safe when they have more control over closeness and distance, and that happens better at once a week.
Those are the only patient group that I‘ve had fairly good success making therapeutic progress, not just holding them, twice a month. Because again, there the anxiety around being too close to me, and the anxiety about being too far away, for many of them, is met comfortably at twice a month. Now, they don‘t get, so-called, ―better.‖ They don‘t extend the range of tolerance they have for intimacy and for being alone very much when they‘re coming twice a month. But it can give them decent support so that they can function better in their lives.
So with that patient group I would try, but I would explain to them, in doing so, that if they want to cut down from, say, once a week to once every two weeks, ―Sure, let‘s try it. Let‘s take a look at what‘s happening, whether you continue to make progress in feeling more comfortable with people, in feeling more sure of yourself when you have to assert yourself. Let‘s see how you do if we cut back and we‘ll take another look at it if it‘s not working‖ and if the patient says, ―I cannot afford it,‖ I am always very out front, especially with this group of patients, saying, ―I understand that perfectly; I‘m with you on that score. But you know, the point is that you are seeing me and paying me for help, and we have to have an arrangement between us which will support your aims here. And no matter how much it costs, if it‘s not going to work for you, it would be better to do nothing than to do that, and to start up again when things are better.‖
That group of patient will hear that, they get that and they‘re ok with it. I‘ve never had the schizoid patient be disturbed by frankness of that kind. It‘s a very pragmatic approach: we can try it, but let‘s keep an eye on it.
ALEXANDER: The narcissistic person?
CLARK: The narcissistic person is going to hear all of that in terms of a kind of grading as to whether one is perfect or a failure, so you can‘t say that very comfortably to a narcissist. You have to feel your way into a different way of talking to them. It really will have to involve whatever you do which communicates to them your complete understanding of the stress of the financial burden of psychotherapy. But then, you‘re
104 going to have to be realistic with them, too, and say, ―But unfortunately, if you don‘t come at a certain level, nothing‘s going to happen, so you need to just do it.‖
ALEXANDER: And the rage, the anger at you that you won‘t reduce your fee?
CLARK: You have to take that and understand it the way you would with any narcissistic patient, but you can‘t budge. See, with that group of patients, with the narcissists, you‘re reinforcing the idea that they‘re special and you can‘t do that. I mean, they think it. You‘re not going to say, ―Who do you think you are? You think you‘re so special,‖ and the rest of that, but you don‘t go out of your way to support the grandiosity. It‘s not realistic.
I‘ll tell you a story, although again this is not exactly a recession/depression story. I had a narcissistic patient who blew into my office one day and said to me that she couldn‘t pay me, by the way, this month because the tire blew up out onto her car and she had to replace a set of tires, so she didn‘t have the money. So I said to her, ―Okay, then we‘ll stop therapy and you call me when you‘ve got enough money to resume.‖ And she was in a rage at me, as you would expect: ―Why wouldn‘t I just carry her?
I said to her, ―Ms. X, if you went into Nordstrom‘s and found a dress you liked, would you go up to them and say, ‗I can‘t pay you for it, but would you let me have it anyway?‘‖ She looked at me and she said, ―Nobody‘s ever said anything like that to me and you‘re right.‖
(laughter)
I was very sympathetic. You know, sure, I‘d like to be able to be the good witch Glenda, you know, the good fairy, but I‘m not, and the transference with me which is based on my being the good fairy is a neurotic or psychotic transference. It‘s not something I want to collude in. So I have to stand for reality.
This moves us for just a minute. You‘ve nudged me back to the issue of what other kinds of patients and what you do with them, because I think you‘re beginning to see that you have to think it through in terms of the nature of the relationship between you and the patient. What‘s going on in the therapy is the thing that guides you, as you think your way through this. What you must never do, however, is violate the basic tenets and conventions of our profession. Those have to hold you and the patient.
ALEXANDER: You talked about ―the framework,‖ ―the therapeutic frame.‖ That‘s what you‘re referring to there.
CLARK: That‘s right. The elements of the frame are that the contract between you and the patient is that you meet for agreed upon times at agreed upon intervals, and both people agree to show up. The patient agrees to pay you a given amount for that time, and that amount of money, unless you‘re working at an agency, should be based on what you think your time is worth, not what the patient can afford to pay. Unless you
105 yourself have no concerns about money, you‘re in it for a living. That‘s legitimate. You don‘t have to give your services away. You‘re not Nordstrom‘s with a sale rack.
ALEXANDER: Or a lay-away plan.
CLARK. That‘s right, exactly. So the contract has to be non-exploitive on both sides. Your fees have to be reasonable and the patient has to agree to pay them because those are the ground rules of a relationship that will work on any level, but most particularly, in psychotherapy, that‘s the ground work on which basic trust can be formed.
ALEXANDER: So now let‘s say that you, as the therapist, have financial issues of your own, and you see your people sort of dropping away. You have to make sure, within your own self, that you‘re totally honest and not telling them that they need to be there. You have to be really clear with yourself.
CLARK: Absolutely, and that‘s very hard Barbara. You and I spoke about this when we talked and set up this meeting. I told you that I was struggling with this all the time because when the pressure is on for oneself to feed one‘s family, and when we‘re all feeling worried financially, and also have self-esteem and competency issues on the line when something like this happens, the pressures on us are huge. I move first to the frame to hold me so that I don‘t give way and let patients do things I don‘t think are good for them just to keep them around, because that‘s the tendency I would have -- to make bargains with myself, kind of bargains with the devil, that would let the person stay in therapy when deep down inside I know that they shouldn‘t be because the frame violations are going to destroy any decent work we do.
So I go first to what I know in terms of hour length, in terms of frequency, in terms of what the minimal frequency is for any kind of work, and again that‘s coefficiented by your goals. If you‘ve been doing insight work with a patient who‘s coming two or three times a week and they‘re going to cut down to once a week, you‘re going to have to ratchet back your therapeutic goals. You can‘t keep looking for the same amount of progress. You‘ll have to move to a more supportive stance and a less interpretive stance if you‘re seeing the person less often. If they want to go down below once a week, as I said, I think you have to look very carefully at the person‘s nature and what their issues are because it could actually be counterproductive.
See, with a narcissistic patient -- I don‘t think I said this before -- if they go down below once a week, the merger is likely not going to hold. It‘s too much because their tendencies are to take any kind of suggestion that they and you are not of one mind as tremendously threatening and they devalue you or withdraw. Those are their major defenses. So it‘s much more apt that you won‘t be able to repair little ruptures in the merger in a timely way if the person isn‘t coming often enough. They‘ll end up by firing you. They can‘t hold. They‘ll tail off, whereas a schizoid person can hold much better with the disappointments and tensions if they come less frequently.
106 ALEXANDER: So, back to the borderline...
CLARK: The borderline person is another problem altogether, and I have to tell you that I don‘t know when the last time is that I‘ve seen one! Number one, I think that the population has changed and the kind of child-rearing practices that led to borderline personality development are less common nowadays than those that lead to narcissistic and schizoid type personalities. So I haven‘t seen a borderline person in a long time, but what I imagine would happen with them is they would put a lot of pressure on you to see them and regress so that you would basically be saying to them and yourself, ―I can‘t abandon this person; they‘re falling apart on me.‖ Well, that‘s exactly what the borderline‘s schema of the world is: if you act helpless and like you can‘t cope, someone will step in and take care of you.
As the therapist, you can‘t afford to do that. You have to make arrangements for them to go somewhere else if you can, but if they can‘t pay a reasonable fee, and they can‘t come a reasonable number of times, which is at least weekly, they can‘t be in therapy with you; you will do them harm. You will reinforce the very beliefs which make their lives non- functional. So you can‘t do it. You might want to do it, but you can‘t do it, so you have to do something else.
ALEXANDER: That is so interesting.
CLARK: Yeah, it‘s so painful isn‘t it?
ALEXANDER: It is, and what seems to be such a, well, cut and dry situation: you know, ―I make this much amount of money, and I have to pay this much on my mortgage or my rent, and I have to pay this much for my child‘s braces,‖ and this that and the other thing. You could go through a person‘s whole budget and see that there‘s nothing left for psychotherapy and…
CLARK: Yes, and you can sympathize, and you don‘t treat it as resistance. You just treat it as reality: ―That‘s right, there is nothing left for psychotherapy.‖ Isn‘t that awful?
ALEXANDER: It is! Well, when is it resistance? Can if be resistance if the person‘s… you know, there‘s a television program on now in which the leading character says, ―Everybody lies.‖ ―House‖ is the program, and he says, ―Everybody lies,‖ and by golly, the screenwriters have got it down. Everybody leaves out some significant factor, but yet there is a reality and so, when is it resistance?
CLARK: Well, are you‘re saying that there are people you are seeing who will tell you they cannot afford you in order to get you to lower your fee?
ALEXANDER: To get you to lower your fee, or to get out.
107 CLARK: If they want to get out, sayonara! It‘s not your job to keep them there, so again the frame will help you. How many times in your life have you been suckered by that kind of person? If you and I were in the same room, I would be raising my hand and flapping it over my head, ―Me,me,me,me,me.‖ It‘s happened to me more than what? I‘d be embarrassed to say on a public piece of broadcasting how many times I have fallen for that one way or another, because that steps right into my own particular countertransference struggles, which come out of my character. I like feeling like a good guy and I like feeling like I‘m a helper. So I‘m very vulnerable to that kind of thing, so I have been snookered. People have lied to me and I have fallen for it.
Again, what‘s my protection? What have I come to lean on more and more? The rules, you know, ―Gee, I‘m sorry you can‘t afford this.‖ You don‘t have to know whether they really can or not. ―I‘m sorry you can‘t afford this because if you can‘t afford the dress, you can‘t have it.‖
ALEXANDER: Alright, well, let‘s say that you are in a struggle with a client or patient over something. You‘re at an impasse. And then all of the sudden, the patient comes in and says, you know, ―I‘ve lost my job‖ or ―I can‘t afford this anymore,‖ or ―My trust fund is all gone,‖ or, ―Everything is all gone and I can‘t afford this anymore.‖ And as it happens, it‘s in the middle of a very important piece of therapeutic work.
CLARK: Yes, it‘s too bad isn‘t it?
ALEXANDER: Yes.
CLARK: But you see what you‘re tempted to do? And this is something I‘m tempted to do over and over again: I make it my problem -- it‘s a problem that suddenly I have to solve for them. It isn‘t my problem. It‘s their problem!
ALEXANDER: Right.
CLARK: See how easy it is to lose that? Especially when you‘re in the middle of a struggle, you‘re apt to be very involved at that point emotionally, and engaged, and you want things to work out, and you kind of forget whose therapy it is. You‘re there to help the person do the therapeutic work. You‘re not there to do if for them. You‘re not there to make it happen while they sit around with big eyes. In a very over-generalized way, that‘s an infantile wish, right? Momma will come in and make everything better, Momma has to do all the work and if momma does enough, then you‘ll feel fine and everything will go well in your life. You yourself don‘t have to alter things to make a better life for yourself.
Now that‘s an infantile wish, isn‘t it? It‘s one that our patients have almost universally and I think many therapists, maybe not all of us, but many of us, certainly, when we enter the field, enter it in some way turning passive to active, and in some way become the all- giving mother that we didn‘t have either. So you know, it hits right in the core of our own conflicts and wishes to have somebody be all things to us and for us. When we
108 think of ourselves as being all things to another person, again the frame will help you with that because it reminds you, again, that you can feel very badly that a person lost their job and can‘t afford therapy, but if they want the therapy, they then have the problem of how they can work it out to afford it and if they can‘t, then they have to mourn it.
ALEXANDER: And you‘re not there to help them hold their hand while they‘re mourning.
CLARK: Well, you could be if they could afford it. If not, they‘re going to have to do it another way. You don‘t have a choice. See, this is not within your power. Anything that you do to ameliorate that reinforces fantasies on the patient‘s part of what the world is like.
Especially in a recession or a depression, none of us can afford those fantasies. We need to be realistic in terms of what the world really does give us and what we have to give ourselves. These are not pretty truths. I can hear it in your voice. I feel this every day of my life when I‘m with my patients or with the people I consult with who come to me with these problems, and I have to tell them things like, ―The patient needs to go. They cannot afford to see you, they can‘t afford to see you. You can be as sorry as you‘d like, but you can‘t change that reality. That‘s not in your power.‖
ALEXANDER: So you‘re really providing starch to a lot of people too.
CLARK: I think so. It‘s starch, but it‘s really just reality. It has its comforting side for people as well as its uncomfortable side, but basically it‘s sort of inarguable. If you don‘t have the money, you can‘t have the dress.
ALEXANDER: It helps really, doesn‘t it, to put it as such a concrete thing.
CLARK: Yeah, yeah. Exactly, and you know, who among us would ask Nordstrom‘s to give us a dress? (laughter) We might want to but we wouldn‘t ask. It would never enter our minds to, so why do we ask our therapists?
ALEXANDER: Yeah, why?
CLARK: Because we have unconscious fantasies of the therapist as the all-giving, omnipotent parent. These fantasies are frustrated by reality, but we, as the therapist, have to stand for reality.
ALEXANDER: Wow! Dr. Clark, I love talking to you.
(laughter)
109 CLARK: Thank you. I would not imagine that this is a conversation that would be comfortable for you, or for any listener, any more than it is for me, but that‘s just the way it is.
ALEXANDER: That‘s the way it is. I‘m trying to imagine the look on a salesgirl‘s face if you go into Nordstrom‘s and you say, ―I love this dress but I can‘t afford it. Why don‘t you give it to me?‖
CLARK: That‘s right, will you give it to me?
(laughter)
ALEXANDER: It‘s astounding. You know, when you make that analogy, it just gets crystal clear.
CLARK: I know. It clears the mind!
ALEXANDER: It does!
CLARK: Frankly, when I made that analogy myself, it was a great relief to me because then I got it! I got what I was saying and why I was saying it to the patient so I wasn‘t, by rote, repeating a rule about therapy in the frame. I was saying something I believed and that‘s always much preferable.
ALEXANDER: Oh my. Well, thank you, Dr. Clark, I really appreciate this.
CLARK: I‘m glad you do and I hope you can use it. If anybody listens to this, I wish them good luck with it because we‘re basically all in this together.
That‘s the other piece of advice, Barbara. Just even in this call, I think you can feel some of it. We have to talk to each other a lot at times like this, because we‘ll get lost in it with patients if we can‘t turn to colleagues to help us step out of the pressure to do too much and to be unrealistic about it.
ALEXANDER: Thank you again, Dr. Clark.
CLARK: Thank you, Barbara
This concludes our interview with Dr. Karla Clark. We hope you learned from this interview and that you enjoyed it. You may contact her at (415) 456-3138; Email: [email protected].
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
110 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Self Disclosure—a New Paradigm”
RICHARD GEIST, Ed.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
RICHARD GEIST, Ed.D. 1095 Beacon Street Waban, MA 02468 Tel: (617) 332-3323 Email: [email protected]
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading interview 9 in our program on The Therapeutic Relationship.
In this program, we‘ve been looking at attachment—its development through infant research, its neurological underpinnings, and its relevance in psychotherapy. With the concept of attachment comes the obviously related concept of connectedness.
Our next speaker, Dr. Richard Geist is interested in the clinical possibilities that the concept of connectedness offers. He defines connectedness as a conscious or unconscious "felt sense of sharing and participating in another's subjective emotional life while simultaneously experiencing another as participating in one's own subjective life." As such, therapists can use the concept of connection as a central organizing principle in the way we listen, interpret, make interventions, and experience our patients. Connectedness is the essential ingredient, the "moving edge," that remobilizes thwarted developmental needs and offers the potential of an optimally functioning self.
Geist believes that this "felt presence in another's subjective world" is bi-directional. It is the interpenetrating experience of connection that contributes to the development of the self-object transference, the structuralization of the self, and the capacity for mutual intimacy. With bi-directionality, not only does the therapist experience and have empathy for the patient; the patient also experiences and has an empathic understanding of the therapist.
111 So what about boundaries? The patient obviously discloses to the therapist and in so doing, discloses or learns about himself. The therapist discloses to himself, but—what about the therapist disclosing to the patient? It used to be shocking, a no-no. The therapist‘s anonymity was to be absolutely maintained. This prohibition has opened up over the past few decades, and now we will hear a very different point of view about self- disclosure. In this new paradigm, it is often the therapist‘s ―deliberate‖ self disclosure that enhances our therapeutic effectiveness.
Richard Geist, Ed.D received his undergraduate degree and his doctorate in Psychology from Harvard University and for 30 years was Clinical Instructor, Department of Psychiatry (Psychology), Harvard Medical School. He is a Founding Member, Faculty, Supervising analyst, and former member of the Board of Directors of The Massachusetts Institute for Psychoanalysis and has been a senior supervising psychologist at Children‘s Hospital, Massachusetts General Hospital, and Mass. Mental Health Center in Boston.
Dr. Geist was one of the first psychologists in Boston to embrace Self Psychology and Intersubjectivity theory and practice, and he has been teaching and supervising it for over 25 years. He has taught self psychology seminars in the training programs at Children‘s Hospital, Mass General Hospital, and Mass School for Professional Psychology. Former Director of the Young Adult Consultation and Study Center at Children‘s Hospital and a consultant to the Psychosomatic Unit and the Orthopedic Surgical Service, as well as Unit Chief of the Adolescent Psychology Services, Dr. Geist has also applied self psychology to understanding how investors make decisions under conditions of risk and has published a recent book on the topic—Investor Therapy.
His many publications can be found in psychoanalytic and psychiatric journals. Currently he is working on a book on the clinical use of Relational Self Psychology in Psychoanalytic Work. Dr. Geist maintains a private practice in psychoanalysis and psychotherapy in Newton, Massachusetts where he sees children, adolescents, adults, and couples.
ALEXANDER: Dr. Geist, we‘re going to talk about self-disclosure right now. What is amazing to me is that some many years after my training, where self-disclosure was pretty taboo and pretty shocking if you were to do that, all of a sudden now, it‘s really quite different. What do you think accounts for the change that is making it now okay?
GEIST: Well, I think the change came about primarily from the patient‘s point of view. I think there were a lot of patients that came away from their analyses feeling that they had all sorts of insight into themselves and yet there was no change. There was a very interesting article written by the Grunebaums at Cambridge where they interviewed analysts ten years post their analysis and he asked them what were the meaningful factors of their analysis? None of them could remember any interpretations that were given. They all said to a T that what mattered was their relationship with their analyst and how the analyst reacted to them, which we would interpret now as meaning how willing the analyst was to share their subjectivity.
112 I think what really happened was people began to realize that talking about dynamics and genetics, however important that may be, was not a factor in cure. It was a factor in insight, but insight in many instances did not lead to cure.
As a result some key folks gave up their analyses and started commuting to Chicago to see Kohut. As that happened, it opened up a whole range of different ways of the analyst‘s interacting with the patient and the patient interacting with the analyst. It really shifted from a one person to a two person process. Certainly in physics, we knew this long ago. We knew that the observer had an impact on the observed and changed the whole process of how he or she observed what was going on.
So it was a slow process that started, I think, with Self-Psychology and then led to a Relational perspective, but there are stark differences between Relational and Self- Psychological treatment. I think it‘s important to note them because for Relational folks, authenticity is privileged over empathy.
That‘s what you see, by the way, in the ―In Treatment‖ series. When Paul reveals issues about himself, one doesn‘t get the impression that those are based on his empathic immersion in the patient‘s needs and then he provides what he thinks the patient needs. Rather, what one sees in that series is that authenticity is good in and of itself and is therapeutic. That‘s a very different stance from Self-Psychology. Self-Psychology believes that empathy is privileged over authenticity, so that one is authentic with one‘s patients but only where empathically, the therapist realizes that this is going to be growth promoting for the patient.
ALEXANDER: What you are talking about is the difference between the therapist‘s authenticity and empathy?
GEIST: Yes. I was saying that many theories, particularly Relational, emphasize authenticity over empathy and Self-Psychology privileges empathy over authenticity. Both use self-disclosure but we don‘t believe that self-disclosure is in and of itself necessarily helpful unless we empathically immerse ourselves in the patient‘s needs and collect data which indicates that revealing something about ourselves will in fact promote the remobilization, for example, of self object needs.
ALEXANDER: That‘s the big question isn‘t it? How do you know? Well, let me go back… can you define and explain more about what you mean by ―authenticity‖ on part of the therapist.
GEIST: ―Authenticity‖ really refers to revealing the subjectivity of the therapist. In other words, the therapist brings to the dyad his public and private theories. By that I mean what one believes internally but isn‘t really stated -- that‘s the private theory. The public theory is whatever public theoretical orientation one embraces. So the therapist brings his public theory, his private theory, his history, his ways of relating, his feelings about the patient to the dyadic process and what parts of that are revealed are referred to as ―the therapist‘s subjectivity or his authenticity.‖ How he reacts to what the patient
113 says would be included in his authenticity.
ALEXANDER: What would be an example of ―not authenticity?‖
GEIST: An example of ―not authenticity‖ would be where the patient accuses the therapist of being sleepy during the hour and the therapist, for whatever reason, is uncomfortable, perhaps feels shameful that he or she was feeling tired, and therefore denies it, whereas an example of ―authenticity‖ would be to own the patient‘s observation and say, ―Yes, I had a hard night last night. I didn‘t sleep very much so you‘re picking up something that‘s accurate in me.‖ Then the therapist would explore how that must, if one knows the history, resonate with the patient‘s history and how understandable it is that the patient would feel rejected, or alone, or abandoned -- whatever the feelings are. So one is confirming both that the patient‘s perceptions are accurate, finding the kernel of truth in the patient‘s perceptions, and conveying that to the patient.
ALEXANDER: Now in Self-Psychology, the patient says, ―You‘re falling asleep,‖ and the therapist says, ―No I‘m not.‖ So, in Self-Psychology, that would be viewed as a rupture, or what?
GEIST: Well, the rupture would be the patient‘s feeling that he‘s become disconnected from the therapist as a result of the therapist falling asleep. The revealing of one‘s subjectivity is a way that Self-Psychology has -- it‘s been referred to as ―wearing the attribution‖-- but it‘s a way the therapist has of repairing the rupture. So there would be a major difference between some folks who would say, ―Okay, the patient is feeling I‘m falling asleep; I‘m going to focus on what that means to the patient and how that resonates with earlier relationships in the patient‘s life.‖ One would see it as correcting a distortion in the patient‘s transference. Self-Psychology would emphasize the need to reconnect with the patient, so that whatever self-object transference was in place could be put back in place because it is through the rekindling of those transferences, that cure occurs from our point of view. Is that clear at all?
ALEXANDER: Yes it is. At one point, I was shadowing some therapists in their work with some couples and one therapist really kept talking about herself incessantly. The couple only had to say a word or two and this therapist was off talking about her children, and her garden. This is not therapeutic self-disclosure. I don‘t know what it was.
GEIST: It‘s self-disclosure with the underlying assumption that any kind of authenticity is helpful to the treatment and that‘s where there is this significant difference. Self-Psychology believes self-disclosure is only helpful when you‘ve empathically collected enough data from the patient to realize that self-disclosure at this particular moment in the treatment might be helpful, for whatever reason, to the patient.
The reason that we (Relational therapists) would say it‘s helpful is because when the patient gets to know the subjectivity of the therapist in the right context, it means that what‘s consciously felt like getting to know one‘s therapist is actually arriving at a more integrated sense of one‘s self.
114
Now why should that be so? One patient, who had been in several previous therapies and knew a great deal about me, said or asked, ―Isn‘t it obvious that the more open you are and the more I know about you, the more intimate we become, and the more intimate we are, the more the boundaries get blurred? There‘s also something about you being open: it reveals your vulnerabilities.‖
So what I would emphasize is that when empathically, we think it‘s helpful, what we‘re really doing is thinking it‘s helpful because it helps the patient arrive at a more integrated sense of oneself, not that one‘s getting to know the other. The therapist or analyst‘s willingness to express his perceptions and feelings, even when they differ from those of the patient, is often felt as a self-enhancing quality of the patient‘s self-organization, not an expression of otherness, and if you believe just in ―otherness‖ then you‘re likely to be authentic whether the patient needs it or not.
ALEXANDER: I don‘t think I understood that part.
GEIST: Okay, let me try from another angle. One of the forgotten things that Kohut said about self-object transferences was that in any transference the patient becomes a part of the therapist‘s or analyst‘s self, and the analyst becomes a part of the patient‘s self. So when, for example, the mother picks up the cranky baby and calms him down, it‘s not just another person doing something to the baby. The baby experiences that picking up and being calmed down as something that‘s part of his or herself also. In other words, it‘s unclear who‘s doing what to whom because there‘s a blurred permeable boundary between people in those situations. The baby experiences the mother picking up the baby as the baby‘s own beginning capacity to calm oneself down.
ALEXANDER: In other words, the baby thinks, assuming that the baby thinks, which it doesn‘t …
GEIST: Right. Or the child…
ALEXANDER: If the child were to think, ―Oh this feels better,‖ and then the next thought would be, ―I can feel better,‖ theoretically.
GEIST: Yes, and it‘s unclear where that ―better‖ comes from for the child. It‘s partially from the outside but the child also feels it from the inside, that ―I‘m helping myself to feel better as well.‖
Let me go on to give you an example actually from the therapeutic point of view because it clarifies this. If you really believe that about permeable boundaries and that one experiences the therapist or analyst as part of one‘s sense of self, then it provides a rationale for what we were talking about before. The patient says to the analyst, ―You screwed up,‖ and the analyst owns that and says, ―Yes, I made a mistake and I can see how you would feel hurt and injured as a result of what I said.‖ Now what‘s important in that and what people fail to recognize is that because the patient feels that the analyst is
115 part of him or herself, when the analyst says, ―Yes, I made a mistake,‖ the analyst is empathizing with himself or herself. But because he is part of the patient‘s self, the patient also comes to feel empathic with his or her own pathology, and unless the patient can get to the point where they can be empathic with themselves, I don‘t believe any change can occur.
ALEXANDER: That‘s a powerful statement. Why would you want to get and be empathic with the parts of yourself that are horrible?
GEIST: Because in growing up, developmentally, the parts of oneself that are ―horrible‖ resulted from the caregivers‘ not being able to respond to certain affects. When those affects are not responded to, for example, when the parent withdraws slightly from certain affects, those affects, to the child, become bad, shameful, and need to be gotten rid of. Unless the patient, as an adult, can begin to empathize with those feelings, those feelings will remain split off or repressed and never get reintegrated into the patient‘s life, and therefore allow one‘s sense of self to expand and include a wider affective range, of emotions.
ALEXANDER: This is very different from anything that I ever understood about self- disclosure. I think that I was concerned previously about the patient asking the therapist -- and we‘re talking here about therapist as well as analyst, wouldn‘t you say?
GEIST: Yes, no difference. If one‘s using the same theory -- the same theory of cure, the same theory of development -- then the only difference between analysis and therapy is probably the intensity of the experience.
ALEXANDER: Okay. Well the patient asks the therapist a personal question like, ―What‘s your religion?‖ and the therapist either says nothing or says, ―Why is it important for you to know that?‖ or ―What difference would it make to you to know that?‖ So the therapist may or may not ultimately answer the question but would want understand why that would be important for the patient to know.
GEIST: Correct.
ALEXANDER: So what is that, then? Is that a rejection of the patient‘s question? Or should you say, ―Well I‘m…‖ whatever your religion happens to be, and ―How do you feel about that?‖
GEIST: Let me give you an example that illustrates an answer to your question.
ALEXANDER: Okay.
GEIST: The patient asks the therapist, ―I saw XYZ movie last night. Have you seen that movie?‖ and the therapist says, ―Did you notice you asked me a question?‖ and the patient gets angry and says, ―Obviously I know I asked you a question. Why didn‘t
116 you answer it?‖ and the therapist says, ―We need to understand what this anger is all about.‖
Those kinds of therapeutic avoidances lead to artifice within the treatment. In other words, it‘s not the anger of the patient that‘s important when the therapist refuses to answer a question.
In my example, and in your example of what religion are you, from the self- psychological vantage point, the patient is trying to remobilize and rekindle self-object transferences. In other words, they‘re trying to remobilize and bring into the treatment developmental needs which weren‘t responded to in early childhood. Those developmental needs, we call, ―self-object transferences.‖
So what‘s likely, if we‘re going to hypothesize in your example, is that when the patient asks, ―What religion are you?‖ that there‘s a tendril of rekindling a certain kind of transference. In other words, ―I want to know if we share something in common,‖ just as my patient, said, when I asked her if she saw that movie, ―I wanted to know that you liked the movie, that you shared my opinion about this movie.‖ In other words, it‘s the beginning tendrils of a twinship transference. ―I want my therapist and me to be the same.‖ If you don‘t answer the question, you‘re cutting off the beginnings of what could be an important remobilization of early self-object needs, or a particular kind of transference.
It‘s the same issue when the patient says, ―I don‘t want to do this myself; this is your job.‖ The therapist has to recognize that self-psychologically as the patient saying, ―I‘m rekindling an idealizing transference where I have someone who I can look up to, is all- knowing, who will help me with this,‖ not an answer that says, ―We have to do this together,‖ which cuts of the remobilization of the idealizing transference.
It‘s only within Self-Psychology that those kinds of remobilizing transferences are welcomed and responded to or even recognized. In most other theoretical orientations, we‘re back into what Freud called the difference between transference and the real relationship. It was only in the transferences, the repetition of past relationships that are distorted with the therapist, that the cure occurred. For us, the reemergence for self- object needs or transferences are attempts at self-healing and therefore have to be welcomed at every stage of development. That‘s a major difference between Self- Psychology and other theories.
ALEXANDER: So the self-object relationship…?
GEIST: The self-object relationship is an attempt at self-healing. All transference in this model is an attempt by the patient at self-cure to be welcomed rather than to be seen as something that is projected, distorted, or displaced from earlier relationships.
ALEXANDER: Well then, what about countertransference?
117 GEIST: Countertransference, in this model, is the therapist‘s remobilization of self-object needs in response to the patient‘s demands or remobilization of self-object need. So if the patient says to the therapist, ―You‘re not helping me,‖ what‘s being denied is the therapist‘s mirroring needs, in other words, the need to be thought of as a helpful person.
We have the exact same self-object needs as the patient has, but hopefully through our own treatment, we‘ve been able to deal with those needs so we don‘t impose them on the patient. But that‘s where patient and therapist get into trouble because when the therapist feels hurt and that his or her self-object needs are not recognized, or that his sense of self is not appreciated, the therapist can react in critical ways which are hidden behind the attempt to accuse the patient of harboring all the pathology.
In other words, the patient says, ―You‘re not helping me,‖ and the therapist then subtly accuses the patient of not being able to take in what the therapist is offering, rather than realizing, ―I‘m saying that because I‘m reacting to this patient not confirming my need to be thought of as a helpful person because we all go into this field to be helpful.‖
ALEXANDER: What would you say in response to the patient saying, ―You‘re not helping me?‖
GEIST: ―Gee, I must be doing something wrong…‖
ALEXANDER: You‘d say that out loud?
GEIST: Yes. ―That isn‘t what you need. Let‘s see if you can tell me a little more about what you need so that I can change what I‘m doing to be more helpful.‖
ALEXANDER: In another interview that appears earlier in this program, I told the story of a patient who said to me, ―You are a B+ therapist -- I give you a B or a B+, and I need a therapist who‘s an A+.‖ Of course I was not happy.
(laughter)
GEIST: No, because it injured your sense of self.
ALEXANDER: And I just didn‘t know what to do to make it better, and neither did she know what to say. I said, ―Well, what would an A therapist be doing?‖ -- or something like that. I think she said something like, ―I don‘t know, but I‘d know it if I felt it,‖ sort of like saying, ―I don‘t understand art but I know what I like.‖ It was that kind of a thing. So what might I have said or done? Other than get a grip on myself!
GEIST: Right, well that is the first issue. See, self- psychologically, because we‘re not placing the pathology all on the patient and because we‘re much more interested in cure occurring through the remobilization of healthy self-object needs, rather than the cure of pathology, we tend to be much more protective of our patients. So when
118 the patient says, ―You‘re only a B+ therapist and I need an A therapist,‖ the first thought that goes through our minds, self-psychologically, and we wouldn‘t necessarily say this to the patient, is, ―Oh my goodness, this patient is not feeling as helped as I want her to feel.
Kohut talked about having a natural protective feeling when the patient gets angry or disappointed, rather than immediately jumping to, ―What‘s this patient‘s pathology that they get so angry at us or feel like we‘re not being useful?‖ So the first step is realizing that.
The second step is basically conveying to the patient something to the effect that, ―Gee, if I‘m only a B therapist for you, that must be terribly disappointing when you know and you‘re probably right that you need an A therapist if you‘re going to get better. I‘ve got to think about how I can become more helpful to you and I need you to help me understand, as you say, what you recognize in me that feels right and what you recognize in me that doesn‘t feel right.‖
What one is doing by that type of statement is telling the patient, ―I‘m accepting what you‘re telling me, that I‘m not being helpful. This is not your pathology; this is legitimately your healthy attempt.‖
Probably for many patients, it is the first time they are able to say what they need, so I would say, ―I want to welcome your being open and honest about what‘s helpful, because when you did that as a child, what you found was your caretakers backed off slightly and saw it as your faults.‖ So there‘s a going out of our way to welcome those kinds of statements as healthy, and to pick up on the healthy aspects of those statements.
ALEXANDER: Alright, I‘m going to give you a hard time on this because this is the hard time that‘s been given to me over the years too. The patient says, ―I don‘t want to have to tell you. Why should I have to tell you how to do your job? I‘m paying you!‖
GEIST: ―You know, you shouldn‘t have to tell me. You‘re absolutely right. Every child at some point in their lives has the right to expect that their parents will know what they need without them having to say it. That‘s what‘s so important because you‘re able to bring that into the therapy right now and yes, I‘m failing that right now, but the fact that you‘re able to tell me that is enormous progress. It‘s up to me to think about this carefully enough so that I can begin to respond to you without you having to tell me. I may, unfortunately, need your help at times, but you‘re absolutely right -- I should be able to know what you need without you telling me.‖
In other words, one is acknowledging the developmental appropriateness of the patient rekindling those early legitimate needs. That‘s the birthright of the child.
ALEXANDER: I‘m going to tell you something else about this particular patient: she was a twin and the parents were pretty overwhelmed. What the parents did was they hung bottles of milk or whatever, juice, from strings on the ceiling so that when the little
119 girls were thirsty or hungry, they would go to these bottles hanging from the ceiling and just drink.
So here‘s the question: Say you know that piece of developmental history. Would you bring that in at this time?
GEIST: That‘s a clinical judgment but that does go back to what Anna and Paul Ornstein call, ―understanding and explaining.‖ In other words, one first has to go through a long period of time just empathically understanding the patient‘s needs. Once that is secure enough, one then brings in the developmental correlate to that. So yes, absolutely if you feel empathically that the patient could hear that, then yes, you begin to explain. That‘s the interpretive aspect of Self-Psychology. You begin to explain what you first empathically understood and that‘s the developmental correlate.
So the answer for that question is absolutely yes, but only if that patient is far enough along in therapy to hear that connection. That‘s a very subjective judgment that hopefully, one is trying to use one‘s empathic collection of data to find out. Eventually, ―Yes‖ is the answer.
ALEXANDER: I‘m going to give you another example. A friend of mine told me that he had been in therapy for a while and that when he went one day into his session, his therapist looked totally terrible, bereft, horrible, and he noticed this and asked, ‗What‘s the matter?‖ The therapist said, ―I just received a phone call that my best friend died.‖ My friend‘s reaction to this was that for the first time, he noticed himself feeling empathy, and this was a tremendous breakthrough for him in his life. I think that‘s a kind of self-disclosure that‘s pretty direct; it‘s not subtle.
GEIST: Right, absolutely. One could argue, and I don‘t know, that that therapist empathically knew this patient enough to know that it was important to acknowledge the patient‘s recognition of the therapist‘s emotional state. There is developmentally a natural need that children bring to empathize with other people and the only reason that goes by the wayside is if the parents don‘t allow that empathic capacity to develop by hiding their own feeling states and other affects that are readily apparent to the child. So what promotes empathy, or what promotes mutual empathy is both partners, where appropriate, sharing their feelings because again, we go back to this forgotten notion that Kohut emphasized so heavily: we are part of the patient‘s self and they are part of our self. When the therapist reveals something like that, because he is part of the patient‘s self, just as the therapist is feeling empathy for himself, it allows the patient to feel empathy.
It was Stolorow, I believe, about twenty-five years ago who wrote that once one begins to recognize that each is part of the other‘s self, one never hears analytic material the same way again. I think that‘s very true. If you really believe you‘re part of each other‘s selves with permeable boundaries, that is what creates empathy on the part of the patient.
ALEXANDER: I could just keep giving you example after example, but I have to move
120 on to another question that I have. That question has to do with the risks involved in self- disclosure. When I was developing this question, I was thinking about the ―old‖ kind of self-disclosure where you say what your religion is or if you are married, or if you saw that movie. I wasn‘t thinking about the kind of self-disclosure that you‘re talking about. Maybe it should have a different name; maybe it should be called something else…
GEIST: Well, I think it should be called something to the effect of whether one is willing to reveal one‘s own vulnerability, because the other kinds of self-disclosure always involve vulnerability on the part of the therapist. One is saying something that one feels, that one has strong feelings about.
ALEXANDER: In this view point of self-disclosure, are there risks? For instance, is there a risk that what you‘re saying would have nothing to do with the patient‘s experience? Or is there a risk that you‘re acting out in some way?
GEIST: Yes, those are the primary risks, the two that you pointed out. That‘s why Self-Psychology says that authenticity is, in and of itself, not necessarily helpful, that there has to be, previous to that authenticity, enough collection empathically of data.
Remember, Kohut defined empathy as feeling and thinking oneself into the patient‘s world, so that one saw the world from the patient‘s perspective. If one has been able, and the patient has to confirm that you‘re seeing things correctly so it‘s a mutual empathy, but if you‘ve come far enough along with the patient so that you‘ve collected enough data empathically to know that revealing your vulnerability would be helpful, that‘s what you do.
But you know, every time that you do it, you‘re taking a risk because you could be wrong. You tend to be less wrong if empathically, you‘re sure of how the patient sees the world, but I think you only do it when you have collected enough empathic data which sways you in that direction. You‘re still going to be wrong some of the time and then there‘s going to be a disruption in the empathic connectedness which will need to be repaired. But most of the time, if you‘ve empathically collected data, revealing your vulnerability tends to be helpful to the patients.
ALEXANDER: Now what about when your own feelings become too strong to contain about something that the patient is saying or doing or experiencing. I saw somebody who was chronically late, fifteen, twenty minutes late every time. I knew that I shouldn‘t be angry; this was her problem, it was her issue, and yet I was very angry. Finally at one point I did sort of -- I sort of exploded, really. I just couldn‘t hold back my anger any longer. I wonder to what extent that was acting out or if I might have been a better way to handle it much earlier on in the situation by saying that …I don‘t know what I might of said, so that‘s why I‘m asking you. I‘m asking you in hopes that this experience is common to the people who are listening here.
GEIST: Oh, I think it‘s very common because we all have patients who go through periods where they‘re chronically late. One could see that as a resistance, but
121 then that‘s putting the pathology on the patient. One could see it as, for example, a hope that they won‘t be kept waiting and therefore an understandable way of protecting themselves from being injured.
There are all sorts of ways that one could formulate it, but if it‘s getting to us and we‘re feeling angry and those angry feelings overflow, what becomes important is not so much feeling that they shouldn‘t overflow, but saying to the patient, ―I know this is my problem, not yours, and I will take responsibility for it.‖
It‘s the same as if a patient asks you a question and you feel uncomfortable answering. You should never be authentic just to be authentic if you feel uncomfortable about answering the question. What you have to do is say to the patient something that says, ―You know, I welcome the question; I just feel uncomfortable answering it. I don‘t know why I do and I‘m going to think about it, and I‘ll let you know if I figure it out, but this is my problem not yours. Your asking the question was helpful.‖
The same thing with being late: ―You know, I‘m angry about it but I know it‘s my problem. You wouldn‘t be late if there weren‘t good reason that you had for being late, which we may not understand yet.‖
I think it‘s incumbent upon us to assume responsibility when that happens, rather than as some interpersonalists, for example, might say -- they would treat it as an enactment and say, ―Your being late caused me to be angry and this is what you must do outside to anger other people, so it‘s important that we look at the impact you have on me or other people.‖ That‘s a whole different theory and it differs sharply from a self-psychological view.
ALEXANDER: And a relational view.
GEIST: Well, interpersonal theory is a relational view. It‘s a particular kind of relational view which comes out of William Alanson White, but it is separate from many other relational views which are much more overlapping with Self-Psychology.
ALEXANDER: Dr. Geist, boy, my analysis was back in the late sixties and it was a Freudian analysis. I know that my analyst might have done it a little bit differently today, because he‘s very involved in Self-Psychology; this I know. But this was so early in Kohut‘s thinking -- this whole thing makes me want to go back…
(laughter)
GEIST: I had the same experience. My analysis was a traditional analysis in the early seventies and I think it was Michael Basch who once said, ―I wish I could have been analyzed by Kohut after he came to Self-Psychology rather than before,‖ so I think we all feel that way. Unfortunately, back in those days there wasn‘t anyone to go to who understood Self-Psychology, short of Kohut and the small group of people who were circling around him at the time. I think most of us came to Self-Psychology, in part --
122 and if you go to Self-Psychology meetings, actually the older folks there will tell you they came to Self-Psychology because it helped them understand what was wrong with their analyses!
ALEXANDER: That‘s really interesting.
GEIST: I have a funny story. When I was in an office and in training, there was a bookstore in Boston called Mandrake‘s. It was run by a guy named Mr. Rosen, and his was the only bookstore that sold psychoanalytic books, purely. I went in there one day and I saw Kohut‘s first book – his 1971 book on the Analysis of the Self. I sat down and was browsing through it and felt his tap on my shoulder and I looked up and there was Mr. Rosen and he said, ―Dick, are you alright?‖ and I said, ―Yes, why?‖ and he said, ―Well you‘ve been here for three hours!‖ and I said, ―Well, I‘m fine because I just discovered what was wrong with my analysis and my training.‖ I think that‘s how a lot of us came to self psychology.
(laughter)
ALEXANDER: Dr. Geist, this interview has meant a lot to me and I hope it will be also meaningful to the people who are listening to it. Thank you so much.
GEIST: Good, I‘m glad it was helpful.
This concludes our interview with Dr. Richard Geist. We hope you learned from this interview and that you enjoyed it. You may contact him at (617) 332-3323; Email: [email protected]
I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, this is Barbara Alexander. Thank you for listening.
123 © On Good Authority, Inc.
THE THERAPEUTIC RELATIONSHIP
“Termination”
DENISE DAVIS, Ph.D.
Interviewed by Barbara Alexander, LCSW, BCD
(Edited slightly for readability)
DENISE DAVIS, Ph.D. 108 Harding Place, #201 Nashville, TN 37205 Tel: (615) 646-1957 Email: [email protected] www.denisedavisphd.com author of Termination Strategy: A Professional Guide to Ending on a Positive Note
Welcome to ON GOOD AUTHORITY. I‘m Barbara Alexander. You are listening to or reading the final interview in our program on The Therapeutic Relationship.
The goal of every client or patient‘s psychotherapy is the attainment of treatment goals, be they changes in behavior or attitude, or more profound personality changes. A planned, successful termination of psychotherapy is viewed as an important phase which, when handled appropriately, contributes to the client‘s autonomous functioning and long term success. While it is an essential phase of each patient‘s treatment, how we say goodbye can be complicated, given the strong attachment that can form, even in brief psychotherapy.
Astonishingly, while there are many volumes written on beginning and conducting therapy, only a handful of research has been conducted on the subject of termination. Traditionally, termination has been conceptualized using a ―termination as loss‖ model, suggesting that termination inevitably is a difficult process in which symptom relapse is probable. A second conceptualization or model proposes that termination serves as a catalyst for growth, crystallizing the process of psychotherapy and one‘s personal growth.
As a result of her research, our next speaker, Dr. Denise Davis, has been able to identify five types of terminations. In her book, Mastering the Art of Termination, and in this interview, she discusses how clinicians can end therapy responsibly, even when conditions are challenging. She discusses how to handle pitfalls in the process, and
124 presents a number of essential steps for negotiating a clinically and ethically sound termination.
Denise Davis, Ph.D., is assistant director of training in clinical psychology at Vanderbilt University. Co-author of numerous book chapters and articles on cognitive therapy, she has combined academic work with the active clinical practice of cognitive and behavioral therapy. She has held faculty appointments at Indiana University School of Medicine, Department of Psychiatry, Indiana University-Purdue University at Indianapolis, Department of Psychology, Vanderbilt University School of Medicine, Department of Psychiatry, and Vanderbilt University School of Arts and Science, Department of Psychology. She is a Founding Fellow of the Academy of Cognitive Therapy and founding editor of the journal, Cognitive and Behavioral Practice. She has published more than 25 scholarly articles and book chapters, and with Dr. Aaron Beck and Dr. Arthur Freeman, she co-authored Cognitive Therapy of Personality Disorders.
Dr. Davis has provided numerous community service lectures as well as continuing education workshops for professional psychologists. She is a past-president of the Indiana Psychological Association and served on the Tennessee State Board of Examiners in Psychology, to which she continues serving as a consultant.
She maintains a private practice in Nashville, TN.
ALEXANDER: Dr. Davis, there is so much to talk about on the subject of termination, and so little has been written about it. So let‘s just dive in. I‘d like to ask you to talk about your book and your research, and the reasons for termination that you‘ve elucidated.
DAVIS: Ok, well, I took a multifaceted look at termination as a process and wanted to get to the root of what kind of changes are we grappling with in termination in some of the newer models of therapy. As a cognitive behavior therapist, I found that what I had learned about termination often didn‘t really fit or I simply didn‘t have guidance around the various challenges that I faced over the years in practice. As I looked at it closer, it seemed that we really didn‘t have a good exploration of how we go about conceptualizing termination in the more short term therapies. I say that in parentheses because sometimes, cognitive behavior therapies are not necessarily short term, and so taking that into account, I‘m wondering what was our approach to that? So I put together a set of thoughts about how we think about termination in time limited therapy, in a skills oriented therapy where we‘re not trying to have a long term relationship necessarily to resolve a transference. But yet, we understand that sometimes therapy is medium length and sometimes it‘s long term. What kind of implications does that have for how we conceptualize termination?
ALEXANDER: Yes, because in longer term therapy, you could take months to plan out the termination. It could really be months or even a year when you say, ―Ok, I‘m ready to terminate - let‘s look at a year from now or three months from now,‖ or something like that.
125
DAVIS: And you may have really long stretches of time where you‘re not really thinking about or talking about termination, and yet with many of the service delivery models that we have today, it‘s not really possible. Termination comes up because of financing issues. It may be forced by a number of different factors. So if we don‘t have some way of addressing that, then you feel like we‘re in a dilemma. What do we do? How do we approach this? Is it abandonment? So we do want to take a look at all these issues.
ALEXANDER: If you‘re doing brief treatment and the client or the patient knows, ―Okay, we‘ve got five sessions; we‘ve got eight sessions‖… does that automatically imply that there‘s a termination? You know there‘s an end so from the very beginning you know, ―Boom. In eight sessions, we have to stop.‖
DAVIS: So we can learn something from that: addressing the issue when we know right up front, ―This is all the time we have.‖ We are beginning with the end in mind. We are understanding and know already where the point of termination is. That‘s an instructive principal because in some ways, that makes it easier if you know. We may not like it, we may think, ―We‘d love to have ten, or twenty, or fifty sessions. But if we know we only have five sessions than we‘re going to work around that‖ and we can take that idea and apply it, really, to therapy of any length because we can begin with step one, being planned-for termination in some fashion, and try to formulate an idea of what are our potential outside limits if we take all factors into account, not just what is our ideal plan here for treating the disorder clinically?
We want to go for that if that‘s at all possible but we also have to integrate other practical matters. Also, ethical matters are considerations because we don‘t necessarily know if the treatment is going to be effective, or if the relationship is going to work, so we‘re looking at that and considering that we need to evaluate this as we go along and consider the possibility of termination.
ALEXANDER: So is the kind of termination where you know it from the very minute you walk in as a patient and the therapist, you know it right away, is that one of your types of terminations? What would you call that?
DAVIS: Well, we would call that a ―prospective termination.‖ I talk about five types of termination and if there is an ideal one, the prospective termination is the ideal one. We know in advance when it‘s likely to happen, and I say ―likely‖ because it isn‘t set in stone. It may be, but it usually isn‘t. We‘re going to identify this as the potential point of departure. That‘s identified in advance, so that‘s ―prospective.‖ Usually that‘s positive, even when it is forced.
There‘s just a very little research on the topic of termination. What we do have suggests that when we know in advance and we talk about it along the way, even when therapy is more abbreviated than we prefer, it can be positive because that process of having a sense of control about at least knowing when it‘s going to happen is a positive one. So usually,
126 the prospective termination is one that happens when we have it planned in advance and if we don‘t have a time limit, it‘s going to be when we arrive at our goals.
ALEXANDER: Does that minimize the feelings of loss, do you think, or does it make any difference?
DAVIS: The whole concept of loss in termination is an idea that that we believe is a predominate theme. Again, this is limited research, but what some of the research has shown is that loss is not as predominate as therapists might tend to be concerned about. Certainly there are feelings of loss, but it can co-vary with how intense the relationship is, how dependent the client has been on the therapist for support. It can vary from the normal bitter-sweet feeling of ending of a good relationship, but also balanced with feelings of accomplishment, positive resolution, relief. So there, the positive feelings associated with effective therapy typically outweigh the negative feelings of loss. It will be kind of a bittersweet thing, so that‘s different from feeling like a lost opportunity, or a loss of a sense of hope, or a loss of a significant other which happens less often from what the little research we have shows us.
ALEXANDER: What are the other types of terminations, then?
DAVIS: Again this is something that as I‘m looking at the spectrum of what clinicians report that they‘ve experienced or what I‘ve seen in my own experience, we have times where we terminate ―Flexibly.‖ This is not necessarily planned in advance but something comes up, things happen fairly quickly, circumstances change, and closure is necessary. This may be due to rapid progress or it may be due to a change of circumstances so either the therapist says it may be time to stop, or the client - and more often the client says, ―I think I want to take a break here,‖ or that ―I‘m going to need to stop.‖ Then we‘re going to respond to it based on our case conceptualization -- if this makes sense for the client right now in this point in time, or if it‘s absolutely necessary.
ALEXANDER: Ok.
DAVIS: That‘s like a second type. A third type is what I call the ―Oblique termination,‖ and that‘s where the client essentially abandons therapy. If it happens early on, we‘re probably going to call it a ―Premature termination.‖ We can also call it a Premature termination even if it‘s much further down the line. It‘s when the client doesn‘t explain why they‘re leaving. They leave therapy and it‘s not clear what‘s happened from their point of view and they don‘t respond to follow up. It could be that just something‘s come up, or it could be that there‘s some conflict that they‘ve responded to by abruptly withdrawing.
That‘s different from a ―Complex Termination,‖ which is the fourth type. That would be a category where there‘s any difficulty, any conflict, or unusual interaction. So there‘s communication between a client and therapist, but it can be when there‘s a disagreement about whether or not it‘s appropriate for the client to terminate. They say that they want to terminate, but you think it would be better for them to stay in therapy. It could be
127 when the client terminates in anger and then comes back. There‘s some sort of complexity to the relationship. We‘ve done a little looking at this and one of the therapy outcome studies that was being done at Vanderbilt found that 75% of the terminations that we would classify as ―Complex‖ involved clients with Axis 2 psychopathology of either cluster A or B, which is the eccentric or the highly emotional clusters.
ALEXANDER: The personality disorders?
DAVIS: Yes, those two. Cluster C, the anxious personality, is more often going to have a Prospective Termination. They‘re not necessarily going to have difficulty in the relationship, but they may take more time to achieve an identified point where they‘re ready to leave therapy or try things on their own because of the anxiety. What we say in a very small sample is that that client has more of an ability to plan and attempt a termination in a sequentially planned fashion.
ALEXANDER: So we‘ve got the ―Prospective,‖ we‘ve got the ―Oblique,‖ that was the third one.
DAVIS: ―Flexible.‖
ALEXANDER: ―Flexible,‖ and the fourth one is the ―Complex.‖ And the fifth one?
DAVIS: This is the one that we try to avoid at all costs, and certainly can, we hope doesn‘t happen… and that‘s ―Unprofessional.‖ That‘s where termination is clearly below an expected standard of conduct, and might constitute -- I say, ―might,‖ because we don‘t know for sure, but it ―might‖ constitute abandonment of the client. That would be something very significant such as just abruptly not showing up for your practice, not being there, not giving notice; and doing something that would clearly be below an expected standard of conduct for informing clients and attending to an orderly or planful for a resolution of the therapeutic relationship.
ALEXANDER: So this is even worse than the therapist saying, ―I don‘t think we can work together anymore. I‘m going to give you the name of somebody else.‖ This is even less attuned than that. It‘s like non-attention right?
DAVIS: That‘s correct, because it‘s not unprofessional to say to the client, ―Well I‘m not sure,‖ or ―I don‘t think, in my professional judgment, that we‘re progressing or that I‘m the right doctor for you and I‘m going to give you some alternate recommendations.‖ That‘s a very professional action, depending on how it‘s carried out. That would be Flexible or Prospective, or possibly Complex depending on how the client responds to it. If they say, ―No no no no no, I cannot see anyone else,‖ or ―That wouldn‘t work, I‘m not letting go‖… then we have a Complex termination.
ALEXANDER: In that situation. what do you do?
DAVIS: Get a consultant. Get some outside consultation and proceed carefully
128 to a planful and therapeutic resolution.
ALEXANDER: So that would not be the last session?
DAVIS: That would not be the last session, that‘s right. If there is some information that comes forth, the client reacts badly, then it‘s important to use clinical judgment and we wouldn‘t say that it‘s appropriate, necessarily, to end things right then, depending on what the client does. If they threaten your life, then it may be appropriate to end at that session. If they say, ―No, you can‘t do that,‖ -- this is very unlikely but in that event, then that could be the last session. But we‘re going to assume that that‘s a very unlikely thing so it probably wouldn‘t be the last session; you‘d attempt to work things out. But difficult situations might develop from there, and that‘s where it‘s important to get some outside consultation so that you‘re not entering into a non- therapeutic and potentially unprofessional interaction with the client where there‘s argumentation going on and it‘s not helping them.
ALEXANDER: Let‘s say you have eight sessions, or twenty, or hundred. Is how each session ends something that you can look to in order to predict how termination would go?
DAVIS: That‘s a really interesting question, Barbara. I think that‘s a great question for research. I don‘t think that we could answer that right now. That would be an interpretive hypothesis and I‘d like to see some evidence to see if there‘s something we could learn there.
ALEXANDER: I didn‘t mean to throw that at you. It was just occurring to me to wonder if somebody has trouble ending a session, does that mean that they‘ll have trouble terminating, if that would be a predictor? Well at any rate…
DAVIS: Are we talking about the therapist or the client?
(laughter)
ALEXANDER: Could be either one, I suppose.
DAVIS: I‘m going to think first about the therapist. How well does the therapist take the lead, because it‘s the therapist‘s professional responsibility to guide the termination process: to watch for the client‘s sign, to work collaboratively with them. Ultimately it‘s their responsibility to accept someone as a client at the beginning, to manage the ongoing relationship, and then draw it to a close in a way that is professional and responsible to the client‘s needs.
So I‘d look first at the therapist and say, ―How are they doing with that? How are they managing the front and the back door of therapy? When they‘re accepting people in, are they accepting clients who are appropriate for their practice and how do they end each session? Maybe how they handle each session, looking at the client‘s progress at each
129 session, bringing each session to a closure and linking it to the next would be a good way of assessing that. I think you‘ve tapped into a neat way to think about the skills involved in termination.
ALEXANDER: Well, let‘s talk about them.
DAVIS: One of the things I talk about in the Terminating Therapy book is some work that was done by Jeff Youngren and Mike Gottlieb in a paper that they wrote about ending therapy. They defined ―abandonment,‖ and they talked about seven reasons for ending therapy or termination. This makes a lot of sense to me so I‘ve summarized that as well.
You think about it as the ―exit signs.‖ Do we recognize the exit signs? So that‘s one of the skills for therapists: to understand ―These are the potential exit signs.‖ We focus, many times, on just the clinical indications: I want to know when my clients are ready, and that‘s the ideal - that‘s fabulous, of utmost significance. But there may be other exit signs. So the first exit sign would be, ―We‘ve arrived, we‘ve reached our goals. We are there.‖ ―Are we there yet?‖ is the question we are going to ask. ―Have we reached the goals,‖ which are the maximum benefit that therapy might offer this person? That‘s a tough judgment call. That‘s going to link back to what we set out to do in the first place, where we decided to go: did we set limited goals to resolve a particular situation or answer a particular question, or did we set broader goals for feeling more stable over a long period of time, or resolving larger issues? That‘s going to depend on the needs of the client, a number of clinical factors.
But some of the other reasons can include assessing early on that we‘re stalled, or we‘re not going in the right direction. Things are not progressing in the manner that we thought we would. That‘s time to just stop and think, not necessarily to terminate. You might reevaluate, redirect, see if we can get on a good direction that‘s productive for the client, but that‘s one question.
If we‘re stalled or going the wrong way, is it time to terminate? Are we working together? That‘s another question that we want to ask and if that‘s not the case, if we don‘t seem to be working toward common goals or it‘s not comfortable using the same approach, if the client is really looking for something else … For example, if I have someone who comes for behavior therapy yet they want to explore childhood dynamics, if I‘m able to provide that I will, but if I‘m not, then we might not be working at the same purposes and we‘ll have to take a look at that. That‘s a possible point of termination.
That brings me to the fourth reason which is, ―Am I the right provider for the job? Or am I STILL the right provider for the job,‖ because what the client needs might fall outside my range of skills. We all have that, don‘t we?
ALEXANDER: Yes, yes.
DAVIS: That question comes up the more we know about what we do best, the
130 better we can serve our clients by letting them know when that falls outside the range of our skill sets, either for the type of problem or population. As the client progresses and their needs change, it may be that you were the right provider early on, but now maybe they need a different therapist or maybe some other type of service.
ALEXANDER: So for example, you‘re five or eight sessions into a treatment process, maybe you don‘t have a fixed date ahead of time, or maybe it‘s fairly unlimited, and you learn something new about the patient, let‘s say that they were raped and you don‘t have skills as a rape counselor…
DAVIS: Right…
ALEXANDER: Something that you don‘t have the skills for, or they reveal some secret. So that‘s an example of what you‘d be talking about?
DAVIS: Exactly. As you‘re delving into the presenting issue, and if, as you‘re looking for some of the origins of this, you‘re finding that there was some trauma… If you don‘t have the training - or maybe you do have the training in treating trauma, but this is a particular type of trauma that you know somebody else is really a focused expert in this, and they might be better served, you could present that as an option: ―I could continue working with you, or there‘s Dr. C over here who really specializes in this and I think you might be better served. Why don‘t we consider this?‖ Or it may be an alternate type of service: marital therapy; or maybe we want to look at some medication as an alternative, or an adjunct or some other service that may or may not indicate that it‘s time for us to complete our work together.
ALEXANDER: Well then, let‘s say there‘s child abuse that the person remembers, or reveals some early child abuse or something that‘s not anything you know much about how to do, and you send them to somebody, do you say at that point, ―Look, when you have finished with that therapist, if you ever want to come back to speak with me about other things …? Would that make it be a flexible termination or… it‘s sort of open- ended?
DAVIS: You‘re picking up on those concepts. That‘s exactly the idea. There might be a flexible termination there, depending on the client‘s needs and resources. If they need to see just one person at a time, we‘d decide this together. Collaboration is so important. From my approach, we‘d want to bring up what the options are and decide what will work best for this person. Rather than having a set of procedures that this is how it‘s done, we‘re going to think about these options and identify the best way to make it work for this client depending on their needs. So exactly. We might have them consult that person, see if that‘s going to be something important for them and if the person needs to, ―Come back and talk to me,‖ or we might continue working simultaneously. It just depends on what we think is best.
ALEXANDER: Ok.
131 DAVIS: There are a few other exit signs. Those could include running out of time or money. That may be a reason that we draw things to a conclusion, or at least flexibly terminate, take a hiatus because the resources for this continued work need to be adjusted; they‘re just not there and there may not be an opportunity. Or the client may not want to see an alternate therapist. They just want to decrease the frequency of their sessions, or take a break. So that could be a flexible termination. I don‘t know about you but that‘s been coming up more often in my practice and I‘m hearing that from virtually every one of my colleagues.
ALEXANDER: Yes, the impact of the economy.
DAVIS: Exactly. We certainly had the advent of dealing with that with managed care, and now we have the economy on top of managed care, so we‘re dealing with limits of time and money very frequently. On top of that and very closely related to that is change in circumstances. Sometimes terminations are precipitated when people move, or change jobs, or their life circumstances change in such a way that it makes it not feasible or effective for them to continue. So that might also be a flexible termination.
ALEXANDER: What about when the therapist is a trainee, let‘s say a resident or an intern? It‘s part of their training and their year there at the clinic or hospital is done and then the client may go back into the patient pool and then in the following year, get another student therapist.
DAVIS: Right, so then they go through a termination, and then starting again. That‘s a ―We‘re out of time termination.‖ But it‘s also Prospective. The reason is we‘re out of time, but we hopefully knew that in advance, and any time we can predict an advance, we want to be able to do so. We want to have some prospective planning whenever it‘s possible.
ALEXANDER: Do you tell the person if you‘re a trainee? That‘s always been sort of a bugaboo of mine, feeling that a lot of patients or clients in training settings get tricked in a way, I would think.
DAVIS: Well, Barbara, I would want to recheck the ethics codes for the range of healthcare professions. I‘ve looked at that and I know for sure for psychology, it‘s specified in our ethics code that we must inform our clients when there‘s a trainee status. That‘s an ethical obligation, and I think that‘s included in the spirit if not the letter of the various professions‘ ethics codes. It‘s an obligation we have to let people know that there is a limit here that one is in training because that involves supervision, so you‘re disclosing information about what‘s happening. Most state licensing laws are going to require supervision for anyone who‘s in training. I don‘t know any state that doesn‘t. You have to disclose information to your supervisor and it‘s then a professional responsibility to inform the client that that disclosure is happening, and the other implication being you‘re going to come to the end of the line with your training there.
One of the things that happens in many training settings is that the trainees stay on. They
132 may end their placement in June or December, or whenever their semester academic segment ends, but they continue to work with the client. Some settings allow that, some don‘t. The client doesn‘t have to confront that ending and maybe that‘s why they don‘t inform them about the potential end because there‘s a possibility the trainee may continue. So that‘s handled on an agency by agency basis, but the responsibility about informing a client about being a trainee, I think, is fairly standard.
ALEXANDER: Another change in circumstance would be when a therapist moves from one setting to another.
DAVIS: Exactly.
ALEXANDER: Changes jobs… and can they take the person then with them?
DAVIS: Exactly.
ALEXANDER: That would depend on the agency then wouldn‘t it? Or the employer? It would be part of the practice manual that it would be allowed or not allowed, is that right?
DAVIS: Right, whether or not it‘s going to work. Let‘s say you‘re in private practice and you get a job to work at the Veterans hospital. You‘re not necessarily going to be able to take your private practice clients to the Veterans hospital. You may make arrangements to keep your practice going until those clients are finished in therapy, or you may end up closing that part of your practice and referring those clients. It‘s really going to depend on the situation. Those are some examples of changes in circumstances that can be cause for termination. That‘s not an abandonment, at least in my opinion, as long as there‘s an orderly professional process of notifying the client, giving them the information in advance, and allowing them an opportunity to locate other providers without abruptly failing to show for your next session and saying, ―My practice is closed, I‘m sorry.‖ That would be an Unprofessional termination.
ALEXANDER: What about the steps for negotiating a sound, well-done termination? I understand that there are some steps that you‘ve outlined and you‘ve determined some steps in negotiating a good termination. I‘m hoping we can have some time to go into those with some examples.
DAVIS: I am always looking for tools that are going to help therapists. I do a lot of work in training young and new therapists and one of the questions that comes up for new or even seasoned therapists is, ―How do I know I‘ve done enough around the point of termination?‖
It‘s become so real for us in the era of managed care when we don‘t have the time to leisurely arrive at a place or a destination where a client is ready, we wait for them to bring it up, and that‘s wonderful, we can do that. But we don‘t always have the time or the opportunity to wait until the client says, ―I think I‘m coming to a point where I‘ve
133 gotten a lot out of this, I‘ve met my goals,‖ so we go through a process with that. Instead, we are out of sessions, we come to the end of the line with training, we have clients - for all of those other reasons that we have just outlined - so the therapists are wondering, ―How do I know I‘ve done enough? Have we gone through a termination process?‖ because the old model was that it may take months or even a year planning termination. We don‘t have a year to plan termination any more.
So I thought about, ―What are some steps? How can we know if we have done enough to say that we‘ve made reasonable efforts?‖
This is a protocol that we can use to evaluate our own actions and to assess what we‘ve done and outline the steps that we‘ve taken. The first step is to plan ahead for termination, to be thinking about it instead of seeing it as a distant thing that‘s going to come up when we‘re ready but to address that at the very beginning: to be thinking about what are some of the potential points of terminations and to incorporate that into our informed consent when clients first come in, so the termination process means that clients are informed about potential end points and they‘re on board and working with you. It‘s not that you‘re going to just discharge them.
This is where we differ from medical procedures in that the physician says, ―The procedure‘s done; you‘re discharged now.‖ This is different. We‘re working together to identify points of completion. So we‘re going to engage the client in that process beginning with the planning for it from the very beginning and incorporating that into informed consent.
ALEXANDER: That‘s good.
DAVIS: Yes, that‘s the first step. Think about that, put it in informed consent, get the client on board so that it‘s not a taboo subject that we don‘t touch. The research has suggested that you just have to touch on it. Talk about it a little bit: where would we end? What would we need to do? And, it‘s very helpful for goal setting because you can ask the question, ―What do we need to do to know that we‘re done? What do we want to have accomplished in order to say, ‗Ok, that‘s enough?‘‖
ALEXANDER: One of the things in longer term therapy is that from the first point that you talk about termination, everything following that -- it‘s somewhat like when you start talking about vacation -- everything following that has to be seen through that screen or sieve. Have you found that to be true?
DAVIS: I would say that that‘s a point of divergence and a different model for treatment. While cognitive behavior therapy may end up begin long term, we might work on longitudinal issues, we are looking at it as a comprehensive process and a joint decision-making where that is part of the process. It‘s a task of the therapy. That decision-making is part of the therapy process. So we‘re going to identify that as part of our process from the beginning, but no, we don‘t see everything through that lens from the time that it‘s brought up. It‘s much like saying, ―In five years, we‘re going to take
134 this vacation,‖ but we don‘t spend all of our time thinking about that vacation for the next five years.
Maybe a better example would be when you start college. You know you‘re going to graduate, but you‘ve got a lot of work to do before it‘s graduation day. So your entire focus is not on that. It‘s on the work that you have to do and hope to get done in the time that you have, and addressing the intervening reasons that you might need to end sooner than that, if they come up. So everything isn‘t seen through that lens, but it‘s something that we‘re aware of so we don‘t miss the important points where we need to be talking about it and thinking about it. That‘s step number one.
Step number two is assessing the client‘s progress as they go along and their movement towards that goal. We‘re thinking about whether we‘re traveling together: ―Are we accomplishing what we want to accomplish?‖ because we don‘t want to continue to provide therapy that isn‘t helpful, where there is no benefit. Again, we have an ethical obligation not to provide therapy when it‘s not helpful, or to terminate when the client no longer needs it, or is potentially being harmed by it, if they‘re getting worse. One form of harm is a loss of resource, of spending money they don‘t need to spend if there‘s no benefit coming from it.
So, we‘re going to be assessing progress. In my book, I talk a lot about looking at progress very broadly and identifying progress in a sophisticated way that‘s based on a client‘s conceptualization. We were thinking about the micro level on that, and if we‘re making slow, steady progress, and that includes their perception that this is value, this is serving some purpose, then we‘re making progress and we‘re going to proceed toward the goals, if we can.
Maybe it would help if I overviewed the third, fourth, fifth, and sixth steps and then I‘ll explain each one and you can ask me some questions. The third step is to make sure you‘re checking on your ethical and legal duties when termination is contemplated, and then to conceptualize and consult whether or not termination is appropriate here. The fifth step is to process and part with the client, so that‘s the point of having some termination sessions, the point in time. Then the sixth step is to create a record of disposition so there‘s closure there. We plan from the beginning, assess the client‘s progress, and have the client assess their progress. We do it together. Make sure we‘re thinking about ethical and legal duties, conceptualize this from a clinical, practical, ethical, perspective and get some consultation if needed, process it with the client and then make sure we‘ve noted termination in the record in a clear disposition.
We were talking about the ethical/legal duties and that‘s broadly stated; it would depend on the situation. Most times, the common perspective is that it‘s unethical to terminate a client if they don‘t want to be terminated. That would constitute abandonment. I make the point in the termination book and elsewhere that that‘s got to be counter-balanced with the ethical responsibility to only provide services that are necessary. Many times, therapists will overlook the idea that they might be providing prolonged therapy rather than thinking in the interest of trying to avoid any abandonment of the client, rather than
135 bringing up the idea that termination or referral might be appropriate.
The only time that I know we have, at least for psychologists, any ethical prohibition against termination is when we‘re terminating therapy to engage in unprofessional actions.
ALEXANDER: Like dating your patient?
DAVIS: Exactly. That‘s the one time you‘re not – ―Thou shalt not terminate in order to date your client, or your client‘s sister, or someone closely affiliated with them.‖
Otherwise if you look carefully at our ethics codes, the recommendations imply that we have an obligation to constrain or limit services in order to make sure that there‘s no harm coming to the client, there‘s no conflict of interest.
We haven‘t really talked about conflict of interest, but that‘s an important point to be made. When a conflict of interest develops, as they may, then that calls into question whether or not therapy should continue.
ALEXANDER: What would be an example of that conflict of interest?
DAVIS: Let‘s say your spouse goes to work for a client‘s spouse, that some relationship develops. What was the classic one in the film… that your child dates a client? Something comes up. These are the kinds of situations that we can‘t engineer; they land in your lap. Students are great at coming up with, ―Well, what if this happens?
One of the heuristics that I use for conflicts of interest is that when the client feels it might be a conflict of interest, it is. If they feel that it is, then it is.
ALEXANDER: That‘s for sure. We as therapists might feel concerned, and that, we‘d have to deal with in consultation. But if they feel it is, then it is.
DAVIS: If they feel it, then it is. If they don‘t feel it but you believe it is, you may still need to proceed with the termination. They say, ―Oh, there‘s no problem. My best friend‘s mother wants you to see her daughter in therapy, a close family friend.‖ I‘m going to have to say, ―I‘m sorry but in my profession, we regard that as a conflict of interest and I can‘t accept that person as a therapy client.‖
We have to operate within the community, the judgment of our community of peers on that matter where your peers would say, ―That‘s a conflict of interest.‖ Whether the client feels it is or not, if they feel it is a conflict of interest and you think, ―That‘s kind of marginal. I don‘t really have a problem with that,‖ but if they are saying ―Nuh uh,‖ then I would say, ―Nuh uh. Don‘t go there,‖ because it‘s really important what their perceptions are. It‘s also important what our community of peers has established are very likely to be conflicts of interest.
136 These steps are not necessarily absolutely discreet steps. I‘m just highlighting the components that go into a process. Thinking about that is the process of conceptualization, conceptualizing whether or not termination is appropriate clinically, ethically, and practically for this client at this point in time. You‘re thinking about that and if need be, consulting with qualified peers, so we all, hopefully, have peer consultants that you‘re working with. If there‘s any question in our mind, then we‘re going to talk to one, or two, or three of our colleagues to say, ―Does this seem like a potential conflict of interest to you? How do you feel about that? What would you think about that?‖ And we consult with the client. ―We‘re going to talk together about the process of termination, and is it appropriate now. Let‘s think about this.‖
One way to define termination is a process or a point of reevaluation. That‘s what that step four is: let‘s reevaluate, talking with the client, and if we decide it is, then we‘re going to establish a timeline for step five: process and part with the client. You have that last session or last set of sessions, and if we‘ve been doing bits and pieces of this all along, then we‘re probably going to have a shorter… ―phase,‖ if you will. I hesitate over that word because it‘s not a distinct phase; it‘s just where we do view through that lens that this is the point that we‘re terminating. We may be working fully in that last session, that we know this is going to be our last session, or this is our next to the last session, or in four sessions, we‘re going to have our last session. But at the last session, we want to talk about a few things, cover a couple of key points, look at any questions the client has. We want to prompt or probe for these bittersweet feelings. Are there feelings of loss? But not to expect or to frame it as, ―Well you should feel this terrible sense of loss, in case they don‘t.‖
ALEXANDER: That‘s important.
DAVIS: Yes, it could be a very positive thing. One of the things that a little bit of research has found is that the need to talk about that is going to vary with the client. If the therapy hasn‘t been very effective, then they may not want to talk about it a whole lot. We need to be very sensitive to the needs of the client on that extent of discussing what‘s happened. If therapy has been successful, they may not need to talk about it a lot because it‘s been successful. But some people will vary in the need to talk through that process of ending. That may be just unique to the client and their need to use talking as a way of processing, and the closeness of the relationship.
Anxiety may be a factor for either one, the therapist or the client. The ones who are more anxious may want to talk it through, need more sessions, a little bit more testing or fading out sessions, and have a longer time line for their point of coming to the last session. So they might have a session every six months and then decide eventually that‘s going to be their last session.
ALEXANDER: I wanted to ask you about that staged out, phased out termination.
DAVIS: That‘s going to be probably most likely for someone who has high anxiety issues, and people who‘ve had a close long term relationship. This came up –
137 interestingly, a friend told me that her therapist told her that she would give her three years notice when she was retiring. She goes intermittently to therapy and has been over a long period time, so she‘s had a number of flexible terminations, but the therapist has said, ―We‘re going to have a long-term notice,‖ so she‘s realizing that there‘s going to be a point of closure and that‘s giving her long-term opportunity to get used to that and a good fading over time. We may not always have that ability to give that length of notice, nor does everyone need that. But some people might, so it just depends on the needs of the client. Fewer people are going to need that, and we need to identify a point of closure and have that last session. It‘s going to be easier when this discussion has been woven in.
In that last session, a couple of points I would just add as prompts or reminders: do an assessment, a global assessment, of functioning so that you can note that in your records, so there‘s some closing assessment there. And be clear about whether or not follow up is an option. Are you open to it? Most cognitive behavioral therapists I know unless they‘re not going to be available, are going to be open to say, ―Call me if you need to,‖ or depending on the client‘s history and the severity of their problems, ―We‘re also going to work on resilience and relapse prevention.‖ We‘re thinking about their strengths; we‘re doing an inventory of strengths. We‘re ending on a positive note where we‘re thinking of what have they‘ve gained as a process of being in therapy that will help them, what they can tap into in terms of their personal functioning that is going to help them avoid problems in the future and be able to lead to developing their strengths and accomplishing the goals, which most people have, which are to achieve happiness, or stability, or well-being?
I hope I‘ve hit all the points about some of those things to cover in that last session, but the main thing is to look at both sides of how you feel about this, having an open forum, but not to assume that it has to be all about loss but ending on an upbeat note. Most people find that to be very useful, and the research supports that: let‘s look at strengths; let‘s identify this as a positive, and whether or not there‘s going to be future contact.
That does bring up one other point that many therapists have brought up to me in consultations: what do you do when people then want to have a personal relationship? This may not be common, but it does come up. The question now is, ―Can we be friends?‖ Some people want to continue therapy and call it ―friendship:‖ ―Can we meet at Starbucks? Can we go out to lunch? Can I give you a call? How do we do that?‖
This is where the cognitive behavior therapies have been much less clear. I think the traditional transference based therapies have been much clearer and that‘s more useful: ―No, we‘re not going to do that.‖ So it‘s important for the therapist to be clear about how they‘re going to handle follow-ups, how to keep it in a professional context, and not suggest, ―Sure, now I‘m open to a personal relationship.‖
ALEXANDER: It‘s easy to assume, I think, in some of the briefer treatments, that the relationship is not as important.
DAVIS: But it is.
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ALEXANDER: Yes, right, right.
DAVIS: I think that‘s a key point. Don‘t assume just because the therapy has been short that it hasn‘t been affectively intense. A therapist needs to be ready and trained to handle that idea that a very significant attachment has developed here. We want to be sensitive to it, but also clear that we need to keep professional boundaries, and then let time help us understand what the client is going to need -- whether or not they‘re going to need follow- up care, because many clients do return.
ALEXANDER: As a therapist who‘s been in the field for many years, you look back on the people that you have worked with and treated over the course of your adult life, over the course of your career. I remember people so vividly, and I wonder so much what has happened to them, what has been the long-term outcome of our work together. Did that marriage that I thought would never last continue? Did that person have a child after all? There‘s a process of termination that has to go on in the mind of the therapist, I think. What is your opinion on these kind of follow-up wonderings?
DAVIS: That‘s another whole subject. I was hoping in the course of my work to open doors, to identify as we talk about some of those basic nuts and bolts that might help us in our day to day practice, to learn more about what do we need. I think you‘ve just reached that point of touching on that: the therapists‘ needs; the ―I wonder‖ needs. There are other needs too: our therapeutic termination within the providers‘ thinking; the essences in the parting and in our memories of that.
How do we continue to relate to our clients over the long term? As far as I know, no one has studied this. I know that there‘s one fairly obscure study that looked at clients‘ thoughts about therapists, way down the road. Seven years down the road, they were still thinking about their therapist. Ten years down the road, still thinking, so that‘s a fascinating subject to learn more about.
I‘d love to know more about therapists‘ reflections and wonderings, and how they come to terms with the long term memories that they have. Those don‘t go away. Just because the file has been destroyed, the memories are still there. It hasn‘t ended, but the relationship and the contact and the work has its place in time so we have to have a way of thinking about that that has some resolution, and hopefully is positive.
It sounds like what you‘re saying is part of our reality. We have memories and uncertainties about what happened to our clients that we may or may not ever know that long-term outcome to.
I think that one of the ways we cope with that is by having therapist peer support groups and self care. Having that is so fundamental. That‘s another way, another signpost that says, ―This is something we need to do to take care of ourselves,‖ so we can talk to other therapists and know that this is a common experience. We have these wonderings, and we can learn from each other about how we consolidate those memories. How do we
139 resolve the, maybe, regrets we have, or the unfinished business and so forth?
ALEXANDER: Dr. Davis, this is a lovely way to finish our interview, I think. I‘ve enjoyed this very much. This is going to be the last interview in this program on the therapeutic relationship, and it‘s a perfect way to end. I want to thank you very much because you‘ve closed a circle for us.
DAVIS: I hope we‘ve ended on a positive note. It feels that way to me too. I have some great ideas from our conversation and I hope those who listen to the program stimulate their discussion of termination with their colleagues and their peer support groups as well and continue to learn and explore some ideas on that.
Thank you so much.
ALEXANDER: You‘re very welcome.
DAVIS: I appreciate this opportunity.
This concludes our interview with Dr. Denise Davis. We hope you learned from this interview and that you enjoyed it. You may contact her at (615) 646-1957; Email: [email protected], and her website is www.denisedavisphd.com. Her book, Termination Strategy: A Professional Guide to Ending on a Positive Note, is available through all major book sellers.
This also concludes our program on ―The Therapeutic Relationship.‖ I need to say here that the views expressed by our speakers are theirs alone and do not necessarily reflect the views of On Good Authority.
On behalf of On Good Authority, and until next time, this is Barbara Alexander. Thank you for listening.
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