Reflections on the art of psychotherapy
REFLECTIONS ON THE ART OF PSYCHOTHERAPY
Adam Blatner, M.D.
December 28, 2006
[Preamble: Recently, I’ve been reading some books about the art of psychotherapy by other leaders in the field, and while I’ve liked their approach, I’ve also felt that certain things were either not stated at all, or needed further amplification. Also, I gave a workshop for some relatively new therapists and this, too, stimulated my thinking about what I wished someone would have told me when I was just starting out.]
First, the challenge is to clarify what the patients really need. Sometimes it is not psychotherapy per se. Sometimes it’s more of a social-work assessment and intervention, marshaling resources, helping to access consultants and networking with relevant people. Sometimes what’s needed is more of a medical evaluation, and the treatments might be rationally implemented only after making a good diagnosis. Often it’s a mixture of several elements.
A not-insignificant component of the therapeutic process begins when the client just begins the process of doing something about his or her problem. Getting the name of someone, making the phone call—and never underestimate the power of the voice of an answering machine or a secretary, the tone, attitude, and similar variables! From this positive expectations may be generated. Then there is the first actual meeting. Aside from the cognitive process of assessment, an even more basic element is the establishment of what is called a “treatment alliance” or “working alliance,” and that in part involves the therapist’s art of being, first, a reasonably nice person, making the warming-up process on the whole somewhat pleasant.
Admittedly, there are some whose entrance into the process is indirect, and indeed, has been coerced: Patients who are “court-ordered” or presently in prison, rehabilitation, or involuntary hospitalization are often still in denial that they have anything that needs to be looked at, much less changed. They just want those who are supposedly helpers to be their advocates in getting them out of the societal constraints being imposed by others. There are also patients who come for therapy because their spouse threatens to leave or employer threatens to fire them, and many of these also can have a fairly hostile attitude at the outset.
I don’t feel that every therapist should be able to develop a treatment alliance with every client who comes through the door. If, after a bit of time together, the rapport or contract cannot be established, I think it does not reflect on the therapist’s competence for him or her to suggest that the client seek help elsewhere or refers the clients to someone else.
I begin this essay this way because the assumption that professional consultation implies “therapy” immediately biases the situation. Sometimes it doesn’t. More importantly, I want to emphasize the component process of evaluation or assessment. When I use the word “diagnosis,” I don’t mean putting a label on the complex of signs and symptoms. (Actually, in some cases that can be most helpful, but often it is misleading, suggests more understanding than is actually operating in the system.) Rather, the term, derived from the Greek word roots, “dia-“ for through, as in “diaphanous,” and “-gnosis” to know, refers to really having a plausible understanding of what is going on.
Diagnosis is always partial and unfolding. One simply needs to reach a critical mass of information so that it becomes practical to formulate a plausible plan for beginning treatment. We should expect that further information will emerge in the course of treatment, and, indeed, sometimes indicate a change in strategy, modality, approach. Not infrequently, one approach may be used for a while, but as new information becomes available, either by emerging more clearly into the client’s consciousness or into the shared field of communication because the client has come to trust the therapist (and/or others present—other family members, the group, etc.), a review of that information, history, associations may be important before proceeding further.
For example, sometimes only after a few sessions—or even a good many—will a client admit to an addiction, an unusual sexual fantasy or compulsion, a history of some kind of abuse or trauma—these can be repressed and not come out in the course of an initial evaluation!—, a spiritual issue, a marital problem, and so forth. Indeed, I would say that this actually fairly common, and is one of the reasons why therapy is by no means a predictable process. (This is a dig at those therapies that are manually-driven, or that presume that all patients can be treated on a short-term basis.)
Two Parallel Processes
Therapy should be recognized as involving two parallel processes, one addressing particular issues, analyzing and correcting them, and the other aimed at a general strengthening of the system. In some people, the problems aren’t so overwhelming, but the overall system is weak, demoralized, laced with counter-productive habits and attitudes. In others, the overall personality is relatively strong and resilient, but the problems have become stressful enough to generate symptoms.
The point is that therapists need to weave both elements in as needed, and diagnosis needs to address not only the specifics of problem elements but also where deficiencies or other issues may be operating within the general system. One of the key elements here is the process of encouragement. If a problem seems to be too difficult or too shameful, too “fast” or too “soon,” clients will “resist.”
About resistance: I don’t like that word, because in any new learning if there isn’t a proper warm-up, if I feel overly pushed or threatened, I can’t help but shut down a bit—I really cannot will myself to stay open beyond a certain mild degree of mental or emotional “stretching.” So it does no good to use a word that implicitly blames the client or student when in fact it is the teacher / helper / therapist who has introduced material beyond what the psychologist Lev Vygotsky calls the “zone of proximal development.” That means that we can push ourselves to stretch a bit in our emotional stamina, physical stamina, imagination–but only a bit. Good learning operates in that “bit” zone, the stretch. Beyond that zone, though, people experience an influx of negative feedback, overload, pain, humiliation, vulnerability, and the nervous system reacts instinctively. One cannot will oneself to be braver or more emotionally stoical than the mind-body will allow.
So if we must use the word “resistance,” let it mean simply feedback that we as therapists need to back off immediately and introduce more playfulness, encouragement, reassurance, opportunity to relax, even coaching how to relax and become grounded. We need to use that as a signal, as valuable information about what might be the next step.
Often the problem has to do with a general status of vulnerability, of a preponderance of conscious or unconscious thoughts and beliefs that reduce self-esteem. Some people who pretend (to themselves as well as others) that they’re okay may suffer from an deep streak of vulnerability, emptiness, guilt, shame, or lack of connection with an inner source of solace or “okay-ness.” This dynamic is more pronounced in people with diagnosable “narcissism,” but it operates to a lesser, more subtle degree in many people—clients and ordinary folks not in therapy.
A motto I use is: Don’t put people in touch with their negative voices until they are first helped to be in touch with their positive voices. It’s surprising how many people have a relatively weak connection to self-encouraging, self-affirming inner voices! Part of therapy involves helping people re-connect and consciously use these self-coaching, self-reminding positive sources! They can include such elements as:
– spiritual ideals that are affirming of courage and reassuring and forgiving of frailities
– friends whose loyalty includes an awareness of the person’s weaknesses (sometimes this can be spouse, parent, other group members, adult children–people “who believe in you”
– higher self, inner wise part, oneself healthy five years in the future
– review and properly weigh achievements (in contrast to the interesting tendency of shameful and guilt-evoking memories tend to seem much larger in proportion in our memories)
– become grounded in a determination to frame one’s self-narrative in a way as to evoke positive, forward motion (also known as faith-filled living)
– giving oneself credit for wanting to heal, love, be more positive, clean up one’s act
I find that much of therapy needs to be periodically laced with the “tonic” of exercising this kind of self-esteem review. It need not support denial or evasion of healthy guilt—and the appropriate associated need for changing one’s attitudes, values, goals, as well as behavior. Encouragement, though, bolster’s one into an optimal range of self-esteem so that one can face oneself squarely and get on with the job.
Therapists must be sensitive to the fact that this threshold of courage and will fluctuates, rises and falls with many variables, ranging from the therapist’s facial expression and voice tone to small defeats or stresses in the time between sessions. The point here is that therapy (or education) should not be overly task-oriented: Let’s just analyze the problem and fix it. Let’s just get on with the learning. Always there is the emotional readiness for such work, which entails (if you think about it) an ongoing process of confronting one’s ignorance, the shame of trying and not “getting it,” the low grade fear of being scolded. Such attitudes are near-universal and are as much a product of the average school system as they are of any particular family background. Peer groups and competitive games also increase the “shame-sensitivity” syndrome, and I’ll go so far as to say that such sensitivities are near-universal. In other words, we need to weave encouragement into our work all along the way.
A General Theory of Therapy
This theory has two parts: First, I use a medical model in the following sense: Medicine two hundred and fifty years ago (and more) used to operate as competing schools of thought, some thinking that all illness was from an imbalance of humors, others a depletion of “excitability” of the tissues. Gradually, as science progressed, the field discovered some underlying principles of physics, chemistry, and biology, and more, an amazing and ever-growing complexity.
Being a physician myself, I confess I identify with this noble profession, in spite of the way some of its current practices have become subject to the crassest of pitfalls of “managed care”— an oxymoron, actually. Anyway, “we” discovered that the principles underlying the functions of the different body systems were largely different, so that for the respiratory system, the physics and chemistry of gasses are what must be learned; for the liver, mainly biochemical transformations; for the heart, principles of hydraulics; for the kidneys, principles involved in filtration and osmosis—chemicals passing through membranes; and so forth. What I’m getting at is that complex systems can have many different kinds of dynamics.
The same is true for the realm of mind, which operates along many channels, and at many levels. Disturbances can similarly be very different and their mechanisms must be understood as constituting a large variety of types.
The tendency of psychology as a relatively new science was to prematurely seek oversimplification, and as a result, in the mid-20th century, a number of “schools of thought” emerged which competed with each other more like religions than like science. The insights and techniques of most of the innovators and their followers were wrapped in a kind of package. In fact, though, most of these different thinkers had a number of excellent ideas, some good ones, and some that were more limited in their scope—or perhaps even mistaken. Similarly, the techniques used by each “school” had a range of ease and usefulness.
In medicine, this process “shook itself out” fifty to a hundred years earlier, and the main practice since has been to test and evaluate the best and most enduring insights of each innovation. Eclecticism is the norm, and it’s unprofessional to refuse to consider using a given indicated approach just because its inventor may have been wrong about certain other theories or practices.
Nor is there any oversimplification in the diagnosis of disorder. It is understood that there can be literally thousands of not just diagnoses but actual causes. Also, many patients suffer from more than one condition at a time, and some of their symptoms are produced by the interaction of more than two underlying disorders—this is called “co-morbidity.” We need to recognize this as operating in the psycho-social problems of humanity, also.
The Pedagogic Challenge
Pedagogy is the art of teaching, and in this case, what is the best way to train psychotherapists? If we overload them with too much variety, they’ll simply be intimidated and retreat to a narrower approach. Therefore, it is useful to offer an organizing theory that yet can keep them open to learning about and making use of the best insights of all the other theories. To this end, I suggest the following, an approach I call “Applied Role Theory.” (I may come up with a better name in the future. Richard Schwartz’ term, “Self-Management” is a possible candidate.)
The basic overarching theory is simple: We play many roles, and our management skills in organizing, modulating, balancing, and integrating the various roles we play can always be improved. There are a goodly number of component skills involved:
– identifying problems
– analyzing problems
– checking out beliefs
– deciding and re-deciding
– accessing imagination
– clarifying values
…. and many others (More about this approach– “The Choosing Self” )
To play a role is to behave in a way that includes a certain mixture of individual and social expectations. A role is any complex of thoughts and behaviors that could be played on a stage, even using dramatic elements to bring out the subtleties. In fact, a great part of the human condition can be formulated as roles, and in fact, it is actually more useful to think of situations as the sum of interacting roles being played. The use of the role concept as the unit of language in psychology is as easy and practical as the use of the concept of “note” in music! In contrast, most other theories of psychology are weighted down with a jargon that is excessively tied up with the details of that specific theory. Applied role theory, in contrast, is fairly familiar in the general population, though its more systematic application has not yet been widely taught. But anyone who sees movies or plays knows about roles being played.
In addition, people know about the role of the director who coordinates the actors in the roles they play. Applied role theory simply invites us all, and clients especially, to develop the role of inner director. In many people this role is taken for granted and ignored, and thus remains under-developed. Indeed, many psychiatric conditions might be better understood from this viewpoint as reflecting a mediocre or sub-mediocre functioning of the inner manager. It’s not only in big business that a CEO (chief executive officer) can be foolish or corrupt—it happens within the personality of individuals, too.
One way of thinking about the many different kinds of psychotherapy is that they share an implicit process of strengthening and developing the functions of the inner director. Yet they don’t recognize this role as separate from the self—which is really an aggregate experience of relative personal cohesiveness. In Applied Role Theory, we simply extend this process a bit more, make it explicit, and personal psychological education, maturation, therapy, wisdom development, all these have to do with building up the many different kinds of abilities of that part of the mind that operates as inner manager, executive officer, “decider,” or playwright-director.
When I do therapy, I instruct the clients briefly on this model and then as we proceed with the many facets of diagnosis and beginning therapy, I comment on these operations, encouraging the clients to begin to learn to do this for themselves, and to learn to do these functions with some ongoing increase of skill. (At times I find different metaphors to be useful.) This itself weaves in a positive expectation, helps the clients to remain oriented to the process, and helps anchor the lessons learned in therapy! (In contrast, some therapeutic processes can be quite bewildering, leaving clients quite unclear as to why this or that line of conversation is being pursued, why the therapist has stopped interacting in a conventional manner—i.e. this is admittedly a dig at the classical psychoanalytic silence technique—, or why some more active technique is being suggested.) Along with all this, I encourage the clients to become not just competent, but beyond that, creative. Nor do I forget to weave in attention to higher values, and opportunities to re-develop a sense of philosophy of life that is not overly selfish (as too many contemporary therapies sometimes do).
Eclecticism in Practice
There are a number of ways to be more systematically eclectic. If I had to start by choosing a system, I would probably use Arnold Lazarus’ Multi-Modal Therapy. (I don’t agree with only one idea that Lazarus notes: He questions whether eclecticism can be theoretically supported. I think it can, using the modified medical model mixed with Applied Role Theory described above.)
As I begin the process of diagnosis, I interweave two main considerations. First, I follow a process that focuses on a sequential series of rough decisions: Based on the most general themes of age, gender, and perhaps, if obviously relevant right off, marital status or vocation, first, the chief complaint: What are the most pressing symptoms? Based on these I begin the process of making a differential diagnosis: What are the most obvious situations and conditions associated with these symptoms?
Then as I move into the history of the present condition, questions are asked in order to begin to hone in on or eliminate the more obvious alternative possibilities. There is room to let the client talk, tell his or her story—it’s not just a rapid-fire questioning. Still, this conversation is somewhat guided as I simply try to get oriented.
One question I keep in mind early on is whether anyone else needs to be involved in this evaluation or therapy—especially regarding spouse or family members. With children, there may be a need to get history also from teachers, or other extended family members.
A second question is that of determining whether some major crisis is happening and whether something like hospitalization is needed, or more intensive diagnostic intervention. Many outpatient therapists like their leisurely schedule, but in fact, some people need to be seen for longer than 50 minutes, and perhaps have a second or third visit that same week to address the acuteness of the symptoms. This alternative should at least be considered: Not what is convenient for the therapist, but what does the client need?
Too often, it seems to me, therapists deceive themselves into imagining that all their clients can afford the fees and can come when it is convenient to the therapist. They “should” be able to contain their problems when the therapist take a vacation or a trip. Often this is so, but sometimes it denies the urgency of the patient’s actual needs. Not everyone “in therapy” can be treated the way the books describe. First of all, thirty and forty years ago prices were far lower and often insurance was more supportive—all that seems to have changed.
Adding in taking off from work, commuting time, and the cost of therapy, this approach should not be seen as a “benign” procedure! That the therapist’s intentions are kindly and supportive should not cloud the therapist’s awareness that clients suffer from the costs—hidden and overt—involved in participating in this self-exploratory and not obviously cost-efficient procedure! Add to this the restrictions and pressures of modern third-party payers (e.g., insurance systems), and the tendency to not speak up frankly, and the recommendation for therapy should be viewed as a considerable decision.
Negotiating a Formulation
Another challenge for therapy is again taken from the best of the medical model. Psychotherapy can just drift if it is not addressed directly. The early analytic process could begin and there might never be a moment when it’s time to stop and answer the patients’ questions: What do you think is wrong with me? What needs to be done to fix it? How long will it take? How much will it cost? What procedures will be involved? How will I know if we’re making progress? Therapists should keep in mind that these questions are there and many patients are two intimidated or too new to the process to know to ask them overtly.
I think therapists should be creating a tentative formulation, revising it, changing it, thickening it, as the interviews proceed. The possibilities of alternative diagnoses should not too quickly be dismissed, as well as the possibility of a new diagnosis that hadn’t been previously considered. This is a degree of humility that I’d wish for any doctor that treated me.
In simpler cases, the therapist can sometimes give a general sense of what needs to be done after 45 minutes or so; in more complex cases the therapist may need to have a few diagnostic sessions before a schema or sense of coherent pattern emerges. There are as many as 20% of cases, though, that even more time is needed for further diagnostic procedures—and often this means not so much exotic tests as just continuing review of the history in greater detail. So clinicians working in mental health clinics or according to managed care guidelines that seek to determine diagnoses and plans for length of session are subject to an artificial standard that they should recognize as grossly unprofessional, unrealistic, and stupid. They may learn to play the game, but they should not internalize those imposed values and think that indeed, in all cases, they should be able to come up with such clear diagnoses and treatment plans and then stick to them. Rather, they should expect in their own minds that half the time they may need to revise such plans, and seek also to get support from their supervisors about this reality.
The point here is that after a session or two, and thereafter, periodically, some time should be given to reviewing what the therapist thinks is going on and what is needed further. Clients have a right to know. It’s not for us to tell clients what they are thinking. (I sometimes say to them, “I will not come to conclusions about you without your permission.”) However, they deserve to know our working model or tentative theory of what’s going on and what we think needs to be done. There are times when this process can include mutually-agreed-upon decisions, such as:
– which theme should we discuss next (where the therapist is relatively neutral, seeking to know what seems most pressing or important)
– whether certain tasks should be undertaken in therapy now, soon, or put off for months or years—with the understanding that the client need not stay in therapy during this whole time. It’s reassuring to recognize that certain goals or types of growth can be anticipated when there is more strength, support, etc., and not everything must be addressed now. These themes are neither ignored nor overly weighted with urgency.
– whether some sessions should be held with (or without) key other people, such as a spouse, or whether someone else needs to be included for one or several sessions. (The old tradition of making one-to-one sessions an expected or precious modality needs to be challenged!)
– might adjunctive experiences such as ongoing group therapy, a special type of weekend workshop in body work, psychodrama, or some other modality, or other kinds of learning experiences be helpful
– types of homework, breaks from therapy for weeks or months, tapering off, increasing frequency for a while, shift in type of modality, etc.
However, the main point is to re-align the client as active collaborator, inform the client of the current strategy and rationale, be open to suggestions. This is also a good time to restate the generally unifying theme that in some ways, therapy is also an educational process whereby the inner choosing self learns ever-more-effective ways for self-management, ways to work out inner conflicts, sharpen certain kinds of sensitivity, empathize with others, ground oneself in the big picture, and so forth. It’s an opportunity to review what has been done as not only what the therapist has done “to” the client, but also what the client is learning to do to and for himself.
The Real Diagnostic Variables
While it may be wise to learn to play the game of knowing how to use the official diagnostic manual, especially in clinic or hospital situations, it is also wise to recognize that those systems are very limited. They generally fail to inform about four categories that are far more crucial in determining prognosis—i.e., how well the patient is likely to do, and as a corollary, how much time and energy will be taken in treatment, or what kinds of treatment are most realistic to offer.
The four categories include:
1. Voluntariness: How much is the client willing to engage in the self-exploration and self-change process, to work with the therapist and use the method? This can vary from not at all to strongly engaged and allied. Many people are somewhere in-between.
2. Psychological-Mindedness: How much is the client able and interested in examining and thinking about the way s/he thinks? Young children, not at all; middle school, highly variable; those leaning towards personality disorders, hardly. Most people, mixed.
3. Ego Strength: This category has a number of sub-categories, but in general, refers to general capacities, intelligence, and achievement, emotional maturity, and the like. Some people are fairly high in many elements but perhaps not all of them. Some are fairly low in many components.
4. Psychosocial Resources: This includes transportation, access to help and to other activities and support systems, presence of supportive people at home or beyond therapy, money and insurance or other economic supports for accessing therapy (e.g., qualifying for inclusion in Veteran’s benefits or the scope of an agency’s services), etc.
(More about these on another paper on this website.)
I keep such issues in mind, and also address the diagnostic and therapeutic work to strengthening all of these variables as much as is reasonably possible.
Considering the Various Schools of Therapy
I think all these schools should be deconstructed in two ways: First, they offer certain perspectives on that immensely complex field of mind and social matrix, how it works, how it doesn’t always work, what is needed, how it breaks, how to heal it. Second, they offer a set of techniques that implement these perspectives. The interesting thing is that some of the techniques from Approach A may be helpful in a holistic perspective in which a number of insights from Approach B seem relevant. Thus, it is possible to use, say, psychodramatic methods as partial or prominent tactics within a frame of reference that is largely influenced by Adler’s Individual Psychology approach or Jung’s Analytical Psychology. We need not—indeed, should not—feel obliged to take one package at the expense of accessing another.
I find that every school of thought misses certain aspects of life, and is thereby limited in that regard. On the other hand, an intelligent eclecticism can draw from perspectives from all the different approaches, and also new ones coming along, including ideas that are not particularly associated with any approach at all. This is true in medicine.
Lest this seem like just using ideas and techniques in a hodge-podge, grab-bag fashion, let me affirm first, that, yes, it can be just this. Any approach can be used in a shallow and foolish manner! However, this approach can also be used in a wise and rationally-thought out fashion, and the key element here is the formulation. Again, no formulation is complete. (To fully understand another person may be as impossible of a goal as perfection or the speed of light—such ideals are called “asymptotic limits.”) Still, there are varying degrees of partial formulation, and their accuracy and practical applicability (ideally) develop with the therapist’s experience. (I say ideally, because a true professional is humble and continues to grow, learn, deepen, develop himself or herself as an instrument of healing, and so forth; yet it is not so difficult to lapse into prideful complacency, routine, and folly. It’s possible for a psychotherapist to improve in skill and wisdom for 80 years—there’s no endpoint; it’s also possible to become a dud early on and, alas, just get by for many years, perhaps helping some, hurting some, learning little.)
The exercise of learning to formulate a case can be done with a consultant who is more experienced and discerning, and the dialogue can be an important way to develop professionally. (Peer-group consultation can’t achieve this end, because peers tend to unconsciously collude with their colleagues in supporting relative ignorance. There needs to be a significant gradient of learning.) Just preparing and presenting a case and exploring different formulations is a good learning process. Alas, many clinics have neglected this practice as their administration is taken over by business people rather than professionals with a deeper ideal about what the growth of professional ability is about.
Elsewhere on this website I have posted a number of related articles that speak to the art of psychotherapy. Many have been alluded to and linked to above.
Some are: Mutuality in Psychotherapy Useful Metaphors in Psychotherapy
Re-Story-ing the Soul
Others may be noted below, or perhaps I’ve failed to note a specific link. Often there are aspects of a problem you may be having with a client that I’ve addressed in other ways. I hope you have found this stimulating, and, being a webpage, I’m able to go back in and revise it. Therefore, I would appreciate your sending in questions about parts that seem ambiguous, argue with me about issues that you think need revision, suggest other references, and so forth: Email me at firstname.lastname@example.org !
REFLECTIONS ON THE ART OF PSYCHOTHERAPY
Adam Blatner, M.D.