Can One Be A 'Master Therapist'?

It is from Adam Phillips and Todd Dufresne (in his very astute introduction to a new translation of Beyond the Pleasure Principle) that I have learned to regard the whole concept of being a 'master' of something with a good deal of skepticism. 

In several of his books (but perhaps especially Terrors and Experts from 1997, and more recently his The Cure for Psychoanalysis), Phillips notes that we should in fact be suspicious of the whole idea of mastery of the psyche (and much else). Any psychoanalysis or psychoanalyst that promises such a thing exceeds its brief, Phillips says, arguing that there is no such psychoanalytic equivalent as the King's English or an 'authorized translation' or editio typica of the mind. 

I must say that it has taken me rather a long time to make my peace with this, but I think Phillips is right: mastery is not ever completely possible, and it should in fact be interrogated when such a desire reveals itself. Though I have spent rather a lot of time on the analytic couch, and it has been invaluable in ways too numerous to mention, it was only my second analysis that led me to let go of my infantile wishes for omnipotence and omniscience and to abandon the hope that I ever could examine and thus come to control every part of my mind, draining it of all ambivalence and ambiguity and the anxiety both sometimes produce. (Put in a Winnicottian way, I would be tempted here to say I'm on better terms with my primary process!)

I have achieved a lot of insight, but it is not and never will be complete, nor anything approaching mastery, and I am now not only at peace with that but--thanks again to Phillips--rather amused (instead of alarmed and angered) at the surprises my unconscious will produce from time to time. As Phillips says "A good life entails the tolerance and enjoyment of inner complexity....There is no final resolution here" (On Flirtation: Psychoanalytic Essays on the Uncommitted Life).

None of this is to say, however, that 'mastery'--as in mastering a skill--is something I reject. Quite to the contrary, I do believe that when it comes to such practices as learning languages, playing piano, or comparable activities, mastery can and should be aimed at. 

That is especially the case with psychotherapy though--as we shall see--it seems paradoxically true that one crucial hallmark of being a 'master psychotherapist' is precisely an ongoing uncertainty about whether one is a master or not, and a recognition that one still has things to learn. The master therapist, it seems to me, is the one who never feels he has learned everything. 

With this as background, I picked up Jeffrey Kottler and Jon Carlson's On Being a Master Therapist: Practicing What You Preach (Wiley, 2014) and read it with interest. 

The authors begin on the right footing, by raising the right questions, asking whether 'mastery' of therapy is "based on the mastery of certain clinical skills, particular personal qualities, or professional characteristics" (p.11). They next note problematic ways of finding master therapists: do you self-nominate? are you nominated by colleagues? are patients who love you or got better with you able to nominate you as a master?

All of these selection methods have, of course, problems, so we are no closer to an answer of how and where one might find master therapists. Instead, the authors add additional questions: does mastery differ based on the type of therapist or therapy? They inch towards an answer by suggesting that "no two master therapists perform therapy in the same way" (p.16). 

From here we get some suggested characteristics that are likely to be encountered in those recognized as masters:

• they are more inventive
• they are more humble
• they are uncomfortable drawing attention to themselves
• they prefer difficult truths to comforting illusions
• they are emotionally honest with themselves and their patients
• they perceive things, and more quickly, that others usually miss

This takes us up to the end of ch.1 where the authors write: "the concept of a master therapist is neither easy to define nor easy to grasp, especially considering all the different ways such excellence might be manifested" (p.24). 

Ch.2 takes us into increasingly familiar territory: examining the person of the therapist and noting that good therapists are those who "think differently in a multitude of ways," enabling them to make connections others might miss, and to "apply a variety of complex theoretical constructs and then adapt them to any particular case" (29). 

Forming the Alliance:

From here they quote Barry Duncan to the effect that forming "solid therapeutic alliances" is the key to distinguishing great therapists from the mediocre. But this must extend not merely to the worried well, or the patients you like or find similar to yourself or can easily relate to: it must extend to those court-ordered into treatment, those extremely reluctant or resistant to engaging with you, those whose lives seem radically different from your own. If you can build a solid alliance with these sorts of people, then you may be on your way to mastery.

Additional signs that you are on your way include:

• flexibility
• creativity (reinventing therapy for each patient)
• originality: finding your own voice
• learning from mistakes
• evolving views responding to new evidence
• seeing the patient as the greatest teacher.

Learning How to Listen:

Ch. 3 focuses on deep compassion and caring, while ch.4 looks at the skills of a master listener. These latter are marked by an ability, of course, to listen with the third ear, which enables them to hear between the lines, to hear what is doubled, denied, denigrated, overlooked, and so on. 

Your listening is supplemented by sight: what is the patient doing when they tell you for the third time in ten minutes that life is great? What are they not doing that you might well expect them to do? 

Listening prompts speech, and here the authors say master therapists are not afraid to draw on a variety of approaches, including being quite directive when it is appropriate. But most of the time good listening requires that one be as centred in the session and focused on the patient as possible: "Many experts that being present is the most important element of helping others heal" (p.85). 

Speaking the Truth in Love:

When one does speak, the so-called master therapist will "practice transparent honesty with as much tact and diplomacy as appropriate," always guaranteeing to the patient that you will be truthful and will say the things nobody else will say (p.111).

Be Not Afraid to Make Mistakes:

The authors quote several researchers, including Scott Miller and Bruce Wampold, to the effect that not only are great therapists going to make mistakes, but they may "make more mistakes than others, or at least are more inclined to admit them" (p.129). Such therapists are more self-critical, looking honestly at what they are doing and not doing, and what is working and not working. They fault themselves--and not the patient--if things are not working; but they are also gracious towards themselves in their criticism. Their self-critiques are not totalized or masochistic.

Obtaining Feedback:

The authors note the importance of obtaining accurate, useful feedback from patients on a regular basis. This can prevent ruptures from worsening and patients simply silently walking away. Duncan has written about this, as has Scott Miller, and before them Jerome Frank. 

Key Personality Traits:

At the end of ch. 10, the authors list what they regard as key personality traits in great therapists:

1. Trustworthiness
2. Dependability
3. Integrity
4. Flexibly tolerant
5. Modestly self-assured (believing in the patient, the process, and themselves)
6. Truthful
7. Spontaneous and Intuitive without being Impulsive
8. Kindness

But the most important trait is the outgrowth of kindness: love. As they begin to wrap the book up, Kottler and Carlson devote a chapter to the role of Love, putting me in mind of Freud's celebrated comment to Jung in a 1911 letter that "essentially, one might say, the cure is effected by love."

Jeffrey Kottler on Being a Therapist

This book, On Being a Therapist, is now in its fifth edition (Oxford University Press, 2017). As the author, Jeffrey Kottler, notes in the introduction, it could scarcely have been imagined in the mid-1980s, when this book was first published, how much would change today in the field of psychotherapy--not just advances in techniques, but in psychopharmacology, the insurance industry, and much else besides. Nevertheless, the author has sought to keep the book updated in light of new developments while aiming it at the widest audience of clinicians from all backgrounds--social work, psychology, counselling, psychiatry. He says it is especially aimed at students in all those disciplines who get into one of those professions without always fully realizing the personal consequences, with which he begins the book in Ch.1: The Therapist's Journey.

In this chapter the author sketches out the lofty potential of the therapeutic vocation: the ability to make a change in the lives of others unlike anything else, leading potentially to "spiritual transcendence" (p.1).

The ability to effect such change depends in good measure on the therapist's personality. Here Kottler echoes something much remarked upon in many other publications: above and beyond theoretical orientation and even certain techniques, the personality, and from it the therapeutic alliance, are fundamental, leading to change not just for patients but also therapists themselves. Kottler notes that therapy can produce an "altered state of consciousness" in both therapist and patient. This is especially so if the alignment is right and healthy, when there can be a kind of "second sight" at work.

Much like Nina Coltart (whom he does not quote or seem to have read), Kottler speaks of the importance of faith in the process, faith in the therapist, as being key factors in helping motivate people to seek and find change. Beyond that, Kottler suggests we go too far in thinking we can always and everywhere pinpoint the cause of change, even after lengthy in-depth study.  Therapists have to have "learned to love this sort of ambiguity and complexity" or else probably find another career (p.5). A little later Kottler says that "I have never really trusted anyone who claims to understand how therapy works. I think it is far too complex" (14).

That complexity and ambiguity can open the door to self-understanding and experimentation by the therapist, who also functions as a model: if the therapist models courage, it may aid the patient in being courageous enough to risk and experiment with change in his or her own life.

Ch.2: Struggles for Power and Influence contains some important reflections on serious issues.

Kottler begins by noting something that goes back at least to Freud: resistance. Therapists want to encourage change, but patients will not only resist that, but turn the tables, fighting to change not themselves but the therapist. They will want the therapist to take their side, to adopt their view, to love them more, to reduce and belittle the therapist and thus attempt to work out their own sadomasochistic transferences (a process which, as several others--e.g., Robert Stoller--have recognized, is often a reflection of early trauma).

Kottler notes a change here that has occurred in the last several decades: the decline of the therapist as all-knowing, largely aloof guru or expert. Thankfully that is a model and an approach largely in disfavor today. Instead patients increasingly see therapists as people with specialized training and insight whose job is to help patients discover what it is they want and need, and try to help them attain that at least in part. Kottler uses the metaphor of a "coach" here to try to capture something of this shift. He also speaks of the therapist as "model" of some beliefs, behaviors, and practices that the patient may very much want to try out and eventually adopt.

What is it that therapists should model? Here Kottler notes numerous important and distinguishing characteristics of therapists, including their

• tolerance
• sincerity
• serenity
• tranquility
• self-assurance 
• self-disciplined regularity that can nonetheless be spontaneous

He also notes in this chapter that the "energy" of the therapist can be hugely helpful and influential, not just as a model for long-term change, but in the immediacy of the here-and-now of the consulting room. The containing therapist, who offers a strong "holding environment," as Winnicott famously called it, can have a profound effect on disturbed and distressed patients.

A few other random things that stuck out to me in this book: In his fifth chapter, Kottler notes how much of "continuing education" is a scam, designed to offer a continuing source of cash and credentialing power to various groups, but very often only the most superficial "education" imaginable. I've heard this from other therapists, and from perusing some prominent websites, seen it up close.

His reflections on seduction in the transference is especially useful. Noting that patients may be seductive for reasons other than the straightforwardly or explicitly sexual, he notes that regardless of motives, there are no easy ways to deal with this problem. He further notes this can be a desire to establish a deep emotional relationship rather than a physical one, and that this obtains even when patient and therapist are of the same sex.

Kottler is also helpful on dealing with difficult patients, offering several insights, starting with the fact that it is important to recognize that at least some of the time it may not be them, but you: are you too impatient to change them, too resentful of a perceived loss of control in the relationship? Maybe they are "difficult" and resentful and resistant because the relationship is misaligned. As my supervisor often says, you need in these moments to check the goals of therapy because chances are good the "resistance" here is due to a misalignment of goals--e.g., the therapist wants to go farther, or faster, or further into an area than the patient does or can currently handle.

In this light, Kottler also offers advice I've seen in others: resistance is a powerful message. Try to understand and interpret it. What is it protecting? What was its function?

Perhaps more important, and certainly more difficult, is to ask yourself whether "it could be said that much of client resistance results, in part, from some blocking that occurs in the therapist" (p.208). This, as I've also learned from Otto Kernberg and Nina Coltart, is where mining the counter-transference is crucial for knowledge about blockages in the therapist as well, of course, as--possibly--the patient.

But look, moreover, at cultural background to see if some of the struggles can be located here. Regardless of origin or cause, the therapist needs to remain flexible, patient, compassionate, and available to help people change at their own pace when they are ready, recognizing that some people may never get there or may be incurable. Have the humility to admit this, and also to admit that sometimes the most difficult patients can also be the greatest teachers.

Finally, have not only humility, but plenty of self-compassion, Kottler reiterates several times. This is good advice I've seen in others, including Adam Phillips, about whom much more another time.