Principles and Effective Practice
My aim in this book is to examine in detail what the therapist can say that can contribute to the process of healing and change, in the therapy setting. I believe that nuances of phrasing and meaning can be the crucial difference between comments that are therapeutic and those that unwittingly perpetuate the patientís problems. I refer here to those individuals who come for help as "patients" because the original Latin meaning is "one who suffers," while "client" means "one who depends." Our aim in this work is not to foster dependency, but to assist those who are suffering, so "patient" seems more appropriate.
The Talking Cure
There is very little in the psychological literature on what therapists actually say. In the early generations of our profession, psychoanalysts rarely spoke at all, but now most therapists do talk back. But they are rarely taught to give their own words the kind of scrutiny that they give to their patientsí words. Listening skills are stressed and taught, but how to communicate the understanding that listening affords is not taught. Yet it is possible to develop and learn ways of saying things that produce less resistance in the patient, and are more respectful of the patientís self-esteem.
A key principle of my argument is that every focal message (the "what" or content of the therapistís remarks) also carries a "meta-message" (the "how" of the therapistís communication). Closely akin to tact, the meta-message has great potential for helping or hindering the process, as it induces in the patient a view of the therapist. It conveys the therapistís attitude, and this the patient picks up unconsciously.
In truly therapeutic communication, the therapist cloaks his focal message in a meta-message, both of which are presented in such a way as to make it possible to address the disagreeable matters the patient has evaded in ways that the patient is able to hear and deal with. This process may be likened to the process of tissue grafts. If done carefully, the foreign tissue "takes." Similarly, if the patient is delivered unpleasant ideas skillfully, he or she can take in and process the material, rather than reject it.
This process is made more complicated by the fact of transference, which makes it almost certain that the focal message the therapist intends is not the meta-message that the patient hears. If the therapist is aware of this, and speaks being mindful of it, the discrepancy can be lessened, and he can also estimate the impact of both focal and meta-message on the patient.
Another benefit of the use of therapeutic communication is that "therapist noises" can be eliminated or lessened. "Therapist noises" are those familiar phrasings we use when unsure of what to say. We know when we are doing this: We have a hollow feeling, a sense of discomfort, fraudulence or stiltedness. We find ourselves saying "perhaps," rather than the more casual "maybe," or clearing our throats. All of these noises are signs of self-protection, and the patient notices. Good communication skills make such self-protective mechanisms less necessary.
The style of a therapistís speech can have as significant an impact on the patient as what is actually said. All too often, what is said by the therapist comes across to the patient as lowering his/her self-esteem. The therapistís attitude is conveyed by the tone and rhythm of voice, or postureóall of which are impossible to disguise. As a result, the therapist needs to monitor continuously his/her participation in the therapeutic process, noticing especially emotional reactions to the patient. A bonus for such sensitive attention to oneís own language is that the therapist gains an acute indicator of countertransferential feelings and attitudes, which can help make the therapist conscious of these more quickly.
Cyclical Psychodynamics I: Vicious Circles
Cyclical Psychodynamics is the name for the theory that guides my work with patients. It originates in the psychodynamic tradition, and gives a central role to repetitive cycles of interaction between people, and to cycles of reciprocal causation. It integrates insights from interpersonal psychodynamics, and the behavioral and family systems traditions, using a multi-process view of change. In its approach, cyclical psychodynamics seeks to address certain features of our society that create psychological problems, in particular: our isolating individualism (with its myth of autonomy and denial of interdependency), the encouragement of consumerism as a substitute for relational bonds that consumerism weakens, the impact on the environment of the growth that consumerism demands, and our increasing difficulties in maintaining a commitment to equality and social justice.
Cyclical psychodynamics recognizes that people live in contexts and behavior is always in relation to someone or something. I regard a neurosis as a joint activity or cooperative venture of a peculiar sort. This is important to remember when working toward therapeutic change, because a key element of the process is understanding how the patientís difficulties are perpetuated. The neurotic does not live in a vacuum, and there is an unconscious process whereby people in his life are continually recruited into a maladaptive pattern (which is the neurosis itself).
Cyclical Psychodynamics II: The Centrality of Anxiety
The patient in therapy will employ defenses, but these are just one instance of a more general tendency to avoid what causes anxiety. Attempts by the patient to avoid anxiety tend to generate their own consequences over time, such that the patientís skills in living become impaired. Cyclical psychodynamics puts special attention on an understanding of anxiety. The patientís problems come from his learning early in life to be afraid of feelings, thoughts and inclinations. The therapeutic effort is focused on helping him reappropriate these feelings and incorporate them into a fuller sense of life. In taking this stance, cyclical psychodynamics challenges the common notion in psychoanalysis that the patientís basic impulses are antisocial and regressive. The approach in cyclical psychodynamics is more accepting toward repressed feelings.
The central grounding concept here is anxiety. The patient is anxious, rather than adversarial (which is how psychoanalysis regards the patient). The task in therapy practiced from a cyclical psychodynamic perspective is not to bring to light what the patient has kept hidden (as in psychoanalysis) but to help the patient overcome the anxiety that made the hiding necessary. This overcoming is achieved most powerfully by exposure to what has been avoided.
The curative factor in therapy is the patientís experiencing or feeling the feelings that heretofore were the cause of anxiety. The therapist assists in this partly by modeling the lack of fear, but also through his artistry in figuring out how to bring the patient into contact with the experiences he has avoided, gradually and in ways that maintain his self-esteem. This is "artistry" because it cannot be taught like a cut-and-dry technique in science. A therapist with true talent for this work is one who can get the patient to confront previously avoided feelings and thoughts in a way that does not feel demeaning. Specific phrasings and communications strategies of the therapist can help do this.
Cyclical Psychodynamics III: Insight, the Therapeutic Relationship and the World Outside
Most insight-oriented psychotherapies stress the need for the therapist to be neutral, anonymous and disavowing of active efforts to assist the patient. Cyclical psychodynamics takes a more active approach. With its triple aims of furthering self-understanding, helping the patient become more fully an active agent in his own life, and encouraging him to be an active participant in his own therapy, cyclical psychodynamics requires the therapist to confront the obstacles impeding the patientís self-acceptance and self-direction.
Cyclical psychodynamics also has a different view of "insight." In most traditions, this term is used cognitively: the therapist comes to know what is going on with the patient. But in cyclical psychodynamics insight is both cognitive and also a corrective emotional experience. We recognize that insight often follows changes, as well as causing change. Hence, insight is not simply an epiphenomenon: Insights help to consolidate and deepen changes brought about in other ways.
Cyclical psychodynamics includes the "therapeutic alliance" or "working alliance" between therapist and patient. This is not based on the paradigm of interpretation used in most traditions. Rather, in cyclical psychodynamics, the therapist must do more than make correct interpretations. She also has to act in a healing way. This includes being as authentic as she can.
Cyclical psychodynamics also takes a broader view of transference. In classical psychoanalysis, transference was seen in the context of the adversarial process between analyst and analysand. Transference is not adversarial in cyclical psychodynamics, but inclusive of all aspects of the patientís functioning, including all the persons with whom he lives and interacts. Cyclical psychodynamics recognizes that all transference reactions are hung on some "hook," some actual characteristic that provides the initial basis for the patientís perception. These reactions are never therefore totally wrong, but most often reflect a very selective type of perception that produces a highly personalized and tendentious picture of whatís going on that is a distortion.
It is common in therapy for a therapist to demean or devalue the patient via the pathologizing formulations and comments she makesóthis, despite the expressed desire to keep the transference "uncontaminated," and to help the patient heal. But cyclical psychodynamics recognizes this idea of keeping the transference "pure" is a myth, that in order for the patient to become engaged in the process, the therapist must too. Only by including the therapist in the process will the issues be illuminated.
Cyclical psychodynamics regards the therapeutic relationship as a catalyst, mobilizing the patient to take actions in the world that are necessary for change to be enduring. Genuine therapeutic change requires that the patient have corrective emotional experiences, that is, experiences when he can see, first hand, that the expression of feeling is not as dangerous as he has long feared. Most of the time, this discovery is made in the context of the patientís living with other people who may be ambivalent about his changing. So the therapist needs to be present, engaged in the process, so she can pay attention to the role of these other people. She needs to develop skill in assuring that the patientís daily life is on the side of his therapy, not subverting it. This is a key to the success of the process. In all of this, phrasing and connotations of what is said are decisive factors in success or failure. But this central role of communication has been almost completely overlooked in the education of most therapists.
This is most ironic, given that psychotherapy is, and has been regarded for generations, as the "talking cure." Words are important, the primary medium for the therapistís participation. But more than words communicate to the patient: timing, tone of voice, inflection, and body language can be eloquent too.
Accusatory and Facilitative Comments: Criticism and Permission in the Therapeutic Dialogue
The truth is always multi-faceted. It might be said that there are many truths, but not all are equally therapeutic. The patientís difficulty usually comes from how he frames the truth: how he organizes, categorizes and gives emotional meaning to the events of his life. A goal in therapy is to point the patient to a version of the truth that can help him see new possibilities for his life and to change those life patterns that have given him trouble.
In working toward this goal, the therapist will comment, with focal messages that the patient hears along with a meta-message. What is said gets heard as a permission or a rebuke. If the therapist is savvy, her interpretation is permission-oriented. Some aspect of the patientís experience is addressed that he had previously avoided. The message is conveyed that it is all right to be more accepting toward that experience.
There are many forms such permission-granting meta-messages can take. Here are a representative sample:
"You seem rather harsh with yourself when you sense any..."
"You seem to expect something terrible to happen to you if you have any wish to..."
"I have the sense youíre angry at... but think itís awful of you to feel that."
"I think youíre feeling critical of... because youíre afraid if you... youíll... and ... wonít think...; maybe that kind of caution isnít really necessary."
These and similar phrases help the patient feel affirmed, understood by the therapist, and also encouraged to acknowledge and accept his feelings.
Most schools of therapy create a very different atmosphere, with their stress on inhibition, silence by the therapist, nonengagement, unasked and unanswered questions, wariness, and the pejorative view of the patient as developmentally stunted or immature. Such an atmosphere does little to help change the feelings of unentitlement and self-disparagement that are at the heart of most patientsí psychological difficulties. Cyclical psychodynamics, by contrast, puts great emphasis on the therapist having a more positive, or at least neutral, view of the patient, recognizing that patients can rise, or fall, to our level of expectations, and therefore, therapists need to be aware of how they think about their patients.
Most therapists work with a model that sees therapy as a process of uncovering the secrets of the patientís mind. But this is not so. We get a version of the patientís life story, rather than the truth. Reality is inherently ambiguous, and the therapistís job is to convey to the patient a way of understanding himself that allows him to experience change. This is done through language that demonstrates understanding and respect for the patientís experience and point of view.
One key element of such language is the use of "entry phrases," figures of speech that lead the patient into experiences he has been hiding from. Some entry phrases include:
ē "at least," as in "I guess concentrating on how people mistreat you feels like the best deal you can get. If you canít have what you want, at least you can feel you are due the sympathy of someone who has been wronged."
ē "even more," as in "Youíve been noticing how much the intimacy you and Diana have means to you, and itís stirred the wish in you for even more."
ē the use of questions to get a point across, as in "There seems to be something potentially uncomfortable about actually succeeding, and even though you come very close to succeeding on many occasions, and clearly are capable of it, somehow something happens to interrupt it. Do you have any idea why you might want to avoid succeeding, what it might be that would be scary about that?"
Such phrases open the door to addressing situations and life patterns that have caused the patient anxiety.
Exploration, Not Interrogation
While questions can be useful as "entry phrases," care must be taken that they not be heard by the patient as interrogation. They are therapeutic if they are forms of intervention, but become adversarial, or serve to minimize the patientís self-esteem, if they come across as interrogation.
The key principle when dealing with questions is to remember that the patient is in conflict. For many questions, an accurate assessment of what he is feeling or thinking would yield an ambiguous or vague answer that would serve little to advance the process. Better than direct questioning is it to find chinks in the patientís defensive armor and go in through them. Side with the patientís defense in order to promote the effort at self-exploration. Do this via "protected probing."
This is a technique that overtly supports the patientís denial, while freeing the patient to move past it. It acknowledges the part of the patient that is resisting, and structures the question to be safe. In short, it uses a defense to breach a defense. Hereís an example: The patient was to call the therapist if he was going to have to miss the next session, but failed to do so. Rather than interrogateówith the obvious question "What didnít you call me?"óthe therapist says, "You must have had some good reason for not calling. Would you like to tell me about it?"
But of course, full insight into this, or anything else in therapy does not need to be achieved to yield real and lasting therapeutic gains. As therapists we initially accept the patientís externalizing orientation so as to help him over time find his way deeper into his own experience. In doing this, "identificatory transference" is very useful. This phrase refers to how the patient reacts to the therapist as he models how significant others in his own life treated him in the past. This is a version of role reversal: the therapist becomes the child and the patient is the parent.
As the process evolves, by using attributional comments, the therapist gives the patient credit for an insight, for being ready to change a problematic pattern, and so forth. The therapist is not neutral or disengaged here, counter to classical theory. In fact, the therapistís refusal to participate can lead to an exacerbation of the patientís lack of trust in his own perceptions, and further his tendency to invalidate his own feelings.
Building on the Patientís Strengths
In the same way, the therapist is not neutral as she works to build on the patientís strengths. In this emphasis, cyclical psychodynamics is unusual, as few schools of psychotherapy put the patientís strengths at the center of concern. Most psychologists, in fact, wear pathocentric blinders, seeing only whatís wrong with the patient, in a one-sided focus on the negative.
Carl Rogers was a notable exception here. He developed a client-centered therapy that sought to affirm and build on the patientís strengths, recognizing that change is built on strength, not weaknesses.
In a way similar to Rogers, I teach therapists to look for clues that show the patient is breaking maladaptive patterns. Then the therapist supports this effort and points it out to the patient. Support here is necessary because change is threatening, even if the old behavior was a source of pain. So the patient will need encouragement to continue.
The therapist also must be aware of the likelihood of testing-by-regression, those times when the patient will fall back into patterns that produced trouble in the past and do so again. The therapist has to be alert for these regressions, and recognize that they are inevitable and not cause for despair.
Because of cognitive habits, the patient is not usually the one to spot changes first (because of the tendency to discount what does not fit with expectations), so it falls to the therapist to spot the changes the patient is achieving. For the patient, old patterns and ways of perceiving feel like reality.
Making change permanent requires the therapist and patient address defensive efforts; the patient to modify his style of perceiving and thinking, and then to apply the new insights in his life. In this process, there are several strategies that can be used to prevent the undermining of the clinical process. For example:
the therapist can interpret the defense first. This makes the patient aware of the defense, and it disrupts the defenseís operation.
the therapist can note to the patient how he is less defensive that earlier; if the patient has made genuine progress, pointing it out can help solidify it.
the therapist can recognize the back and forth motion of the healing process, with resurgences of anxiety that lead to retreats to an earlier defense
the therapist can then help the patient regain momentum, through awareness, concrete suggestions for the next course of action etc. In this context, part of therapeutic tact is knowing how to discriminate between resistances that require analysis and those which donít.
This whole endeavor holds the temptation, which will seem very powerful at times for the therapist, to pathologize (regard the patient as sick). Rather than falling into this temptation, the therapist needs to seize the two-pronged challenge of affirming what is good and strong in the patient while promoting necessary changes in the patient.
Affirmation and Change
This challenge is not the only conflict inherent in the job of therapist. Another is the dual role of empathizing with the patient (seeing the world through his eyes and appreciating his perspective) while also working as a change agent, to help the patient transcend his reality. It is not enough to empathize. It is not enough to achieve true understanding. These things do not produce change, and the patient is suffering in the reality he created for himself. He needs to change.
Therapists deal with patientsí illusions and also with the consequences of those illusions. Both cause suffering. But, paradoxically, change is built on acceptance of reality as it is. So the therapistís task is simultaneously to validate the patient while helping him accept and learn to cope with distressing emotional experiences. It is good for the therapist to be immersed in the patientís experience, but no so much that she sees no way out for the patient.
The patient also faces paradox: As the old saw goes, the patient wants to get better, but without changing! He lives in conflict, both in his life and in the therapy, as he seeks the therapistís aid, but also tries to impede change, due to fear, uncertainty and inner competing visions.
Given such conflicting roles and paradoxes, the therapist must focus on the conflict so as to address the twin poles of affirmation and challenge. When faced with the temptation to lay out for the patient what is really going on, instead of saying "What you really feel is...," say "I guess it feels only fair that..."
Other verbal tips:
Substitute "also" for "really," e.g. "Maybe youíre also feeling that toward me." This is both more respectful of the patientís experience, and also serves to point the inquiry in a direction the therapist feels may be fruitful.
Use "also" in place of "instead:" "I wonder if there are other parts of your life that are also making you angry?"
Use of such words gives the patient more of a sense of support from the therapist, and support is the key to getting the patient to explore frightening issues. In the profession, however, "support" is a difficult word, with dual meanings. On the one hand, it has a negative connotation in the psychoanalytic literature, given its orientation toward tearing down defenses. Support here inhibits that process. On the other, it has a positive meaning in newer models of therapy which seek to build up a curative relationship. For this support is critical, for without it the patient cannot access unconscious material.
Support is the key to the exploratory process in therapy. The basic principle might be put thus: "Be as supportive as you can be so that you can be as expressive [exploratory] as you will need to be." In taking this stand, I advocate that the therapist bear more of the burden of change than has been traditional in insight-promoting therapies. I see dependency issues being resolved not by achieving insights into its roots in childhood, but rather by developing effective patterns of living that make further dependency unnecessary.
Attribution and Suggestion
If therapy is going well, the patient is a person in transition. The therapist facilitates change by predicting and describing it as she notices it. When done as if standing side-by-side with the patient, several techniques can serve the therapist well in this endeavor.
The first is attribution. The therapist spots some nascent positive change or insight and attributes it to the patient, even though, as yet, the patient has not become aware of it himself. There are a variety of types:
blurring boundaries: through identification the therapistís viewpoints and patientís blend, and the therapist can attribute positive views to the patient
letting the patient own feelings, e.g. "As I hear what youíre saying..." The patient did not word the idea quite as the therapist, but there was a glimmer of insight, and the therapist attributes it to the patient via a phrase like this. Another is "It must be hard to know... (e.g. how much your mother hated you)"
accentuating the desirable: The therapist attributes the momentum of change to the patientís agency, or redescribes the patientís experience in a way that magnifies the change dimension.
The other technique is suggestion. There are many forms this can take, including:
describing the source of distress of problematic behavior as temporary, e.g. "Yes, I can see you are temporarily more distressed [or some other emotion] but it seems to me that thatís a transitional response to the new situation..."
conveying the patientís reaction as understandable and acceptable
assuming common knowledge with the patient, e.g. "As weíve both seen..." "As I know you are aware of..."
pointing toward action, e.g.: "It sounds like what youíd like to say [do] is..." This makes it seem like the patient came up with the action. In this form, the therapist lends her ego to the patient at the moment a new idea is born. This type of suggestion can also address the resistance, e.g. "It sounds like what youíd like to say [do] is... but you feel that if you do, it will be..."
Some practitioners question the place and ethical use of suggestion in therapy: Does it impose the therapistís values on the patient? Does it destroy his autonomy? Is it taking advantage of the transference? The rule here, in response to these concerns, is that suggestion must be used in an ethical and sophisticated fashion that deepens the patientís aims. To try to eliminate it from psychotherapy would be as futile as it is impossible, but it must serve to help the patient confront the conflictual issues of life.
In all of this, it is important to remember that resistance is not negative, as it guarantees the legitimacy of the process and protects the patientís autonomy. If suggestions are made by the therapist that might not be in his interest the resistance will take up and oppose them.
Reframing, Relabeling and Paradox
Psychological difficulties are often due to misinterpretation of life events. Part of the healing process thus is the creation of new meanings for what happens in the patientís life. Reframing and relabeling are two processes that deal with this.
Reframing comes out of the family systems perspective, and it is a divergent process. Traditional psychoanalysis was built on a positivist, objectivist notion of interpretation as a process of discovery, which is a convergent process. By contrast, reframing seeks not the convergent "true" meaning in a behavior pattern, but the most useful way to understand the pattern.
Reframings are usually positive. They give meaning to psychological events that point to possible solutions to dilemmas the patient has interpreted in a way that make solution impossible. Reframing can also be used to give the patient new perspectives on the behavior of other people in his environment. The point behind reframing is to shift the patientís perspective.
Paradoxical statements are another useful communicative tool, quite common in therapy since the patient is in conflict. An example is the phrase "No one understands how you feel," which at once accepts the patientís discouraged sense of not being understood and paradoxically, in doing so, conveys that he is understood. Such paradoxes get the therapistís point across indirectly, and thus they tend not to generate much resistance.
Therapist Self-Disclosure: Prospects and Pitfalls
The therapeutic relationship is a professional, limited, and asymmetrical one. In some schools of therapy (e.g. psychoanalysis), the relationship between analyst and analysand is quite rigid, with virtually no self-disclosure by the therapist, and a premium put on neutrality and anonymity. Psychoanalysis purports that the analyst is a "uniform analyzing instrument" relatively interchangeable with other analysts. This cannot but be detrimental to the patient, who comes to feel he is having no impact on the therapist (replaying the feelings of childhood, and risking a retraumatization).
By contrast, cyclical psychodynamics advocates a degree of therapist self-disclosure, so as to limit the patientís idealization of the therapist (too much of which can give an authoritarian cast to the therapy) and to allow the patient to take back some of the projections he puts on the therapist.
But the key words here are "a degree:" Self-disclosure can serve a useful purpose, but only if done very judiciously and in limited ways. This is because therapy is demanding work, and privacy is essential. Not disclosing information about oneself is a key component to maintain privacy. It also gives the patient more freedom to explore matters that he would be reluctant to take up with a person with whom he was "friendly." Additionally, too much self-disclosure could threaten the asymmetry of the therapeutic relationship.
There are no hard-and-fast rules for when, or how much self-disclosure is appropriate, as all patients are different. The key consideration is who the patient is and what his personality is like. One who is very shy and introverted, who shrinks from knowing the person of the therapist might benefit greatly from knowing a bit more, whereas the patient who is regularly disappearing behind others could use probing questions as another way to try to hide.
Only in one realm must patientís questions about the therapist be answered: those questions about professional qualifications for the work. The patient has the right to know the professional background of the person to whom he has entrusted his life. This is not to say that "labels" or "orientations" are important. Often the therapist does not know his or her orientation, and the patient would not know what it meant if he were to be told.
Another context in which self-disclosure can be helpful is the sharing of a dilemma. When the therapist recognizes a dilemma in their work together, it often is very freeing for the therapist and promoting of insight for the patient if she openly discloses that she doesnít know what to do, to say, or whatís going on. This disclosure of ignorance or confusion can help the patient reclaim projections of omniscience he may have put on the therapist.
Achieving Resolution of the Patientís Difficulties: Resistance, Working Through, and Following Through
Successful therapy involves the patient reworking his internal representations and changing the patterns of his interaction with others. This is one element of the process.
Another is the "working through" phase, when the patient, with the therapistís help, finds ways to travel the paths he has begun to glimpse. This is often the most time-consuming and difficult phase of the work. If therapy fails, it usually does so here, not in the insight phase.
This phase is difficult because it requires that the patient change how he lives, especially with regard to the patterns of his close interpersonal relationships. To do this the patient must rework his internal representation of himself. Then he has to construct a different set of psychological structures for apprehending and experiencing the world. And this, in turn, means that he has to modify the vicious circles that are at the heart of his difficulties.
The central premise of cyclical psychodynamics is that psychological difficulties are maintained most of all by cyclical patterns of interaction in which the patient repeatedly engages. When the therapist helps the patient in the "working through" stage, she may
ē make suggestions (usually slightly beyond where the patient has ventured so far)
ē give directions
ē help the patient role play some anticipated interaction with another person
ē model a certain behavior or wording of a statement
ē work with the patient to rehearse a confrontation with someone
ē give the patient graded tasks, structuring these so that they are consonant with what the patient can handle.
Throughout this process the therapist reframes the patientís behavior so as to highlight his changes. This is done via following, or tracking, the behavior. The whole point here is to make the patient aware of how he is changing.
The patient also needs to gain a better understanding of others, particularly those in his immediate circle. It is highly likely that these close relationships involve vicious circles that are part, at least, of what led the patient into therapy, so the therapistís intervention here has to be multifaceted, to anticipate othersí reactions and prepare the patient.
Over time, as the patient works through his problems in real life, his anxieties slowly lessen, and with them, his resistances lessen. As the therapist points out his own lack of power, the patient becomes more cooperative, responsive, and willing to take responsibility for his own life.
When all is said and done, cyclical psychodynamics is only a psychotherapeutic approach, and any such approach is only as good as the therapist applying it. By giving time, thought and attention to how he or she communicates, the therapist is likely to be more successful in facilitating change and healing in patients.