Beginnings in Psychotherapy
As the days of August tick rapidly by, and the fall semester looms on the horizon, I am eagerly reading any number of books that I can get my hands on, including Mary Jo Peebles-Kleiger, Beginnings: The Art and Science of Planning Psychotherapy (Analytic Press, 2002). Both the title and the timing are apt as I am beginning a clinical practicum later this month, and am very excited about that.
The book has many good insights, though in my reading of it these are largely confined to the first six chapters.
Begin as You Mean to Go On:
The author begins with what might seem obvious, but can get overlooked: If therapy is to end properly it must begin properly. She notes that what goes on in that first hour very often communicates our theory, our views of patients and their problems, and how the process will play out.
She reiterates what I have seen said time and again in many books in the past year: the role of the therapist's personality and our "competence, hope, and humanity...will minister strongly (or, some would argue, more strongly) than the particular modality we eventually select" (p.1).
Wearing Diagnoses Lightly:
I have seen others whom I respect note that one cannot and must not be hidebound about diagnostic labels. Peebles-Kleiger says that one may often start with a diagnosis, but one can equally start with a case formulation--a narrative that goes beyond symptoms and causes to be grounded in history of relationships, taking a wider view. I very much incline towards this latter. In any event, one must recognize, as she rightly puts it, that "no system of diagnosis is fully comprehensive....diagnosis is ongoing" (p.4).
Early on, her approach is to put together a clear picture of the patient that takes account of and has some idea of:
1) History, including that of relationships
2) Patient's capacity for forming the therapeutic alliance
3) What functions do the symptoms serve?
4) What is psychological cost of change?
Having accounted for these, one can proceed to step 5): Form what she calls a "blueprint" for treatment that focuses on "connection, focus, joint activity, prioritization, and choice" (13).
Later on she offers further recommendations on the taking of a patient history (cf. Nina Coltart, discussed elsewhere on this blog, about the huge importance of getting this done as comprehensively as possible early on), noting that it is best to take history "which flows out of the investigation of current emotions, behaviors, and ideas" (52). Indeed, some of those current emotions and behaviors will show up in the consulting room, and careful observation of the patient and his or her activities will often give clues of an historical nature which should then be examined together. E.g., she refers to a patient who always came precisely 15 minutes late to every session. This obviously had a history behind it needing to be explored, as they did.
The Therapeutic Alliance:
In her second chapter, Peebles-Kleiger offers a helpful reminder that the alliance is beginning to be formed (or thwarted!) the moment you walk into the waiting room and make eye contact with the new patient for the first time. Here and throughout your entire time working together, she says that "respect, even reverence, is the order of the day" from first greeting patients to the end of their treatment. I like that "reverence" here for each person's unique dignity.
She notes something often seen in other books based on wide-ranging research: building the alliance repeatedly shows the crucial importance of the therapist's "ability to show empathy, sincerity, and unconditional acceptance of the patient" (16). This allows her to note, moreover, that other
"research has documented that if a patient feels accepted, understood, and liked by the therapist early in the relationship, then therapy tends to be successful" (14). This, she says, is pantheoretical.
She differs--rightly in my view--in not following early psychoanalytic techniques and requirements aimed at "curbing spontaneity and remaining unresponsive" because doing so "could actually have a negative impact on the relationship" (17; cf. Coltart again). She does, however, agree with the formative experience and expectation--going back to the early days of psychoanalysis--that insisted on the therapist also being in therapy, if not as a prerequisite then as a concomitant to his or her own clinical practice: "There is empirical evidence for a positive correlation between having had personal therapy oneself and being better able to facilitate a positive alliance in treatment" (23). (I am, frankly, amazed that this is not still a widespread requirement today of prospective clinicians.)
Naked Logic:
I really liked her counsel to avoid appearing or trying to be some kind of aloof expert handing down recommendations from on high. This is not original to her, of course, but goes back at least to Carl Rogers. In any event, she rightly says that transparency in the therapist's thinking--taking off the outer later to see the logical gears working underneath--can be very important. This "invites the patient to be a diagnostic partner and to reason along with you. The end result is that the patient not only knows how a particular treatment recommendation was arrived at, she also feels that she helped critique and shape its construction" (22). Such collaboration helps the alliance.
Goals and Treatment Plans:
As someone whose entire experience thus far has been psychoanalytic, I found her third chapter, Focus, helpful. She begins by noting that some people (I confess I incline towards this) are suspicious of too much attention on focus, on goals, on treatment plans because they fear this will undermine the capacity for spontaneity, creativity, and above all free association. To us she says it may be helpful to see our role as similar to a personal trainer: advocating for a repeated focus on attaining certain goals for improvement in the patient's life. She says that the research is clear: focus and goals across modalities are key to successful therapy. And, she insists (though this needed much more development), focus and goals are not at cross-purposes with free associating. Nor are they aimed only at symptom relief. You can be doing several things at once in therapy.
The author's sixth chapter, What Material Is Important?, poses some important questions and offers some not terribly original answers that are nonetheless still important to underscore.
One of the really obvious things she says to pay attention to is "repetition (of phrases, themes, behaviors, sequences, mannerisms, emotions).... The more repetition the more attention is warranted" (p.69). I have learned this from reading the great child therapist and psychoanalyst Adam Phillips over the years, but I first learned it from what is perhaps my favourite of Freud's technical papers, "Remembering, Repeating, and Working Through."
In addition, do not fail to note strong emotions, idiosyncrasies, and especially dramatic losses of control or wildly singular behaviors--even if they only occurred once and were never repeated, they may offer a deep vein of significance to be explored.
Jumping, finally, to Peebles-Kleiger's nineteenth chapter, on the Psychological Costs of Change, I found much gratifying material here, too, which reflects my own attempts at rethinking "resistance." I've come to the view that resistance must be seriously respected, not merely scorned as something to be gotten rid of, or around, as quickly as possible. This, too, comes out in Freud's paper mentioned above: the resistance plays a role, and the clear-eyed clinician must try to see what role that plays. As Peebles-Kleiger notes here, symptoms can be bothersome but also productive and useful. Some symptoms may protect from grief or hold anger in check. Some may be resistant to change until and unless (as Winnicott might say) the patient learns that it is okay to hate the therapist.
Though she doesn't mention him here, I had another of Freud's works in mind here, the centenary of which is this year: Beyond the Pleasure Principle, with its controverted theory of the death drive and the less controverted and I think more clinically abundant phenomenon of the repetition compulsion. The repetition of symptoms, and of resistance, must be examined and taken seriously by, inter alia, asking what the plan is for their replacement. As she notes, lots of therapy without such a plan will falter: you can't remove something and leave nothing in its place for most people. You must replace something pathological with something adaptive.
Anyway, such were some of my thoughts in reading Mary Jo Peebles-Kleiger's useful book, Beginnings: The Art and Science of Planning Psychotherapy
The book has many good insights, though in my reading of it these are largely confined to the first six chapters.
Begin as You Mean to Go On:
The author begins with what might seem obvious, but can get overlooked: If therapy is to end properly it must begin properly. She notes that what goes on in that first hour very often communicates our theory, our views of patients and their problems, and how the process will play out.
She reiterates what I have seen said time and again in many books in the past year: the role of the therapist's personality and our "competence, hope, and humanity...will minister strongly (or, some would argue, more strongly) than the particular modality we eventually select" (p.1).
Wearing Diagnoses Lightly:
I have seen others whom I respect note that one cannot and must not be hidebound about diagnostic labels. Peebles-Kleiger says that one may often start with a diagnosis, but one can equally start with a case formulation--a narrative that goes beyond symptoms and causes to be grounded in history of relationships, taking a wider view. I very much incline towards this latter. In any event, one must recognize, as she rightly puts it, that "no system of diagnosis is fully comprehensive....diagnosis is ongoing" (p.4).
Early on, her approach is to put together a clear picture of the patient that takes account of and has some idea of:
1) History, including that of relationships
2) Patient's capacity for forming the therapeutic alliance
3) What functions do the symptoms serve?
4) What is psychological cost of change?
Having accounted for these, one can proceed to step 5): Form what she calls a "blueprint" for treatment that focuses on "connection, focus, joint activity, prioritization, and choice" (13).
Later on she offers further recommendations on the taking of a patient history (cf. Nina Coltart, discussed elsewhere on this blog, about the huge importance of getting this done as comprehensively as possible early on), noting that it is best to take history "which flows out of the investigation of current emotions, behaviors, and ideas" (52). Indeed, some of those current emotions and behaviors will show up in the consulting room, and careful observation of the patient and his or her activities will often give clues of an historical nature which should then be examined together. E.g., she refers to a patient who always came precisely 15 minutes late to every session. This obviously had a history behind it needing to be explored, as they did.
The Therapeutic Alliance:
In her second chapter, Peebles-Kleiger offers a helpful reminder that the alliance is beginning to be formed (or thwarted!) the moment you walk into the waiting room and make eye contact with the new patient for the first time. Here and throughout your entire time working together, she says that "respect, even reverence, is the order of the day" from first greeting patients to the end of their treatment. I like that "reverence" here for each person's unique dignity.
She notes something often seen in other books based on wide-ranging research: building the alliance repeatedly shows the crucial importance of the therapist's "ability to show empathy, sincerity, and unconditional acceptance of the patient" (16). This allows her to note, moreover, that other
"research has documented that if a patient feels accepted, understood, and liked by the therapist early in the relationship, then therapy tends to be successful" (14). This, she says, is pantheoretical.
She differs--rightly in my view--in not following early psychoanalytic techniques and requirements aimed at "curbing spontaneity and remaining unresponsive" because doing so "could actually have a negative impact on the relationship" (17; cf. Coltart again). She does, however, agree with the formative experience and expectation--going back to the early days of psychoanalysis--that insisted on the therapist also being in therapy, if not as a prerequisite then as a concomitant to his or her own clinical practice: "There is empirical evidence for a positive correlation between having had personal therapy oneself and being better able to facilitate a positive alliance in treatment" (23). (I am, frankly, amazed that this is not still a widespread requirement today of prospective clinicians.)
Naked Logic:
I really liked her counsel to avoid appearing or trying to be some kind of aloof expert handing down recommendations from on high. This is not original to her, of course, but goes back at least to Carl Rogers. In any event, she rightly says that transparency in the therapist's thinking--taking off the outer later to see the logical gears working underneath--can be very important. This "invites the patient to be a diagnostic partner and to reason along with you. The end result is that the patient not only knows how a particular treatment recommendation was arrived at, she also feels that she helped critique and shape its construction" (22). Such collaboration helps the alliance.
Goals and Treatment Plans:
As someone whose entire experience thus far has been psychoanalytic, I found her third chapter, Focus, helpful. She begins by noting that some people (I confess I incline towards this) are suspicious of too much attention on focus, on goals, on treatment plans because they fear this will undermine the capacity for spontaneity, creativity, and above all free association. To us she says it may be helpful to see our role as similar to a personal trainer: advocating for a repeated focus on attaining certain goals for improvement in the patient's life. She says that the research is clear: focus and goals across modalities are key to successful therapy. And, she insists (though this needed much more development), focus and goals are not at cross-purposes with free associating. Nor are they aimed only at symptom relief. You can be doing several things at once in therapy.
The author's sixth chapter, What Material Is Important?, poses some important questions and offers some not terribly original answers that are nonetheless still important to underscore.
One of the really obvious things she says to pay attention to is "repetition (of phrases, themes, behaviors, sequences, mannerisms, emotions).... The more repetition the more attention is warranted" (p.69). I have learned this from reading the great child therapist and psychoanalyst Adam Phillips over the years, but I first learned it from what is perhaps my favourite of Freud's technical papers, "Remembering, Repeating, and Working Through."
In addition, do not fail to note strong emotions, idiosyncrasies, and especially dramatic losses of control or wildly singular behaviors--even if they only occurred once and were never repeated, they may offer a deep vein of significance to be explored.
Jumping, finally, to Peebles-Kleiger's nineteenth chapter, on the Psychological Costs of Change, I found much gratifying material here, too, which reflects my own attempts at rethinking "resistance." I've come to the view that resistance must be seriously respected, not merely scorned as something to be gotten rid of, or around, as quickly as possible. This, too, comes out in Freud's paper mentioned above: the resistance plays a role, and the clear-eyed clinician must try to see what role that plays. As Peebles-Kleiger notes here, symptoms can be bothersome but also productive and useful. Some symptoms may protect from grief or hold anger in check. Some may be resistant to change until and unless (as Winnicott might say) the patient learns that it is okay to hate the therapist.
Though she doesn't mention him here, I had another of Freud's works in mind here, the centenary of which is this year: Beyond the Pleasure Principle, with its controverted theory of the death drive and the less controverted and I think more clinically abundant phenomenon of the repetition compulsion. The repetition of symptoms, and of resistance, must be examined and taken seriously by, inter alia, asking what the plan is for their replacement. As she notes, lots of therapy without such a plan will falter: you can't remove something and leave nothing in its place for most people. You must replace something pathological with something adaptive.
Anyway, such were some of my thoughts in reading Mary Jo Peebles-Kleiger's useful book, Beginnings: The Art and Science of Planning Psychotherapy
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