A Letter from a Psychotherapy Veteran & My Reply

You can find the original article By Bonnie Burton here:
A Psychotherapy Veteran's Thoughts on Treatment Methods

In an entry entitled "Psychotherapy Veteran," Ms. Burton writes a number of provocative points that, as a therapist, I'd like to respond to:

Ms. Burton writes: "It didn't take me 30 years to realize that if I say something to my therapist that produces laughter in other people, and my therapist doesn't laugh but instead simply continues to look at me, the absence of a response still constitutes a reaction on the part of my therapist. It's just not the reaction I expected... My friends thought it was funny, so why didn't he? …First, this may come as a shock to some of you, but from many patients' perspectives, the neutral, non-reactive therapist is actually far from neutral, because the absence of a natural reaction to the patient is, in fact, still a reaction."

As the interpersonal school, of which I am quite fond (Sullivan, et.al) would argue, it isn't "non-reaction" that is the issue: It is the therapist's capacity to react in a way which does not support the typical behaviors that are causing the person psychological problems. If a person chronically uses humor to avoid painful or difficult material, a skilled therapist catches on soon enough. After laughing a few times, the therapist may point out the defense, and from then on, instead of laughing and being entertained, may wonder aloud why humor is being used by the client at this particular moment.

I agree with her, that if the client has no idea why the therapist isn't laughing along, the therapist may not have explained him or herself adequately. The client shouldn't be left wondering whether the therapist is socially stunted. The therapist should clearly point out that the client IS funny, and that's just the point: the entertainer routine is a defense.

Ms. Burton writes: "What matters isn't how YOU feel; what matters is how WE feel! Now, don't some of you feel just a little bit silly?"

What I find interesting about this, is her assumption that this is somehow 'big news' to therapists. In the last two sentences, she says this is a truism in therapy: "There is one belief you all seem to share regardless of your theoretical persuasion -- that what matters isn't how YOU feel, what matters is how WE feel." All the research she mentions focuses on just this issue: the connection between the client and the therapist. She appears to argue that this is an "either/or" proposition. It isn't.

Ms. Burton writes: "In my own experience of crying during a session, my therapist's silence actually did lead to a new awareness about myself...I have repeatedly found that anytime the tears begin to flow in a therapy session, what I remember first is not how I felt as a child -- it's how I felt as a patient in the "here and now" -- the anguish of feeling desperately alone in the presence of my therapist, and I consequently attempt to push those feelings aside."

According to Ms. Burton, the experience initially leads to a "new awareness" but as therapy progressed, she could no longer connect with her "inner child" but was instead forced to face the pressure of the present-- a feeling of differentiation, a separateness from the other--and an equal pressure to deny that reality.

Ms. Burton writes: "the offer of a tissue might have contaminated and lessened the experience of "reliving" the trauma, my therapist's lack of response also contaminated the experience by exacerbating my pain. What he perceived as a reliving of the original experience was more than that -- it was a combination of reliving the experience AND once again experiencing the pain of psychological abandonment by someone who was supposed to care about me. Maybe a response would have temporarily "removed me" from the past... but I would have also been more willing to go there again in the future."

I don't know what 'brand' of therapy this guy practices, and he might actually believe that "reliving" trauma is healing, I don't know. Personally, I don't believe anyone is actually capable of "reliving a childhood trauma." Too much time has passed and maturation alone changes one's brain. But regardless, she appears to have found the diamond, and has thrown it out because it scratched her. Our relationships with significant others in childhood are a central (but not sole) template used to establish new relationships in the present. For some psychotherapy schools, helping clients become “aware” of these relationships is adequate. However, for others, such as the interpersonal school, experiencing psychological abandonment on the part of her therapist IS at the crux of therapy. In this school, we assume that feeling abandoned by important people continues to happen over and over again "in the real world." It is her reality, her "dream" and "she makes it happen." She essentially “brings her past into the present,” and the present is what gets dealt with.

This is the diamond that she sees as somehow the "fault" of the therapist's paradigm, but it's not. Her willingness or unwillingness to "go [into childhood memories] in the future" is irrelevant therapeutically. It is her current interpersonal experience--her profound disappointment at being unable to be "held" adequately by her therapist when she reveals herself-- that can make or break her treatment. Every parental caregiver at times “drops” the baby psychologically, as does every therapist. No one has a perfect childhood, or a perfect therapist. Therapy is effective when the client gradually realizes that the expectation of a “perfect” parent or a “perfect” therapist is, itself, a problem. While not all of us had families that “did the best that they could,” those of us who grow to adulthood have done so because of our own resilience. Parental limitations didn’t stop developmental growth (even if it marred it) and therapeutic blunders don’t prevent psychotherapeutic growth, either. Hopefully her therapist has the capacity to engage with her around her disappointment in him, and help her tie in these _present_ feelings with earlier experiences.

Ms. Burton writes: "I have had destructive experiences with therapists who became too involved, who lost the ability to separate their issues from mine, and the amount and kinds of self-disclosure in those situations were not at all helpful in my treatment."

Like Goldilocks, the therapists are either "too hot" or "too cold." What she misses is that her _need_ for "just right" is at the heart of the therapeutic process.

Ms. Burton writes: "Perhaps, in a genuine reciprocal encounter, where the therapist reacts naturally while placing the patient's needs above his own, an exploration of how the patient felt when the therapist reacted could follow. This could be the catalyst for subsequent exploration of both present and past relationships. The therapist could ask how the patient might have felt and reacted if he had either remained "neutral" or responded in an unexpected manner, encouraging the patient to engage in active self-reflection."

Here we see more of the rub, the bind she (and all clients, perhaps) demand of therapists: Act naturally, but place my needs first. While she argues that the client's feelings are of paramount importance, she also wants a "genuine reciprocal encounter," and this is the paradox that starting therapists become so confused about. It is problematic interpersonal relationships, and a person's reactions to them, that bring our clients to therapy in the first place. For a therapist to truly "act naturally" would offer the client "more of the same."

Therapists of the interpersonal school can point out to Ms. Burton that we, as people, are no different from subatomic particles: We change as others interact with us. It DOES matter how therapists feel and it DOES matter how clients feel. Together, we try to do what has been called "The Impossible Profession." Impossible, perhaps, because we try to model a different way of being with our clients--an "abnormal" or "non-socially acceptable" way-- and we warn her up front that that's what we'll be doing.

Good therapists "act weird" and the disclaimer at the start tells clients what to expect. We'll interrupt her in mid-sentence. We'll ask her to repeat what she just said several times. We won't hand her a tissue or we'll cry along with her. We might find her joke funny, but not laugh. We aren't being disingenuous by not laughing. Our impossible profession expects us to understand that her charm and wit, while entertaining to us at a cocktail party, may be interfering with her establishing deeper friendship ties. It might be stopping her from feeling vulnerable with us right now, and we don't find that limitation funny.

TV and films love to poke fun at "wacky therapists" acting "weird" in social situations. It certainly can be an occupational hazard to not "switch gears" when we are ‘off duty.’ The real world is not the therapy hour, and people have a right not to be "analyzed" without permission. We also have a right to be ourselves when we aren't working. Sometimes a cigar is just a cigar.

We should warn her that if she had left other therapists for being "unsympathetic" or "disappointing" her, she might be tempted to do the same thing with us. It is being "genuine" to tell her that if she gets angry at us for not appearing "sympathetic" or "engaged" she should do the "socially unacceptable" thing and tell us. We tell her that it is likely that the more skilled we are, the more profoundly we are likely to disappoint her. In other words, we have to somehow tell her that as she continues to be herself, and do what she does in the outside world, she will more than likely feel intense reactions to us. She might get angry. She might be hurt. She might want to leave therapy because we are "uncaring." When this happens, and we say this early in the therapy, we ask only one thing from her: be curious about yourself and your reactions to us. We tell her this is a difficult task. It is hard to "watch yourself" have intense feelings. It is hard not to blame someone else who appears to be "causing them." We say this up front, and we remind her of it again, when these feelings arise.

I will give you an example of this from my own psychotherapy practice. When a client told me how his illness enabled him to avoid doing the unpleasant, I told him "It is quite likely that you will want to use your illness to avoid coming here, too, when things get tough." Some time later, after a particularly difficult session, he came in and said "I was going to call you and tell you I was sick and couldn't make it. Then I remembered what you said, about using my illness to avoid confronting things, like what we were talking about last week. I wanted to say I was sick to avoid it, just like you said I would." Some would call that "therapeutic insight." I call it "curiosity." He could see himself doing a typical behavior and decided to change it to see what the change might bring him.

Repeating the same behaviors or having the same reactions to different important people in one's life doesn't just happen in therapy. At the beginning of my relationship with my husband, when we were both idealizing each other, I told him: "There will come a time when you start seeing me acting just like your ex-wife and I'll start seeing you like my ex-husband. It is unavoidable. We can't help but create each other in our own image." His response was: "That will never happen. You are nothing LIKE my ex-wife." But around the seventh year, the "magic year" for so many couples, he had just that thought after an argument: "She's just like my ex-wife." My words came back to him. At the time, early in the relationship, he thought I was crazy for saying that. He couldn't imagine it. I told him, however, that I was no fortune-teller in my predictions. I just understood that we can't escape being ourselves. The best we can do is learn to make corrections.

Learning to make corrections is never an easy task or a steady course. It isn't uncommon for a person in therapy to "feel worse" at some point. It is a matter of good clinical judgment whether this is a sign that something is going wrong or something is going right. It may be that at the very moment Ms. Burton wants us to ask if we are doing “something wrong” that we believe therapy itself is being most effective. Of course, it could be the wrong thing for the client, and checking in with the client from time to time is good common sense. But if "feeling worse" is part of a more positive process of coping with anxiety, then learning to manage it effectively is also important. Sometimes "helpful" doesn’t feel "warm and fuzzy."

If the therapist has done a good enough job of introducing what therapy is all about, here is where they point out that sometimes "helpful" feels “awful” and anxiety provoking. Like Ms. Burton, I think that clients should always have the final say when to stay and when to leave therapy. But I disagree that clients’ "feelings" should always be the arbiter of that decision, unless it's accompanied by an equally strong dose of curiosity. Like a good teacher, who neither bores the students to sleep nor creates so much distress they don't learn anything, a good therapist creates both a sense of dis-ease and curiosity. The dis-ease comes when the client does the same thing she's/he's has always done but no longer gets the same reaction. The curiosity comes from a basic trust in oneself and the feeling of mutual respect you sense to and from the therapist. If a client repeatedly fails to see an empathetic connection in their therapist's eyes when they are feeling totally emotionally exposed, they would have to be "crazy" to stay in therapy. On the other hand, challenging the therapist's reactions in this situation can be profoundly impactful to both.

As I've said before, most of us remain who we are for our lifetime, and therapy helps us make minor adjustments to better enjoy being that way. Therapists are no different. In my own case, I really want to be liked by other people. But as a therapist, I am more invested in being effective, than in being liked by my clients. Of course, I want to be both, but when push comes to shove, I'd rather earn my income and be effective. Being liked is a personal weakness of mine that I need to guard against when I put on my "therapist hat." Also, in everyday life, I prefer to rely on my intellect, rather than my emotions in figuring out situations. I “think” rather than “feel” my way around. This too, I need to adjust for as a therapist.

How to self-adjust? I might be more inclined to allow myself to say something "unlikable" or to "tear up" at an emotionally powerful story. In contrast, a therapist that tends to be overly emotional might want to 'shut off the spigot' more often than is comfortable for them when they are working with emotional material. This is one way therapists "self-correct." Some might argue that this self-adjustment is phony and harmful to clients, but I don't agree. We all have "personalities" and a therapist's capacity to "use themselves" in service of the therapeutic relationship is what separates the beginner from the seasoned clinician. Knowing ourselves and having a capacity to use that knowledge to benefit the therapeutic relationship is a powerful teaching lesson.

What she is describing as good therapy is practiced within the interpersonal school: The therapist doesn't "reward" problematic behavior by "acting naturally." They don't "get angry" when the client "does something anger-provoking." But they do explore the client's reactions to the encounter, in the here and now. Abused children sometimes provoke a parent who was physically abusive but reforming by saying "Hit me, don't you love me?" It is a difficult but essential therapeutic mission to not respond in kind (getting hurt or angry when the client is insulting or angry) while at the same time reinforcing the notion that the therapist is indeed invested in the client. A therapist, who is capable of differentiating at that moment, truly doesn't feel angry or upset at the client. But if your client’s way of connecting to people is by getting angry with them, such a response seems like “indifference.” They essentially ask: “Don’t you care enough about me to get angry back?”

The more complicated is the situation where the client _has_ become a master at finding and exploiting the area where the therapist actually _does_ get angry. To deny the feelings are disingenuous. To express feelings aloud may or may not be therapeutic. In either case, the therapist needs to gain perspective and process both what is happening inside them at that moment, as well as what might be happening with the client.

A therapist may say "Wow. What you just said made me really angry. Was that your intention?"

How the client reacts to this statement is a goldmine to the therapist. Should the client deny it, and the denial appear genuine, the therapist has a chance to look into their own psychology for better self-understanding or bring it up in their own supervision. If the client denies it, but the therapist doesn't believe them, the therapist can comment on what were the physical signs: "Your voice sounded pressured when you said it, and now I notice that you are talking loudly and rapidly. It was the way I heard your voice last week when you said you were angry at your boss. Were you aware of that? Do you mind if I point that out to you, the next time I hear it?" No incident by itself is significant of anything, and, if the denial continues, the therapist should drop it. Behaviors like this will repeat, if they are part of a larger interpersonal style.

Ultimately, skilled therapists are masters at noticing. Their best tools are their own thoughts and reactions, and, as Carl Whitaker once said, “their willingness to advance or retreat from any position." While I can't speak for Ms. Burton's therapy, I can say that a collaborative relationship between therapist and client remains the cornerstone of good therapy. However, collaboration doesn't imply equal areas of responsibility. We get paid large sums of money because therapists are asked to impact people's lives in significant ways. We receive years, sometimes decades of education and supervised training. And, as people, we choose a particular school and way of practicing that is unlikely to be randomly picked. We chose it because it suits our personality and because we believe it works (at least for us).

While it is true for some therapists that instead of 10 years of clinical experience, they have one year repeated ten times, this hopefully is not the norm. It is true that one tends to repeat what has been found successful in the past. Perhaps that is what Ms. Burton's therapist suffers from when she asks "Can we do something differently?" and he answers "No, I'm being consistent." On the other hand, consistency is exactly what some clients need and do not want. They use a variety of maneuvers to avoid feelings, or have a “duck and run” strategy when “people get too close.” It is always uncomfortable when a therapist holds up a mirror to our chronic self-defeating behaviors. For some clients, when faced with this discomfort, they plead: "Let's do something different" but this might not be what is in their best interest. While connecting with a client is essential to success, pleasing them at every turn is not.