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. 

On the Working/Therapeutic Alliance and its Measurement

I recently finished reading B.L. Duncan et al, eds., The Heart and Soul of Change: Delivering What Works in Therapy, 2nd ed. (APA Press, 2010). Like all academic collections, this one is uneven, with some chapters managing the unpleasant trick of overpromising and being very thinly sourced, putting one in mind of that 1980s Wendy's commercial "Where's the beef?" 

But two chapters alone are worth the price of the book, and have changed my thinking (and soon my clinical practice!) in a couple of significant ways. These are chapters four ("The Therapeutic Relationship" by John Norcross) and eight ("Yes, It is Time for Clinicians to Routinely Monitor Treatment Outcome" by Michael Lambert). 

Before we get to them, just a few brief comments on the first part of the volume. In the Preface, the editors note that what unites this volume is that it "brings the psychotherapist back into focus as a key determinant of ultimate treatment outcome--far more important than what the therapist is doing is who the therapist is" (xxviii). This is indeed a common theme and welcome focus throughout the book, and it highlights what has often been discussed--but without as much depth--elsewhere: the personhood and personality of the clinician matters far above theoretical orientation, technical prowess, and all the rest. 

The Hideous Effects of the Market are Still Here: 

As we move into the introduction, the editors begin, in my view, to strain credulity somewhat in repeatedly asserting rather flatly that the mania for different models is over ("the fire for the novel, different, and exotic therapies has for the most part been extinguished") and thus proclaim that 'the great 'battle of the brands'" is behind us (25). I am distinctly unconvinced of this, however much I wish it were so. 

The Challenges We Face:

Some sobering facts are laid out in the introduction, some of them picked up later in the book for discussion, including the fact that those who need and want to pursue therapy are often put off by doing so not just by cost but also real doubt about its efficacy, which doubt leads "nearly half of those who begin psychotherapy [to] quit" (31) early on. This has been much commented on elsewhere, but for all that still amazes me. 

How to Account for Variable Outcomes?

Again and again this book lays out impressive evidence that "much of the variability in outcomes in therapy is due to the therapist" (31) and to the "therapeutic relationship" (37) or the therapeutic/working alliance, the power of which is attested to "in more than 1000 findings." A positive alliance is repeatedly demonstrated in the clinical literature as "one of the best predictors of outcome" (37).

Key Components of the Alliance:

The editors briefly outline that an alliance involves three things:

i) "agreement about the tasks and goals of therapy";

ii) a "cogent rationale" that offers an "adequate explanation for the presenting problems"; and

iii) a "set of procedures consistent with the rationale" that will aid towards the accomplishment of the goals in a way the patient can see and understand.

One of the valuable lessons I have heard from both of my supervisors this year is that if you set goals beyond what the patient wants to do or where to go, you will find that s/he will not follow, and so-called resistance will manifest itself. Equally I have learned from both that if you get out too far in front of the person in trying to hurry them along towards the goals, you will turn around and find yourself standing alone. Thus you need, as the editors say here, always to remember "the importance of starting where the client is" (38). 

If you find the person is not with you, or that things are generally out of alignment, then the editors recommend that you simply ask the person what their views are of the goals, alliance, and relationship. This will be the crucial theme developed in the fourth chapter. 

The Gifts in Front of You at the Very Outset: 

Before that, however, let me just posit some theses drawn from the third chapter, "Clients: The Neglected Common Factor in Psychotherapy" by A.C. Bohart and K. Tallman who note, inter alia, that we cannot overlook the phenomena of:

• self-generated change
• spontaneous recovery
• a person's existing strengths
• resilience
• post-traumatic growth
• integration and adaptation of what happens in therapy according to extant ways of thinking and living in the life of the patient.

It is important to take stock of all this from the very beginning and figure out ways you can draw on these gifts in the work that lies ahead.

These authors go on to note that the research indicates how rarely "particular techniques" are mentioned when patients are surveyed about their experiences in therapy. Instead, "studies have consistently shown that" what is emphasized and remembered includes "feeling understood," having "support" to deal with problems but also try out new behaviours, and a "safe space" (or, as I prefer, following Winnicott, a healthy holding environment) for all this to take place. 

What Kind of Therapist Not to Be:

Later in the chapter the authors outline problematic behaviours from therapists that will almost certainly contribute to treatment failure or collapse. These include therapists who:

• are authoritarian
• are prone to hurtful remarks
• are not good listeners
• are aloof, distant, unresponsive
• are too dissimilar in personality from the patient
• are unwilling to offer ideas or practical exercises or advice.

To the above I would want to add something I have learned from reading Jonathan Shedler: therapists who do not challenge their patients to change and grow are also not helping them, and the relationship, if it consists only of affirming and supporting, will prove less than fruitful.

That having been said, everything turns on how the challenges are posed. These authors note later in the chapter that "controlled research trials, particularly in the addictions field, consistently find a confrontational style to be ineffective" (130). Instead, the therapist needs to manifest empathy, be able to deal with resistance, support self-efficacy, and bring discrepancies to the fore; all these, they say, are characteristic of motivational interviewing. 

The Therapeutic Relationship:

We come now to Norcross' chapter of the above name. It repeats some of the findings from earlier in the book about the centrality of the therapeutic relationship over and above theory and technique. 

But it goes on to make a point that I have only once, and briefly, encountered before in a more informal manner, and that was from reading Yalom's The Gift of Therapy, where he will regularly ask patients "How are we--you and I--doing?" as a way of gauging the therapeutic relationship and any possible ruptures to it. When I read that book earlier this year I filed Yalom's question away and thought I might bring it out on occasion. But Norcross, in this chapter, has thoroughly convinced me that it needs to be brought out systematically and regularly, not least because he says (in a finding I have seen repeated elsewhere), "psychotherapists are comparatively poor at gauging their client's experiences of their empathy and the alliance" (117). In fact, therapists very regularly, and by an alarmingly wide margin, overestimate the strength of the alliance and underestimate the problems in it and the patient's willingness to walk away from it with little or no notice. 

To avoid these blind spots and biases, therapists, Norcross says, must regularly ask for feedback from patients to see how the working alliance is, and to repair it when that becomes necessary, as it regularly will. The methods and challenges of asking for such feedback are taken up by Lambert in the eighth chapter, which has some invaluable references to published research, some examples of which you can, happily and helpfully, find online in places such as this. 

Measuring the Working Alliance:

Lambert and others (including Scott Miller, linked above) have been pioneers in developing short, practical, accessible, and easy methods of soliciting regular feedback from patients, not least because without it "practitioners grossly underestimate negative outcomes" (240). 

Before going on, let me record here my previous unreflective snobbery for modern psychology's fetish for measurement. Much of that is still merited (especially towards the rest of the social sciences), but on this issue Lambert's chapter has totally changed my mind. I don't want to sound like a convert, because all converts to anything are a pest whom one should regard with deep suspicion and keep well clear of, but let me record my gratitude for having been forced take account of the evidence that Lambert and others have amassed in an impressive and convincing manner. 

What evidence is that, you ask? There is evidence, first--as noted above--that therapists are not good at discerning the strength of the alliance, or anticipating breaches. There is evidence, second--again noted above--that half of people who begin in therapy never finish and drop out very often because of deficiencies in the relationship, therapist, or both. And finally, and most important here, there is increasing evidence that therapists who solicit and respond to regular feedback "about client progress" see much improved outcomes for those predicted to be at risk of deteriorating or dropping out entirely. 

Looking at studies in both Europe and North America, Lambert has noted dramatic decreases in drop-out and deterioration rates by patients whose therapists regularly sought and used their feedback. He goes on to review a variety of recent mechanisms to solicit this feedback, noting strengths and weaknesses of each. He does all this "because the empirical literature has shown that the quality of the therapeutic alliance is consistently related to outcome" (247). 

Additional benefits of using such feedback include the ease with which such mechanisms fit in to a diversity of approaches: one can use them "regardless of theoretical orientation." For them to work, of course, they need to be brief and easy to follow, and to my mind the best one is the four-question model illustrated in the Miller, Duncan et al article linked above and here. It is certainly something I want to start using. 

If you are like I was, and still skeptical about this, then you very much want to review this chapter in detail, and the very considerable bibliography it provides of additional studies and evidence. Other chapters in the book may be of value to you as well. 

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!