On Mentalizing and Attachment

I have been aware for some time of the work of Peter Fonagy in England. But it was only more recently that I discovered his American colleague Jon G. Allen. Both have written about "mentalizing" as important in therapy. The pair of them have teamed up together with Andrew Batemen to write Mentalizing in Clinical Practice (APA Books, 2008). I mined this book for some good insights, and was not disappointed. Herewith a few of them:

Mentalizing: What Is It?

In their introduction they offer several quick, simple definitions of mentalization, including:

holding mind in mind

attending to mental states in yourself and in others

understanding misunderstandings

seeing yourself from the outside while seeing others from the inside

In the concluding appendix, they return to offer another simple definition of mentalizing: "You are mentalizing when you're aware of what's going on in your mind or someone else's" (311). Examples of this might include asking yourself "Why did I do that?" or "Why did she say that hurtful thing?" 

Practical Recommendations:

These authors offer some very practical recommendations in trying to increase the capacity for mentalization in patients: take your time; don't rush this; don't get out of step with your patient. If in doubt, confirm first (the patient's thoughts/experiences) and challenge later. 

Why do this? Why is mentalizing important? They find that its lack is almost always related to an attachment failure, early abuse or trauma, or substance abuse. Restoring the ability to mentalize can be both healing in itself but also open up further depths to be explored in therapy. The whole point of therapy is to open up alternate interpretations and to insert spaces where there were none before. This extends to allowing and encouraging the pt. to mentalize the transference: to look at this relationship now and imagine what might be going on in the therapist's mind while also discussing what is going on in your mind as a patient. 

Without Memory or Desire:

These authors offer what I would characterize as some very Bionian counsel: Be very at home in not knowing, not having memory or desire. Do not be an expert, for you are not an expert in the patient's mind! 

If you are trying to be mindful of their mind, then they recommend that the therapist make contrary moves: if the patient is excessively introspective, invite them to consider how another mind might see something; if they are obsessed with how others see it, invite them to offer their own thoughts from their own mind. 

As you and they offer such thoughts, watch the adverbs! Avoid using such terms as clearly, only, obviously, just, etc. If your patient uses them, you might want to challenge them gently, especially if such adverbs precede significant minimization of major events or issues or pain. 

Ask for feedback if a conflict is brewing: What have I just said/done that seems to be making you more and more agitated and upset?

I read Mentalizing in Clinical Practice after having finished Allen's Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. Let me next offer some comments about this book which was also valuable. 

I confess that anyone who uses the phrase "plain old therapy" is going to command my attention rather immediately and easily. I further confess my ever-increasing lack of interest in, and sometimes scorn for, the mad rush of a lot of people to coin and then copyright acronyms and to trademark modalities. Allen has little interest in such things, and I am at one with him here. 

Neither of us, however, is willing to dismiss evidence or defend things merely because we have theoretical preferences. I do not doubt for a moment that in some cases some of these things (DBT, EMDR) work, but it seems clinical psychology is engaged in a frenetic and relentless chase after commodification of its services in a way that is profoundly off-putting, and usually for one of two reasons at least: either much of what is proffered is just needlessly complicated manual therapy like DBT, or recycled earlier approaches. 

In the foreword to this book, Peter Fonagy says that "plain old therapy [is] a mentalizing relationship in which the therapist's empathy allows the patient no longer to feel alone in emotional pain" (xiii). This approach, both he and Allen recognize, antedates all forms of psychotherapy, going back thousands of years and still being practiced today in regular forms of relationship with friends and family who help us by and with their empathy as we struggle. 

This approach, he further recognizes, has much in common with the ever-popular mindfulness today, but he distinguishes them thus:

Mindfulness is attention to and acceptance of present experience

Mentalizing is attention to and acceptance of mental states (mindfulness of mind).

Trauma and the Failures of Attachment:

For Allen, as for Fonagy, a failure of mentalizing often lies behind trauma, attachment failures, and substance abuse. What these situations have in common is that the person is left psychologically alone in distress, and so much find maladaptive ways of coping, including substances, disorganized attachment, or other personality disorders. 

In traumatic failures of attachment, especially situations of childhood abuse and neglect, those attachment failures always get re-enacted in other relationships, showing that re-enacting is always a failure of mentalization (what Freud called "remembering" in his invaluable essay "Remembering, Repeating, and Working Through").

Allen uses an interesting metaphor in working with severely traumatized patients: what were and are their "islands of security"? Find them, explore them, and then see if you can get them off the tiny island and onto a more secure mainland in their own mind. 

Importance of I Statements:

Two final words of counsel I found helpful, and have already seen work well in my consulting room: the first (which other therapists I have read, including Yalom, also recommend) is to give voice to struggles in the session and relationship by using I statements: e.g., "I seem to wonder if we are not going around in circles" and leave it at that. This method often sees the patient pick this up and elaborate, or adopt your view and allow themselves to be carried forward. 

Another effective version of such a statement that I have used with success marries what Allen recommends with what Nina Coltart also recommends: take cool soundings from the counter-transference, paying special attention to images or nick-names that your unconscious throws up. I have found myself saying things like "I have this image of you in mind" or "I'm wondering why I want to give you the nick-name of Invisible Man." Both of these opened up new depths and directions to be explored. 

Minds inside Minds:

Finally Allen notes that the patient has to be able to find him/herself in the therapist's mind just as the therapist has to be in the patient's mind. I think the former might be especially important around those notoriously destabilizing transition moments--a summer holiday or Christmas break, say. For some patients the knowledge that their therapist holds them in mind outside the session can be helpful and healing in itself, especially if they had no significant early attachment figures. 

Vamik Volkan Discussing His New Book

As I indicated earlier in the week, Vamik Volkan is a clinician and scholar from whom I have learned much. He has a new book out, Large Group Psychology, just published by Phoenix Books, whose website everyone interested in psychotherapy, psychoanalysis, and much else should keep a close eye on. Rare is the week that does not see Phoenix publishing something, or advertising books soon to be published, all of which look fascinating. 

I sent Dr Volkan some questions about his book. Here are his thoughts:

AD: Tell us a bit about your background

VV: I was born in 1932 to Turkish Cypriot parents on the Mediterranean island of Cyprus when it was a British Colony. The first humans on the island arrived about ten thousand years before the birth of Christ. As the centuries went by, invaders and traders multiplied. In my childhood I was exposed to people with different large-group identities: Cypriot Greeks, Cypriot Turks and, in much smaller numbers, Armenians, Maronites, people who considered themselves as descendants of Phoenicians and, of course, the British – all living side by side. Only much later I begin to wonder what history means for people with different large-group identities.

In early 1957 I came to the United States armed with my medical degree from the Ankara University’s Medical School in Turkey and only 15 dollars in my pocket, but I had a job at a hospital in Chicago. I became an American citizen a few years later. My departure to the United States was part of the phenomenon known as the ‘brain drain.’ The United States lacked medical doctors at this time and therefore attracted doctors from around the world. I had my psychiatric and psychoanalytic training in the USA.

In 1977, Egyptian president Anwar Sadat visited the Knesset and famously referred to a psychological “wall” between the Israelis and the Arabs—a wall that, he stated, accounted for 70 percent of the problems between them. In response, the American Psychiatric Association’s Committee on Psychiatry and Foreign Affairs, of which I was a member, brought influential Arabs and Israelis together for unofficial dialogues for six years to find out if this “wall” could be made permeable. This is how I started my decades-long work in unofficial diplomacy.

I met and had opportunity to spend time with many political and community leaders (For example, Jimmy Carter, Mikhail Gorbachev, Yasser Arafat, the Emir family in Kuwait, North Cyprus President Raif Denktaş, Turkish President Abdullah Gül, Estonia President Arnold Rüütel and Archbishop Desmond Tutu). This also helped me to study leaders-followers interactions and national, ethnic, religious and political large-groups’ psychology. As an academician, generally speaking, I stayed away from the news media. However, I believe that deeper knowledge about what lies behind what we see, hear and learn daily is useful for the public

AD: What led to the writing of Large Group Psychology: Racism, Societal Division, Narcissistic Leaders, and Who We are Now?

VV: I have been living in Charlottesville, Virginia since 1964. Following the deadly 2017 white supremacist rally in my city numerous fatal attacks on churches, synagogue and mosques occurred worldwide. In many countries, people are asking the metaphorical question “Who are we now?” and coming up with seemingly opposite answers. I could no longer ignore the urge to write a new book about large-group problems.

During my decades-long activities in the international arena I have learned that behind observable factors like politics, economics and law, the central psychological factor in starting and keeping alive large-group conflicts is the protection and maintenance of large-group identity. During my work I heard the subjective experiences of such large-group identities being expressed in terms such as “We are Palestinians,” “We are Lithuanian Jews,” “We are Russians living in Estonia,” “We are Polish,” “We are Communists,” “We are Sunni Muslims.”

AD: I visited Cyprus in October 1993 for an international ecumenical conference in Limassol devoted, in part, to overcoming division and conflict between Christians. As a young, naive kid from Canada I was almost entirely ignorant of the conflict until we were given a guided tour of Nicosia, getting as close to the DMZ/Buffer Zone as we were allowed. I've never forgotten the shock of seeing that, like a huge open scar right across the city streets. That division and its conflict are very personal for you, as you tell us in your moving first chapter. Is that conflict part of your own working through of the "rescue fantasy" (p.1) you speak of as motivating some therapists and clinicians?

VV: My arrival in America in 1957 coincided with the Cypriot Greeks’ struggle against British rule in order to unite Cyprus with Greece. The Greek Cypriots began to oppress Turkish Cypriots and an ethnic conflict was inflamed. I experienced a terrible stabbing pain six months after taking up residence in America. My father sent me a newspaper clipping with very grave tidings. My roommate, Erol, from the days when we lived in clapped-out lodgings in Turkey while attending the same medical school had returned to Cyprus to tend to his ailing mother. He was the nearest thing to a brother that I have had. A Greek terrorist shot him seven times, killing him, in a pharmacy where he was buying medication for his mother.

He was murdered in order to terrorize the ethnic group to which he belonged. After receiving the news of his death, I felt numb. I did not cry. I was in Chicago, in a foreign environment in which I was close to no one, so I did not share the news of my former roommate’s murder with any other person. Much later I would become aware how the murder of my roommate played a role in my involvement for finding ways for a more peaceful world.

Relationship between Cypriot Greeks and Cypriot Turks changed greatly since your visit to the island in 1993.  Border crossing points are now available. Due to COVID-19 there are the necessary cautions for border crossings.

AD: Your discussion of group psychology is, as of course you note at the outset, indebted to Freud and his book Group Psychology and the Analysis of the Ego.
One of the key points you repeat in your book is that group psychology exists "in its own right." Tell us a bit more what you mean by that and why it's important to be clear about this.

VV: Sigmund Freud and his followers (in the clinical setting) described what belonging to a large ethnic, national or religious group means for an individual and how an individual unconsciously perceives his or her large group as a symbol of a mother or father figure.

My work is very different. As a psychoanalyst I have studied the shared psychological processes within a large group and relationships between opposing large groups. Large-group psychology in its own right means making formulations about the conscious and unconscious shared past and present historical/psychological experiences that exist within a large group. Making such formulations enlarges our understanding of the emergence of present-day societal-political-religious events, and leader-follower relationships. 

Doing this allows us to look at the interactions between opposing large groups in depth. This is similar to a psychoanalyst making formulations about his or her analysands’ developmental histories associated with various conscious and unconscious fantasies in order to understand what motivates certain behavior patterns, symptoms and habitual interpersonal relationships.

AD: Two other key phrases recur in your book, reflecting some of your earlier work: "Complicated mourning" and "survivor guilt." From everything I'm hearing in this pandemic, there seems to be a lot of both being experienced by people today. Tell us a bit about those and how you understand them.

VV: I wrote about my roommate Erol’s murder above. Since I did not have family members or friends in Chicago at that time, I had no one to share my feelings and thoughts about my loss. My mourning process was complicated. 

Also, I was not aware of my “survivor guilt.” While I was safe in the US my family members in Cyprus were living under very difficult conditions and my former roommate was dead. Decades later I realized how I handled my “complicated mourning” and “survival guilt.” My first academic research was on these topics. I wrote papers and books on these subjects. My book (with Elizabeth Zinti), Life After Loss has been translated into several languages.

In the present book, the reactions to loss are seen in the  Addendum, which describes 16 analysands’ initial responses to the pandemic. These patients returned, consciously and unconsciously, to their childhood losses and re-experienced anxieties and old defense mechanisms and fantasies linked to such losses. Moreover, when I gave a seminar for 8,000 Chinese mental health workers on trauma due to COVID-19 pandemic on April 3, 2020 I encouraged them to study the psychology of mourning.

AD: You note (p.29) that an individual who has difficulty in mourning can often pass that on to succeeding generations, resulting in the transgenerational transmission of trauma. Is that also a dynamic we see at work in groups, indeed whole countries? Could it be said that some of the rage and grief today over police brutality and racism are at least partly due to America's never really having grieved the legacy of slavery and attempted to heal from it?

There are variations of transgenerational transmissions and all of them depend on the permeability of the psychological boundary between children and their mothers or other important caretakers. It is not only anxiety that travels from the mother or other primary caretaker to a developing child through the permeable boundary. Other psychological “messages” are also  given to the child.

Important adult persons may push their specific self- and object-images into the developing self-representation of the child. In other words, the “other” uses the child, mostly unconsciously, as a reservoir for certain self- and object-images that belong to that adult.

The experiences that created these mental images in the adult are not “accessible” to the child, but instead are deposited or pushed into the child, but without the experiential/contextual framework that created them.
In the psychoanalytic literature there are many papers and books that examine the psychology of the transgenerational consequences of the Holocaust for the children of the survivors as well as the perpetrators.

The rage and grief today over police brutality and racism are mostly due to America's never really having mourned the legacy of slavery. Mourning is a slow process related to remembering and relating to lost persons and things and, if everything goes Ok, saying “good bye” to such lost objects. What we see in the streets can be considered as an expression of shared mourning. I hope that it will take a positive course.

AD: In that vein, can we see your notion of a "linking object" as helpful in trying to understand some of the battles over statues, including over the removal of the Robert E. Lee statue in Charlottesville in 2017, which you say in your introduction was part of the motive for writing this book?

I described linking objects and linking phenomena in 1972. A linking object is an item chosen by an adult mourner that unconsciously represents a meeting ground for the mental image of the lost person or thing and the corresponding image of the mourner.   

Not every keepsake is a linking object; the item is a linking object if the mourner makes it “magical” and uses it as a “tool” for postponing the work of mourning. For example: after his father’s death, a young man picks up his father’s broken watch and hides it in a desk drawer.  For the young man, this broken watch becomes “magical.”  He becomes preoccupied with repairing the watch, but he never gets it repaired.

Some statues and monuments are shared linking objects. They connect many people to their ancestors’ losses or glories often without hurting or humiliating other large groups. But in the US some such shared linking objects humiliate another group (African Americans).

We are now more openly becoming aware that the beginning of American greatness was accompanied with the history of slavery. This reality now is hitting us openly. We need good leadership and open discussions to come up with ideas about what to do with some statues and monuments.

AD: Over the years, since discovering your work, I've found your concepts of "chosen trauma/glory" and "time collapse" enormously valuable. In this new book you introduce a concept I've not come across before in your work: "Entitlement ideology." Would you give us a sense of that and perhaps a current example?

Entitlement ideologies refer to a shared sense of entitlement to recover what was lost in reality and fantasy during the ancestors’ collective trauma. They deny difficulties and losses that had occurred during it, and imagine their large group as if it is composed of persons belonging to a superior species. Holding on to an entitlement ideology primarily reflects a complication in large group mourning, an attempt both to deny losses as well as a wish to recover them, a narcissistic reorganization accompanied by “bad” prejudice for the other.

The white supremacists openly verbalize their (fantasied and delusional) entitlement ideology, to have an America populated only by  white people from selected locations.

Some entitlement ideologies are known by specific names in the literature. What Italians call “irredentism” (related to Italia Irredenta), what Greeks call  “Megali Idea” (Great Idea) (an irredentist concept that expressed the goal of reviving the Byzantine Empire), what Turks call “Pan-Turanism” (bringing all the Turkic people together from Anatolia and Central Asia), what Serbs call “Christoslavism,” and what extreme religious Islamists of today call “the return of an Islamic Empire” are examples of entitlement ideologies.

We should remember the horrible consequences of the inflammation of the Serbian entitlement ideology (to have a greater Serbia) under Slobodan Milošević and be aware and careful about the inflammation of American white supremacists’ entitlement ideology.

AD: On pp.54-55 you speak of the "formal and informal systems of 'checks and balances' in a well-functioning democracy [that] prevent a leader's personality...from exerting undue influence over government and the governed." It seems ever more widely accepted by clinicians and observers today that such a system in this country is under the greatest and most severe strain ever. Is that an assessment you would share?

Yes.


AD: You refer to some of those clinicians (p.98) before, in ch.9, talking about "persons with exaggerated narcissism." Here you draw on the works of Kohut, Kernberg, and Jacobson. Tell us a bit more about this phenomenon of extreme or exaggerated narcissism. Is this a helpful way of understanding Donald Trump?

In my book I describe Charlottesville Psychoanalytic Study Group’s years-long study of persons with exaggerated narcissism.  An in-depth description of such individuals’ behavior patterns, need to be number one, language peculiarities, inability to have empathy and other characteristics help us to see observable personality characteristics of Donald Trump.


AD: Sum up your hopes for Large Group Psychology, and who especially would benefit from reading it:

VV: First, today we see a preoccupation with Donald Trump’s tweets, verbalizations, and behavior patterns. In the book the reader will learn about narcissistic personality organization, why it evolves and how it can lead to destructive or reparative societal processes. Such knowledge will help the reader to have a better understanding of Donald Trump and his influence on his followers.

Second, there are severe societal/political divisions in the USA. The reader will read why there is a need to have allies and enemies in human nature.

Third, racism, ethnic prejudice, removing or not removing some statues are discussed. In the book I describe the experience and views of an immigrant to the USA in late 1950s on these issues.

Fourth this book illustrates the need to have an in depth psychological/historical understanding of large groups and the meaning and the power of large group identity in order to find new solutions for political/societal problems.

Fifth, I wrote this book before the COVID-19 pandemic started to illustrate shared psychological processes of the Trump-era America and the world. The corona virus pandemic made me to realize that deeper knowledge of such psychological processes is sought by the reader. At the present time the personality of political leaders, racism, societal/political divisions and political propaganda preoccupy public interest. 

Sixth and finally, this book is written without my hiding behind technical psychoanalytic terms. It is easily readable.

AD: Having finished this book, do you have other projects on the go at the moment--other books in the works?

VV: I just finished writing another book. Soon I will send my manuscript to my publisher.  This one is on non-chemical addictions. I describe how some individuals remember their childhood traumas and their own “solutions” with compulsive actions. I hope that this book will also help the reader to have a deeper understanding of some political leaders’ repeating actions.

How Much Light is in the SOLER System?

In discussing Neville Symington recently, I noted in passing his welcome comment about the importance of a therapist's office.

This is a question I spent some time investigating earlier this semester when one of our graduate classes introduced the so-called SOLER recommendations for doing therapy. (SOLER = Sitting Squarely while having an Open posture as you Lean in, maintain Eye contact, and have Relaxed body language.) 

I confess upon reading this that I immediately had questions, and so spent a happy few days ransacking the literature going back to the early 1970s to see what it said, and to see if there is a consistent evidence base justifying all these arrangements as a feature of a consulting room. It turns out--as they say in some Scottish trials--that the case is "not proven," or at least not proven to any degree sufficient to convince me. 

I do not pretend that what follows is an exhaustive literature review, but I can report the following: One early study (Broekmann and Moller, 1973) yielded ambiguous results, in part because, the authors say, their 30 randomly assigned test subjects were regular students, not patients in therapy. This study found that in some cases students preferred chairs side-by-side, rather than facing each other squarely, but in other situations preferred chairs facing each other squarely but with a large table in between them. 

Another old study found that room arrangements differed considerably between patients and therapists: “clients had different preferences for seating arrangements than did counselors. In general, clients preferred spatial arrangements that were more protected than those preferred by the counselors” (Haase and DiMattia, 1976, p.414). Once again, however, both groups of subjects in this experiment were American university students (and all men), not those in therapy, and they were assigned very particular cognitive tasks of learning and conditioning not always found in therapy, so I am not sure how useful these results are. Still, it did uncover that a larger room consistently invited longer verbalization by the subjects than a smaller room. But as for furniture and its arrangements, the results uncovered merely “a marginally significant effect due to furniture arrangements” (p. 419). The authors then conclude that “It would be desirable to replicate this study with a group of actual clients…in addition to analogue studies.”

Further analogue studies from the same time (e.g., Chaikin et al 1976) emphasized the need for a consulting room to be a “warm, intimate” place to facilitate greater self-disclosure. Another focused primarily on the therapist’s attire and office decorations, but said nothing about furniture and its arrangements (Amira and Abramowitz, 1979). More recent research (e.g., Miwa and Hanyu, 2006) also focuses on lighting and decorations while, again, saying little about furniture and its arrangement.

A 2011 study (Nasar and Devlin), also with students, uncovered several interesting findings: a warmer, more intimate space consists largely of using more classical wood materials rather than colder and harder steel and concrete, or brick; plants are very often a encouraging sign of vitality; the display of diplomas almost universally increases perceptions of the clinician’s trustworthiness and credibility; and a messy desk is rated more positively than an excessively neat one (which is seen as somewhat stiff and cold, or as Freud might say, anal retentive!). 

A significant difference in this study is that “We sampled real environments: 30 offices used by psychotherapists” (p.311). Test subjects were shown real photographs of offices, mostly in Manhattan. From this it emerged that subjects ranked matters thus: “Neatness and chair comfort were rated as most important, followed by order, space, style, and color. The first two items were judged significantly more important than were the rest” (p. 317). It’s important to note here that the “chair” in question is the therapist’s chair, pictures of which were shown to subjects in this study—the discussion of furniture here was limited to this one chair only. As they note in conclusion, “Although the therapist’s chair was the focus of the photograph that respondents viewed…client seating could be the focus of future study.”

A 2013 study (Devlin et al), using the same method as the study just mentioned from 2011, this time asked a cross-cultural group of subjects to look at pictures of the therapist’s chair and office surrounding it. Here it was found that among student populations in the US, Turkey, and Vietnam (more than 1/3 of whom had been to therapy at least once) there was consensus on things like colour, neatness, perceived “softness” and “orderliness” of the offices, but no substantial comment on furniture arrangement beyond noting that “participants rated chair comfort as highest in importance, and neatness and orderliness among the most important attributes in influencing their judgments” (p.15). Once again, the reference here is to the therapist’s chair only, and nothing was said about its position in the room.

Another 2011 study, a qualitative survey of practicing psychologists, has yielded fascinating data into how they see their offices, how they arrange them, and how strongly they have a desire to have control over such elements. The authors began by admitting that “psychologists’ offices have been largely absent from contemporary theoretical and methodological discussions of therapeutic environments.” They note that “in general, the therapeutic setting should be a holding environment; psychologists and their offices should provide comfortable and secure environments within which clients feel free to communicate sensitive information” (Watkins and Anthony, 2011, p.2). That use of “holding environment” is of course a signature idea of object-relations theory, which these authors explicitly reference several times, especially the works of Winnicott and Klein. I found it very encouraging that they admitted “If necessary, a few psychologists were even willing to rearrange furniture for specific clients” (p.8).

Three other studies recognize a lack of data. Gass (1984) has admitted with commendable candor that “Recommendations that concern the seating arrangement in therapy are based more on intuition than on empirical research,” which accords with my initial suspicions (see below).

In one of the longest and most comprehensive studies I’ve yet found, surveying a wide variety of clinicians (psychiatrists, social workers, counsellors, etc.) in many contexts, the author (Backhaus, 2008) noted that research over the last forty years has rarely focused on arrangements of furniture and related details in consulting rooms before going on to argue that “the seating arrangement in the therapeutic environment is perhaps the most controversial aspect of the physical environment of the therapy room. Based on results from several studies, there does not appear to be one recommended method for seating arrangement” (p.22). Whence comes this controversy she mentions? The author does not say. But it is noteworthy, and reassuring, that there is not one prescribed arrangement everybody must universally follow.

She does go on to tip her hand somewhat, nothing that “in intimate situations, both parties often sit next to each other versus across the room from one another” (p.23). Her most valuable suggestion, to my mind, is that clinicians should be “offering clients several seating options including chairs that can be easily moved” (p.22). I think this is extremely wise: flexibility and a focus on what the person prefers should be uppermost considerations in the design of a consulting room.

The most recent research by Jackson confirms the gap first noted by Gass in 1984. Jackson (2018) admits that “Despite its importance, the subject of the therapist's office has been largely absent from contemporary literature, with a few exceptions.” 

Interestingly, she does quote a 1988 book, Psychotherapy Tradecraft: The Technique and Style of Doing Therapy, by a former APA President Theodore Blau, who does have some concrete recommendations over furniture and its arrangement. She quotes him as having “encouraged thoughtful seating options that ‘consider comfort and convenience,’ and that ‘the most comfortable and orthopaedically correct seating possible is strongly recommended in order to avoid back problems’ for the therapist.” She also later avers to “the use of chairs that are moveable or large enough to allow clients to choose their positions, providing a sense of control over their environment” (p. 235). Once again, then, we see there is encouragement to be flexible and have one’s furniture be portable. I find this exactly right and most encouraging. 

Beyond peer-reviewed journals other reflections (e.g., Saari, 2002) remain vague about clinical environments, as do APA  and a handful of other professional blogs I have seen, which talk in generalities about office design and patient-therapist arrangements, always emphasizing that patient needs come first, which is exactly right. 

In sum, then, and putting this preliminary literature review together, then, and recognizing that it doesn’t pretend to be exhaustive but I think fairly representative nonetheless, I have thus far found very little specific, explicit, concrete, and repeated evidence (or even discussion) justifying SOLER. 

Given that I’ve not found much evidence so far, I can’t help but return to my original suspicion that perhaps SOLER arrangements began as a personal preference (from someone like Rogers perhaps?) that has then been simply copied by others without much thought or research precisely in the same manner as Freud’s famous couch was almost mindlessly copied with no comment, let alone deeper reflection or empirical study, in the psychoanalytic literature for the better part of a century. 

Only very recently, in fact, have two fascinating books been published looking critically at the role of couches: Kravis, 2017; and Gerald, 2019. He himself only justified the couch by saying that he could not stand being looked at for 8 hours a day, but otherwise wrote nothing about the couch, which seems to have been a holdover from his early attempts at using hypnotherapy.

Is it possible, then, that SOLER arrangements remain as undertheorized and under-researched as Freud’s couch? Gass, Backhaus, and Jackson all strongly suggest as much. I think, therefore, that there are strong arguments to be made about alternate arrangements, some of which, some of the time, for some people, may well prove to be more therapeutically effective than SOLER.

Here are my arguments and concerns with the presuppositions in the literature:

Constantly facing people square on presupposes that they want you to do that, that they are comfortable with such an arrangement, and that their progress in therapy will be helped, not hindered, by such an arrangement. I do not make those assumptions, and would want, as part of an intake process or after a preliminary session, to invite people to express their preferences and, at the next and subsequent sessions, to position themselves as they wish. If therapists are there to serve patients, then surely these latter need to have some choice as to posture and position in the consulting room.

Why do I say that? Four reasons. First, as Judith Herman’s Trauma and Recovery and other books in traumatology suggest, severely traumatized patients often feel like they have few or no choices, and feel profoundly disempowered. Giving them even modest choice and power to decide things, she says, is important in therapy.

Second, does SOLER presuppose a Western audience—and even within such an audience presuppose that every “Westerner” is comfortable with such an arrangement? Do we know if other cultures would be equally at home with such an arrangement? I've found little evidence that this question has even occurred to previous researchers apart from the Devlin et al study discussed above. Thus I have to wonder: Is it not possible that some cultures would find a SOLER arrangement if not threatening then at the very least considerably uncomfortable, perhaps so much so that therapeutic progress is attenuated?

Third, my own experience as an analysand of course enters here. I found the couch very helpful in recounting especially bizarre dreams or traumatic memories. These things were hard enough to vocalize to begin with, but I’m quite sure I’d never have gotten into them if I had to face my analyst. (Indeed, for our first three intake sessions, when facing her in a chair, I danced around a lot of stuff, speaking only in extremely vague generalities because I couldn’t talk about certain things while having to make eye contact. Once on the couch, however, it was easier to begin, however gingerly, to wade into deep and dark waters.)

Fourth, I have had difficult conversations with students on campus while walking side-by-side and not facing each other, as well as with my own son, neither of which would, I wager, have gone successfully and smoothly if my interlocutor was forced to look me in the eye the whole time.  

For all these reasons, then, I would invite people in my consulting room to one of three arrangements. First would be the SOLER arrangement—two chairs face to face. (Some people, I know, really do prefer that arrangement.) Second would be to have an additional chair placed beside my own, both facing the same direction, slightly angled and with a modest gap (e.g., small table) between them. Thus a person could choose to sit either across from or beside me. The third option would be a couch. And I would invite people to make use of both chairs and the couch as they saw fit, without requiring that they be consistent. Some days they might feel the need to lie down; others to sit but not face me; and still others, to see me and know I’m there. I'm quite happy with their doing whatever they need to from session to session. 

There are, I must confess in conclusion, some perhaps more "selfish" reasons connected to the fact that I know my own posture could be misinterpreted, and that my own tolerance for leaning in and constantly facing someone would be diminished if not exhausted after a time. For me, sitting with hands behind my head, or arms crossed, are often postures for me not of being closed, but of being more physically comfortable and thus freed up to listen more carefully. I find that when trying to listen more deeply with my “third ear” (Reik 1948) to hear what else the person might be saying unconsciously or trying to avoid saying, I sometimes find it very helpful not to lean in and maintain eye contact, but to sit back and look off into the distance or even close my eyes, trying to catch, in Eliot’s lovely words,

The voice of the hidden waterfall
And the children in the apple-tree
Not known, because not looked for
But heard, half-heard, in the stillness
Between two waves of the sea.

++++++++++++++++++

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Reik, Theodore (1948). Listening with the Third Ear: the Inner Experience of a Psychoanalyst. New York: Farrar Strauss & Co.

Saari, Carolyn (2002). The Environment: Its Role in Psychosocial Functioning and Psychotherapy. New York: Columbia  University Press.

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