Brent Dean Robbins
I believe that theory and practice of psychotherapy are intertwined and, ultimately, cannot be teased apart. One is blind without the other. My reflections on being a psychotherapist, thus, is both theoretical and practical.
Traditionally, theory and practice of psychotherapy has been developed from the position which argues that therapy can and should be "value free." The intention behind such an assumption is that the therapist must remain value neutral in order to evaluate the client "objectively"; that is, as untainted by "subjective" values imposed upon the client. Psychotherapy inherits such a view from natural science, based on Cartesian metaphysics.
Guignon (1993) writes:
endeavor from the outset has aimed at being value-free and objective, basing
its findings solely on
observation and causal explanation. The result is a deep distrust of authoritarian pronouncements and value
judgments. (p. 217)
Yet, one must question such an assumption: Is it, indeed, possible to remain value neutral? Rutan & Groves (1992) argue that it is not only impossible to be value-free, but not desirable. All therapies are guided by theories of health and pathology, whether these are implied or explicit. Further, these theories, although often held up as "scientific statements," are nevertheless more akin to systems of values. For Rutan & Groves, a theory involves a "leap of faith." That is, theories are embedded with codes of ethics which are "extensions of faith systems" (p. 6). They contain latent assumptions regarding what is and is not normal.
Even if a theorist makes truth-claims based on the testimony that their theory is "empirical" and "objective," this also implies a system of values. Empirical science is a "leap of faith," as Rutan & Groves point out. Empirical science involves a faith in the 'truth' of "objective" facts, of a transcendent reality which must be quantified and stripped of "subjective" qualities in order to be predicted and controlled. It is a belief in the gulf between the 'subject' and the 'object,' and the implication that the observer must maintain a distant, detached gaze in order to seize the 'truth' of a distant world. It is the "classical value system" which holds the value that one must be "value free" to attain 'truth.'
As Rutan & Groves write: "It is impossible to live without some schema or system" (p. 6). This holds for psychotherapy as well, and, thereby, schools of psychotherapy may be understood as 'churches' in which psychotherapeutic techniques are 'rituals' which "always follow and are rooted in theory" (p. 11). It follows, then, that therapeutic techniques, attitudes even, always implicate the theory and intend the means and ends of the therapy based on the theory's notion of health and pathology. There is no getting around it. And this implies that there is a danger with any approach to any phenomena, including therapy, which holds that it has no values, but, instead, lays claim to an "objective" truth. For, in this way, the values of the theory -- of the therapist -- remain doubly latent, and the therapist remains 'unconscious' of the notion of 'normalcy' which guides his or her thought. The therapist/scientist holds as universally true that which is highly dependent upon the age in which he or she happens to live.
What if the age in which a client happens to live is that which provides the conditions for the client's pathology? If, as van den Berg, asserts, neurosis is "sociosis," the therapist who holds as universal that which is a condition of the client's pathology is likely to perpetuate the very conditions which make possible the pathology in the first place. Guignon's (1993) exploration of a Heideggarian understanding of psychotherapy, moral values and authenticity uncovers just such a scenario. Guignon writes: "It is because mainstream theorizing fails to account for the role of values in human life that psychotherapy risks becoming 'part of the neurosis of our day rather than part of the cure' (p. 221).
Through the insight of Heidegger's (1927/1962) notion of Eriegnis (Event of Appropriation), the human being is understood as "an unfolding event or happening." In understanding the human being in this fashion, it becomes possible to begin to explore the role of values in psychotherapy. The assumptions of "naturalism" (which understands the self as a thing or object, understands "action as based on means-end calculations," and props up the individual as inexorably separate from the other and things) are unable to reflect upon questions concerning "the good life" -- that is, 'mere living' versus 'higher' existence (Guignon, p. 219). The notions of the "good life" remain undisclosed and unarticulated. Heidegger's ontology, in the contrary, provides a foundation upon which to begin to explore questions concerning "quality of life," the very questions which remain outside the grasp of natural science.
From an existential-phenomenological perspective, we may begin to ask questions such as: What is mental health? What is mental illness? How does one distinguish superficial problems from real problems? These are questions of value, of the "quality of life," yet no one person or society can lay claim to the 'truth' of the answers to these questions outside of the socio-cultural context in which they are raised. The therapist cannot lay claim to the 'truth' of such values. Instead, the therapist may assist the client by providing a space at the level of engagement which may open for the client new possibilities from which the client may begin to reflect upon the values which guide his or her life. From the influence of Ricouer (1980), therapy can be understood as providing an opportunity for the client to "renarratize" their "life story" through "moral reflection."
In the past two years, I have been given the privilege of sitting with clients and being a psychotherapist. Many of the people I have worked with are very similar to me. They often have very similar interests, goals, etc., and we certainly share a cultural understanding of what it means to be human. Yet, I have continuously been surprised, when I am open, to notice how each person, despite these similarities, come to articulate a conception of "the good life" which is very different from my own. It is a constant temptation to interpret clients from my own perspective — to be the one who ‘knows.' Yet, when I am patient and slow down, I find that the meanings of the client's world are, in many ways, very different than my own, often even radically different from my initial assumptions. In these moments, I am reminded of Levinas' (1961) articulation of the Other as being radically ‘Other,' a radical alterity which always resists being totalized and which forever remains, at least in part, wholly transcendent. And, yet, when I am able to let go — to truly listen — I can be face-to-face with the client and I can hear and be beckoned by the ‘call' of the Other. How often do we listen to a client — really listen — to the way a client unfolds his or her story and catch site, often in fleeting moments, of a mystery at the heart of it, something alien and wholly Other, which must be respected as such lest we do a kind of violence to the Otherness of the Other? In these moments, I am called back to my ownmost values which echo back to me against the resistance of the client to be totalized in such a way. In these moments, I often learn more about myself, about my implicit values which guide me as a therapist, than I do about the client. I think this is essential to being a good therapist, though too often I fall short of this ideal. For lack of a better word, it seems to me that being a good therapist requires a capacity for humility. It is this kind of humility, I think, which guides Boss (1994) in his distinction between "anticipatory care" and "intervening care." To anticipate rather than intervene requires a holding back, a waiting-toward the other, which requires an ability loosen one's grasp on cherished assumptions.
Many might argue that, if the therapist cannot be the ‘expert' — the ‘subject supposed to know' (Lacan, 1977) — then what is the point? What good is a therapist who is not an expert? Of course, therapist are experts, but not experts at knowing and pushing ‘shoulds' onto a client, as if most clients didn't have enough of those already. Therapists are experts at developing therapeutic relationships. Thus, my goal at all times as a therapist is to develop the relationship between myself and the client — and most importantly to make the dynamics of the relationship explicit to the client. While I cannot totalize the client as other, I can interpret how I understand what is happening between myself and the client.
Carl Rogers (1986) states the following as his "central hypothesis":
has within himself or herself vast resources for self-understanding, for
altering hir or her
self-concept, attitudes, and self-directed behavior -- and that these resources can be tapped if only a definable
climate of facilitative psychological attitudes can be provided. (p. 135)
Based on this assumption, Rogers elaborates three conditions for the therapeutic relationship in order for it to inhabit the "definable climate" of which he speaks:
1) "Genuineness, realness, or congruence"
2) "acceptance, or caring, or prizing — unconditional positive regard"
3) "Empathic understanding" (p. 135-136)
These conditions define what Rogers calls his "person-" or "client-centered approach" to therapy. This approach is described by Rogers as more a "basic philosophy" than a particular technique or method, which involves a "basic trust in the person" rather than a skeptical or distrustful attitude (p. 136). Rogers' approach begins with the assumption that human nature is essentially ‘good,' that the person shares with all living organisms an "actualizing tendency...to grow, to develop, to realize its full potential" (p. 137). Rogers places himself in contrast to traditional psychotherapy which views the human being as "innately sinful" and, in turn, which involves a skeptical attitude toward the client (p. 137).
Friedman's (1992) dialogue between Rogers and Buber reveals both similarities and differences between the two thinkers. Buber, for one, is more inclined to view human beings as polar, in distinction from Rogers' trust in the power of "self-actualization" to heal from the ‘good' inner core of the person's natural resources. This leads to a fundamental difference between how Rogers and Buber understand the relationship between "acceptance" and "congruence." For Rogers, the terms imply one another, whereas Buber does not equate the two. Buber insists that "confirming a person as he or she is" merely marks the first step in confirming what "in the present lies hidden what can become" (p. 46). In short, it seems that Buber is less inclined than Rogers toward merely trusting in the hypothesized ‘goodness' of the person's "self- actualizing" potential to lead the person to this potential.
In support of Buber's distinction, Friedman writes: "Healing does not mean bringing up the old, but rather shaping the new: It is not confirming the negative, but rather counterbalancing with the positive" (p. 46). Buber and Friedman seem to have a good point in that their take on Rogers allows for a darker side to human nature. Buber understands the human being as potentially destructive as well as growth-promoting. Therefore, Buber's viewpoint, as Friedman understands it, considers confirmation a "wrestling with the other against him or her self" in order to strengthen the ‘positive' pole as opposed to the ‘negative' pole (p. 47). The question remains, however: Who is to differentiate the ‘negative' from the ‘positive'?
As mentioned above, theory inevitably implies a system of beliefs which have ethical implications. In the light of Friedman's dialogue with Rogers and Buber, there is clearly such a struggle to reconcile two very similar belief systems which contain different assumptions regarding the nature of the human being. In turn, this implies two potentially different views of the nature of the therapeutic relationship. Yet, can these two views be reconciled?
In support of Rogers, I must say that Buber's idea could potentially lead to a therapeutic relationship in which the therapist becomes the arbiter of ‘truth,' the one who decides which pole is ‘positive' and which is ‘negative,' the one who is ‘supposed to know.' This is potentially dangerous, for obvious reasons. Instead, Rogers' view allows for an understanding of the human being as ambivalent without the need to push the client toward any particular direction. Rogers' view allows for a therapeutic relationship in which the therapist and client may share the struggle.
Ultimately, Rogers' elaboration of the three necessary conditions of therapy (outlined above) are geared toward facilitating an atmosphere which enables the client and therapist to share in the struggle toward healing. As Miller, Duncan & Hubble (1997) point out, therapy is "best understood as a collaborative process," and, therefore, they keep within the spirit of Rogers' "person-centered therapy" (p. 105). The therapist "wrestles" with the client, not by taking on one side or the other of the client's ambivalence, but by being with the client in the struggle; that is, participating in the client's struggle.
Miller, Duncan & Hubble move a step beyond Rogers by outlining an approach which helps to assure the therapist is aligned with the client's struggle. They recognize that therapy involves "extratherapeutic factors" as well as "relationship factors," which need to be taken into account in order to create a therapeutic alliance (p. 87). First, the therapist should be aware and accommodate the client's "motivational level of state of readiness for change." The stages of change are outlined as follows: 1) precontemplation, 2) contemplation, 3) preparation, 4) action, 5) maintenance, and 6) termination. These stages of "readiness for change" involve a continuum from a position where the client has no motivation to change to a position in which the client's ambivalence transforms into action to change (p. 104). Eventually, the client takes steps to maintain this change. Second, the therapist must strive to understand and respect the client's goals for therapy. As Miller, Duncan & Hubble (1997) write:
is both more effective and more efficient when the client's goals are accepted
at face value without
reformulation along doctrinal lines, and when these goals, in turn, determine the focus and the structure of the
intervention process. (p. 105)
Miller and colleagues generally emphasize the client's view of the therapeutic relationship. In turn, they are lead to view empathy as an "attitude," the therapist's "thoughtful appreciation" of what the client brings to therapy (p. 112). This thinking is in line with Rogers' distinction between empathy and inclusion, which he stressed in his later writings (Friedman, 1992). Inclusion recognizes that the therapist is always entering the therapeutic relationship "as if" it were his/her own. The emphasis on the "as if" is a recognition that empathy is never entirely accurate, since the person must always understand the other's world in terms of his or her own world. Similarly, Miller and colleagues point out that the most important thing is that the client is able to "perceive the therapist as trying, even struggling, to understand what they deem important and meaningful" (p. 112).
When the therapist 1) respects the client's values over and above his or her theoretical perspective, 2) strives for genuineness by the avoidance of "making the special claims on a corner of reality," 3) and validates the client, the therapist can be said to be creating a "collaborative" relationship with the client (pp. 113-120). Moreover, Miller and colleagues create an open space in which Rogers' and Buber's concerns can be reconciled. This is particularly true of their discussion of "validation." When the therapist "legitimizes" the client's concerns, acknowledges the significance of the client's problems, and affirms the client's ability "to withstand and eventually overcome the problem," he or she both "accepts" and "confirms" the client (pp. 117-118).
Personally, I constantly feel the pressure, both inside and outside of therapy, to be the "expert" and to solve problems for my clients. Over the past two years of doing therapy, however, I have quickly learned that doing so is more trouble than it is worth. I find that, when I give in to a client's desire to know my opinion, I largely do so for my sake rather the client's. It is out of my own anxiety that I give in to the client's demands to be the one who ‘knows.' However, when I hold to the therapeutic frame, although difficult, I always find it to be a fruitful enterprise, even if, in the short run, it causes discomfort for both parties. However, unlike Rogers, I do not simply reiterate. How then does one do interpretations without giving the impression that one ‘knows'? I've learned that one can do so by moving to the interpersonal dynamics between myself and the client. I become curious, not about the content of the question or demand, but about the question or demand itself. Yet, this is a very delicate process. It requires very good timing, which takes practice and experience to learn, and, even more, it requires an ability to truly listen on multiple levels.
If I am to "struggle with" the client without giving in to the temptation to be the "expert,' listening is the most important talent I can bring to the therapy. As Nichols (1995) writes: "Few motives in human experience are as powerful as the yearning to be understood. Being listened to means that we are taken seriously, that our ideas and feelings are known and, ultimately, that what we have to say matters" (p. 9). If the therapist is to be truly empathic, this involves an extreme effort on his or her part to listen to the client in such a way that the client feels listened to. I've always considered myself to be a pretty good listener. Yet, as Nichols acknowledges, most people think they are good listeners! Being a psychotherapist, I've discovered a healthy sense of humility. It is amazing how often I can fail to truly listen to my clients. Most often, I feel a distinctive pull to attend to the "facts" of the stories my client's tell. This is certainly a form of listening, but is also leads me to feel compelled to engage the client in such a way that I want to intervene with the client's story to get the ‘facts' straight.
Nichols points out that there are two purposes to listening: one purpose is to "take in information" and the other purpose is to "bear witness to another's expression" (p. 15). When I feel the pull to ‘get the facts straight,' one could say that I have placed my emphasis on the former purpose while, perhaps, neglecting the latter. However, I've begun to learn that I am the best listener when I am able to listen on multiple levels. I can listen to the content of a client's story without buying into it too easily; instead, I can listen to how the client is demanding or asking to be heard and how this creates a particular dynamic in our therapeutic relationship. It is these particular interpersonal dynamics, I've discovered, which provide the best material for interpretation — it is what remains implicit in the therapeutic relationship, lived but unarticulated. By making such dynamics thematic, one could be said to be making the implicit explicit — or the ‘unconscious' ‘conscious.' Again, these kinds of interpretations require good timing, and, before leaping in, I've found it is best to simply "bear witness" to the client's unfolding story without the need to meddle or jump in with interpretations. I've found that, if I am truly listening, I am almost always ‘called' at a very visceral, ‘lived' level (a ‘felt sense') to make the interpersonal dynamics explicit with an interpretation.
Ironically, the best interpretations erupt from a place of ‘not knowing.' In this sense, ‘not knowing' can be viewed as a kind of bracketing of my presuppositions in order to be open to the possibilities of the client's language. Yet, I'm also aware that it is virtually impossible to be without presuppositions. To perform such an epoche means, then, to be self-reflective in such a way that one is still with the client, still engaged with the client in-the-world of the therapy. It requires, at the most optimum level of engagement, an attunement — a ‘feel' for the mood of the therapy and how these moods shift and pull one to be a certain way with the client. The best interpretations (which are symbolic in nature since one must give language to the pre-thematic) seem to arise from a lived, pre-thematic, pre-verbal, ‘felt' movement with the client. Yet, when one rushes to interpret too quickly, this can actually be a defense against this felt movement with the client; that is, it can be a way to create distance between myself and the client. This, in itself, of course, is part of the attunement. Even if a make such a hasty move, I can at least reflect on ‘why now?' Such reflection can give me an idea of how my own values and issues may be interfering with the therapy — or it can lead me to an insight that the client may be subtly influencing me to collude with the avoidance of something that calls to be spoken yet remains unspoken, perhaps still too anxiety-provoking to be thematized.
Anderson & Goolishian (1992) write:
To not-know is
not to have an unfounded or unexperienced judgment, but refers more widely
to the set of
assumptions that the therapist brings to the clinical interview. The excitement for the therapist is learning the
uniqueness of each individual's narrative truth, the coherent truths in their storied lives. This means that
therapists are always prejudiced by their experience, but that they must listen in such a way that their
pre-experience does not close them to the full meaning of the client's descriptions of their experience.
This can only happen if the therapist approaches each clinical experience from the position of not-knowing.
To do otherwise is to search for regularities and common meaning that may validate the therapist's theory
but invalidate the uniqueness of the client's stories and thus their very identity. (p. 30)
I find Anderson & Goolishian's insights to be very reassuring and validating. When I have been able to lay aside my initial desire to interpret, I've learned to develop a capacity to be truly curious about the client's world. When I begin to do this, I realize that there is a subtle, yet very powerful, shift in my being as a therapist. I begin to feel more natural and less mechanical and rely less on technique-like approaches. At these moments, I have indeed found the "excitement" of which Anderson & Goolishian speak.
Margulies (1989) is especially privy to the benefits of laying aside one's desire to be the one who ‘knows' as a therapist. For Margulies, it is the "creative capacity to suspend closure, to know and not know simultaneously" which is the common ground between phenomenology, psychoanalysis and poetry (p. 3). All three, as an ideal, strive to achieve a sense of wonder before the phenomenon under investigation in order to see the phenomenon in a truly originary, if not pure, state. Further, all three of these disciplines also recognize that doing so goes against one's ‘natural tendency.' As Margulies writes: "By innate design our egos, minds, and brains organize our experience and establish patterns of perception (p. 13). Therefore, it takes extreme effort to view phenomena in such a way that one may, like a child, stand before it in wonder and curiosity. I very much agree with Margulies. I can truly say that when I ‘trust my curiosity,' I have the most powerful sessions with my clients. The client, at these times, can feel profoundly heard and understood, and I have witnessed clients weep with joy in the presence of such a moment. Granted, these moments are rare, but, I would argue, they are the heart of the healing process of psychotherapy. In these moments, I truly feel honored to be given such a privilege — to participate in such a profoundly affirmative and transformative moment for another human being. At those times, I feel like being a psychotherapist is the most wonderful job in the world.
I've also discovered that really listening to a client ultimately leads me to contemplate the language of the client in a way that is very much different than the ‘everyday' engagement with language in the ‘natural attitude,' so to speak. Guignon accurately points out the benefits of understanding language in therapy from a Heideggarian perspective. A person's character or identity can be understand as a "happening" or "event" that unfolds over a lifetime and which "can be grasped only in terms of his or her life story as a whole" (pp. 224-225). When this understanding is supported by Ricoeur's notion that the "temporal unfolding of life" may be understood as "the structure of a narrative," the importance of the role of language becomes quite obvious (p. 225). The narrativization of one's life is provided by the socio-historical context in which one lives.
"Language is the house of Being," wrote Heidegger. Language makes the "event of appropriation" possible by illuminating beings which have been given by Being within Language. As Griffith & Griffith (1994) point out, both Heidegger and Merleau-Ponty imagined that the "metaphors available to us in our language" can be understood "as lanterns that light up a small area of a dark forest" (p. 23). The metaphor ‘illuminates' the region of the human place, the clearing in which Being can presence, and yet this clearing is always also a covering over, a concealment, in which Being recedes, leaving only traces of its presence. The therapist, by attending to and mirroring the language of the client, allows the client to dwell within his or her language, thereby making it possible to re-narratize his or her life story. By listening to the Saying of language as it speaks through his or her language, the client may be called to new modes of openness to the world, to possibilities previously shrouded in darkness. When the client begins to reflect on the language of his or her story, he or she is also engaged in a process of making explicit what had been previously implicit or taken-for-granted in his or her everyday mode of being. In listening to his or her speaking, the world is made explicit and thematized, and, in turn, the client may take the opprtunity to "take a stand in a world where things are genuinely at stake" (Guignon, p. 227).
Gendlin's (1996) "focusing-oriented psychotherapy" is one approach to providing such a therapeutic context. Gendlin differentiates between "therapy" and "talk." He understands that ‘language' is an embodied phenomenon, not mere words. One can "talk" with worlds without the words resonating for the person in a bodily way. When words tap into a ‘felt sense' in the body, this means that the words have a deeper connection to one's experience. When one's words "resonate" in such a bodily way, this means, for Gendlin, that one has brushed up against the murky edge of one's unconscious, lived experience which is implicit. For Gendlin, any other ‘talk' in therapy leads to a dead-end instead of leading toward transformation of the whole person. The human being, as a world-openness of possibilities, can be transformed when language speaks through the body, through one's attunement to what matters. To use Griffith & Griffith's metaphor, the client may shed light on those aspects of the ‘forest' which had previously remained in darkness. A previously constricted existence can be opened to new modes of engagement with others and the world.
I have found that I do my clients a great service by mirroring his or her language. This is similar to what Gendlin means by "reflecting." "To reflect," writes Gendlin, is "a rare and powerful way to let clients enter further into their own experience." The therapist, in this way, is able to be with the client in a therapeutic way without imposing on the client. Gendlin, however, does not merely reiterate, but actively encourages the client to unpack those words or phrases which resonate, and, as he argues, prevents the therapy from leading to dead-ends from mere talk. Again, this kind of attending to language is much more than listening to mere content. It is listening to mood, to the ‘felt sense.' When one is attuned to gaps, fissures and words that resonate, one can invite the client to unpack these words, and, almost magically, the client's dwelling within his or her own language creates a space for language to speak — the words come and speak what, before, had remained pre-thematic and lived. Like a flower from the mouth, the unfolding of the latent meaning shows itself in the symbolic. This is essentially the way I understand the making conscious of the unconscious.
Thus far, in summary, I have presented my perspective that the therapist cannot be neutral, but, instead, must meet the client at the level of engagement. This process, for me, begins with the facilitation of a therapeutic alliance in which I strive to hold the client with "unconditional positive regard" and mirror his or her language. By being-with the client in a mode of active listening, I try to allow the client to move into his or her own language, thereby making explicit what had been implicit. Eventually, when the therapy feels safe enough for the client and the timing is right, I make interpersonal-oriented interpretations regarding what is happening between us. Implied, I feel that the client's feeling of being safe in the therapy with me is truly an essential ingredient to my approach. Rather than strive for a fictional neutrality with the client, I strive to make the client feel safe enough to be genuine and open with me.
Stolorow (1994) also holds the belief that the "myth of the neutral therapist" is a false myth. For Stolorow, ‘neutrality' implies that the therapist can and should be able to "eliminate his own psychological organization from the analytic system," which is, in actuality, impossible (p. 147). Instead, writes Stolorow:
What the analyst
can and should strive for in his self-reflective efforts is awareness of
his own personal organizing
principles -- including those enshrined in his theories -- and of how these principles are unconsciously shaping
his analytic understanding and interpretations. (p. 147)
There is no such thing as "uncontaminated transference." Transference occurs within the therapeutic frame in the relationship between therapist and client. The client is evoked by the therapist to interpret the therapeutic relationship according to some developmentally performed organizing principle. Therapy evolves, as Stolorow argues, in the "intersubjective field" established between the therapist and client (p. 151). I agree with Stolorow that, rather than pretend I am neutral, I can maintain "sustained empathic inquiry" by beginning first from the "subjective" world of the client; that is, the client's "subjective frame of reference" (p. 148). In this light, I understand "unconditional positive regard" as an attitude by which I attempt to maintain a consistency regarding the client's story without favoring one course of action over another. I can maintain "sustained empathic inquiry" by being equally concerned with the client on all levels and by respecting and caring for the client regardless of what he or she has to say. By moving in a direction which begins with the "subjective frame of reference" of the client, I am, in a sense, placing my personal and theoretical assumptions in "brackets."
This sounds easy enough. But I've also learned that it is not possible to place one's feelings and beliefs regarding the client entirely in "brackets." I often feel pulled to be a certain way with certain clients and this is very compelling. Inevitably, I fail to maintain "sustained empathic inquiry" at all times. The beauty of this approach, however, is that my failures, ultimately, are not failures; instead, I can use this deviation from "sustained empathic inquiry" to actually deepen my understanding of the client and my therapeutic alliance with the client. When I deviate from such a consistent attitude, this in itself becomes a reflective moment, a part of the epoche, and I can begin to inquire about "why this, why now?" The way I am pulled to be a certain way with the client tells me about what is happening in the relationship. It tells me what the client wants me to be and my implicit desire to give over to this demand — perhaps to be the one who ‘knows' or to play a particular transferential role for the client. I can also use this as a way to catch site of my own implicit demands regarding the client. In each of these cases, I can use myself, my own feelings and thoughts regarding the client, to deepen the therapeutic alliance. And, by doing so, I develop material which, with the right timing, I can use to interpret what is happening between myself and the client. Interestingly, these kinds of failures are often the best material for interpretations. I like to think this is what Rogers meant by saying that the therapist should be "genuine."
For this process to unfold in a way that the client feels safe, the therapy must be constructed in a certain way that is very different from one's everyday engagement with others outside of therapy. As Langs (1989) so adeptly acknowledges, psychotherapy becomes a therapeutic relationship by virtue of its deviation from our typical, everyday, pedestrian relationships. As Langs writes:
Given the realities
of our culture, it is the very nature of its existence as a commodity that
and sets it apart from a friendship or from the sharing of problems with a neighbor. In fact, one might say that
the therapeutic interchange exists only by virtue of its structure as a service. The therapeutic relationship
brackets off a time and place for activities removed from the linear effort of everyday survival issues. (p. 54)
The therapeutic frame, as a deviation from the "everyday" mode, necessarily involves ‘boundaries' which define the therapy. It is from the ‘boundaries' of the therapeutic frame that the very meaning of therapy emerges and, without which, a relationship may no longer be considered therapy as such. Furthermore, it is within this context that both client and therapist are given the framework in which to make explicit that which is implicit. This process is often uncomfortable and takes effort to maintain. For, as Langs maintains, the "conscious system" is "uncomfortable with the structured frame of psychotherapy" (p. 55). While the therapeutic frame provides stability, the "conscious system" experiences this stability as entrapping. The paradox implies a struggle both for and against change for both parties. Rather than face this ambivalence by making the implicit process explicit, it often becomes a great temptation to break the therapeutic frame. As Langs writes: "Because this paradox is an issue for all of us, therapists as well as patients feel the same kinds of pressures to defend against awareness. The easiest defense open to either party is to undermine the therapeutic frame."
Being that both the therapist and the client are under similar pressures, it is likely that the therapist and client will often conspire to undermine the therapeutic frame. Therefore, the therapist who wishes to avoid such pitfalls must learn to hold fast to the therapeutic frame despite the temptation to deviate from it. This necessitates a need for a set of "ground rules" from the beginning so that the therapist may hold to the frame and recognize his or her unconscious pull to deviate from the frame. In general, this is the ‘pull' I discussed early: the pull away from the frame tells me something about what is happening between myself and the client. I often fail to hold the frame in therapy, but, when this happens, it can be genuinely healing for the client when this is interpreted and discussed between myself and the client. I find that this is very powerful, and, almost always, the ‘pull' I feel involves transferential dynamics, if not counter-transferential dynamics. In short, the frame allows for the interpretation of the transference, which is in line with Freud's (1917) original assertions:
of the patient's illness...is concentrated on a single point -- his relation
to the docotr...When the
transference has risen to this significance, work upon the patient's memories retreats far into the background.
Thereafter it is not incorrect to say that we are no longer concerned with the patient's earlier illness but with
a newly created and transformed neurosis which has taken the former's place. (p. 144)
Healing in therapy happens when my relationship with the client is used to make the patterns of the client's relationships explicit in the therapeutic frame, which must necessarily be a safe place if the client is to avoid re-experiencing original traumas at the heart of the transference (as opposed to "a newly created and transformed neurosis which has taken the former's place").
There are various "ground rules" which I feel are essential for therapy. When these ground rules are violated or I feel the pull to violate them, this becomes a red flag, so to speak. First, I try to be consistent with the client. By maintaining a degree of consistency, I can avoid favoring one action of the client's over another; thus, I strive to maintain "sustained empathic inquiry." Whenever there is a violation of this ground rule, which happens often enough, I acknowledge this deviation. The deviation, thus, is made explicit and ‘conscious' rather than implicit or ‘unconscious.' Once this deviation is acknowledged, the transference is brought to the table. The client and I are no longer talking about distant past relationships, but we are now working with our relationship in the moment. And, ultimately, this is where the healing of therapy must take place.
As Kahn (1997) points out, remembering is not enough, and, if so, "what is missing is re-experiencing" (p. 57). Kahn quotes Gill (1982), who emphasizes the essential nature of ‘re- experiencing' in psychotherapy:
is primarily a result of the patient's efforts to realize his wishes, and
the therapeutic gain
results primarily from re-experiencing these wishes in the transference, realizing that they are significantly
determined by something pre-existing with the patient, and experiencing something new in examining them
together with the analyst -- the one to whom the wishes are now directed. (p. 44)
In keeping with Gill's sentiments, I am constantly striving in therapy with my clients to bring the transference into the open so that it can be re-experienced in the therapeutic relationship. And even when I find myself avoiding this, this in itself becomes an object of curiosity, and it, too, can be used as part of the interpretation. This concept is central to what I have already discussed so far. By being attuned to the client's mood and deepening the client's language, I attempt to allow the client to be in touch with his or her feelings. I do not think this can happen unless the client feels safe in the therapy; thus, "unconditional positive regard" and "sustained empathic inquiry" are essential for providing a feeling of safety for the client, as is my effort to hold the frame. When these feelings are resonating in the room, I can ‘feel' them — they are palpable, visceral, and felt through my lived body with the client. I feel the ‘pull' of the mood of our relationship. When the timing is right and I feel the client feels safe enough to bring that material from a distant past to the present moment between us, I offer this as an interpretation in a non-judgmental, nondefensive and interested way. In time, I am then able to make connections regarding how what is happening between us is related to transferential phenomenon — how it is related to the client's past, that is. The past, in this case, is no longer a distant past, but a past already being re-experienced in the therapeutic relationship.
Other, perhaps more obvious, elements of the therapeutic frame (‘ground rules') are also essential: dual relationships are off limits, and physical contact, self-disclosure, advice-giving, and undue deviation of time lengths are all avoided. In all of these cases, these aspects of the frame separate the therapy relationship from a pedestrian relationship, which gives the client a safe space within which to re-experience transferential phenomena without re-experiencing the trauma in damaging ways. Transference in pedestrian relationships involves repetition of the trauma, whereas the therapeutic relationship is in the service of using transference phenomena for psychological transformation towards healing and growth.
As LeShan (1996) has pointed out, the therapist is "all to human." As he writes:
A therapist who
is not in supervision should be regarded either with suspicion or with
awe. He or she is making
a statement that they learned all that is needed for one of the most complex problems in existence -- helping
others to be as fully human as possible and to survive and exult in the human condition. (p. 91)
LeShan points out an important lesson which I have learned full force since first becoming a psychotherapist: I have much more to learn. Yet, I've also learned that I have the capacity to be therapeutic by sticking to the therapeutic frame and, even if I inadvertently deviate from this frame, I can acknowledge this within the therapeutic context. I am human and fallible, but that does not mean I am not competent. I feel, today, that I am a much more competent therapist compared to two years ago. And, within the next several years, I expect that I will continue to become more competent. I've appreciated the professors and supervisors who have helped me along the way. I know now that I can engage a client in therapy in such a way that it is truly therapeutic and transformative for the client because I have seen the results of my work. I expect that I will only get better and that feels good.
One of my constant struggles with my approach to therapy is how to deal with the issue of "resistance" by my clients. As I mentioned previously, I am influenced by Levinas' (1961) philosophical anthropology which implies that the client is always radically alterior, radically Other. To totalize the client, to attempt to fully ‘know' the client, is to do a kind of violence to the client's transcendency as the Other. In this sense, I feel that there is a health in what is termed "resistance" by the client — the client always resists being fully known. Thus, part of my struggle is the question of how to deal with "resistance." When is "resistance" healthy and when is it pathological? Even with the "sustained empathic inquiry" of a non-directive approach to therapy, resistance occurs. Yet, there is little agreement as to what "resistance" means. Further, the way a therapist interprets the meaning of "resistance" can actually evoke from the client a particular manner of "resistance," and, in turn, will influence the way the therapist responds.
Kepner (1987) identifies four different understandings of resistance: "common sense," psychoanalytic, Reichian, and Gestalt perspectives. "Common sense," according to Kepner, may understand a client's resistance to change as "anti-self" (alient to the ‘I'), as "weakness (lack of will)," as "irrational," or as "force of habit" (p. 61). Yet, as Kepner points out, there is a potential danger inherent in the "common sense" understanding of resistance. The person who is resistant to change may, in fact, attempt to change by overlearning a new, good habit to replace the old habit. In doing so, the person risks masking the original conflict which may become "inaccessible beneath a thick layer of secondary repression" (Kepner, 1987, p. 62).
"Common sense" thinking believes that a person will inevitably change if only they really want to change. Freud, on the other hand, uncovered another possible understanding of change: Wanting to change, yet being unable to do so. Freud saw resistance as a person's defense against internal drives that threaten the personality structure. It follows that Freudian psychoanalysis understands resistance as some-'thing' which should be ‘overcome' in order to make the unconscious conscious. Reich, further, expanded upon Freud's notion of resistance by seeing resistance as a function of the person's ‘character and character armor' which he saw as equivalent to the ‘body armor' of one's ‘chronic physical tensions.'
Kepner also recognized a potential
problem with both the Freudian and Reichian theories of resistance.
One's resistance can also be understood as a "protection." If so, the client,
by resisting the therapist, is protecting himself or herself from a perceived
harm. Therefore, Freud and Reich's approach to resistance, as requiring
it to be "overcome," implies an intrusive maneuver by the therapist to
penetrate and/or remove the resistance. Yet, how can one expect a
person to relinquish his or her "protection" when he or she perceives the
therapist as a potential threat?
Gestalt therapy provides an alternative to the Freudian and Reichian approaches to resistance. As Kepner explains:
is not considered a mechanism or tool of the self; it is seen as the self
itself in action. There is nothing
behind the resistance itself, no 'true self' different from the resistance. Both the defense and the defended are self...
To break down or eliminate resistance would be the same as breaking down and eliminating a capacity of the self.
The therapist, by attempting to "overcome" the client, runs the great risk of creating a situation in which the person's defenses become even more rigid. The therapist does, indeed, become a threat — a threat to the very ‘self' of the client. Nevertheless, the insight of psychoanalysis sheds light on the double knot of the self: The self both seeks and resists change. As long as a person's resistant ‘self' remains outside of awareness, this reduces the possibility for the client to express his or her resistance from a position of choice; that is, until it is fully owned. The therapist's task, therefore, is the gentle art of assisting the client in becoming aware of both aspects of his or her ‘self'; the ‘self' which wants to change and the ‘self' which resists this change. I use this ‘non-violent' approach to therapy in order to allow the client the openness necessary to dwell in this ambivalence, to notice it as if for the first time without the need to immediately take up one side or the other. Once the client's ambivalence is "fully owned," the client can then be said to be acting from a position of choice. Further, if therapy is about making the unconscious conscious, it is an error to believe that one must break through a client's resistance in order to do ‘real' therapy. I feel that the person's growing awareness of their own "protective" styles of engagement, as part of what constitutes their being as a particular person, is what makes therapy therapeutic. Therefore, the therapist's engagement with the client's resistance is the therapy, rather than a hindrance to therapy. I believe this is in keeping with Levinas' (1961) understanding of ‘ethics.' This is ethical therapy in the service of the other as radically other.
While Kepner utilizes the insights of Gestalt therapy to uncover the nature of resistance, Teyber (1992) moves a step further by articulating ways in which the therapist can address resistance in such a way that will be therapeutic. Like Kepner, Teyber recognizes that resistance can be understood as stemming from the client's ambivalence. Teyber also, like Kepner, views resistance as a way for the client to protect him- or herself. He sees resistance as stemming from "layers of fear" tied to the client's presenting problems (p. 2). Yet, Teyber also realizes that therapists avoid dealing with a client's resistance out of their own insecurity — based on naive notions of the therapeutic relationship — from a position which understands the therapist as ‘superior' or out of a desire for the therapist to be liked (p. 3). For Teyber: "Both the therapist and the client must honor the client's resistance, as it originally served a self-preservative and adaptive function" (p. 4). Ultimately, for Teyber, the therapist should encourage the client to talk about their negative feelings about therapy. Otherwise, the client is more likely to act out on these unspoken feelings by dropping out of therapy.
Teyber and Kepner's approaches to resistance are consistent with my non-directive approach to therapy which I have elaborated in this paper. Teyber's approach is also consistent with Stolorow's notion of "sustained empathic inquiry" and Rogers' idea of "unconditional positive regard." I feel that if I am truly unconditionally curious about everything a client has to say, the client will feel more free to openly discuss his or her ambivalent feelings — and, indeed, my experience has proven to me that this is the case. Even when I feel the need to break through a client's ‘defenses,' I instead strive to be deeply curious about the client's ‘defenses' in a non- threatening manner, neither ‘breaking through' nor avoiding them out of a desire to be superior or to be liked by the client. Through mirroring the client's language and well-timed interpersonal interpretations, I strive to assist the client in recognizing his or her unconscious defenses, and, thereby, I've found that the client can then begin to "own" these largely ‘unconscious,' unarticulate, lived, ‘protective' styles of moving through the world.
From this perspective, Buber's idea of "wrestling" with the client can be understood in an alternative way. I "wrestle" with the client, not against the client by bearing witness to the client's struggle to change. The client deepens his or her understanding of his or her language by attending to the words and phrases which "resonate" in the body, and he or she begins to catch site of the dynamics of our relationship which discloses habitual styles of relating to others. In turn, he or she may begin the process of a change which begins with a "felt sense" and moves toward "renarrativization" of his or her story: A story which opens up new opportunities for healing and growth and which literally involves a reconfiguration of the client's horizons. The client can discover a new openness to new possibilities and a wider perspective compared to his or her old, constricted world-relatedness from which the client had suffered.
Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee & K. Gergen (eds.), Therapy as social construction. London: Sage.
Boss, M. (1984). Existential foundations of medicine and psychology. Northvale, NJ: Aronson.
Freud, S. (1917). Introductory lectures on psychoanalysis, lecture XXVII. In The standard edition, vol. 16.
Friedman, M. (1992). Dialogue and the human image: Beyond humanistic psychology. London: Sage.
Gendlin, E. (1996). Focusing-oriented psychotherapy: A manual of the experiential method. New York: Guilford.
Gill, M. (1982). The analysis of transference, vol. 1. New York: International Universities Press.
Griffith, J., & Griffith, M. (1994). The body speaks: Therapeutic dialogues for mind- body problems. New York: HarperCollins.
Guignon, C. (1993). Authenticity, moral values, and psychotherapy. In Guignon (ed.), The Cambridge companion to Heidegger. Cambridge: Cambridge University Press.
Heidegger, M. (1962). Being and time. New York: Harper & Row.
Kahn, M. (1997). Between therapist and client: The new relationship. New York: W.H. Freeman and Co.
Lacan, J. (1977). Ecrits: A selection. New York & London: W.W. Norton and Co.
Langs, R. (1989) Rating your psychotherapist. New York: Ballantine.
LeShan, L. (1996). Beyond technique: Psychotherapy for the 21st century. Northvale: Aronson.
Levinas, E. (1961). Totality and infinity: Essays on exteriority. Pittsburgh: Duquesne University Press.
Margulies, A. (1989). The empathic imagination. New York: Norton.
Nichols, M. (1995). The lost art of listening. New York: Guilford.
Ricoeur, P. (1980). Narrative time. In W. Mitchell (ed.), On narrative. Chicago: University of Chicago Press.
Rogers, C. (1986). A client-centered/person-centered approach to therapy. In H. Kirschenbaum & V. Land Henderson (eds.), The Carl Rogers reader. Boston: Houghton Mifflin.
Stolorow, R. (1994). Converting psychotherapy to psychoanalysis. In R. Stolorow, G. Atwood & B. Brandschaft (eds.), The intersubjective perspective. Northvale: Aronson.
Rutan, J. & Grobes, J. (1992). The value system of the psychotherapist. In J. Rutan (ed.), Psychotherapy for the 1990's. New York: Guilford.
Teyber, E. (1992). Interpersonal process in psychotherapy. Pacific Grove: Brooks/Cole.
Van den Berg, J.H. (1983). The changing nature of man: Introduction to a historical psychology. New York: Norton & Company.
TO PSYCHOANALYSIS AND BEYOND PAGE
RETURN TO MYTHOS AND LOGOS HOME PAGE
Copyright 1999, Brent Dean Robbins