A client says, “I come in week after week and complain about the same thing. Do you ever get tired of my complaining? Are we getting anywhere?”
These two questions are critical to the process of psychotherapy. Both questions are intertwined, linking and conflating assessment of psychotherapy progress with the client’s need for approval and the therapist’s concern about efficacy. The client wants to be a good client and the therapist wants to be a good therapist.
Most clients wonder what their therapist thinks of him or her, are fearful of the worst, and are afraid to ask. This is often the subtext of therapeutic conversations, wedded to the transference that relationally bridges core feelings of self-worth with perceptions of others. When brought to the surface, the conversations that ensue are often relieving, mobilizing, and liberating the client to speak more honestly.
Equally important is the question “are we getting anywhere.” This speaks to the broader issue of how to assess psychotherapy progress, and in this case, a long-term psychotherapy. It is also connected to the therapist’s self worth and ability to examine the possibility of ineffectiveness and failure as well as to examine theoretical assumptions that often have counter-transferential significance. If a therapist has to always be good, then the question, are we getting way is translated into am I good enough. If a therapist believes that every therapy is a long-term process, then a lull will more likely be seen as simply a pause.
Each therapy has its own rhythm, mood and tone that change over time. It is not unusual for the rhythm of therapy to ease into a lull where not much seems to be happening either in the client’s life or in therapy. It is not self-evident whether these periods represent a transitional phase, the flattened gradient of the working through process, or a sign that the therapy is nearing the end.
This skill set needed to assess psychotherapy progress should be an integral part of the psychotherapist’s toolbox. This navigational skill is more than a rating form. It enables the therapist to recognize the subtle signs of progress, the non-overt signs of a negative transference, the significance of lulls, and to have some sense of direction and focus that extends over time. The skill set becomes ever more complex within the trajectory of a long-term psychotherapy.
This skill set has become particularly relevant in our era of evidence-based treatment, where there is growing pressure for accountability and for this accountability to be measured. Long-term therapy by definition exceeds the time-limited framework of evidence-based treatment. While it is beyond the scope of this essay to critically examine the issues that evidence-based treatment raise, therapists have a responsibility to assess the extent of progress, the quality of the therapeutic relationship, and make a determination when therapy is not working.(1) If there is anything instructive about evidence-based treatment, it is the challenge to develop subjective, collaborative, and qualitative guidelines that are appropriate to the complexity of a long-term in-depth psychotherapy.
The slope of therapy inevitably levels out. The client might start sessions by saying I have nothing to talk about today or wonder about coming every week. The therapist might feel tired, bored, or distracted, and relieved when sessions end or the client cancels. These are crossroads in therapy that first and foremost need to be recognized as such. Therapeutic crossroads present opportunities for a thoughtful, mutual assessment of therapeutic progress.
Many therapies conveniently end at this point where both therapist and client unconsciously and or implicitly agree to not go further without exploring the deeper unexpressed feelings that have been tailing the therapy like a ghost. Conversely, there are therapies that just keep on going interminably fueled by habit and convenience. In these cases, the implicit contract, that the client keeps talking and the therapist keeps listening (and getting paid) is never questioned. It is comforting to work with a client who you like and who trusts and values you. For multiple reasons it is difficult to end these relationships.
In the blogs that follow I will explore case examples that illustrate an approach to assessing psychotherapy progress that is individualized, subjective and collaborative.
1 The Heart & Soul of Change: Delivering What works in Therapy. edited by Duncan, B.L., Miller, S.D., Wampold, B.E., & Hubble, M.A. 2010, Second Edition explores the findings from 6 decades of psychotherapy research, including a critiques of evidenced-based treatment.
On more than one occasion, I have left home after an early morning argument with my wife needing to clothe myself in the comfort of therapeutic garb and do for others what seems so difficult to do for myself: break the “doer/done to” cycle of he said/she said. So I prepared for my first client of the day who I had not seen in several weeks since because of vacations. He is a thoughtful individual who has been struggling in a marriage characterized by years of chronic conflict. Prior to my vacation, he had reached a bleak point following a bad argument with his wife that led to a brief separation.
In the morning session, he described feeling much better, and felt that he had turned a corner. He described how he had gone to a bookstore and bought a copy of Thich Nhat Hahn’s book, Anger Wisdom for Cooling the Flames. He told me that the turning point occurred when he was able to shift focus from how he was being hurt by his wife to how he was hurting her. This turn seemed so simply stated, yet significant. From this perspective he was able hear his wife’s words not as criticisms but as statements about how she felt. In the past, he saw himself as a passive victim, a nice guy who always accommodated and tried to be helpful. In reactions to his wife’s perceived“ criticisms” he felt devalued, hurt, and victimized and would lash out.
As I listened to my client, I felt the unsettling recognition that he could be describing me. The thought occurred to me that perhaps I had something to learn not only from my client but also from my wife.
The shift from looking at how one is being treated to how one is treating another represents a radical change in perspective, a relic of ancient wisdom enabling one to move from a self-centered focus to an empathic one. Making this shift is a herculean task for the heroic ego that reacts to psychological injury with flight, flight or submission, each with its concomitant distorted view of reality. This shift involves moving outside the ego’s comfort zone into a space influenced by the other. It challenges the ego’s determination to be right and its need to feel safe. It opens the doors to mutuality.
“Wear the projection” is a supervisory suggestion made to psychotherapists in training. It is a way to teach empathy. It asks them to take in and absorb what the client says about them in order to understand their client’s perspective. Wearing the projection is antidote to being trapped in an endless “doer-done to” cycle. It is a complex effort of self-reflection that involves vulnerability, openness to others, and the ability to step back from the emotional heat of a discussion.
Wearing the projection is a process that can be broken down for illustration into a set of steps that operationalizes empathy. First, empathy emerges out of a certain mindset that I am calling psychological mindedness. This mindset understands that reality is a blend of multiple perspectives and that one’s thoughts and feelings reflect one’s subjectivity and not reality. Second, it involves realizing when one is emotionally activated and its impact on experience. Emotional activation is typically a call to action, hardwired in our brains. Psychological mindedness recognizes activation as a signal to pause and think about what is happening. Why am I feeling so riled? Am I overreacting? Reflection is critical to empathy in that it leads to the understanding that one’s emotional reactions might be influenced by past experiences that color present perception. Third, having done the difficult work of thinking about experience, one is ready to wear the projection. Wearing the perception can feel like putting a shoe on the wrong foot. This discomfit represents the experience of change that involves breaking down the attachment to old and faulty ideas and sorting through the debris to discover new ideas. And this discomfit needs to be tolerated in order to empathize with another and learn from experience.
Wearing the projections leads you into the realm of paradox and possibility. Making room for the other’s perspective entails mental wizardry to create a space that didn’t exist within the impasse of “doer-done-to.” My wife and I are having a heated discussion. She says. ”Stop yelling at me.” I reply automatically, “I am not yelling.” The conversation can devolve into a she said/I said impasse. What if we are both right? We are both activated. I am not yelling in my mind and I am yelling in her ears. If we both recognize this duality, then we can move forward. If neither of us recognizes this, then we are stuck. If only one of us recognizes this, then there is an asymmetry that most likely reflects a fault line in the relationship.
Christopher Bollas, a psychoanalyst, described in The Shadow of the Object the “self- analytic element” which is the capacity to receive “news from the self” in relationship to others. This idea of “news” represents the capacity to understand something new and different about oneself in relation to others. Relationships, especially close relationships, can be seen as x-rays of the psyche that provide valuable information about the self.
Often we are either too busy seeking approval or too defended to be open to receiving “news.” Bollas suggest that in between projection, the casting out of pre-conceived notions of how things are and introjection, the taking in something you already know there is evocation, which involves the creation of a new mental experience. Vulnerability, empathy, and evocation provide the possibility for both personal transformation within a relationship and resolution of interpersonal conflict.
The Lithuanian philosopher Emanuel Levinas has articulated a radical relationship between individuality and empathy in his book Alterity and Transcendence. He states, “It is my inescapable and incontrovertible answerability to the other that makes me an individual ‘I’. This idea translates into a principal of “hospitality” where one puts aside one’s assumptions, prejudices, beliefs, and convictions, and stretches to view oneself and others through the eyes of the Other.
How have I hurt my wife? What is valid in the “accusations” that she has communicated to me over the years: “you’re don’t realize how angry you are; you’re too sensitive, you take everything I say as criticism?” If I were to think of her comments not as criticisms, but as statements having valuable information, what would I learn about myself? Is there something that I have not been able or ready to see? Am I that angry person who can only see how he has been hurt?
I ended my morning session and still couldn’t shake the anger-hurt. My wife had said mean things. She needs to recognize how she hurt me and what her role is in our conflict. I could not see beyond my pain. Justifying my position, obsessing about the things she said fed the anger that kept the wound alive.
My schedule could not have been better planned. My next appointment was a couple that I had not seen for a while. For years they had engaged in brutal verbal battles that had resisted the efforts of a battalion of well-intentioned therapists. The viciousness of their accusations and cross-accusations were painful to sit with. It seemed that they couldn’t talk to each other even in a therapist’s office without activating rage. They were bound to each other, both unwilling to end the relationship.
At my wits end, short of terminating what seemed like futile work, I set a limit on their abusive conversation in my office. At the end of a very disturbing session, I said that we needed to change how we worked. I forbade them to make comments about what their spouse was doing or not doing to them and insisted that they could only communicate how they were feeling, their emotional pain. I asked them to shift focus from what was being done to them to what in their nature was being activated in the relationship.
Deeply pained by the cruelty of their rage, I wanted to understand my anger. “Wear the projection of an angry, overly sensitive man,” I said to myself. Yes my wife had said hurtful things, and yes there was validity to my anger. And yes the hurt was interwoven with past hurts that I had been carrying with me that were not always apparent.
So I tried on the projection. I went through a day remembering and forgetting to notice my reactions to people and things. I became increasingly aware over many days and many cycles of rupture and repair with my wife of two antithetical poles of my personality: One pole collected frustration, burdens, hurt, and disappointment. It operated quietly, secretively, and semi-autonomously. It felt anger, resentment and bitterness and acted accordingly. It generated self-justified explanations for its behavior. And it didn’t communicate directly. The other pole was infinitely giving and forgiving, patient and willing to go the extra mile. However, this quality wasn’t simply a virtue, but a duty that insistently tugged at me to do the right thing.
The two poles of my multi-sided-self neither knew each other nor realized that there was more to me than these two sides. This was news! The space of possibility had been sandwiched between accommodating and resenting. Seeing things exclusively from either side led to misperceptions of others and to a foreshortening of my self. Getting into this middle ground opened up the possibility of discovering “news” from myself and from others.
To my surprise the couple took my prescription to heart. In the next session, the wife was able to describe how at the core of her pain was the feeling of being overwhelmed, alone and abandoned. She had felt the burden of having to do it all by herself throughout her childhood. Feeling burdened in the marriage enraged her, and she would become volatile. Her husband stated how he hated unreliable and volatile women because of his childhood growing up with an alcoholic mother. Seeing signs of instability in his wife freaked him out, leading to rage.
Before this couple could recognize what they were doing to each other, they needed to feel their own pain and not simply as a reaction to their spouse. They also needed desperately to have their pain felt and understood by their spouse. When they were able to do this, they were able to see how their behavior not only contributed to their conflict, but also perpetuated their own suffering. Past hurt had been fused with the present in such a deep way that their partner had come to represent everything that was hurtful in their life.
The ability to transcend one’s limitations and empathize with others bridges the gap that separates and alienates individuals, and feeds the conflicts that threaten our world. Empathy undoes the “doer-done-to” dynamic that perpetuates cycles of endless repetition. It addresses the Other and allows for the possibility of mutual recognition and connection.
Changing personal belief systems, narratives of how one sees the world, is the last thing that most people would think could be beneficial. Individuals have an implicit set of beliefs that organize their perceptions of the world and ground their reality, particularly how they see themselves and others. These beliefs are woven into the fabric of their identity. Like a map, it delineates the psycho-emotional geography of interpersonal space. To give up these beliefs is equivalent to asking a person to surrender their identity or a leopard to change its spots. Yet these beliefs are often what cause and perpetuate interpersonal conflict, and ironically stand in the way of realizing one’s deeper self.
Personal beliefs are a product of unconscious and conscious factors strongly influenced by interactions with parents and significant others across development. However flattering it is to assume that we are the architects of our beliefs, they are not simply ideas one picks off a shelf. They are cognitive-emotional complexes embedded so deeply in our being that they seem hard-wired into our brains.
While many psychological qualities exist on a continuum between rigidity and malleability, stressful life situations can activate recurrent, rigid emotional reactions, the default of our being-in-the-world. Such reactions are most apparent in intimate relationships.
After listening to many couples describe their difficulties in couples therapy, I am no longer surprised by how differently each individual in the couple sees the relationship. Usually couples therapy begins as a tale of two relationships. These tales are often organized around unrecognized psychological pain and trauma, the baggage that individuals bring into relationships. Many individuals unwittingly see their world through a wound-broken lens that is dissociated from its painful origins. Each new insult or disappointment is experienced as a virgin insult. The hard work of therapy when successful leads to a narrative that transforms the two stories into a shared third that recognizes the pain at the heart of the difficulty.
Jessica Benjamin (1), a contemporary psychoanalytic theorist, describes how most relationships struggle with mutual recognition. Mutual recognition depends on the ability of two individuals to recognize, accept, and appreciate each other’s subjectivity, i.e. their differences. It involves each individual managing the conflict between assertion of self and recognition of the other. The crux of the conflict is simple: the person who we need recognition from is also the person who needs recognition from us. Couples need to learn how to share their subjectivities.
In other words to get a little, we need to give a little. Or to quote Lennon and McCartney, “And in the end, the love you take
is equal to the love you make.” This simple principle that is taught in preschools seems so difficult for adults to practice in their intimate relationships and seems almost contrary to human nature. One only has to look at the level of violent, unrelenting cruelty for evidence.
What makes this lesson taught in preschool so difficult for adults to incorporate into their close relationships? So much of our psychological energy is devoted to the development of our individuality, giving voice to our uniqueness, worrying about and protecting our self-worth. To this end, we sacrifice relational skills. From the narrow perspective of the self, relationships are challenging and potentially threatening. We want to be liked, validated, and respected for our ideas and opinions, especially by the people closest to us. Our need for love is intertwined with our need recognition on our terms. This need for recognition stands in conflict with our partner’s need to be recognized. When push comes to shove, when identity seems on the line, most individuals either push back or retreat: fight or flight. And this battle line is often drawn around the most inconsequential issues.
Many relationships that struggle with mutual recognition go through repeated cycles of break down and repair without learning from experience. Benjamin describes the breakdown of mutuality in terms of complimentary or “doer-done to” relationships. In “doer-done to” relationships each person feels unable to gain the other’s recognition, and feels misunderstood, devalued, and judged, in other words, “done to” by the other. Ironically, both individuals occupy the same position without recognizing how they are “doing-to” their partner what they feel their partner is doing to them.
The resolution of this impasse challenges the self to change perspective: its narrative of self and other that is deeply woven into the cloak of identity. Making such changes often feels like surrendering power. A complaint I have heard from clients who are frustrated with their spouse criticisms is “This is the way I am. She/he wants me to change who I am!”
Intimate relationships present an opportunity for self-transformation. Psychological development hinges on the individual’s ability to balance autonomy with dependence, assertion of self with recognition of the other, and assimilation of the new with accommodation of the old. The idea of the autonomous individual is a cultural construct that doesn’t recognize the value of inter-dependence.
- Jessica Benjamin has written extensively about mutual recognition and psychoanalytic theory. Her writing style is dense and complicated, but worth the effort. To read her directly, go to https://www.msu.edu/~lotz/classes/f2006intersubjectivity/pdfs/benjamin%20recognition%20and%20destruction.pdf “Recognition and destruction” is a chapter from her book Like Subjects, Love Objects: Essays on Recognition and Sexual Difference. (1995) New Haven: Yale University Press.
As I dip into the sixth decade of my life with the growing consciousness of one who is aging, an awareness that frequently startles itself with the longing to be young, I feel the impossibility of summation or balance in my thinking, and a ground swell of questions and contradictory thoughts. This dilemma in contrast to the mid-life crisis of my 40’s is a somatically driven realization of a changing biology: a personal evolution pitching spirit/soul against soma, where the ultimate dialectics of Being wrestle their near final bout: body aches contend with ambition, desire dusted with new parameters, and a passing thought that this upheaval, this graying sturm and drang is adolescence revisited. Ah to be young again…but in an aging body: curse, blessing, and ironic twist of life?
The irony of this belated coming to age is irrepressible: after years of struggling to come of age, which often translates into fumbling efforts to realize one’s idealized version of self, one reaches a certain psychological summit. One might naively assume perspective comes from such a perch. Yet experience of having been young colludes with self-deception to sustain the internal perception of youth. This subjective baseline transports one through life’s stages, forever tempting one with illusory possibilities.
As I approached 60, I spent an inordinate amount of time wondering how people perceived me. Did I look old was the question I often asked as I sat down at a restaurant, or at a professional meeting. The puzzling counterpoint was represented by my internal self-image of a young man. I would look at people who appeared younger and see them as older. I knew the self that looked out represented a perennially young, distorted state of mind. Over time, I realized that my self-consciousness was an integral part of coming to terms with aging. I was slowly internalizing my age: I am 60 not 40, not 50, but 60. When I caught myself peering through my youth-tinged glasses, I performed this corrective.
Acceptance has never been an easy task, and yet never so compatible with development than at this stage of life. The aging process speaks through a language of aches and complaints that pose a series of unavoidable existential questions and create a gradient of difficulty that youth ill-prepares us for. Coming to terms with one’s age involves engagement with one’s aging body, the limits that it imposes, and reconciling this body with one’s mercurial psyche.
Acceptance is a process and not a singular event. Realizing that I am 60 solved one problem: I understood what I was not. This helped me to reel in my efforts to recreate youth and helped in adjusting my expectations about what I could and could not do. Closing the door on youth opened another door full of questions. What does 60 mean? What can I expect from 60? What is unique and emergent at this stage of life?
My enthusiasm rubs against cautiousness. My historic diet of apprehension feeds on it’s old self leaving me hungry for new, “age-appropriate” adventure, not for youthful recreations, but to discover what can only be realized at a certain point in one’s life when one understands there are diminished abilities and lost possibilities.
“Believe those who are seeking the truth, doubt those who find it.”
– Andre Gide
In The Heart and Soul of Psychotherapy: Delivering What Works, second edition, the author’s review decades of psychotherapy outcome research. The findings clearly affirm the value of psychotherapy. The research indicates that 80% of individuals who receive psychotherapy benefit in comparison to those who don’t. Beyond this reassuring data, the research challenges certain assumptions that many therapists hold as well as assumptions underlying evidence-supported therapy.
The research indicates that psychotherapy effectiveness is the result of common factors that different theoretical orientations share. The effectiveness of different therapeutic approaches is attributed to common factors that activate natural healing resources within the individual. The research does not support the specificity hypothesis that underlies evidence-supported therapy nor the idea that one therapeutic approach is better than another. No single approach is effective for all individuals and each particular approach needs to be tailored to the specific individual in distinction to the often over-generalized diagnostic category to achieve optimal results.
In examining the common factors that are associated with change, the research indicates that client variables are most strongly associated with psychological change. Client variables include factors such as motivation, degree of impairment, and the availability of both internal and external resources. The most important contribution that therapists make is their ability to form and sustain a collaborative therapeutic relationship tailored to the specific needs of individual clients. Somewhat sobering is the conclusion that therapeutic technique and placebo have comparable effects on promoting change and are of much less importance than either client variables or the therapeutic relationship.
Three interrelated research findings concerning the therapeutic relationship are noteworthy and have implications for increasing clinical effectiveness as well as for training.
- It is the client’s perception of the therapeutic relationship and not the therapist’s that is associated with positive therapeutic change.
- Therapists and clients perceptions are not always in agreement.
- Clients tend not to share their negative perceptions with therapists.
The therapeutic relationship is a complex, non-linear, intersubjective process that requires ongoing mutual feedback to optimize clinical effectiveness. Difficulty in this relationship is often imperceptible and not readily communicated. Appearances can be deceiving. When there is turbulence and conflict in therapy, it might signify progress. When therapy is moving smoothly, it might belie collusion and accommodation. Since there is a gradient of disagreement between therapist and client perceptions of the therapeutic relationship, the authors encourage clinicians to actively monitor the therapeutic relationship by eliciting feedback from their clients. Since clients typically don’t share negative feelings about therapy, therapists need to be sensitive to implicit, subtle signs that signal problems as well as to signs that conventionally signify progress. Since clients typically don’t share their negative feelings, therapists need to invite and re-invite them to share their feelings about therapy, both positive and negative. The research indicates that avoidance of these signs leads to negative therapeutic outcomes. Through my practice, I have learned that clients often communicate their dissatisfaction with their feet..
Therapeutic effectiveness derives neither from technique, nor from the elegance or sophistication of our theories. What differentiates effective from less effective therapists is their brilliance but their empathic ability to establish and sustain a therapeutic relationship. Statistics as well as theoretical reconstructions break down at the strange and unpredictable interface where two individuals come together and create what Bion called an “emotional storm.” Contending with this interpersonal storm that is characterized by ambiguity, mystery, and interpersonal disjunction is perhaps one of the greatest challenges of doing psychotherapy. The meaning gap between two individuals is a persistent, subtle and variable component of communication.
Effective therapists face this difficulty with empathy that simultaneously facilitates understanding of the client while enabling them to de-center from their perspective. Am I pushing too hard, am I missing something in the client’s narrative, does what I say make sense to you are questions to pose to clients. They exhibit a quality of humility that allows them to adjust their interventions to the needs of their clients. I have often thought with some clients I work like a CBT therapist might, with other likes an analyst, and others like a friend. The ability to hold lightly not only one’s theory but also one’s subjectivity, what Donna Orange has referred to as “theoretical fallabilism,” creates the space for client’s growth. This ability to de-center, to turn the activity of assertion into the passivity of reception and welcome the presence of the client is critical to therapeutic collaboration and subsequent changes within the client.