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!

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 

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.