Mary Jo Peebles on Psychotherapy and the Wisdom Found in its Impasses and Uncertainties

I previously wrote at length about the wisdom gained from reading Mary Jo Peebles' 2002 book Beginnings: The Art and Science of Planning Psychotherapy. 

Her name was recently brought back to mind by Jonathan Shedler on Twitter, from whom I continue to learn a great deal. He was favourably quoting from her new book, so that meant I had to get a copy and read it, which I did earlier this month. 

So let us turn our attention to her newest book, released late last year, When Psychotherapy Feels Stuck (Routledge, 2021), 164pp. I finished reading it last weekend and found it a profitable read, not so much for any new ground it breaks as for the many useful reminders it offers.

She starts off by very calmly advising that not knowing where to go next in treatment can be a very good thing: "I want you to be unafraid to not-know" (xiii). This, as I have written about often on here, is a familiar and welcome counsel, going back--for me--to at least the early 1990s when I read Nina Coltart's break-out book Slouching Towards Bethlehem, about which I wrote at length here. 

Towards the end of her preface, Peebles returns to this, writing winsomely that not knowing about your patient, or where to go with a patient, can in fact be a gift: 

feeling stuck and not-knowing...is a gift we are given to be able to learn something new. It is a sacred trust we hold when we invite our patient to share themselves with us. I want you to feel less of the fear and more of the wonder and sacred trust when you feel tense or confused. I want you to come to appreciate that if we listen, the knowing will come (xv).

She will return to these themes--of the sacred and of gift--in the concluding pages of the book, as we will presently discover. 

Her first chapter, "Change Takes Time," is one of those messages that needs to be heard more than ever today. The pressures from insurance companies and other agents of iniquity to shorten psychotherapy are notorious. Helpfully Peebles here launches straightaway into an analogy about learning a language and how much work and time that takes. In many ways, she shows, good psychotherapy is about learning how to talk (think, feel, etc.) about yourself in a different way so why should we expect that to be quick and easy? "Change that lasts is incremental," she reminds us (p.5), and such change is compared to compound interest: "our investment of time compounds over time" (p.9). (In this, she reminds me of a line from one of my favourite of Adam Phillips' books where he says of psychoanalysis that "the cure can begin only after the treatment has ended.")

"How We Say It Matters" is the second chapter and I confess I found it gratifying for such a seasoned clinician to be advocating a practice that I had just found myself falling into without having read about it before or seen it sanctioned elsewhere: "Perhaps you involuntarily wince when a patient excoriates himself. Let that show." This might be through body language or a simple "Ouch!" voiced aloud, shaking the patient's "obliviousness" (p.250). 

I can confirm that this is very effective if the timing and tone are right, though with some patients it needs to be done semi-regularly until their hitherto relentless super-ego attacks begin to lessen and they develop their strength and ability to stand "Against Self-Criticism."

Ch.3, "The Value of Awareness" contains a helpful list of questions, some of which I have used before--either in thinking of a case or in supervision, or both. All of these are very worthwhile and should be considered regularly to avoid epistemic closure and unjustified certainty. Peebles says (my paraphrase) we should be asking:

• Are there other ways for me to understand this?
• How would others of different theoretical persuasions see this?
• What am I missing or ignoring?
• Have I made assumptions about my patient instead of asking them questions?
• Am I discounting or dismissing something the patient said because of theoretical or clinical priors?
• Am I in danger of seeing the same symptoms and diagnosis in too many people? 

Ch.4, "Transforming the World Within," was perhaps the most challenging for me. Here she issues a number of welcome reminders, including this splendid aphorism: "the goal of psychotherapy...is to rattle our patient's certitude about his conclusions" (p.49). To do this, we must enter their world, and we must enter not just via their mind--their intellectual world--but above all their emotional world: "we must focus as therapists on our patient's sensations, not just on his ideas" (ibid). Peebles says that therapists who struggle to do this need to be in their own personal therapy. (I do, and am!)

Ch.5, "Learning to Not-Know," begins with an epigraph from W.R. Bion and his infamous "Notes on Memory and Desire," about which I essayed some thoughts here. Peebles quotes him thus: "'the only point of importance in any session is the unknown'." 

This is not easy to do! I find that to be especially difficult in working with psychotic disorders. The drives to know and control and fix--what Phillips talks about as our desires for omnipotence and omniscience--are strong! They are stronger still when under pressure from the parents of adolescent patients who, naturally enough, want a cure and want a guarantee that their children will never suffer another psychotic break ever again. 

Bion presents (so I thought until recently) especial difficulty with his insistence that the psychotherapist "must aim at a steady exclusion of memory and desire" and must also "aim at achieving a state of mind so that at every session he feels he has not seen the patient before." At first, I regarded these as counsels of perfection, absolutist and almost suspiciously totalizing in their demands and largely unachievable in most practices in this country today. But I must report that I have rethought my suspicion of him on this point recently, and was startled to realize in one case that Bion was right and I needed to do what he advised! Suddenly one day instead of thinking I was out in front waiting for a patient where we had ended the last session, I realized they had moved unexpectedly and thus surpassed me and I was playing catch-up: my memory of past sessions had deceived me, just as Bion predicted it would! 

To return to Peebles, she says there are two significant gifts which not knowing can offer: first, it can allow for creative thinking to emerge, for new ways of looking at and working on something. Second, "when therapists are able to tolerate uncertainty, the therapeutic alliance strengthens" (p.80). (This has been confirmed by my own recent experience with one patient in particular.)

A toleration of uncertainty, she continues later in the chapter, is connected to "being humble about the limits of our knowledge." We need to cultivate humility, but not of a masochistic kind: "humility is the child of self-assuredness" (p.81). In other words, as I have heard others put it, you can be certain of yourself as a person, but uncertain as a therapist as to what to do, and both are not just okay but exist in necessary relationship. 

A toleration of uncertainty goes well with a spirit and practice of playfulness in psychotherapy. This--though she does not cite him--is very much in keeping with Winnicott's ideas, as I noted here. 

Peebles ends this chapter with another timely reminder and reiteration of her central point: "the more comfortable we are with not having answers or next steps right away, the more opportunities we will afford our patients to resist concluding, endure not-knowing,...and master uneasiness" (p.91). This, in turn, will pay dividends in allowing patients to be freed from the often restricting, infantilizing, or even paralyzing certainties with which their lives have been ruled hitherto. 

Ch.6, "Relationship," focuses not just on the therapeutic alliance, but on negative emotions in that alliance. This was, for me, the most useful part of the chapter. She brings in some of the greats here--Winnicott, of course, on hate in the counter-transference; but also Searles on counter-transference; and others I was not familiar with but whose works I am now tracking down. She focuses not just on hate, but on what might perhaps be called lesser negative emotions, and how to deal with those. Her advice is masterful: "talk with our patient about the negative energy with the calm and respect that comes from knowing how to learn from negative process rather than be railroaded by it" (p.102). 

Timing, she says later in the chapter, is crucial here. Watch for, and even anticipate where possible, ruptures and outbursts of negative emotion, and handle them calmly and promptly. Left untended, they can damage the alliance and relationship. But handled quickly and well, the alliance can in fact be strengthened. 

Other useful and familiar reminders abound here: about the importance of good supervision; about self-care; about taking "cool soundings" (Coltart) from the counter-transference; and once again about the importance of the therapist having his or her own psychotherapy.

This chapter ends by compiling a list (quoting from this article) about the qualities of  master therapists properly so called, who are described as "'voracious learners, curious, reflective, and valued cognitive complexity and ambiguity; they were emotionally receptive, self-aware, non-defensive, and open to feedback'" (pp.112-13). 

The last chapter, Creating Meaning, takes us back to where we began: the costs and challenges of change, and the resistances to it which crop up. Noting that change brings loss and ambivalence, and takes time, Peebles concludes her worthwhile and helpful book with what I would call an existentialist turn, reminding us of past luminaries such as Viktor Frankl  and the present challenge of creating space where patients might explore questions such as the meaning of suffering, the questions about grief ("grieving is not giving up," she flatly asserts late in the book [p.132]) provoked by losses associated with change, and more broadly "spiritual" questions. 

In this final chapter, Peebles is also undertaking what I would call an implicit rebuke of instrumentalist or purely pragmatistic views of psychotherapy as means of overcoming "disease" or "disorder" in order to get back to being a quiet, compliantly cheerful employee and obedient citizen. Her view, rightly, is much more expansive than that, and reminds one of others, including Michael Eigen, not least in his book The Psychoanalytic Mystic.

Thus she says that "psychotherapy presents the opportunity for a mystical journey, however brief the encounter or modest the epiphanies" (p.124). On this felicitous note we take our leave of When Psychotherapy Feels Stuck, grateful for the wisdom of the author and her eminently useful book. 

Beginnings in Psychotherapy

As the days of August tick rapidly by, and the fall semester looms on the horizon, I am eagerly reading any number of books that I can get my hands on, including Mary Jo Peebles-Kleiger, Beginnings: The Art and Science of Planning Psychotherapy (Analytic Press, 2002). Both the title and the timing are apt as I am beginning a clinical practicum later this month, and am very excited about that. 

The book has many good insights, though in my reading of it these are largely confined to the first six chapters. 

Begin as You Mean to Go On:

The author begins with what might seem obvious, but can get overlooked: If therapy is to end properly it must begin properly. She notes that what goes on in that first hour very often communicates our theory, our views of patients and their problems, and how the process will play out.

She reiterates what I have seen said time and again in many books in the past year: the role of the therapist's personality and our "competence, hope, and humanity...will minister strongly (or, some would argue, more strongly) than the particular modality we eventually select" (p.1).

Wearing Diagnoses Lightly:

I have seen others whom I respect note that one cannot and must not be hidebound about diagnostic labels. Peebles-Kleiger says that one may often start with a diagnosis, but one can equally start with a case formulation--a narrative that goes beyond symptoms and causes to be grounded in history of relationships, taking a wider view. I very much incline towards this latter. In any event, one must recognize, as she rightly puts it, that "no system of diagnosis is fully comprehensive....diagnosis is ongoing" (p.4).

Early on, her approach is to put together a clear picture of the patient that takes account of and has some idea of:

1) History, including that of relationships
2) Patient's capacity for forming the therapeutic alliance
3) What functions do the symptoms serve?
4) What is psychological cost of change?

Having accounted for these, one can proceed to step 5): Form what she calls a "blueprint" for treatment that focuses on "connection, focus, joint activity, prioritization, and choice" (13).

Later on she offers further recommendations on the taking of a patient history (cf. Nina Coltart, discussed elsewhere on this blog, about the huge importance of getting this done as comprehensively as possible early on), noting that it is best to take history "which flows out of the investigation of current emotions, behaviors, and ideas" (52). Indeed, some of those current emotions and behaviors will show up in the consulting room, and careful observation of the patient and his or her activities will often give clues of an historical nature which should then be examined together. E.g., she refers to a patient who always came precisely 15 minutes late to every session. This obviously had a history behind it needing to be explored, as they did. 

The Therapeutic Alliance:

In her second chapter, Peebles-Kleiger offers a helpful reminder that the alliance is beginning to be formed (or thwarted!) the moment you walk into the waiting room and make eye contact with the new patient for the first time. Here and throughout your entire time working together, she says that "respect, even reverence, is the order of the day" from first greeting patients to the end of their treatment. I like that "reverence" here for each person's unique dignity. 

She notes something often seen in other books based on wide-ranging research: building the alliance repeatedly shows the crucial importance of the therapist's "ability to show empathy, sincerity, and unconditional acceptance of the patient" (16). This allows her to note, moreover, that other
"research has documented that if a patient feels accepted, understood, and liked by the therapist early in the relationship, then therapy tends to be successful" (14). This, she says, is pantheoretical. 

She differs--rightly in my view--in not following early psychoanalytic techniques and requirements aimed at "curbing spontaneity and remaining unresponsive" because doing so  "could actually have a negative impact on the relationship" (17; cf. Coltart again). She does, however, agree with the formative experience and expectation--going back to the early days of psychoanalysis--that insisted on the therapist also being in therapy, if not as a prerequisite then as a concomitant to his or her own clinical practice: "There is empirical evidence for a positive correlation between having had personal therapy oneself and being better able to facilitate a positive alliance in treatment" (23). (I am, frankly, amazed that this is not still a widespread requirement today of prospective clinicians.)

Naked Logic:

I really liked her counsel to avoid appearing or trying to be some kind of aloof expert handing down recommendations from on high. This is not original to her, of course, but goes back at least to Carl Rogers. In any event, she rightly says that transparency in the therapist's thinking--taking off the outer later to see the logical gears working underneath--can be very important. This "invites the patient to be a diagnostic partner and to reason along with you. The end result is that the patient not only knows how a particular treatment recommendation was arrived at, she also feels that she helped critique and shape its construction" (22). Such collaboration helps the alliance.

Goals and Treatment Plans:

As someone whose entire experience thus far has been psychoanalytic, I found her third chapter, Focus, helpful. She begins by noting that some people (I confess I incline towards this) are suspicious of too much attention on focus, on goals, on treatment plans because they fear this will undermine the capacity for spontaneity, creativity, and above all free association. To us she says it may be helpful to see our role as similar to a personal trainer: advocating for a repeated focus on attaining certain goals for improvement in the patient's life. She says that the research is clear: focus and goals across modalities are key to successful therapy. And, she insists (though this needed much more development), focus and goals are not at cross-purposes with free associating. Nor are they aimed only at symptom relief. You can be doing several things at once in therapy. 


The author's sixth chapter, What Material Is Important?, poses some important questions and offers some not terribly original answers that are nonetheless still important to underscore. 

One of the really obvious things she says to pay attention to is "repetition (of phrases, themes, behaviors, sequences, mannerisms, emotions).... The more repetition the more attention is warranted" (p.69). I have learned this from reading the great child therapist and psychoanalyst Adam Phillips over the years, but I first learned it from what is perhaps my favourite of Freud's technical papers, "Remembering, Repeating, and Working Through." 

In addition, do not fail to note strong emotions, idiosyncrasies, and especially dramatic losses of control or wildly singular behaviors--even if they only occurred once and were never repeated, they may offer a deep vein of significance to be explored. 

Jumping, finally, to Peebles-Kleiger's nineteenth chapter, on the Psychological Costs of Change, I found much gratifying material here, too, which reflects my own attempts at rethinking "resistance." I've come to the view that resistance must be seriously respected, not merely scorned as something to be gotten rid of, or around, as quickly as possible. This, too, comes out in Freud's paper mentioned above: the resistance plays a role, and the clear-eyed clinician must try to see what role that plays. As Peebles-Kleiger notes here, symptoms can be bothersome but also productive and useful. Some symptoms may protect from grief or hold anger in check. Some may be resistant to change until and unless (as Winnicott might say) the patient learns that it is okay to hate the therapist. 

Though she doesn't mention him here, I had another of Freud's works in mind here, the centenary of which is this year: Beyond the Pleasure Principle, with its controverted theory of the death drive and the less controverted and I think more clinically abundant phenomenon of the repetition compulsion. The repetition of symptoms, and of resistance, must be examined and taken seriously by, inter alia, asking what the plan is for their replacement. As she notes, lots of therapy without such a plan will falter: you can't remove something and leave nothing in its place for most people. You must replace something pathological with something adaptive. 

Anyway, such were some of my thoughts in reading Mary Jo Peebles-Kleiger's useful book, Beginnings: The Art and Science of Planning Psychotherapy