Making Contact: Leston Havens on the Uses of Language in Psychotherapy

People for whom I have very great respect, and from whom I have learned and continue to learn much, have said very laudatory things about Paul Wachtel's book Therapeutic Communication: Knowing What to Say When. I have read it twice, and recommended it to students and interns albeit diffidently because I was sure I must have missed a great deal in the book because of my general dimness, laziness, or both. 

And yet, on both readings--three years apart--it has struck me as unnecessarily dense and prolix, needlessly complicated in places, and in want of more ruthless editing. The writing style is also entirely forgettable--it has little charm and even less humour. Does it have valuable things to say? Without doubt. Have I learned from it? Certainly. Does it fill a gap in the contemporary literature? Yes. 

But does it allow itself with some facility to translate memorably into clinical practice? No, it does not, at least for me.

Along comes a book treating the same issue but doing so in a way that is much briefer, written with greater cogency and accessibility, and occasionally has subterranean shots of sarcasm and the driest of dry humour, which we all know is the best kind. That book makes itself almost immediately clinically useful: it is by the late Harvard psychiatrist Leston Havens, Making Contact: Uses of Language in Psychotherapy (Harvard UP, 1986). 

Additional virtues abound in this book: the author name-drops almost never; his intellectual fireworks (as seen, e.g., in the use of jargon) are non-existent; the apparatus is very minimal and does not distract from the text; and he is that rarest of clinical writers in that his vignettes from sessions are usually a half-dozen lines at most. (I suspect I am very odd in finding it vexatious when clinical writers put acres and acres of session notes to illustrate one brief point. Others may benefit from this but I rarely do.)

The book consists of four chapters along with an introduction, the gist of which is that patients, being human, come in wearing disguises and leaving parts of themselves deliberately outside the door--absent, in effect, both consciously and unconsciously. Language has to find a way to outwit both of these phenomena. In order to find the other, the missing other, one employs the language of empathy, a succinct definition of which is given early on: 

empathy is best measured by the therapist's attempting inwardly to complete the patient's sentences. The more closely the therapist can match what the patient then says, the closer he is to the patient (p.19). 

Empathy will get broken down into different types as Havens proceeds through the book. These will then need to be deployed at the right time depending on what the patient presents with, and where they are with you in treatment. 

I: Immitative Statements: 

One begins with these. Havens says they are sometimes called 'doubling' as "in psychodrama and work with children." They consist simply in the therapist "speaking out loud for the patient," especially one who seems very lost, depressed, or to have little developed sense of self. Examples (there are many others):

Issue:                                                    Statement:

Fear:                                                    "Where does one find the courage?"

Doubt:                                                "How can I decide?"

Depression:                                        "What hope is there?"

Dominated:                                        "I have no rights." 

The utility of such statements is that they do two things: they demonstrate that the therapist is with and understands the struggles of the patient, but the therapist is also at something of a remove or a distance, which is important especially early on treatment when trust is not yet fully established and having someone close may be threatening. As Leavens puts it nicely, "the goal is to comfort by our presence, not to startle by our prescience" (28). There are echoes of Winnicott here, it seems to me, in his well-known call for patience in the therapist: "It appalls me to think how much deep change I have prevented or delayed...by my personal need to interpret. If only we can wait, the patient arrives at understanding creatively and with immense joy, and I now enjoy this joy more than I used to enjoy the sense of being clever."

In addition to foreclosing on the ability of the patient to get there before you, untested empathic statements can also be an imposition, Havens says, in forcing the patient to feel what you are feeling or what you feel the patient should feel. Instead you must create room for the patient to feel how and whatever they do. Thus in response to a patient's memory of being forced to eat what he hated because his mother dominated him, Havens said "I have no rights," an immitative statement that, the patient later said, made him realize: Havens is like me, and he also wants me to have rights.

II: Empathic Exclamations:

a) Nonverbal Sounds:

Havens says there is a whole range of these from simple to complex. The simplest of them are not words at all, but "nonverbal utterances" or empathic sounds, which "form an important supplement to what is usually considered the language of emotion, namely facial expression" (42). In 1986, when Havens published this book, he could not of course have forseen the rise of telehealth where, especially on the phone (less so in my limited experience on video calls), such sounds become vitally important. 

I admit I was gratified to read this section because I have found myself rather unselfconsciously making a number of these sounds as a patient is talking. In my experience the benefit is that they do not interrupt or prevent the patient from speaking. They convey not just interest but indeed empathy, but potentially many other things as well. In Havens' words, empathic sounds typically convey "ascent, protest, contentment, outrage, or sorrow." He gives an example of a patient weeping: while acknowledging that sometimes he, too, feels like weeping, what he finds himself instead doing is uttering "brief, low cries." 

b) Adjectival Exclamations:

These are what he also calls "translation statements" as you translate into words the feelings in or behind the story the patient is telling you. Such statements/exclamations are by definition very brief:  

Pain:                                     "Terrible!"   or    "How awful" 

Joy or Victory:                    "That's wonderful!"

Shock:                                   "Good God!"

If the shock strikes the therapist especially strongly, Havens--anticipating something Fonagy would recommend decades later, as I noted here--says you should freely request "Give me a moment to take that in" (p.44). Fonagy says the same thing: when you lose your ability to mentalize, you need to pause the session until you can recover. I've done this several times, especially with borderline and manic patients, and it is very helpful. 

Additional benefits are to be found in using these statements and sounds, chiefly that they can outwit the patient's defenses. They can also "normalize" (my word) what often feel like illegitimate feelings or a great deal of ambivalence in the patient. This is often the case early in treatment--or sometimes well into treatment--when "that rough beast, its hour come round at last, slouches toward Bethlehem to be born" in your presence for the first time. The patient tells you something they have not uttered to another living soul, and have scarcely allowed themselves to think, or feel much about. 

I find this especially in those who have been abused as children and do not, on first telling, know exactly what they are feeling, and whether they have the right to feel anything critical, hateful, or rageful in response to the abuser, especially if that person is still a part of their life. To these I often find myself saying something like "No wonder you were pissed!" (I deliberately use that language after a patient has told me that "We weren't allowed to swear" or "We got into trouble for cussing." My doing so conveys, without drawing too much attention to itself, that such language is fine with me. More important, of course, as Havens recognizes, it gives legitimacy, often for the first time, to the inchoate rage and hatred now heaving into view. 

c) Complex Empathic Statements:

All the statements and sounds Havens lays out for us have the twofold job of getting close to the patient and seeing the world from their eyes but not crowding them out or making them uncomfortable by your getting too close. Such statements as

"No one understands"

or

"No wonder you were frightened" 

have a way of accomplishing this twofold task. A "no one" statement "reconnoiters the field of blame," Havens says, while "no wonder" statements clear it. 

"Wonder" statements are very powerful in several ways, the author continues. As I suggested above, patients may have very covertly allowed themselves only the slightest bit of wonder at what happened ("was this normal? Should I be feeling like this?"), before shutting it down. Your use of such statements legitimizes the wonder and brings it out into the open. "No wonder" statements, Havens says, are a "denial of denial." If the patient has denied himself the right to feel something, your saying "No wonder you hate him!" now allows him to begin doing exactly that--if he chooses. That is an additional benefit here: you are not imposing what you feel, or what some abstract standard of feeling might insist the patient feel: you give them freedom and room now to feel something previously heavily warded off. 

No wonder statments can later on be supplemented or even supplanted by what havens sees as stronger expressions of empathy: "It is natural" statements. 

d) Bridging Statements:

In patients who are "supine" or who have hardly been allowed to live or develop a robust sense of self by parents or other overly dominating figures, or who are so severely depressed that there is little life in them at the moment, or who are heavily conflicted by their conflicting feelings (here I think of patients with obsessive-compulsive personality disorder--not OCD--about whom see some excellent resources here) you need to use bridging statements. These allow you to share the conflict around conflicting feelings, to be ambivalent with the patient in his or her ambivalence. They also, as he says later in the book, function as a form of "noninvasive closeness in which the patient has someone present on his own terms" (p.85).

Again using military metaphors (as Freud did in one of his most important papers, "Remembering, Repeating, and Working Through"), Havens says that in such patients you are entering a state of civil war, and you have to form a "provisional government" to deal with on the patient's behalf: "the seat of governance is found in an unexpected place: the patient's reaction to his own behavior." Precisely to the extent the patient finds his own behavior baffling or terrifying you have material to work with. (Here I am mindful of later developments in motivational interviewing in which you "roll with the patient's ambivalence.") By wading into an internally conflicted patient, the therapist gives both sides permission to acknowledge each other and begin talks toward integration.

Bridging statements to use here include "God knows": 

"God knows you must have wanted to escape from them!" (This, he says, lends support to the desire to get away while also subtly acknowledging problematic ties of authority holding the patient back.)

Another version of this to use is "God forbid you should try to escape." This, of course, is spoken "sarcastically" (p.62). In uttering it, you come alongside the patient in her desire to escape and to tell off the domineering authority figures. 

e) Causal Extensions:

One should not--I hope this is obvious to seasoned clinicians--use questions to demand of such patients as above "Why didn't you leave?" Those are very counter-productive approaches. Instead, Havens recommends causal extensions:

"If I say 'Why didn't you call?' I am judgmental, inquisitive, and assume that the patient knows. On the other hand, if I say 'You must have had some good reason for not calling,' I put myself with the patient and extend that empathy investigatively."

The above is, he says, a longer version of "no wonder" statements, but it does more work and opens onto a potentially longer line of inquiry. 

III: Good Management:

Later in the book, having fully convinced us of the need for all of the above, Havens then "rights the balance," as it were, by introducing some contrary factors to watch for. (On the very last page, he will later speak of "disciplined passion" so that your statements of empathy are not "empty display.") Here he says--in something that made me think immediately of Nina Coltart's open advocacy of the therapist always operating in "two minds"--the therapist cannot just be a tap pouring out empathy constantly. "Therapists must cultivate attitudes sharply opposed to one another," he bluntly puts it, reminding us that we have to enter into the patient's world via empathy, but we also cannot be "taken in" too much by that, losing our distance, our neutrality, our abstinence, our ability to mentalize. (There is little of clinical utility in my thinking empathy requires me to hate the patient's alcoholic mother or abusive husband as much as she does.) 

Remember, Havens says: "the object is the establishment of a working distance" (p.95) and both parties in the room have to be aware of the other and at the appropriate (and sometimes changing) distance from each other. If you collapse that distance and space--if there is, in Ogden's well-known terms, no room for an analytic third--then one has to wonder if any real work is going to get done. What will likely replace the work is some extended collusion-cum-enactment, and whom does that help? 

The Therapist's Authority:

Maintaining distance and space, however, does not mean a retreat to a preserve of therapeutic authority. Finding the balance here is, Havens freely acknowledges, one of "exquisite difficulty" (p.103). You need to likely have a greater sense of authority at the start so the work can begin, but as it progresses you need to relax that so that the patient does not come to be dominated by you, but to discover more freedom with and through your work together. (Havens is preaching to my choir here for I have long had in mind Erich Fromm's insistence from decades ago that in time a therapist has to be abandoned precisely so the patient's freedom can continue to expand, even by "disobeying" the therapist.) 

On Being Wrong and Acknowledging It:

One way Havens recommends doing this--and I was gratified to find I've just sort of fallen into doing this myself long before reading the book--is by your "willingness to be wrong" (p.105) and your inviting the patient to share whatever they feel, including critical or angry feelings towards or about you. Of course, merely telling the patient they can do this often cuts little ice. Instead, the author says think of what you have to do with frightened children: you yourself volunteer to go up to the barking dog and pet it, thereby revealing to the child that it is okay to do so. (Merely insisting "Go on--he won't bite you! Pet him! Come on!!" of course rarely works and often makes the child more upset.)

Another way to do this (which I have done) is to begin a session with an apology. I had let a patient, on a provisional basis, do something in session for about six weeks that I would not normally have encouraged and do not allow others to do. It became a ritualized part of the session and I half-forgot that it was supposed to be provisional. One weekend I realized it had long outserved whatever modest purpose it had and was now proving to be harmful to our work together. So I began the following session with an apology for letting it go on so long and explaining how I thought it was hindering the work. This so startled the patient that I saw a completely different, much more playful and emotionally fluid side of them that day, and slowly, haltingly, without any further encouragement from me, they began to venture more independent thoughts in session, and to disagree with me. I was delighted.

Projective Statements:

Additional ways to do this are by means of "projective statements." These put the "therapist's fallibility forward first" and reveal an example of your "happy receptivity" to being corrected.

One way I have found to do this is by using some version of the following prefaces:

"I could be wrong about this......."

"This may sound really off the wall, but I'm wondering if....."

"I really don't know if this is the best word for it, but I can't think of another at this point." (This often gets the patient thinking for a better one, and very often it is better and we happily agree on it.)

Havens suggests the utility of these projective statements with erotic and loving transferences, and his example of how to handle these is extremely close to the way that Andrea Celenza (as we saw here) recommends: by saying "You love me and naturally want me to love you." That normalizes things and goes some way to balancing them. But then you follow up with "Would that I could! Would that work made room for them both!" (p.107).

Counter-Assumptive Statements:

The goal here is to shake assumptions without getting drawn into a long debate about them. (They are especially useful if you find yourself caught in what I would call the agonies of an idealizing transference.) In brief, you do this by taking the patient's expectations and then "throw a dash of salt on those expectations" (p.115). Such disconfirming responses might include (only well after a solid alliance has been established!) saying "Yes, I know: you're a real idiot." Here you are sarcastically siding with the patient's inner prosecutor and the shock of your sarcasm, if done well and at the right moment and in the right way, can jolt them out of agreeing with that prosecutor. (I have done this many times and can report that it is very effective.)

I will pass over sections on counter-projective statements and others in the interests of wrapping this up.

Idealizing and Mirroring and Loving:

Some of the richest material in the book, for me, comes in the last chapter, and here again I thought of work with OCPD patients in particular. This leads Havens to reflect on the place of ideals and the therapist's use of what he calls Performative Statements: "the power of performatives is based on the therapist's authority and on the patient's need to be loved. Such statements evoke and then transform the need to be loved" (p.162). 

Havens gives the example of a deeply conflicted patient with internalized hateful objects that attacked the self, inhibiting a healthy self-love. So Havens sided with the kind, gracious aspects of the patient he saw, and called those out for attention, affirming them. The very "performance" of such affirmation ipso facto strengthened the kindness in the patient and allowed him increasingly to love that part of himself to the point he did not need external affirmation of it after a while. (As he puts it later in the book, "the therapist who finds something to admire in the patient creates the state of being admired.")

Such admiration is needed above all in those patients the author calls "supine." But once admired and loved--and my experience confirms this--they discover some inner resources and strength, so that the need to be admired does not become prolonged or pathological, but leads to real and important independent growth in a capacity for love and corresponding decrease in self-hatred. 

In the End, Love: 

This leads Havens into a very important clarification in the book, worth quoting in full and ending this review with:

Freud's cure through love did not mean any happy result that might spring from the love of a therapist for his patient. Quite the reverse....The cure through love...depends upon the therapist's finding in the patient a quality that can be admired, hoped, or wished for. It is the 'recognition of a promise.'