On the Working/Therapeutic Alliance and its Measurement

I recently finished reading B.L. Duncan et al, eds., The Heart and Soul of Change: Delivering What Works in Therapy, 2nd ed. (APA Press, 2010). Like all academic collections, this one is uneven, with some chapters managing the unpleasant trick of overpromising and being very thinly sourced, putting one in mind of that 1980s Wendy's commercial "Where's the beef?" 

But two chapters alone are worth the price of the book, and have changed my thinking (and soon my clinical practice!) in a couple of significant ways. These are chapters four ("The Therapeutic Relationship" by John Norcross) and eight ("Yes, It is Time for Clinicians to Routinely Monitor Treatment Outcome" by Michael Lambert). 

Before we get to them, just a few brief comments on the first part of the volume. In the Preface, the editors note that what unites this volume is that it "brings the psychotherapist back into focus as a key determinant of ultimate treatment outcome--far more important than what the therapist is doing is who the therapist is" (xxviii). This is indeed a common theme and welcome focus throughout the book, and it highlights what has often been discussed--but without as much depth--elsewhere: the personhood and personality of the clinician matters far above theoretical orientation, technical prowess, and all the rest. 

The Hideous Effects of the Market are Still Here: 

As we move into the introduction, the editors begin, in my view, to strain credulity somewhat in repeatedly asserting rather flatly that the mania for different models is over ("the fire for the novel, different, and exotic therapies has for the most part been extinguished") and thus proclaim that 'the great 'battle of the brands'" is behind us (25). I am distinctly unconvinced of this, however much I wish it were so. 

The Challenges We Face:

Some sobering facts are laid out in the introduction, some of them picked up later in the book for discussion, including the fact that those who need and want to pursue therapy are often put off by doing so not just by cost but also real doubt about its efficacy, which doubt leads "nearly half of those who begin psychotherapy [to] quit" (31) early on. This has been much commented on elsewhere, but for all that still amazes me. 

How to Account for Variable Outcomes?

Again and again this book lays out impressive evidence that "much of the variability in outcomes in therapy is due to the therapist" (31) and to the "therapeutic relationship" (37) or the therapeutic/working alliance, the power of which is attested to "in more than 1000 findings." A positive alliance is repeatedly demonstrated in the clinical literature as "one of the best predictors of outcome" (37).

Key Components of the Alliance:

The editors briefly outline that an alliance involves three things:

i) "agreement about the tasks and goals of therapy";

ii) a "cogent rationale" that offers an "adequate explanation for the presenting problems"; and

iii) a "set of procedures consistent with the rationale" that will aid towards the accomplishment of the goals in a way the patient can see and understand.

One of the valuable lessons I have heard from both of my supervisors this year is that if you set goals beyond what the patient wants to do or where to go, you will find that s/he will not follow, and so-called resistance will manifest itself. Equally I have learned from both that if you get out too far in front of the person in trying to hurry them along towards the goals, you will turn around and find yourself standing alone. Thus you need, as the editors say here, always to remember "the importance of starting where the client is" (38). 

If you find the person is not with you, or that things are generally out of alignment, then the editors recommend that you simply ask the person what their views are of the goals, alliance, and relationship. This will be the crucial theme developed in the fourth chapter. 

The Gifts in Front of You at the Very Outset: 

Before that, however, let me just posit some theses drawn from the third chapter, "Clients: The Neglected Common Factor in Psychotherapy" by A.C. Bohart and K. Tallman who note, inter alia, that we cannot overlook the phenomena of:

• self-generated change
• spontaneous recovery
• a person's existing strengths
• resilience
• post-traumatic growth
• integration and adaptation of what happens in therapy according to extant ways of thinking and living in the life of the patient.

It is important to take stock of all this from the very beginning and figure out ways you can draw on these gifts in the work that lies ahead.

These authors go on to note that the research indicates how rarely "particular techniques" are mentioned when patients are surveyed about their experiences in therapy. Instead, "studies have consistently shown that" what is emphasized and remembered includes "feeling understood," having "support" to deal with problems but also try out new behaviours, and a "safe space" (or, as I prefer, following Winnicott, a healthy holding environment) for all this to take place. 

What Kind of Therapist Not to Be:

Later in the chapter the authors outline problematic behaviours from therapists that will almost certainly contribute to treatment failure or collapse. These include therapists who:

• are authoritarian
• are prone to hurtful remarks
• are not good listeners
• are aloof, distant, unresponsive
• are too dissimilar in personality from the patient
• are unwilling to offer ideas or practical exercises or advice.

To the above I would want to add something I have learned from reading Jonathan Shedler: therapists who do not challenge their patients to change and grow are also not helping them, and the relationship, if it consists only of affirming and supporting, will prove less than fruitful.

That having been said, everything turns on how the challenges are posed. These authors note later in the chapter that "controlled research trials, particularly in the addictions field, consistently find a confrontational style to be ineffective" (130). Instead, the therapist needs to manifest empathy, be able to deal with resistance, support self-efficacy, and bring discrepancies to the fore; all these, they say, are characteristic of motivational interviewing. 

The Therapeutic Relationship:

We come now to Norcross' chapter of the above name. It repeats some of the findings from earlier in the book about the centrality of the therapeutic relationship over and above theory and technique. 

But it goes on to make a point that I have only once, and briefly, encountered before in a more informal manner, and that was from reading Yalom's The Gift of Therapy, where he will regularly ask patients "How are we--you and I--doing?" as a way of gauging the therapeutic relationship and any possible ruptures to it. When I read that book earlier this year I filed Yalom's question away and thought I might bring it out on occasion. But Norcross, in this chapter, has thoroughly convinced me that it needs to be brought out systematically and regularly, not least because he says (in a finding I have seen repeated elsewhere), "psychotherapists are comparatively poor at gauging their client's experiences of their empathy and the alliance" (117). In fact, therapists very regularly, and by an alarmingly wide margin, overestimate the strength of the alliance and underestimate the problems in it and the patient's willingness to walk away from it with little or no notice. 

To avoid these blind spots and biases, therapists, Norcross says, must regularly ask for feedback from patients to see how the working alliance is, and to repair it when that becomes necessary, as it regularly will. The methods and challenges of asking for such feedback are taken up by Lambert in the eighth chapter, which has some invaluable references to published research, some examples of which you can, happily and helpfully, find online in places such as this. 

Measuring the Working Alliance:

Lambert and others (including Scott Miller, linked above) have been pioneers in developing short, practical, accessible, and easy methods of soliciting regular feedback from patients, not least because without it "practitioners grossly underestimate negative outcomes" (240). 

Before going on, let me record here my previous unreflective snobbery for modern psychology's fetish for measurement. Much of that is still merited (especially towards the rest of the social sciences), but on this issue Lambert's chapter has totally changed my mind. I don't want to sound like a convert, because all converts to anything are a pest whom one should regard with deep suspicion and keep well clear of, but let me record my gratitude for having been forced take account of the evidence that Lambert and others have amassed in an impressive and convincing manner. 

What evidence is that, you ask? There is evidence, first--as noted above--that therapists are not good at discerning the strength of the alliance, or anticipating breaches. There is evidence, second--again noted above--that half of people who begin in therapy never finish and drop out very often because of deficiencies in the relationship, therapist, or both. And finally, and most important here, there is increasing evidence that therapists who solicit and respond to regular feedback "about client progress" see much improved outcomes for those predicted to be at risk of deteriorating or dropping out entirely. 

Looking at studies in both Europe and North America, Lambert has noted dramatic decreases in drop-out and deterioration rates by patients whose therapists regularly sought and used their feedback. He goes on to review a variety of recent mechanisms to solicit this feedback, noting strengths and weaknesses of each. He does all this "because the empirical literature has shown that the quality of the therapeutic alliance is consistently related to outcome" (247). 

Additional benefits of using such feedback include the ease with which such mechanisms fit in to a diversity of approaches: one can use them "regardless of theoretical orientation." For them to work, of course, they need to be brief and easy to follow, and to my mind the best one is the four-question model illustrated in the Miller, Duncan et al article linked above and here. It is certainly something I want to start using. 

If you are like I was, and still skeptical about this, then you very much want to review this chapter in detail, and the very considerable bibliography it provides of additional studies and evidence. Other chapters in the book may be of value to you as well. 

Short-Term Psychotherapy

I admit I was not expecting a lot from Alex Coren's 2002 book Short-Term Psychotherapy, but I was very wrong. I picked it up at the urging of one of my recent supervisors who encouraged me to investigate resources on brief or time-limited therapies. I'm glad I took his advice, for reading Coren has forced a major re-think on this question and that is always a bit of an exhilarating and chastening experience. But I am very glad to have read this book and benefited from the reconsideration. 

One of the most interesting things I learned from the moral philosopher Alasdair MacIntyre, on whom I wrote my MA thesis, is the concept of an "epistemological crisis." That is when two rival traditions encounter one another with different answers to the same questions, and one of those traditions experiences a crisis of confidence in what it has hitherto believed. The resolution of such a crisis may take one of three forms: collapse and defeat; stubbornly and willfully blind and cult-like denial of any answers (or even challenges) from the rival; or a reconfiguration in which the weakened tradition learns from the rival and incorporates the latter's wisdom into a new synthesis. 

I admit that for more than twenty years I have been a stubborn defender of long-term therapies for two reasons. First, the simple reason is that my life has benefited enormously from one such long-term therapy, a fairly classical psychoanalysis (four times a week on the couch for seven years). Second, my automatic suspicion of capitalism and its so-called healthcare systems--especially in the absolute worst of them, which is of course here in the US, where the pressure to be "efficient" is relentless and heartless in equal measure--ensures that I would oppose the externally imposed demands for people to be given a handful of sessions of therapy on their "healthcare insurance" plans to get their "behavioral health" (as it is revealingly and increasingly called today) back into line. I loathe capitalist conformism (one must always have compliant citizens, employees, and consumers!) and all its pomps and works, and so I loathed any idea that short-term therapies were to be regarded, as they seem everywhere to be in this country, as normative or superior to the long-term ones. 

Such views of mine were, I now see, fairly unreflective prejudices of long-standing that I have had to put to the question thanks to Coren's useful little book. In fact, if the book had no other virtue than to force me to consider "Where is the evidence for the belief that longer is always better?" and "What about the early history of Freud and psychoanalysis, when short treatments were very much the norm?" it would be well worth it. We'll come back to both questions presently. 

For now, let me just record my gratitude to him for describing how "therapists can have transferences to concepts" (119) as I clearly did to the concept of short, time-limited therapy! Let me also record my gratitude for his reminding me of what I've seen elsewhere but not yet integrated sufficiently: the fact that "all research suggests most therapeutic benefits occur early in treatment for the majority of clients" (163)--before what is often called the "therapeutic plateau" sets in. One final benefit here--though not as well established in the literature--is the limited "evidence to suggest that premature terminations, or drop-out rates, are reduced when clients were offered a circumscribed time-limited therapy" (164). 

Why this Book?

This book has as its goal an examination of the role played by time in therapy, and of time-limited therapies not externally imposed (by some bureaucracy, whether public or private) but as deliberately designed and chosen. Along the way, Coren also offers some helpful insights into the kinds of patients and problems most likely to be helped by time-limited therapies, and the kinds of people and conditions who will not be helped by such an approach, some of whom might actively be harmed  by offering only a few tightly focused sessions.

Some History: 

The first chapter is invaluable in reminding us that the first generation around Freud, including the great man himself, were all themselves analyzed over a short period, and often analyzed patients for brief times--sometimes a handful of days, sometimes of weeks, occasionally some months ("the early Freud was an often extremely brief therapist" [p.26]). 

This is also true of others. For Otto Rank, Sandor Ferenczi, and perhaps especially Alfred Adler, inter alia, short therapies were the norm. So too did Alexander and French insist on shorter treatments (one feature of which was, of course the "corrective emotional experience" which was then controversial but today taken for granted) in their famous 1946 book, where they saw the danger that longer therapies might drift into intellectualization. 

Still others, especially attachment theorists like Bowlby, saw that time is relative, and that in some relationships it is "less a question of the amount of time a caretaker (or therapist) spends" with the child/patient than "the nature and quality of how the time is spent" (98). A little later this is phrased differently in recognizing that a short experience of the therapist may be more beneficial than a long explanation from the therapist. 

Only much later did it come to be accepted as something of a self-serving orthodoxy (whose enforcement Coren compares to "fundamentalist sects") that one must be in analysis for five, ten, or fifteen years. How often one now sees that that long period of orthodoxy has done untold damage to psychoanalysis in a variety of ways, not least by estranging itself from its own rather socially radical roots as uncovered recently in such hugely important works as Elizabeth Ann Danto's Freud's Free Clinics: Psychoanalysis and Social Justice, 1918–1938 and more recently still by Daniel José Gaztambide's People’s History of Psychoanalysis: From Freud to Liberation Psychology. (I have sent questions to Gaztambide for an interview about his magnificent book.) 

It is to Coren's considerable credit that, having unearthed this history, and called out the orthodoxy of long therapies, he does not turn around to become an unthinking partisan of shorter therapies alone. He several times recognizes that in some conditions (see below) longer therapies are absolutely indicated and are essential. Equally praiseworthy is his recognition of the necessity of not giving in to the demands for short therapies merely because impudent insurance companies demand them. They can only be recommended because that is what seems best in the considered clinical judgment of the therapist, not some outside busybody inflicting the "corporatization of psychotherapy" on the rest of us. 

The middle chapters of Coren review brief therapies in a variety of schools--analytic getting the most attention, but also CBT therapies and some ecclectic approaches. Kohut's self-psychology gets a look-in here as well, along with other analytic reconfigurations at the hands of Davanloo (and his more recent disciples, including Patricia Coughlin, whose books I have and hope to write about on here later). Coren notes where each of these may specify a certain number of sessions as part of a pre-conceived definition of time, though he himself seems to prefer leaving things a bit open-ended, saying late in the book that he will often propose, especially to ambivalent patients, "Let's meet X times and review." This is a useful way forward that I have recently seen used in community mental health to good effect. 

Pre-Transference:

One person one does not expect to find here--as Coren explicitly recognizes--is D.W. Winnicott. As that link indicates, I've read a good deal of Winnicott and profited thereby enormously, but I have not read everything, and it is to Coren's credit that he brings forth an especially useful bit of DWW previously unknown to me: the notion of the pre-transference as well as what Coren later calls "transference to the setting." These are useful concepts to think about: what are our patients, even before walking in or making first contact, transferring on to us? What are their transferences to the consulting room and surrounding environs? It bears thinking about these things as one is setting up shop. 

Later on Coren will note that given the limitations of time, the therapist does not need to wait for a full-blown transference to emerge, but can begin using whatever materials might manifest in the pre-transference as well as the transference to place. Given those limitations, he also notes that in some, perhaps most, cases, one cannot presume that the patient will know how to begin, or how therapy should unfold. Do not take this for granted, but instead offer some explanation of how the process typically unfolds. 

One other useful insight from Coren I appreciated hearing, and it ties into something Nina Coltart also says: "There is growing recognition that there are times when the prescription of no therapy is the (non-) treatment of choice." (I saw this done very skillfully in recently shadowing a very experienced therapist, who, during an intake, very quickly perceived that the person had other issues to deal with, whose resolution would almost certainly take away the present unhappiness, thus obviating the need for therapy.)   

For Whom are Time-Limited Therapies Indicated?

Coren suggests that as a general rule of thumb, the farther back the trauma, the more long-term therapy will be required, and thus such patients are generally not going to benefit from time-limited therapies. In general, the following are good signs that patients might be a good fit for this form of therapy: psychological mindedness, a capacity to reflect/introspect, capacity for forming the working alliance, capacity to know one's history and problems but take some distance from them. Additionally, he later says that patients presenting with problems connected to "recurrent interpersonal patterns" will do best with time-limited approaches, not least because such approaches foreclose the possibility of "therapeutic drift" (139). 

The central factor he repeatedly highlights is the working alliance, stressing that it will be the key to the success of time-limited therapy. Interestingly, he suggests that in the dyad both parties reflect on the relationship as the "third" in the room, looking somewhat objectively at their relationship. This, he says, will help prevent an over-dependence on the therapist from arising, making termination of a short therapy difficult.  

Beyond all this, both need (to borrow Winnicott's famous phrase) to be prepared for a "good enough" outcome to the therapy, content to leave some issues unexamined, and the resolution of others ambiguous if 

How Might Time-Limited Therapies Work?

Coren has a model of a Triangle to conceive of the three crucial components of a successful treatment, which works within, and on, the Present Complaint, Transference, and Personal History. Quickly tuning into what he also called the patient's idiom is another crucial component for him (and here he draws on Christopher Bollas). He goes into useful detail about each and all of them. I will not relay that here, but encourage those who are interested to track down and read a book that usefully challenged me and changed my mind in some important ways.

For all that, though, I am not in the least suggesting that all therapy should be short or time-limited. I still do very much think people should be free to pursue it for as long as they need without corporate minders interfering in a process they have no business being involved in. But for some people who would benefit from this approach, and perhaps this approach alone, I have new-found respect and a desire to work with them, too. 

On the Great Nina Coltart

I read a review of this book as an undergraduate in psychology one Saturday in the autumn of 1992 or 1993. It was a review of a new book by a clinician nobody had heard of in Canada who was making her publishing debut in book form: Nina Coltart. The review was laudatory, and conveyed enough of the charm of the book, Slouching Towards Bethlehem to make me go out straightaway and order a copy from my local bookstore. (Remember those innocent days before Amazon? Well you can relive them, as it were, by ordering this book not from Amazon, but from its publisher directly.) It was, and still is, a delightful book and I have recommended it more times than I can count in the last three decades. It changed my life--especially it's second chapter, because after reading it, I screwed up the courage to contact the woman who would become my psychoanalyst, Dr Louise Carignan.

Foolishly, however, at one point I gave the book away, and have ever after regretted it. But now Phoenix Books has done us all the huge favour of bringing out all three of Coltart's books once again so that, as they say, a new generation can appreciate her. Their lists are some of the most interesting today in psychotherapy, psychoanalysis, and related fields, and that website is one every clinician, and those interested in the psychotherapeutic arts diversely understood, should keep close eye on. Phoenix kindly sent me a fresh copy of Slouching to allow me to read it again and post some thoughts about it. 

If, like me, you prefer to know a bit about an author before reading, then the short bio on the Phoenix website gives you some of Coltart's details. 

If, probably unlike me, you grow a bit obsessive about authors you love, and you really want to know rather more about Coltart, then permit me to point you in the direction of a charming if posthumously published Festschrift for her, Her Hour Come Round at Last: A Garland for Nina Coltart, eds. Gillian Preston and Peter L. Rudnytsky (Routledge, 2011). Fascinatingly, that collection contains essays from some of Coltart's former patients as well as colleagues and friends. It also contains some unpublished material that is lovely to read. The whole book is a garland of riches indeed. 

But back to Coltart and her Slouching towards Bethlehem, and a final bit of prolegomena: don't just take my word--that of a nobody teaching in the remoter parts of obscure provinces of the American imperium--for Coltart's virtues. No less a figure than the great Adam Phillips reviewed her book very favourably in the London Review of Books, which you may find here. 

On Attention:

Right, down to business. Given where my previous entry on here ended, with an express desire to think more about how therapists train and exercise their attention and presence within a session, I began with Coltart's very last chapter entitled, quite simply, "Attention." (In the book, which is really a collection of essays, this chapter is linked thematically with the one immediately before it, "The Practice of Psychoanalysis and Buddhism." That is true of all the chapters--there is a thread that links at least two or three of them clearly, but all of them indirectly, making this a very coherent and cohesive collection.) I then proceeded to read the book backwards. I will comment on some but not all of the book's 12 chapters, leaving the rest for you to discover. 

This last chapter, originally written sometime around 1989-90, begins by noting that the topic of attention was then almost completely ignored in the clinical literature despite how central a part of therapeutic practice it has always been. Here in this chapter--and elsewhere--Coltart says that "I believe being a good therapist is a vocation" and shortly afterwards speaks of "psychiatric monks" as well. Though Coltart has a different type of monk in mind (Buddhist, rather than Christian, as the preceding chapter and other writings make clear), both phrases resonate with me today much more than they would have when I first read the book, for, as I suggested last year at this time, following the lead of the eminent historian Peter Brown, the monastic "disclosure of thoughts" pioneered by Evagrius of Pontus in the Upper Egyptian desert of the fourth century was psychoanalytic avant la lettre, and still reminds me that psychotherapy is indeed in some ways monastic--in the sense of being hidden, but also of being focused on one thing only, viz., the welfare and flourishing of your patient. 

To be so focused, Coltart continues, requires a "profound and self-forgetful opening of oneself to another person" (185). This is what she speaks of as "bare attention,"

borrowing a Buddhist phrase. As she defines it, this requires that we "teach ourselves so continuously to observe, and watch, and listen, and feel, in silence that this kind of attention becomes--in the end--second nature to us." The importance of striving regularly to practice such attention with patients seems even greater today, some three decades after Coltart wrote and the computer revolution overtook all our lives, and now our attention is so constantly at risk of ceaseless interruption. 

On Manners:

To allow the beeps of our phones, and texts, and Tweets, to at all interrupt a session with a patient is the sort of thing that would have filled Coltart with horror, regarding it as simply bad manners among other things. At the very least, paying attention--deep, close, self-forgetful attention--to another person in one's consulting room is, if nothing else, simply an extension of basic good, gracious manners. In her meandering style, Coltart reflects on manners as an often middle-class obsession, and what that might conceal, and how in some people (she specifically references the perhaps now-extinct character of a minor aristocrat running some British colonial outpost) manners function as a hard shell preventing them from accessing any depth in either themselves or others.

She resumes her discussion of attention in this chapter, saying that showing basic courtesies to one's patients and colleagues is one of those things, like attention, that we take for granted and is under-theorized but nonetheless crucial: "The capacity to be attentive in all its essential modes is a highly disciplined and hard-earned skill. We need to pay constant attention to attention, its uses, its value, and our power to sharpen it up and refine it" (143). 

On Silence:

We--both patient and therapist--can be paying attention even in silence. Her chapter "The Silent Patient" is one that I strongly gravitate towards, in part because my experience of silence in analysis was, and remains, perhaps its most lasting gift to me. The idea that one was not expected to produce anything took me a long time to adjust to. I was (and remain) a prolific dreamer during analysis and felt daily offerings of dreams were proof of being a good patient. Only much later did I realize I didn't have to do any of this, and so could spend some days on the couch not producing or saying much of anything.

Silence, in Coltart's experience, is rather different and she is not at all inclined to idealize it. She had several patients who were deeply silent for at least several weeks, and some several months, and one for longer still. By "silent" she says someone who speaks less than 10% of the time. In all her cases, it was not so much that patients were leisurely experiencing silence as a welcome respite so much as using it for a variety of reasons, some of them sadistic, others reflecting early trauma, all of them quite serious. 

This chapter, and the very first one in the book, give us the most "infamous" case Coltart ever wrote about: the one where she bawled out a silent patient for his sadistic attack on the work ("attacks on linking" indeed!), an intervention she only used once but it had the intended effect of rescuing the treatment from collapse. (My description is making it sound lurid and will not do justice to it: you must read it yourself.) This chapter is also valuable for its reflections on the role that humour can play in therapy. Though she does not say so explicitly here, we know from other writings (see below) that she very much agreed with Winnicott that one should be able to enjoy one's patients and the work with them. If you only see it as a slog, you'll not last long as a therapist.  

On Love:

To offer attention, and to sit through periods of silence, is to offer love in several ways. Enjoyment, it seems to me, is related here to her reflections on love. This is not nearly so radical as is thought, for Freud himself (in his correspondence with Jung, and in discussions in the Vienna Society before their schism) talked about the role of love in therapy and not merely as "transference love," either. Rather, he said quite rightly that "our cures are the cures of love." 

Coltart very much agrees with Freud on this, but goes beyond him to argue that in fact--all his protestations notwithstanding--there is a moral core and vision at the heart of psychoanalysis and it is best to be clear about this. (I think Coltart indisputably right on this, but as MacIntyre showed us forty years ago now, it is the hallmark of intellectuals to acclaim their own blindness, above all about "morality.") In arguing this, she draws on some of the leading lights of the British Independent tradition, including Neville Symington, Christopher Bollas, Michael Balint, and Winnicott. 

Some Maxims:

Verbal Minimalism: A few maxims from different parts of the book reinforce what I've heard from two excellent supervisors: "When in doubt, say nothing." (This, of course, admits of wide application outside one's consulting room.) Two others reinforce this asceticism of speech, as it were: "Prune where you can." And then, if you find yourself going "On the one hand.....but on the other," Coltart bluntly says stop. 

Don't assume too much power to any one thing you say. Coltart reports how often something she thought brilliant or disastrous had little long-term effect on the patient and, with equal surprise, how often patients, years later after treatment, may send a note or see her on the street and say "I've never forgotten when you said X," and report something the therapist has either forgotten or, worse, thought feeble or rubbish at the time. 

Harnessing Your Aggression: As we saw in Michael Karson, who speaks of "virtuous aggression," so Coltart says a therapist should "harness our aggression skillfully in the service of clinical work and that so doing is a "strongly positive factor" which patients will welcome. But such skillful use requires work in and by the therapist on him/herself so that it is done without fear or anxiety. 

Never Take Notes: At least never in the presence of the patient!

An Apologia:

From Slouching Towards Bethlehem in two separate places are cogent descriptions of how many difficult things the therapist must try to pull off at once, and in every session. These two passages seem to me to be the best apologias for what it is we try to do, and you should feel free to share these widely with your relations or friends or monstrous insurance companies who sneeringly "think" therapy is just two people having a (likely unnecessary) chat, much as one lazily wiles away an afternoon over a cup of coffee in a shop. Instead of that, Coltart says the therapist must be capable of a healthy kind of psychic split, enabling him or her to be capable of

sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (119). 

A therapist can do all this, she says at several points in the book, because we have "faith; faith in ourselves and in this strange process which we daily create with our patients." Such faith constitutes, with love, the only "trustworthy container" for the "hatred, rage, and contempt for varying periods of time" that patients might bring (or we in turn might feel). This idea of faith is tied into earlier reflections on the topic in the first chapter, where she explicitly cites the influence of Bion, especially his book Attention and Interpretation. 

Later in the book, Coltart returns to this in talking about "one of the most difficult technical paradoxes of them all" which is, she says,

the need for consistent scanning and judging, not only of what the other person says, but of what we are about to say, and are saying; and with this scanning, the need for rapid continuous thinking, which may be only half-conscious; the need for repeated moral and technical decision-making; and yet if it is to convey truth, and more importantly, authenticity, in our style of speech we must also master intuitive, unlaboured spontaneity. This is an extremely demanding and complex requirement...[and]...it depends, for success...on...the combination of unselfconscious self-forgetfulness with deep self-confidence (145). 

Final Thoughts:

The sense of exhilaration I had more than twenty-five years ago in reading Coltart was of course not present in my second reading, which was marked by a very different way of approaching this text. Then I was a sophomore unsure of where life was heading and what I would end up doing; then I had not yet embarked upon my analysis, but Coltart's book convinced me to take the plunge. Today I read the book with an eye on what I might use in my own practice now, and on this last score, Coltart's book remains valuable and delightful, and I would gladly commend it to other clinicians formed by or with any interest in the analytic approach, especially as it developed in the British independent tradition, which to my mind remains the richest and most valuable of all the analytic schools. 

I would, however, add to that that I now think--in ways I didn't in the early 90s--Coltart's other two books, both of them also helpfully brought back into print by Phoenix, are perhaps even more valuable. I wrote about both of them earlier this year here and here. Thanks to Phoenix, and if ordered directly from them, you can get all three new and at a very affordable rate. 

The Therapist's Use of the Self

When I was on sabbatical in 2018, I spent part of it on a fellowship at the Chicago Psychoanalytic Institute. There for the first time, in one of our seminars, I actually felt like I began to understand some of the thought of Chicago's most famous analyst, Heinz Kohut, pioneer of so-called self psychology. Prior to this, I had tried several times to read at least two of Kohut's books. And I did manage to read Charles Strozier's lovely biography of him, Heinz Kohut: the Making of a Psychoanalyst. But none of his theory was especially accessible or attractive until we read K. Newman's 2007 article, "Therapeutic Action in Self Psychology," The Psychoanalytic Quarterly 76. Newman managed to put Kohut's ideas into much clearer and far less jargon-riddled prose than Kohut seems able ever to have done. 

It was, I seem now to recall, in our discussion of this article afterwards where I first began to learn about the idea of how much of the therapist's usable self is available for the patient in the working alliance--how, that is, in Kohutian terms, the therapist becomes a selfobject [sic] to the patient. (In some ways this just strikes me as a needlessly complicated reworking of object-relations theory, and in far less felicitous English, but let that pass.)

I have been thinking about that concept of the usable self for a couple of months now, and this led me to pick up John Rowan and Michael Jacob's book, The Therapist's Use of Self (2002). 

It's not the book I thought it was going to be, but it is valuable nonetheless. I think my very mild irritation with the book comes from it being in some ways a literature review disguised as a monograph. I was anticipating more decided and conclusive views from the authors, who instead spend most of the book surveying about four different theoretical schools for their thoughts on such things as counter-transference, abstinence, self-disclosure, and related issues.

But this should not be allowed to detract from the overall utility of a relatively short and straightforward text written in clear and workmanlike prose. The fact that it makes good use of British object-relations theory--including Guntrip, Winnicott, Balint, Bollas, and especially Bion (whom I've come to appreciate a lot more this year)--only increases the value of the book in my view. 

The authors begin by noting that the will explore how the therapist might make use of his self in the therapeutic relationship, and then posit three ascending levels of such selfhood so used: the Instrumental self, the Authentic self, and the Transpersonal self. (I pictured these here like Maslow's famous hierarchy, with Instrumental on the bottom, and Transpersonal on the top.)

In their chapter on the Instrumental self, which they suggest may be the most common of the three approaches, they make a striking observation that, in slightly different ways, has come to me in the past six months or so of training: therapists "appreciate the fact that what they do...does not ask them to change themselves as much as it invites them to come closer to their best and frequently unrealized selves" (11-12). This has been an unexpected but reassuring realization for me this year. (This is augmented later in the book with a passage from Harry Guntrip: "real psychotherapy does as much for the therapist as for the patient.")

Judicious Soundings from the Counter-Transference:

It is within this chapter that they get into some very useful detail about the origins and development of the notion of the counter-transference. I have for some time been influenced in this area by Harold Searles, Otto Kernberg, and then especially Nina Coltart, who advises the therapist to take judicious soundings from the counter-transference as it may offer otherwise inaccessible clues to what is going on in the patient. But how is that possible? Isn't the idea of counter-transference that it pertains to what is going on inside the therapist? How, then, can it offer clues to what the patient might be thinking, feeling, avoiding, or even totally unaware of? Moreover, how certain can we be that what the therapist's mind throws up is in fact reliable or accurate or truthful at all? Maybe it's anxiety from almost getting run over during lunch hour a few minutes ago while fetching the pizza now giving one dyspepsia and making one long for the sweet release of violently expelling the offending food. 

Such questions have long haunted me. How does one know--can one know?--that what one thinks one knows is in fact reliable and real, truthful and objective, and not merely the convoluted production of ones own issues? 

In this light, perhaps the most useful part of this chapter--indeed, book--is the sixfold typology Rowan and Jacobs offer of unhelpful or unreliable counter-transfer reactions that are most likely unreliable and liable to lead the therapist astray: 

Defensive: esp. related to the therapist's unresolved issues around sex, aggression, etc.

Attachment: those that evoke the therapist's need to be admired, successful, loved, powerful, etc.

Transferential: when the therapist responds as though the patient's parent or sibling.

Reactive: when the distortions of the transference neurosis are taken to be true by the therapist who reacts accordingly

Induced: when the therapist is induced to take on the role of giving advice

Identification: when the therapist overidentifies with the patient and/or the patient's child

Displaced: when feelings from other parts of the therapist's life come to be placed onto the patient. (This would be the pizza-induced dyspepsia in my example above.)

The above strikes me as something useful to run through your mind as you are trying to discern your own reactions to the patient to see what might be reliable and trustworthy in them. Later on, drawing on the late Jungian theorist Michael Fordham, the authors note that even if your counter-transference reactions prove illusory, that is valuable nonetheless insofar as it may teach the therapist something about himself. 

In the next chapter, the authors draw on Winnicott (not least his thrilling 1947 essay "Hate in the Counter-Transference"), who apparently modified that 1947 view in the 1960s by insisting that one distinguish between a reaction to a patient and a full-blown counter-transference. It is not entirely clear here what the difference is, though to me it seems plausible that a reaction may be momentary or short-lived, or discreetly focused on one particular thing, and a counter-transference may be a more wholistic, longer-term "package" of reactions. 

Presence and Analysis:

The authors note that the therapist must strive to overcome whatever blocks his ability to be fully present in the session. At the same time, and elsewhere in the book, they equally insist that the therapist cannot become totally lost in his immersion in the patient's world, but must do that all the while maintaining a critical eye, maintaining his critical-observational self. To capture this, they quote the late American therapist James Grotstein who apparently once said the posture of the therapist here is like that of the Pieta: Mary holding the tortured body of her son! 

The challenge of remaining present is perhaps higher today than when these authors wrote thanks to our electronics-addled brains. This is a topic I want to think more about and return to another time. 

Michael Karson on what Every Therapist Should Know

I forget how I came across Michael Karson, What Every Therapist Needs to Know (Rowman and Littlefield, 2018), but I am very glad I did. It is a very valuable book in several ways, above all in what it says about the frame and its management, and about the therapist being neither social nor professional but always and only therapeutic in his role. 

After thirty years in the field, Karson realized he could no longer give a succinct answer as to what books or articles he recommends for new therapists, so he wrote this book as a "condensation of...essentials for the busy practitioner" (p.x). Busy practitioners may be tempted to fall back on a manual, or a tight reduction to problems merely to "biological" origin, but Karson is having none of that. His book is very much of the view that one must always tailor therapy to the individual patient while also taking account of the personality of the therapist.

Look to Literature

Karson starts off by saying new or training therapists should not just have their heads stuck in manuals. Much like Adam Phillips--the English literary scholar and psychoanalyst--Karson argues that therapy can and should be understood in terms of drama, poetry, literature. A therapist who wants to improve should, therefore, ask himself each year (and any colleagues or supervisees as well): what are you reading right now in history, philosophy, literature, and also psychology? Such a conception of therapy allows him a little later in the book to say that therapy is "applied literature, and not a branch of medicine" (20). (The limitations of a strictly medical model come in for a brief aside later in the book when Karson rightly recognizes that "the diagnostic manuals...do not explain what the diagnoses mean" [67].)

Virtuously Aggressive Holding?

Karson is very useful in pushing back on idea you are just there to soothe, or merely provide space for the pt. to do the work. Here is a point I've often heard Jonathan Shedler (whose work is repeatedly cited in this book) make: a therapist must challenge patients to change and grow, not merely console or, worse, collude with them in lamenting the state of the world.

My high-school Latin, now 30-years-old, is clearly rusty as I forgot--and so was startled to relearn--Karson's point that that common medical-experimental term placebo means I will please! Do not, he says, be that doctor who enlarged his practice by only pleasing, and never challenging or curing, his patients! You're going for patient improvement, not patient satisfaction. 

Karson says you do this by getting in touch with your aggression. Use it wisely to challenge patients to experience what is cut off and painful, and to challenge faulty master narratives that hold patients hostage (a point Phillips has also repeatedly made). As Karson puts it with welcome bluntness, "Good therapists are constantly disrupting their patients' master narratives" (6) and as a result are not in the business of merely supplying a comfortable environment to vent (though they do do that, as he makes clear late in the book in talking about how to set up your office to ensure maximal comfort and confidentiality for the hard work of therapy). The problem with merely being a person to whom I can comfortably complain is that "comfort seeking impedes growth" (7).

Challenging patients and their faulty narratives is something that Karson later calls virtuous aggression (29) and gives such examples as challenging bad ideas, collecting the fee, and ending sessions on time. "These things all injure patients, as they should " (emphasis added). There is no point pretending otherwise. 

I admit I found that last bit very refreshing and straightforward. To drive the point home further, Karson says: consider the surgeon. Would he or she for a moment think to deny that cutting someone open and removing and replacing an organ is  is not injuring them in service of a cure? Would he or she flinch from saying you have this slot, and these many minutes, for the procedure, and at the end of it, I am getting paid? 

Evaluating the Therapist:

Patients need therapists who are self-aware and capable of evaluating themselves, of recognizing mistakes and figuring out how to learn from them. But directly asking patients for such input is a highly fraught endeavor. Patient feedback comes perilously close to parenting feedback: is it any surprise that parents who let kids skip vegetables and early bedtime score higher?

Like Nina Coltart (about whom yet more soon!), Karson notes that not everyone can do well in therapy (which he defines as an enterprise seeking to "change the way people react to situations" [10]), but those who might are generally marked by four things: psychological mindedness, capacity for intimacy and curiosity, an ability to learn, and relative tolerance of strong emotions.

Techniques and Treatment Plans:

Later in the book, after reviewing various theoretical schools, the author seems largely to settle on a modified dynamic approach to therapy, stressing that the role of the patient should be conceived and permitted to live in such a way that nothing they say is ever taken as stupid or ruled off limits. This, of course, is just free association. Later Karson will say that if the patient more or less freely and regularly reveals in session what is going on in his or her mind mind, then the working alliance is in good repair (110).

But you cannot just have people start free-associating from the beginning without some guidance (as Freud recognized). You need to talk about treatment plans and thus about goals. Here Karson cautions that "therapists cannot develop a useful treatment plan until they know--or at least make a working guess at--what is motivating a problem behavior"(26). As a result, you may need to meet several times at the outset for things to become somewhat clearer. Here your goal is to begin setting goals for the therapy!

Not History as such but Autobiography:

Perhaps the biggest area in the book to give me pause--and I may have misunderstood this--is when Karson seems to downplay the importance of taking a detailed history at the outset, cautioning (entirely rightly in my view) that the therapist can become a prisoner of that history along with the patient. So he instead asks the patient for an autobiography, which is an interesting way of putting it. (Coltart, by contrast, insists on a very detailed and lengthy history which she seems to have filed away without letting it unduly influence her, confident that bits of it would resurface when she needed them.)

After that, as you are moving into the therapy, Karson, drawing on Shedler, argues that all the best techniques are psychoanalytic in origin even if they are called something else today (for often unserious reasons). Such therapy focuses on seven things: emotions, resistance, patterns, childhood, interpersonal relations, the therapy relationship, fantasy life. Karson believes--as others do, including Yalom, whom he does not cite--that in the therapeutic relationship and frame, the patient inevitably reproduces the problems of other relationships, including those that harmed and mistreated the patient. 

Therapy must therefore consist of inviting the pt. to replay that mistreated self here and now and for us to treat them differently: cf. the corrective emotional experience that French and Alexander made so famous in 1946.

 Conflicts, Ruptures, and their Repair:

Here is more welcome counsel from Karson about a topic that he says too many therapists tiptoe around and try to avoid: conflict. Bluntly he insists that "the overarching lesson about conflict in therapy is that it is better to approach conflict than to avoid it" (90). In fact, you cannot avoid it for "rupture and repair" always happens in therapy. If you are distinctly unc0mfortable with such things, and if you aren't comfortable making mistakes and then examining them, you have no business being a therapist. 

The Working Alliance:

I have seen working alliance and therapeutic alliance both commonly and inter-changeably used, and thought nothing of it. But drawing on Shedler once again, Karson helps me appreciate the real importance of the former (a point my supervisor has been wonderful about underscoring: what are you doing with the patient? what are you working on?). So therapy and its relationship is about work, not just--as we saw earlier--comfort and complaining. 

It is also not just about abstract discussion about "psychological problems." Beware here: discussing problems psychologically is not necessarily therapeutic! You can have a session on connection between anger and grief in abstract terms without actual examples from patient. Do not fall for this! Work to have them bring up examples. If patients declaim ability to remember how something felt or what was going through their mind, ask them to speculate, and maybe even prompt them by saying "it was probably sex, death, or anger!" Or ask for: first, worst, latest, or best. 

Setting Goals:

Karson repeats what I've repeatedly heard from both supervisors I had this year: goal-setting must be a collaboration. If it is not, then resistance will rightly manifest itself and things will quickly go awry if they go at all. Goal setting, Karson says, bringing back this interesting phrase, requires a certain degree of virtuous aggression.

Karson lifts his head from the plough, as it were, long enough to insist that goals should not be too narrow. Here he returns to his earlier discussion about literature and philosophy to note that goals can and should give room to asking about larger life goals: why are you here? what do you want to do with your life? Here Karson recalls that the great pioneers of the past were not afraid of large "metaphysical" discussions: Freud said the goals of therapy were to make you you free for love and work; to these Winnicott added play; and Adler further added doing something for others. I think all of these rightly belong as part of the discussion. 

Patients, of course, often have unclear ideas about goals apart from symptom reduction. It is important therefore that therapist be and remain clear about what therapy is and is not. If patients try to externalize their problems, or talk about someone else, your job is keep bringing it back to: what do you want to do about that? (Again my supervisor was great at doing that in sessions I observed with him and I shall carry these memories forward with me.)

Some patients may start with smaller more socially acceptable goals while hiding the bigger ones. Some can't do this right away, so the first part of therapy's goal is to come to set longer-term goals. 

But goals there must be, for therapy is not like a life-long friendship in the conventional sense. Here I want to introduce a blunt reminder of one of my own supervisors this year: we get paid, and as such are not and never will be your friend, lover, spouse, etc. Moreover, this relationship at some point will end, whereas the real loves in our life, we hope, will go on to eternity. 

Remaining in Role

Remembering these things, Karson says, is part of the crucial task of the therapist always remaining in role. The pt. will try to get out of his or hers, and throw you off, but don't fall for it. They will jump at a chance to be merely social and not therapeutic: you must resist doing likewise. It requires regular concentration and work to retain the frame and focus. 

If the pt. complains about your doing things the role demands--starting and ending on time, or not responding to flirting--the therapist has to explain those behaviors and their connection to the goals. The therapist should be "neither social nor professional" (115), that is, "professional" in behaving like a doctor or lawyer--tightly focused on one rather technical problem and that's it. 

In this light, later he insists (p.146) that you do not take notes during the session. It returns idea of a "professional" relationship, and ossifies a narrative. Better--though he doesn't quote him--to be, as I suggested here, like Wilfred Bion, living each session "without memory or desire." (If, however, you need process notes for legal or insurance reasons, keep them to notes about suicidality, threats of violence, or threats to the frame.)

If you are firm about the frame from the beginning and at all times, it makes things easier: you don't have to spend time and energy deciding to alter things ("should I give him an extra 10 minutes??"), but instead can use that to focus on why the patient wants you to do so. A tight frame is freeing and increases sense of safety in patients. It is a tight embrace, not a cage. This, Karson says, is the very essence of Winnicott's holding environment: tender but firm. 

That tight frame helps the pt. to know nothing leaves that room. There is security in knowing it should not be altered. Indeed, Karson says that any change to the frame that makes life easier or more immediately gratifying to one party or both is to be regarded with suspicion.

This applies, of course, to something seemingly simple but often fraught: time. To start and end on time regardless of sorrow or joy says: all is welcome here, all treated equally. "Patients need therapists to be not only loving but also strong, and time management denotes strength" (124). So whether they are laughing or crying in the last minutes, things end on time. (One concrete tip I've heard from others as well as Karson: put a clock behind the patient so you focus on it and they do not. Give a signal of approaching end like a radio host might.)

Termination

One of my recent supervisors has a great question: how will we know when we are done? What does 'done' look like to you? You can ask this in the early phases as you are setting goals. 

Karson, I daresay, would agree to such questions. He stresses several times that the relationship is not social or professional for in both we often expect the relationship to go on and on (few of us like dumping or being dumped by friends or physicians), but in therapy it will end. Karson suggests that you try to even out the power imbalance at the outset by stressing that therapy goes on only for as long as the patient wants it, and they initiate termination. You agree not to talk them into staying. Most often termination happens rapidly.

Silence: 

I am so very grateful that my own analysis taught me the huge importance of silence. Nina Coltart, whose Slouching Towards Bethlehem (which I will discuss next week I hope in the fresh reprint Phoenix has just sent me) has a rather infamous chapter about this in that book. In role plays in class, I used silence and it rather unnerved some of my colleagues. Karson says that few learn its importance; fewer still are comfortable with it. But our professor reminded us regularly that silence is important, and one of the things he learned early in his clinical work--reinforced by his own supervisor--is that you need to learn to talk less and not fill every space with chatter because of your own nervousness or uncertainty. 

Part of the problem is that silence can seem like withholding instead of providing an atmosphere for pt to be still and start to know their own mind, letting it wander. The therapist may need to tell pt. this is the purpose of silence so it's not misunderstood as punishment. To be silent is not to refuse to speak, but to know when to speak and when to keep still.

Silence will evoke all sorts of reactions and your job is to see what those mean, link them to other behaviors, encourage deeper exploration of the underlying meaning, etc. The pt always reacts in character and in so doing brings into the frame things that can be worked on.

If you don't know what to say, and silence is not called for at that moment, sum up and reflect back as your default so you don't break the "mood" or force things into a different direction. But summarize so as to make a point, inviting a way to think about what happened. 

Lose-Lose Comment 

This, Karson says several times in the book, should be your best friend. Use it in a role conflict so that it allows you to remain in your role as therapist. E.g., pt. dumps something as a doorknob revelation: say "If we extend our time now, it conveys I don't think you're strong enough to go on without dealing with this right now; if I don't extend the time if might convey to you that I don't care. I don't like either option." This lets them know they've been heard and seen but cannot break the frame, for when it's time to stop, it's time to stop. And so I shall!