The gift of therapy yalom

The gift of therapy yalom

• 3. Dedication to Marilyn, soul mate for overfiftyyears. still counting.
• 4. Contents Dedication Introduction Acknowledgments Chapter1 - Remove the ObstaclestoGrowth Chapter2 - AvoidDiagnosis(ExceptforInsurance Companies) Chapter3 - Therapistand Patientas“Fellow Travelers” Chapter4 - Engage the Patient Chapter5 - Be Supportive Chapter6 - Empathy: LookingOutthe Patient’sWindow Chapter7 - Teach Empathy Chapter8 - Let the PatientMatter to You Chapter9 - Acknowledge YourErrors Chapter10 - Create a NewTherapyforEach Patient Chapter11 - The TherapeuticAct,Notthe TherapeuticWord Chapter12 - Engage in Personal Therapy Chapter13 - The TherapistHas Many Patients;The Patient,One Therapist Chapter14 - The Here-and-Now—UseIt,Use It,Use It Chapter15 - Why Use the Here-and-Now? Chapter16 - Usingthe Here-and-Now—Grow RabbitEars Chapter17 - Searchfor Here-and-Now Equivalents Chapter18 - WorkingThroughIssuesinthe Here-and-Now Chapter19 - The Here-and-Now EnergizesTherapy Chapter20 - Use Your OwnFeelingsasData Chapter21 - Frame Here-and-NowCommentsCarefully Chapter22 - All IsGrist for the Here-and-Now Mill Chapter23 - Checkintothe Here-and-Now EachHour Chapter24 - What LiesHave You ToldMe? Chapter25 - BlankScreen?ForgetIt!Be Real Chapter26 - Three Kindsof TherapistSelf-Disclosure Chapter27 - The Mechanismof Therapy—Be Transparent Chapter28 - RevealingHere-and-Now Feelings—Use Discretion Chapter29 - Revealingthe Therapist’sPersonal Life—Use Caution Chapter30 - RevealingYourPersonal Life—Caveats Chapter31 - TherapistTransparencyandUniversality Chapter32 - PatientsWill ResistYourDisclosure Chapter33 - Avoidthe CrookedCure Chapter34 - On TakingPatientsFurtherThanYouHave Gone Chapter35 - On BeingHelpedbyYourPatient Chapter36 - Encourage PatientSelf-Disclosure Chapter37 - FeedbackinPsychotherapy Chapter38 - Provide FeedbackEffectivelyandGently Chapter39 - Increase ReceptivenesstoFeedbackbyUsing“Parts,” Chapter40 - Feedback:Strike Whenthe IronIsCold Chapter41 - TalkAboutDeath Chapter42 - Deathand Life Enhancement Chapter43 - How to TalkAboutDeath Chapter44 - TalkAboutLife Meaning Chapter45 - Freedom Chapter46 - HelpingPatientsAssume Responsibility Chapter47 - Never(AlmostNever) Make Decisionsforthe Patient
• 5. Chapter48 - Decisions:A ViaRegiaintoExistential Bedrock Chapter49 - Focuson Resistance toDecision Chapter50 - FacilitatingAwarenessbyAdvice Giving Chapter51 - FacilitatingDecisions—OtherDevices Chapter52 - ConductTherapyas a ContinuousSession Chapter53 - Take Notesof Each Session Chapter54 - Encourage Self-Monitoring Chapter55 - WhenYour PatientWeeps Chapter56 - Give Yourself Time BetweenPatients Chapter57 - ExpressYourDilemmasOpenly Chapter58 - Do Home Visits Chapter59 - Don’tTake ExplanationTooSeriously Chapter60 - Therapy-AcceleratingDevices Chapter61 - Therapyas a Dress Rehearsal forLife Chapter62 - Use the Initial ComplaintasLeverage Chapter63 - Don’tBe Afraidof TouchingYour Patient Chapter64 - NeverBe Sexual withPatients Chapter65 - Look forAnniversaryandLife-StageIssues Chapter66 - NeverIgnore “TherapyAnxiety,” Chapter67 - Doctor, Take AwayMy Anxiety Chapter68 - On BeingLove’sExecutioner Chapter69 - Takinga History Chapter70 - A Historyof the Patient’sDailySchedule Chapter71 - How Isthe Patient’sLife Peopled? Chapter72 - Interview the SignificantOther Chapter73 - Explore PreviousTherapy Chapter74 - Sharingthe Shade of the Shadow Chapter75 - FreudWas NotAlwaysWrong Chapter76 - CBT Is NotWhat It’s CrackedUp to Be … Or, Don’tBe Afraidof the EVT Bogeyman Chapter77 - Dreams—Use Them,Use Them, Use Them Chapter78 - Full Interpretationof aDream?Forget It! Chapter79 - Use DreamsPragmatically:Pillage andLoot Chapter80 - Master Some DreamNavigational Skills Chapter81 - Learn Aboutthe Patient’sLife fromDreams Chapter82 - PayAttentiontothe FirstDream Chapter83 - AttendCarefullytoDreamsAboutthe Therapist Chapter84 - Beware the Occupational Hazards Chapter85 - Cherishthe Occupational Privileges Notes P. S - Insights,Interviews&More . . . Aboutthe author Aboutthe book Readon OtherWorks byIrvinD. Yalom,M.D. Copyright Aboutthe Publisher Introduction It isdark. I come to your office hutcan’tfindyou.Your office is
• 6. empty.Ienterand lookaround.The onlythingthere isyour Panamahat. Andit isall filledwithcobwebs. My patients’dreamshave changed.Cobwebsfillmyhat.My of- fice isdark and deserted.Iamnowhere tobe found. My patientsworryaboutmyhealth:Will Ibe there forthe longhaul of therapy?WhenIleave forvacation,theyfearI will neverreturn.Theyimagine attendingmyfuneral orvisitingmy grave. My patientsdonotletme forgetthat I grow old.But theyare onlydoingtheirjob:Have I not askedthemtodisclose all feel- ings,thoughts,anddreams?Evenpotential new patientsjoin the chorus and,withoutfail,greetme withthe question:“Are youstill takingonpatients?” One of ourchief modesof deathdenial isabelief inper- sonal specialness,aconvictionthatwe are exemptfrombiolog- ical necessityandthatlife will notdeal withusinthe same harsh wayit dealswitheveryone else.Iremember,manyyears ago, visitinganoptometristbecause of diminishingvision.He askedmyage and thenresponded:“Forty-eight,eh?Yep,you’re righton schedule!” Of course I knew,consciously,thathe wasentirelycorrect, but a cry welledupfromdeepwithin:“Whatschedule?Who’s on schedule?Itisaltogetherrightthatyou andothersmay be on schedule,butcertainlynotI!” Andso it isdauntingtorealize thatI am enteringadesig- natedlaterera of life.Mygoals,interests,andambitionsare changinginpredictable fashion.ErikErikson,inhisstudyof the life cycle,describedthislate-lifestage asgenerativity,a post-narcissismerawhenattentionturnsfromexpansionof oneself towardcare andconcernfor succeedinggenerations. Now,as I have reachedseventy,Icanappreciate the clarityof Erikson’svision.Hisconceptof generativityfeelsrighttome.I wantto pass on whatI have learned.Andassoonas possible. But offeringguidance andinspirationtothe nextgeneration of psychotherapistsisexceedinglyproblematictoday,because our fieldisinsuchcrisis.An economicallydrivenhealth-care systemmandatesaradical modificationinpsychologicaltreat- ment,andpsychotherapyisnowobligedtobe streamlined— that is,above all,inexpensiveand,perforce,brief,superficial, and insubstantial. I worrywhere the nextgenerationof effective psychother- apistswill be trained.Notinpsychiatryresidencytrainingpro- grams. Psychiatryisonthe verge of abandoningthe fieldof psychotherapy.Youngpsychiatristsare forcedtospecializein psychopharmacologybecausethird-partypayersnow reim- burse for psychotherapyonlyif itisdeliveredbylow-fee(in otherwords,minimallytrained)practitioners.Itseemscertain that the presentgenerationof psychiatricclinicians,skilledin bothdynamicpsychotherapyandinpharmacological treat- ment,isan endangeredspecies. What aboutclinical psychologytrainingprograms—the
• 7. obviouschoice tofill the gap?Unfortunately,clinical psychol- ogistsface the same marketpressures,andmostdoctorate- grantingschoolsof psychologyare respondingbyteachinga therapythat issymptom-oriented,brief,and,hence,reim- bursable. So I worryabout psychotherapy—abouthow itmaybe de- formedbyeconomicpressuresandimpoverishedbyradically abbreviatedtrainingprograms.Nonetheless,Iamconfident that, inthe future,a cohortof therapistscomingfroma variety of educational disciplines(psychology,counseling,social work,pastoral counseling,clinical philosophy) will continue to pursue rigorouspostgraduate trainingand,eveninthe crushof HMO reality,willfindpatientsdesiringextensivegrowthand change willingtomake anopen-endedcommitmenttotherapy. It isfor these therapistsandthese patientsthatIwrite The Gift of Therapy. THROUGHOUT THESE PAGES I advise studentsagainstsectar- ianismandsuggesta therapeuticpluralisminwhicheffective interventionsare drawnfromseveral differenttherapyap- proaches.Still,forthe mostpart,I work froman interpersonal and existentialframe of reference.Hence,the bulkof the advice that followsissuesfromone orthe otherof these twoBookNavigation JumpBack perspectives. Since firstenteringthe fieldof psychiatry,Ihave hadtwo abidinginterests:grouptherapyandexistential therapy.These are parallel butseparate interests:Idonotpractice “existential grouptherapy”—infact,Idon’tknowwhat that wouldbe.The twomodesare differentnotonly because of the format(thatis, a group of approximatelysixtonine membersversusaone-to- one settingforexistential psychotherapy) butintheirfunda- mental frame of reference.WhenIsee patientsingrouptherapyI workfrom an interpersonal frame of reference andmake the as- sumptionthatpatientsfall intodespairbecause of theirinabil- ityto developandsustaingratifyinginterpersonal relation- ships. However,whenIoperate fromanexistential frame of refer- ence,I make a verydifferentassumption:patientsfall intode- spairas a resultof a confrontationwithharshfactsof the humancondition—the“givens”of existence.Since manyof the offeringsinthisbookissue fromanexistential frameworkthat isunfamiliartomanyreaders,a brief introductionisinorder. Definitionof existential psychotherapy:Existentialpsy- chotherapyisa dynamictherapeuticapproachthatfocusesoncon- cernsrootedin existence. Let me dilate thisterse definitionbyclarifyingthe phrase “dynamicapproach.”Dynamichas botha layand technical definition.The laymeaningof dynamic(derivedfromthe Greek root dynasthai,tohave powerorstrength) implying forcefulnessorvitality(towit,dynamo,adynamicfootballrun- neror political orator) isobviouslynotrelevanthere.Butif that were the meaning,appliedtoourprofession,thenwhere isthe
• 8. therapistwhowouldclaimtobe otherthan a dynamicther- apist,inotherwords,a sluggishorinerttherapist? No,I use “dynamic”in itstechnical sense,whichretainsthe ideaof force but isrootedin Freud’smodel of mental func- tioning,positingthatforcesinconflictwithinthe individualgen- erate the individual’sthought,emotion,andbehavior.Further- more—andthisisa crucial point—these conflictingforcesexist at varyinglevelsof awareness;indeedsomeare entirelyuncon- scious. So existentialpsychotherapyisadynamictherapythat,like the variouspsychoanalytictherapies,assumesthatuncon- sciousforcesinfluence consciousfunctioning.However,it parts companyfromthe variouspsychoanalyticideologies whenwe askthe nextquestion:Whatisthe nature of the con- flictinginternalforces? The existential psychotherapyapproachpositsthatthe inner conflictbedevilingusissuesnotonlyfromourstruggle with suppressedinstinctualstrivingsorinternalizedsignificant adultsor shardsof forgottentraumaticmemories,butalso fromour confrontationwiththe “givens”of existence. Andwhat are these “givens”of existence?If we permitour- selvestoscreenoutor “bracket”the everydayconcernsof life and reflectdeeplyuponoursituationinthe world,we inevitably arrive at the deepstructuresof existence (the“ultimate con- cerns,”to use theologianPaul Tillich’sterm).Fourultimate concerns,to myview,are highlysalienttopsychotherapy: death,isolation,meaninginlife,andfreedom.(Eachof these ultimate concernswill be definedanddiscussedinadesig- natedsection.) Studentshave oftenaskedwhyIdon’tadvocate trainingpro- grams inexistential psychotherapy.The reasonisthatI’ve never consideredexistential psychotherapytobe a discrete,freestanding ideological school.Ratherthanattempttodevelopexistential psychotherapycurricula,Iprefertosupplementthe education of all well-traineddynamictherapistsbyincreasingtheirsensi- bilitytoexistentialissues. Processand content.Whatdoesexistential therapylooklike inpractice?To answerthatquestionone mustattendtoboth “content”and “process,”the twomajor aspectsof therapydis- course.“Content”isjustwhat itsays—the precise wordsspo- ken,the substantive issuesaddressed.“Process”referstoan entirelydifferentandenormouslyimportantdimension:the interpersonalrelationshipbetweenthe patientandtherapist. Whenwe ask aboutthe “process”of an interaction,we mean: What do the words(andthe nonverbal behavioraswell) tell us aboutthe nature of the relationshipbetweenthe partiesen- gagedin the interaction? If my therapysessionswere observed,one mightoftenlook invainfor lengthyexplicitdiscussionsof death,freedom, meaning,orexistential isolation.Suchexistential contentmay be salientforonlysome (butnotall) patientsatsome (butnot
• 9. all) stagesof therapy.Infact, the effectivetherapistshould nevertryto force discussionof anycontentarea: Therapy shouldnotbe theory-drivenbutrelationship-driven. But observe these same sessionsforsome characteristic processderivingfromanexistentialorientationandone willen- counteranotherstoryentirely.A heightenedsensibilitytoexis- tential issuesdeeplyinfluencesthe nature of the relationshipof the therapistandpatientandaffectseverysingle therapysession. I myself amsurprisedbythe particularformthisbookhas taken.I neverexpectedtoauthora bookcontainingasequence of tipsfortherapists.Yet,lookingback,Iknow the precise momentof inception.Twoyearsago,afterviewingthe Hunt- ingtonJapanese gardensinPasadena,Inotedthe Huntington Library’sexhibitof best-sellingbooksfromthe Renaissance in Great Britainand wanderedin.Three of the tenexhibitedvol- umeswere booksof numbered“tips”—onanimal husbandry, sewing,gardening.Iwasstruck thateventhen,hundredsof yearsago, justafterthe introductionof the printingpress,lists of tipsattractedthe attentionof the multitudes. Years ago,I treateda writerwho,havingflaggedinthe writ- ingof twoconsecutive novels,resolvednevertoundertake an- otherbookuntil one came alongand bither on the ass.I chuckledather remarkbut didn’treallycomprehendwhatshe meantuntil thatmomentin the HuntingtonLibrarywhenthe ideaof a bookof tipsbit me on the ass. Onthe spot,I resolved to put awayotherwritingprojects,tobeginlootingmyclinical notesandjournals,andto write an openlettertobeginning therapists. RainerMaria Rilke’sghosthoveredoverthe writingof this volume.Shortlybefore myexperience inthe HuntingtonLi- brary, I hadrereadhisLettersto a Young Poetand I have con- sciouslyattemptedtoraise myself tohisstandardsof honesty, inclusiveness,andgenerosityof spirit. The advice inthisbook isdrawnfrom notesof forty-five yearsof clinical practice.Itisan idiosyncraticmélange of ideas and techniquesthatIhave founduseful inmywork.These ideasare so personal,opinionated,andoccasionallyoriginal that the readerisunlikelytoencounterthemelsewhere.Hence, thisvolume isinnoway meantto be a systematicmanual;Iin- tendit insteadasa supplementtoa comprehensive training program.I selectedthe eighty-fivecategoriesinthisvolume randomly,guidedbymypassionforthe taskrather thanby any particularorderor system.Ibeganwitha listof more than two hundredpiecesof advice,andultimatelyprunedawaythose for whichI felttoolittle enthusiasm. One otherfactor influencedmyselectionof these eighty-five items.My recentnovelsandstoriescontainmanydescriptions of therapyproceduresI’ve founduseful inmyclinical workbut, since myfictionhasa comic,oftenburlesquetone,itisunclear to manyreaderswhetherIam seriousaboutthe therapy proceduresIdescribe.The Giftof Therapyoffersme anoppor- tunityto setthe record straight.
• 10. As a nuts-and-boltscollectionof favorite interventionsor statements,thisvolume islongontechnique andshortonthe- ory. Readersseekingmore theoretical backgroundmaywishto readmy textsExistentialPsychotherapyandThe TheoryandPrac- tice of GroupPsychotherapy,the motherbooksforthiswork. Beingtrainedinmedicineandpsychiatry,Ihave grown accustomedto the termpatient(fromthe Latinfattens—one whosuffersorendures) butIuse it synonymouslywithclient, the commonappellationof psychologyandcounselingtradi- tions.To some,the termpatientsuggestsanaloof,disin- terested,unengaged,authoritariantherapiststance.Butread on—Iintendtoencourage throughoutatherapeuticrela- tionshipbasedonengagement,openness,andegalitarianism. Many books,myown included,consistof alimitednumber of substantive pointsandthenconsiderablefillertoconnect the pointsina graceful manner.Because Ihave selectedalarge numberof suggestions,manyfreestanding,andomittedmuch fillerandtransitions,the textwillhave anepisodic,lurching quality. ThoughI selectedthese suggestionshaphazardlyandexpect manyreadersto sample these offeringsinanunsystematic manner,I have tried,as an afterthought,togroupthemina reader-friendlyfashion. The firstsection(1–40) addressesthe nature of the therapist-patientrelationship,withparticularemphasisonthe here-and-now,the therapist’suse of the self,andtherapistself- disclosure. The nextsection(41–51) turnsfrom processtocontentand suggestsmethodsof exploringthe ultimate concernsof death, meaninginlife,andfreedom(encompassingresponsibilityand decision). The third section(52–76) addressesavarietyof issuesaris- ingin the everydayconductof therapy. In the fourthsection(77–83) I addressthe use of dreamsin therapy. The final section(84–85) discussesthe hazardsandprivi- legesof beingatherapist. Thistextis sprinkledwithmanyof myfavorite specific phrasesandinterventions.Atthe same time Iencourage spon- taneityandcreativity.Hence donotview myidiosyncraticinter- ventions asa specificprocedural recipe;theyrepresentmyownper- spective andmyattemptto reachinside tofindmyownstyle and voice.Many studentswillfindthatothertheoretical positions and technical styleswill prove more compatibleforthem.The advice inthisbookderivesfrommyclinical practice with moderatelyhigh- tohigh-functioningpatients(ratherthan those whoare psychoticormarkedlydisabled) meetingonce or, lesscommonly,twice aweek,forafew monthstotwo to three years.My therapygoalswiththese patientsare ambitious: inadditiontosymptomremoval andalleviationof pain,Istrive to facilitate personalgrowthandbasiccharacter change.Iknow that manyof my readersmayhave a differentclinical situation:
• 11. a differentsettingwithadifferentpatientpopulationanda brieferdurationof therapy.Stillitismyhope that readersfind theirowncreative wayto adaptand applywhatI have learned to theirownparticularworksituation. Acknowledgments Many have assistedme inthe writingof thisbook.First,as al- ways,I am much indebtedtomywife,Marilyn,alwaysmyfirst and mostthoroughreader.Several colleaguesreadandexpertly critiquedthe entire manuscript:MurrayBilmes,PeterRosen- baum,DavidSpiegel,RuthellenJosselson,andSaul Spiro.A numberof colleaguesandstudentscritiquedpartsof the manuscript:Neil Brast,RickVanRheenen,Martel Bryant,Ivan Gendzel,RandyWeingarten,InesRoe,EvelynBeck,Susan Goldberg,Tracy Larue Yalom,and Scott Haigley.Membersof my professional supportgroupgenerouslygrantedme consid- erable airtime to discusssectionsof thisbook.Severalof my patientspermittedme toinclude incidentsanddreamsfrom theirtherapy.Toall,my gratitude. CHAPTER 1 Remove the ObstaclestoGrowth WhenI was findingmywayasa youngpsychotherapystudent, the most useful bookIreadwas KarenHorney’sNeurosisand Human Growth.Andthe single mostuseful conceptinthat bookwas the notionthatthe humanbeinghasan inbuilt propensitytowardself-realization.If obstaclesare removed, Horneybelieved,the individual will developintoamature,fully realizedadult,justasanacorn will developintoanoaktree. “Just as an acorn developsintoanoak…” What a wonder- fullyliberatingandclarifyingimage!Itforeverchangedmy approach to psychotherapybyofferingme anew visionof my work:My taskwas to remove obstaclesblockingmypatient’s path.I did nothave to do the entire job;Ididnot have to in- spiritthe patientwiththe desire togrow,withcuriosity,will, zestfor life,caring,loyalty,oranyof the myriadof charac- teristicsthatmake us fullyhuman.No,whatIhad to do wasto identifyandremove obstacles.The restwouldfollow automat- ically,fueledbythe self-actualizingforceswithinthe patient. I rememberayoungwidowwith,asshe putit, a “failed heart”—aninabilityevertolove again.Itfeltdauntingtoad- dressthe inabilitytolove.Ididn’tknow how todothat. But dedicatingmyself toidentifyinganduprootinghermanyblocks to loving?Icoulddo that. I soonlearnedthatlove felttreasonoustoher.Tolove an- otherwas to betrayherdeadhusband; itfeltto herlike pound- ingthe final nailsinherhusband’scoffin.Tolove anotheras deeplyasshe didherhusband(andshe wouldsettle fornoth- ingless) meantthather love forherhusbandhadbeenin
• 12. some wayinsufficientorflawed.Tolove anotherwouldbe self- destructive because loss,andthe searingpainof loss,wasin- evitable.Tolove againfeltirresponsible:she wasevil and jinxed,andherkisswasthe kissof death. We workedhardfor manymonthsto identifyall these obsta- clesto herlovinganotherman.For monthswe wrestledwith each irrational obstacle inturn.Butonce that wasdone,the pa- tient’sinternal processestookover:she metaman,she fell in love,she marriedagain.Ididn’thave toteach herto search,to give,tocherish,tolove—Iwouldn’thave knownhow todo that. A fewwordsaboutKarenHomey:Her name isunfamiliarto mostyoungtherapists.Because the shelf life of eminenttheo- ristsin ourfieldhasgrownso short,I shall,fromtime to time, lapse intoreminiscence—notmerelyforthe sake of paying homage butto emphasize the pointthatourfieldhasa long historyof remarkablyable contributorswhohave laiddeep foundationsforourtherapyworktoday. One uniquelyAmericanadditiontopsychodynamictheoryis embodiedinthe “neo-Freudian”movement—agroupof clini- ciansand theoristswhoreactedagainstFreud’soriginalfocus on drive theory,thatis,the notionthatthe developingindi- vidual is largelycontrolledbythe unfoldingandexpressionof inbuiltdrives. Instead,the neo-Freudiansemphasizedthatwe considerthe vast influence of the interpersonalenvironmentthatenvelops the individual andthat,throughoutlife,shapescharacter struc- ture.The best-knowninterpersonal theorists,HarryStack Sul- livan,ErichFromm, and KarenHorney,have beensodeeply integratedandassimilatedintoourtherapylanguage andprac- tice that we are all,withoutknowingit,neo-Freudians.One is remindedof MonsieurJourdaininMolière’sBourgeoisGentil- homme,who,uponlearningthe definitionof “prose,”exclaims withwonderment,“Tothinkthatall my life I’ve beenspeaking prose withoutknowingit.” CHAPTER 2 AvoidDiagnosis (ExceptforInsurance Companies) Today’spsychotherapystudentsare exposedtotoomuch emphasisondiagnosis.Managed-care administratorsdemand that therapistsarrive quicklyataprecise diagnosisandthen proceedupona course of brief,focusedtherapythatmatches that particulardiagnosis.Soundsgood.Soundslogical and efficient.Butithaspreciouslittle todowithreality.Itrepre- sentsinsteadanillusoryattempttolegislate scientificprecision intobeingwhenitisneitherpossible nordesirable. Thoughdiagnosisisunquestionablycritical intreatment considerationsformanysevereconditionswithabiological substrate (forexample,schizophrenia,bipolardisorders,major
• 13. affective disorders,temporal lobeepilepsy,drugtoxicity,or- ganic or braindisease fromtoxins,degenerative causes,or infectiousagents),diagnosisisoftencounterproductive inthe everydaypsychotherapyof lessseverelyimpairedpatients. Why? Forone thing,psychotherapyconsistsof agradual un- foldingprocesswhereinthe therapistattemptstoknow the pa- tientas fullyaspossible.A diagnosislimitsvision;itdimin- ishesabilitytorelate tothe otheras a person.Once we make a diagnosis,we tendto selectivelyinattendtoaspectsof the pa- tientthatdo not fitintothat particulardiagnosis,andcorrespondinglyoverattendtosubtle featuresthatappearto confirman initial diagnosis.What’smore,adiagnosismayact as a self-fulfillingprophecy.Relatingtoa patientasa “border- line”ora “hysteric”mayserve tostimulate andperpetuate those verytraits.Indeed,there isalonghistoryof iatrogenic influenceonthe shape of clinical entities,includingthe current controversyaboutmultiple-personalitydisorderandrepressed memoriesof sexual abuse.Andkeepinmind,too,the low reliabilityof the DSMpersonalitydisordercategory(the very patientsoftenengaginginlonger-termpsychotherapy). Andwhat therapisthasnotbeenstruckby how much easier it isto make a DSM-IV diagnosisfollowingthe firstinterview than muchlater,letus say,afterthe tenthsession,whenwe knowa great deal more aboutthe individual?Isthisnota strange kindof science?A colleague of mine bringsthispoint home to hispsychiatricresidentsbyasking,“If youare in per- sonal psychotherapyorare consideringit,whatDSM-IV diag- nosisdoyou thinkyourtherapistcouldjustifiablyuse tode- scribe someone ascomplicatedasyou?” In the therapeuticenterprisewe musttreada fine line be- tweensome,butnottoo much,objectivity;if we take the DSM diagnosticsystemtooseriously,if we reallybelievewe are truly carvingat the jointsof nature,thenwe maythreatenthe human,the spontaneous,the creative anduncertainnature of the therapeuticventure.Rememberthatthe cliniciansinvolved informulatingprevious,nowdiscarded,diagnosticsystemswere competent,proud,andjust as confidentasthe current membersof the DSMcommittees.Undoubtedlythe timewill come whenthe DSM-IV Chinese restaurantmenuformatwill appearludicroustomental healthprofessionals. CHAPTER 3 TherapistandPatientas“FellowTravelers” Andre Malraux,the Frenchnovelist,describedacountrypriest whohad takenconfessionformanydecadesandsummedup whathe had learnedabouthumannature inthismanner:“First of all,people are muchmore unhappythanone thinks… and there isno such thingas a grown-upperson.”Everyone—and that includestherapistsaswell aspatients—isdestinedto experience notonlythe exhilarationof life,butalsoitsin-
• 14. evitable darkness:disillusionment,aging,illness,isolation, loss,meaninglessness, painful choices,anddeath. No one putthingsmore starklyand more bleaklythanthe GermanphilosopherArthurSchopenhauer: In earlyyouth,aswe contemplate ourcominglife,we are like childrenina theaterbefore the curtainisraised,sittingthere inhighspiritsandeagerlywaitingforthe playtobegin.Itis a blessingthatwe donot knowwhatisreallygoingtohappen. Couldwe foresee it,there are timeswhenchildrenmight seemlike condemnedprisoners,condemned,nottodeath, but to life,andasyetall unconsciousof whattheirsentence means. Or again: We are like lambsinthe field,disportingthemselvesunder the eyesof the butcher,whopicksout one firstand thenan- otherfor hisprey.Soit isthat in our gooddayswe are all unconsciousof the evil thatFate may have presentlyinstore for us—sickness,poverty,mutilation,lossof sightorrea- son. ThoughSchopenhauer’sviewiscoloredheavilybyhisown personal unhappiness,still itisdifficulttodenythe inbuiltde- spairin the life of everyself-consciousindividual.Mywife andI have sometimesamusedourselvesbyplanningimaginarydin- nerpartiesfor groupsof people sharingsimilarpropensities— for example,apartyfor monopolists,orflamingnarcissists,or artful passive-aggressiveswe have knownor,conversely,a “happy”party to whichwe invite onlythe trulyhappypeoplewe have encountered.Thoughwe’ve encounterednoproblemsfill- ingall sorts of other whimsical tables,we’ve neverbeenable to populate afull table forour “happypeople”party.Eachtime we identifyafewcharacterologically cheerful peopleandplace themon a waitinglistwhilewe continue oursearchtocom- plete the table,we findthatone oranotherof our happyguests iseventuallystrickenbysome majorlife adversity—oftenase- vere illnessorthatof a childorspouse. Thistragic but realisticview of life haslonginfluencedmy relationshiptothose whoseekmyhelp.Thoughthere are many phrasesforthe therapeuticrelationship(patient/therapist,client/counselor, analysand/analyst,client/facilitator,and the latest—and,byfar,the mostrepulsive—user/provider),none of these phrasesaccuratelyconveymysense of the therapeutic relationship.InsteadIprefertothinkof my patientsandmyself as fellowtravelers,atermthatabolishesdistinctionsbetween “them”(the afflicted) and“us”(the healers).Duringmytrain- ingI was oftenexposedtothe ideaof the fullyanalyzedther- apist,butas I have progressedthroughlife,formedintimate relation-shipswithagoodmany of my therapistcolleagues, metthe seniorfiguresinthe field,beencalledupontorender helptomy formertherapistsandteachers,andmyself become
• 15. a teacherand an elder,Ihave come to realize the mythicnature of thisidea.We are all inthistogetherandthere isno therapist and no personimmune tothe inherenttragediesof existence. One of myfavorite talesof healing,foundinHermannHes- se’sMagisterLudi,involvesJosephandDion,tworenowned healers,wholivedinbiblical times.Thoughbothwere highly effective,theyworkedindifferentways.The youngerhealer, Joseph,healedthroughquiet,inspiredlistening.Pilgrimstrust- edJoseph.Sufferingandanxietypouredintohisearsvanished like wateronthe desertsandand penitentslefthispresence emptiedandcalmed.Onthe otherhand,Dion,the olderhealer, activelyconfrontedthosewhosoughthishelp.He divinedtheir unconfessedsins.He wasa great judge,chastiser,scolder,and rectifier,andhe healedthroughactive intervention.Treating the penitentsaschildren,he gave advice,punishedbyassigningpenance,orderedpilgrimagesand marriages,andcompelled enemiestomake up. The two healersnevermet,andtheyworkedasrivalsfor manyyears until Josephgrewspirituallyill,fell intodarkde- spair,and wasassailedwithideasof self-destruction.Unable to heal himself withhisowntherapeuticmethods,he setout on a journeytothe southto seekhelpfromDion. On hispilgrimage,Josephrestedone eveningatan oasis, where he fell intoaconversationwithanoldertraveler.When Josephdescribedthe purposeanddestinationof hispil- grimage,the travelerofferedhimself asa guide toassistinthe searchfor Dion.Later,in the midstof theirlongjourneyto- getherthe oldtravelerrevealedhisidentitytoJoseph.Mirabile dictu:he him-self wasDion—the verymanJosephsought. WithouthesitationDioninvitedhisyounger,despairingrival intohishome,where theylivedandworkedtogetherformany years.DionfirstaskedJosephtobe a servant.Laterhe elevated himto a studentand,finally,tofull colleagueship.Yearslater, Dionfell ill andonhisdeathbedcalledhisyoungcolleagueto himin orderto heara confession.He spoke of Joseph’searlier terrible illnessandhisjourneytooldDionto pleadforhelp.He spoke of howJosephhadfeltitwas a miracle thathis fellow travelerandguide turnedoutto be Dionhimself. Nowthat he was dying,the hourhad come,Diontold Joseph,tobreakhissilence aboutthatmiracle.Dionconfessed that at the time it hadseemedamiracle to himas well,forhe,too,hadfallenintodespair.He, too,feltemptyandspiritually deadand,unable to helphimself,hadsetoff ona journeyto seekhelp.Onthe verynightthattheyhad metat the oasishe was ona pilgrimage toafamoushealernamedJoseph. HESSE’S TALE HAS alwaysmovedme ina preternatural way.It strikesme as a deeplyilluminatingstatementaboutgivingand receivinghelp,abouthonestyandduplicity,andaboutthe rela- tionshipbetweenhealerandpatient.The twomenreceived powerful helpbutinverydifferentways.The youngerhealer was nurtured,nursed,taught,mentored,andparented.The
• 16. olderhealer,onthe otherhand,washelpedthroughservingan- other,throughobtainingadisciple fromwhomhe received filial love,respect,andsalve forhisisolation. But now,reconsideringthe story,Iquestionwhetherthese twowoundedhealerscouldnothave beenof evenmore service to one another.Perhapstheymissedthe opportunityforsome- thingdeeper,more authentic,more powerfullymutative.Per- haps the real therapyoccurredat the deathbedscene,when theymovedintohonestywiththe revelationthattheywere fel- lowtravelers,bothsimplyhuman,all toohuman.The twenty yearsof secrecy,helpful astheywere,mayhave obstructedand preventedamore profoundkindof help.Whatmighthave hap- penedif Dion’sdeathbedconfessionhadoccurredtwentyyears earlier,if healerandseekerhadjoinedtogetherinfacingthe questionsthathave noanswers? All of thisechoesRilke’sletterstoayoungpoetin whichhe advises,“Have patience witheverythingunresolvedandtryto love the questionsthemselves.”Iwouldadd:“Try to love the questionersaswell.” CHAPTER 4 Engage the Patient A greatmany of our patientshave conflictsinthe realmof inti- macy, andobtainhelpintherapysheerly throughexperiencing an intimate relationshipwiththe therapist.Some fearintimacy because theybelievethere issome-thingbasicallyunacceptable aboutthem,somethingrepugnantandunforgivable.Given this,the act of revealingoneself fullytoanotherandstill being acceptedmaybe the majorvehicle of therapeutichelp.Others may avoidintimacybecause of fearsof exploitation,colo- nization,orabandonment;forthem,too,the intimate and caring therapeuticrelationshipthatdoesnotresultinthe antic- ipatedcatastrophe becomesacorrective emotional experience. Hence,nothingtakesprecedence overthe care andmainte- nance of myrelationshiptothe patient,andIattendcarefullyto everynuance of howwe regard eachother.Doesthe patient seemdistanttoday?Competitive?Inattentive tomycomments? Doeshe make use of what I sayin private butrefuse toac- knowledge myhelpopenly?Isshe overlyrespectful?Obse- quious?Toorarelyvoicinganyobjectionordisagreements?De- tachedor suspicious?DoI enterhisdreamsordaydreams? What are the wordsof imaginaryconversationswithme?All these thingsIwantto know,and more.I neverletanhour go by withoutcheckingintoourrelationship,sometimeswithasimple statementlike:“How are youand I doingtoday?”or “How are youexperiencingthe space betweenustoday?” SometimesIaskthe patienttoprojectherself intothe future: “Imagine a half hourfromnow—you’re onyourdrive home, lookingbackuponour session.Howwill youfeel aboutyou and me today?What will be the unspokenstatementsor
• 17. unaskedquestionsaboutourrelationshiptoday?” CHAPTER 5 Be Supportive One of the greatvaluesof obtainingintensivepersonal therapy isto experienceforoneself the greatvalue of positive support. Question:Whatdopatientsrecall whentheylookback,years later,ontheirexperience intherapy?Answer:Notinsight,not the therapist’sinterpretations.More oftenthannot,they rememberthe positive supportivestatementsof theirtherapist. I make a pointof regularlyexpressingmypositive thoughts and feelingsaboutmypatients,alongawide range of at- tributes—forexample,theirsocial skills,intellectual curiosity, warmth,loyaltytotheirfriends,articulateness,courage infac- ingtheirinnerdemons,dedicationtochange,willingnessto self-disclose,lovinggentlenesswiththeirchildren,commit- mentto breakingthe cycle of abuse,anddecisionnottopass on the “hot potato”to the nextgeneration.Don’tbe stingy— there’snopointto it;there iseveryreasontoexpressthese observationsandyourpositivesentiments.Andbewareof emptycompliments—makeyoursupportasincisive asyour feedbackorinterpretations.Keepinmindthe therapist’sgreat power—powerthat,inpart,stemsfromour havingbeenprivy to our patients’mostintimate lifeevents,thoughts,andfan- tasies.Acceptance andsupportfromone whoknowsyouso intimatelyisenormouslyaffirming. If patientsmake an importantandcourageoustherapeutic step,complimentthemonit.If I’ve beendeeplyengagedinthe hour andregretthat it’scome to an end,I say that I hate to bringthishour to an end.And(a confession—everytherapist has a store of small secrettransgressions!) Idonothesitate to expressthisnonverballybyrunningoverthe houra few min- utes. Oftenthe therapististhe onlyaudience viewinggreatdra- mas and acts of courage.Such privilegedemandsaresponse to the actor. Thoughpatientsmayhave otherconfidants,none islikelytohave the therapist’scomprehensive appreciationof certainmomentousacts.Forexample,yearsagoa patient, Michael,a novelist,informedme one daythathe had just closedhissecretpostoffice box.Foryearsthismailbox had beenhismethodof communicationinalongseriesof clan- destine extramarital affairs.Hence,closingthe box wasa momentousact,and I considereditmyresponsibilitytoappre- ciate the great courage of hisact and made a pointof express- ingto himmy admirationforhisaction. A fewmonthslaterhe wasstill tormentedbyrecurringim- agesand cravingsfor his lastlover.Iofferedsupport. “You know,Michael,the type of passionyouexperienced doesn’teverevaporate quickly.Of course you’re goingtobe
• 18. revisitedwithlongings.It’sinevitable—that’spartof your humanity.” “Part of myweakness,youmean.IwishIwere a man of steel andcouldputher aside forgood.” “We have a name for such menof steel:robots.Anda robot,thank God,is whatyou are not. We’ve talkedoften aboutyour sensitivityandyourcreativity—theseare your richestassets—that’swhyyourwritingissopowerful and that’swhyothersare drawnto you.But these verytraitshave a dark side—anxiety—theymake itimpossible foryoutolive throughsuch circumstanceswithequanimity.” A lovelyexampleof areframedcommentthatprovided much comfortto me occurred some time agowhenI expressed my disappointmentata bad reviewof one of mybooksto a friend,WilliamBlatty,the authorof The Exorcist.He responded ina wonderfullysupportive manner,whichinstantaneously healedmywound.“Irv,of course you’re upsetbythe review. Thank God forit! If you weren’tsosensitive,youwouldn’tbe such a goodwriter.” All therapistswilldiscovertheirownwayof supportingpa- tients.Ihave an indelible imageinmymindof Ram Dass de- scribinghisleave-takingfromaguru withwhomhe had stud- iedat an ashram inIndiafor manyyears.WhenRam Dass lamentedthathe wasnot readyto leave because of hismany flawsandimperfections,his gururose andslowlyandvery solemnlycircledhiminaclose-inspectiontour,whichhe con- cludedwithanofficial pronouncement:“Isee noimperfections.”I’ve neverliterallycircled patients,visuallyin- spectingthem,andI neverfeel thatthe processof growthever ends,butnonethelessthisimage hasoftenguidedmycom- ments. Supportmay include commentsaboutappearance:some article of clothing,awell-rested,suntannedcountenance,anew hairstyle.If apatientobsessesaboutphysical unattractivenessI believethe humanthingtodois to comment(if one feelsthis way) that youconsiderhim/hertobe attractive andto wonder aboutthe originsof the mythof his/herunattractiveness. In a story aboutpsychotherapyinMommaand the Meaning of Life,myprotagonist,Dr.ErnestLash,is corneredbyan exceptionallyattractive female patient,whopresseshimwith explicitquestions:“AmIappealingtomen?Toyou?If you weren’tmytherapistwouldyourespondsexuallytome?” These are the ultimate nightmarishquestions—thequestions therapistsdreadabove all others.Itisthe fearof suchques- tionsthat causesmanytherapiststogive toolittle of them- selves.ButIbelievethe fearisunwarranted.If youdeemitin the patient’sbestinterests,whynotsimplysay,asmyfictional character did,“If everythingwere different,we metinanother world,Iwere single,Iweren’tyourtherapist,thenyes,Iwould findyouveryattractive andsure wouldmake anefforttoknow youbetter.”What’sthe risk? Inmy view suchcandor simplyin-
• 19. creasesthe patient’strustinyouand inthe processof therapy. Of course,thisdoesnotpreclude othertypesof inquiryaboutthe question—about,for example,the patient’smotivationor timing(the standard“Whynow?”question) orinordinate pre- occupationwithphysicalityorseduction,whichmaybe ob- scuringevenmore significantquestions. CHAPTER 6 Empathy:LookingOutthe Patient’sWindow It’sstrange how certainphrasesoreventslodge inone’smind and offerongoingguidance orcomfort.DecadesagoI saw a patientwithbreastcancer,whohad,throughoutadolescence, beenlockedinalong,bitterstruggle withhernaysayingfather. Yearningforsome formof reconciliation,foranew,fresh beginningtotheirrelationship,she lookedforwardtoherfa- ther’sdrivinghertocollege—atime whenshe wouldbe alone withhimfor several hours.Butthe long-anticipatedtripproved a disaster:herfatherbehavedtrue toformby grousingat lengthaboutthe ugly,garbage-litteredcreekbythe side of the road. She,onthe otherhand, sawno litterwhatsoeverinthe beautiful,rustic,unspoiledstream.She couldfindnowaytore- spondand eventually,lapsingintosilence,theyspentthe re- mainderof the triplookingawayfromeach other. Later, she made the same tripalone and wasastoundedto note that there were twostreams—oneoneachside of the road. “Thistime I wasthe driver,”she saidsadly,“andthe streamI saw throughmy windowonthe driver’sside wasjust as uglyand pollutedasmyfatherhaddescribedit.”Butby the time she hadlearnedtolook out herfather’swindow,itwas too late—herfatherwasdeadandburied. That story hasremainedwithme,andonmany occasionsI have remindedmyselfandmy students,“Lookoutthe other’s window.Tryto see the worldasyour patientseesit.”The womanwhotoldme thisstorydieda shorttime laterof breast cancer, andI regretthat I cannot tell herhow useful herstory has beenoverthe years,tome,my students,andmanypa- tients. Fiftyyearsago Carl Rogersidentified“accurate empathy” as one of the three essentialcharacteristicsof the effective ther- apist(alongwith“unconditional positiveregard”and“genuine- ness”) andlaunchedthe fieldof psychotherapyresearch,which ultimatelymarshaledconsiderableevidence tosupportthe effectivenessof empathy. Therapyisenhancedif the therapistentersaccuratelyinto the patient’sworld.Patientsprofitenormouslysimplyfromthe experience of beingfullyseenandfullyunderstood.Hence,itis importantforus to appreciate howourpatientexperiencesthe past,present,andfuture.Imake a pointof repeatedlychecking out myassumptions.Forexample:
• 20. “Bob, whenIthinkaboutyour relationshiptoMary,thisis whatI understand.Yousay youare convincedthatyouand she are incompatible,thatyouwantverymuchto separate fromher,that you feel boredinhercompanyandavoid spendingentireeveningswithher.Yetnow,whenshe has made the move youwantedand haspulledaway,youonce againyearnfor her.I thinkI hearyou sayingthatyou don’twantto be withher,yetyoucannot bearthe ideaof hernot beingavailablewhenyoumightneedher.AmIrightsofar?” Accurate empathyismostimportantinthe domainof the immediate present—thatis,the here-and-now of the therapy hour.Keepinmindthat patientsview the therapyhoursverydif- ferentlyfromtherapists.Againandagain,therapists,evenhighly experiencedones,are greatlysurprisedtorediscoverthisphe- nomenon.Notuncommonly,one of mypatientsbeginsan hour bydescribinganintense emotionalreactiontosomething that occurredduringthe previoushour,andI feel baffledand cannot forthe life of me imagine whatitwasthathappenedin that hourto elicitsucha powerful response. Such divergentviewsbetweenpatientandtherapistfirst came to myattentionyearsago,whenIwas conductingre- searchon the experienceof groupmembersinboththerapy groupsand encountergroups.Iaskeda great manygroup memberstofill outa questionnaire inwhichtheyidentifiedcrit- ical incidentsforeachmeeting.The richandvariedincidents describeddifferedgreatlyfromtheirgroupleaders’assess- mentsof each meeting’scritical incidents,andasimilardiffer- ence existedbetweenmembers’andleaders’selectionof the mostcritical incidentsforthe entire groupexperience. My nextencounterwithdifferencesinpatientandtherapist perspectivesoccurredinaninformal experiment,inwhichapa- tientandI each wrote summariesof eachtherapyhour.The experimenthasacurioushistory. The patient,Ginny,wasa gift- edcreative writerwhosufferedfromnotonlyasevere writing block,buta blockinall formsof expressiveness.A year’satten- dance in mytherapygroup wasrelativelyunproductive:She re- vealedlittleof herself,gave littleof herselftothe othermem- bers,and idealizedme sogreatlythatanygenuine encounter was notpossible.Then,whenGinnyhadtoleave the groupbe- cause of financial pressures,Iproposedanunusual exper- iment.Iofferedtosee herinindividualtherapywiththe proviso that, inlieuof payment,she write afree-flowing,uncensored summaryof eachtherapyhourexpressingall the feelingsand thoughtsshe hadnot verbalizedduringoursession.I,formy part, proposedtodo exactlythe same andsuggestedwe each handin our sealedweeklyreportstomysecretaryand that everyfewmonthswe wouldreadeachother’snotes. My proposal wasoverdetermined.Ihopedthatthe writing assignmentmightnotonlyliberatemypatient’swriting,buten- courage her to expressherself more freelyintherapy.Perhaps,I hoped,herreadingmynotesmightimprove ourrelationship.I
• 21. intendedtowrite uncensorednotesrevealingmyownexperi- encesduringthe hour:my pleasures,frustrations,distractions. It was possiblethat,if Ginnycouldsee me more realistically, she couldbegintode-idealizeme andrelate tome on a more humanbasis. (Asan aside,notgermane tothisdiscussionof empathy,I wouldaddthat thisexperience occurredata time when Iwas attemptingtodevelopmyvoice as a writer,andmy offerto write inparallel withmypatienthadalsoa self-servingmotive: It affordedme anunusual writingexercise andanopportunity to breakmy professional shackles,toliberatemyvoice by writ- ingall that came to mindimmediatelyfollowingeachhour.) The exchange of noteseveryfewmonthsprovideda Rashomon-like experience:Thoughwe hadsharedthe hour,we experiencedandremembereditidiosyncratically.Forone thing, we valued verydifferentpartsof the session.Myelegantand brilliantinterpretations?She neverevenheardthem.Instead,she valuedthe small personal actsIbarelynoticed:mycompli- mentingherclothingorappearance orwriting,myawkward apologiesforarrivingacouple of minuteslate,mychucklingat hersatire,my teasingherwhenwe role-played.* All these experienceshave taughtme notto assume thatthe patientandI have the same experienceduringthe hour.When patientsdiscussfeelingstheyhadthe previoussession,Imake a pointof inquiringabouttheirexperience andalmostalways learnsomethingnewandunexpected.Beingempathicisso much a part of everydaydiscourse—popularsingerswarble platitudesaboutbeinginthe other’sskin,walkinginthe oth- er’smoccasins—thatwe tendtoforgetthe complexityof the process.Itis extraordinarilydifficulttoknow reallywhatthe otherfeels;fartoooftenwe projectourown feelingsontothe other. Whenteachingstudentsaboutempathy,ErichFrommoftencitedTerence’sstatementfrom twothousandyearsago—“Iam humanand letnothinghumanbe alientome”—andurgedus to be opento that part of ourselvesthatcorrespondstoany deedor fantasyofferedbypatients,nomatterhow heinous, violent,lustful,masochistic,orsadistic.If we didn’t,he sug- gestedwe investigate whywe have chosentoclose thatpartof ourselves. Of course,a knowledgeof the patient’spastvastlyenhances your abilitytolookoutthe patient’swindow.If,forexample, patientshave sufferedalongseriesof losses,thentheywill viewthe worldthroughthe spectaclesof loss.Theymaybe disinclined,forexample,toletyoumatteror gettoo close be- cause of fearof sufferingyetanotherloss.Hence the investigationof the pastmaybe importantnotforthe sake of constructingcausal chainsbut because itpermitsusto be more accuratelyempathic. CHAPTER 7
• 22. Teach Empathy Accurate empathyis an essential traitnotonlyfortherapists but forpatients,andwe musthelppatientsdevelopempathyfor others.Keepinmindthatour patientsgenerallycome tosee us because of theirlackof successindevelopingandmaintaining gratifyinginterpersonal relationships.Manyfail toempathize withthe feelingsandexperiencesof others. I believethatthe here-and-now offerstherapistsapowerful wayto helppatientsdevelopempathy.The strategyisstraight- forward:Helppatientsexperience empathywithyou,andthey will automaticallymake the necessaryextrapolationstoother importantfiguresintheirlives.Itisquite commonforthera- piststo ask patientshowacertainstatementoractionof theirs mightaffectothers.Isuggestsimplythatthe therapistinclude himself inthatquestion. Whenpatientsventure aguessabouthow I feel,Igenerally hone inon it.If,for example,apatientinterpretssome gesture or commentand says,“You mustbe verytiredof seeingme,” or “I knowyou’re sorryyou evergotinvolvedwithme,”or“I’ve got to be your mostunpleasanthourof the day,” I will dosome realitytestingandcomment,“Isthere aquestioninthere for me?” Thisis,of course,simple social-skillstraining:Iurge the patienttoaddressor questionme directly,andIendeavorto answerina mannerthat is directandhelpful.Forexample,I mightrespond:“You’re readingme entirelywrong.Idon’thave any of those feelings.I’ve beenpleasedwithourwork.You’ve showna lotof courage,youwork hard,you’ve nevermisseda session,you’veneverbeenlate,you’ve takenchancesbyshar- ingso many intimate thingswithme.Ineverywayhere,youdo your job.ButI do notice that wheneveryouventure aguess abouthow I feel aboutyou,itoftendoesnotjibe withmyinner experience,andthe errorisalwaysinthe same direction:You readme as caring foryou muchlessthanI do.” Anotherexample: “I knowyou’ve heardthisstorybefore but…” (andthe pa- tientproceededtotell alongstory). “I’m struckby howoftenyousay that I’ve heardthe story before andthenproceedtotell it.” “It’sa bad habit,Iknow.I don’tunderstandit.” “What’s yourhunchabout howI feel listeningtothe same story overagain?” “Must be tedious.Youprobablywantthe hourto end— you’re probablycheckingthe clock.” “Is there a questioninthere forme?” “Well,doyou?” “I am impatienthearingthe same storyagain.Ifeel itgets interposedbetweenthe twoof us,as thoughyou’re notreallytalkingtome.Youwere right aboutmy checkingthe clock.I did—butitwaswiththe hope that whenyourstory
• 23. endedwe wouldstill have timeto make con-tactbefore the endof the session.” CHAPTER 8 Let the PatientMatterto You It was more thanthirtyyears agothat I heard the saddestof psychotherapytales.Iwasspendingayear’sfellowshipinLon- donat the redoubtable Tavistock Clinicandmetwitha prom- inentBritishpsychoanalystandgrouptherapistwhowasretir- ingat the age of seventyandthe eveningbefore hadheldthe final meetingof along-termtherapygroup.The members, manyof whomhad beeninthe groupfor more than a decade, had reflecteduponthe manychangestheyhadseeninone an- other,and all hadagreedthat there wasone personwhohad not changedwhatsoever:the therapist!Infact,theysaidhe was exactlythe same aftertenyears.He thenlookedupat me and, tappingonhis deskforemphasis,saidinhismostteacherly voice:“That,my boy,is goodtechnique.” I’ve alwaysbeensaddenedasIrecall thisincident.Itissad to thinkof beingtogetherwithothersforsolongand yetnever to have letthemmatterenoughtobe influencedandchanged by them.Iurge youto letyour patientsmattertoyou,to let thementeryourmind,influence you,change you—andnotto conceal thisfromthem. Years ago I listenedtoa patientvilifyingseveral of her friendsfor“sleepingaround.”Thiswastypical of her:she was highlycritical of everyoneshe describedtome.Iwonderedaloudaboutthe impactof her judgmentalismonherfriends: “What do youmean?”she responded.“Doesmyjudging othershave an impacton you?” “I thinkitmakesme waryof revealingtoomuchof my- self.If we were involvedasfriends,I’dbe cautiousabout showingyoumydarkerside.” “Well,thisissue seemsprettyblack-and-white tome. What’syour opinionaboutsuchcasual sex?Canyou per- sonallypossiblyimagine separatingsex fromlove?” “Of course I can. That’spart of our humannature.” “That repulsesme.” The hour endedonthat note and fordays afterwardIfelt unsettledbyourinteraction,andIbeganthe followingsession by tellingherthatithad beenveryuncomfortable forme to thinkthat she wasrepulsedbyme.She wasstartledbymy reac- tionand toldme I had entirelymisunderstoodher:whatshe had meantwasthat she was repulsedathumannature andat herown sexual wishes,notrepulsedbyme ormy words. Later inthe sessionshe returnedtothe incidentandsaid that thoughshe regrettedbeingthe cause of discomfortforme, she was nonethelessmoved—andpleased—athavingmat-
• 24. teredto me.The interchange dramaticallycatalyzedtherapy:in subsequentsessionsshe trustedme more andtookmuch greaterrisks. Recentlyone of mypatientssentme anE-mail: I love youbutI also hate youbecause youleave,notjustto ArgentinaandNewYorkand for all I know,toTibetand Tim- buktu,butbecause everyweekyouleave,youclose the door, youprobablyjustgo turn onthe baseball game orcheckthe Dow andmake a cup of tea whistlingahappytune and don’t thinkof me at all and whyshouldyou? Thisstatementgivesvoice tothe greatunaskedquestionfor manypatients:“Do youeverthinkaboutme betweensessions or do I justdrop outof yourlife forthe rest of the week?” My experienceisthatoftenpatientsdonotvanishfrommy mindforthe week,andif I’ve hadthoughtssince the lastses- sionthat mightbe helpful forthemto hear,I make sure to share them. If I feel I’ve made anerrorinthe session,Ibelieve itisal- waysbestto acknowledge itdirectly.Once apatientdescribeda dream: “I’m inmy oldelementaryschool andIspeakto a little girl whois cryingand has runout of herclassroom.I say, ‘You mustrememberthatthere are manywho love youand it wouldbe bestnotto run awayfrom everyone.’” I suggestedthatshe wasboththe speakerandthe little girl andthatthe dream paralleledand echoedthe verythingwe had beendiscussinginourlastsession.She responded,“Of course.” That nettledme:she characteristicallyfailedtoacknowledge my helpful commentsandtherefore Iinsistedonanalyzingher comment,“Of course.”Later,as I thoughtaboutthisunsat- isfyingsession,Irealizedthe problembetweenushadbeen due largelytomy stubborndeterminationtocrackthe “of course”in orderto obtainfull creditformyinsightintothe dream. I openedthe followingsessionbyacknowledgingmyimma- ture behavior,andthenwe proceededtohave one of our most productive sessions,inwhichshe revealedseveral important secretsshe hadlong withheld.Therapistdisclosure begetspa- tientdisclosure. Patientssometimesmatterenoughtoenterintomydreams and,if I believe thatitwill insome wayfacilitatetherapy,Ido not hesitate toshare the dream.I once dreamedthatI meta pa- tientinan airportand attemptedtogive hera hug butwas ob- structedby the large purse she washolding.Irelatedthe dream to herand connecteditto our discussioninourpreviousses- sionaboutthe “baggage”she broughtintoher relationship withme—thatis,herstrongand ambivalentfeelingstoward
• 25. herfather.She was movedbymysharingthe dreamand ac- knowledgedthe logicof myconnectingittoher conflationof herfatherand me,but suggestedanother,cogentmeaningto the dream—namely,thatthe dreamexpressesmyregretsthat our professionalcontract(symbolizedbythe purse,acontainer for money,towit,the therapyfees) precludedafullyconsum- matedrelationship.Icouldn’tdenythatherinterpretationmade compellingsense andthatitreflectedfeelingslurkingsome- where deepwithinme. CHAPTER 9 AcknowledgeYourErrors It was the analystD. W. Winnicottwhoonce made the tren- chant observationthatthe difference betweengoodmothers and bad mothersisnotthe commissionof errorsbutwhat they do withthem. I saw one patientwhohadleftherprevioustherapistfor whatmightappear a trivial reason.Intheirthirdmeetingshe had weptcopiouslyandreachedforthe Kleenex onlytofindan emptybox.The therapisthadthenbegunsearchinghisoffice invainfor a tissue or a handkerchief andfinallyscurrieddown the hall to the washroomto returnwitha handful of toilettis- sue.Inthe followingsessionshe commentedthatthe incident musthave beenembarrassingforhim, whereuponhe denied any embarrassmentwhatsoever.The more she pressed,the more he dugin andturnedthe questionsbacktowhy she per- sistedindoubtinghisanswer.Eventuallyshe concluded (rightly,itseemedtome) thathe had not dealtwithherinan authenticmanneranddecidedthatshe couldnottrust himfor the longwork ahead. An example of acknowledgederror:A patientwhohadsuf- feredmanyearlierlossesandwasdealingwiththe impending lossof her husband,whowasdyingof a braintumor,once askedme whetherIeverthoughtaboutherbetweensessions.Iresponded,“Ioftenthink aboutyour situation.”Wronganswer! My wordsoutragedher.“Howcouldyou say this,”she asked, “you,whowere supposedtohelp—you,whoaskme toshare my innermostpersonalfeelings.Thosewordsreinforce my fearsthat I have no self—thateveryone thinksaboutmysitu- ationand no one thinksaboutme.”Later she addedthatnot onlydoesshe have noself,butthat I alsoavoidedbringingmy ownself intomymeetingswithher. I broodedaboutherwordsduringthe followingweekand, concludingthatshe wasabsolutelycorrect,beganthe nextses- sionby owninguptomy error and byaskingherto helpme identifyandunderstandmyownblindspotsinthismatter. (Many yearsago I readan article by SándorFerenczi,agifted analyst,inwhichhe reportedsayingtoa patient,“Perhapsyou can helpme locate some of my ownblindspots.”Thisisan- otherone of those phrasesthathave takenup lodginginmy
• 26. mindand thatI oftenmake use of inmy clinical work.) Togetherwe lookedatmyalarm at the depthof heranguish and mydeepdesire tofindsome way,anywayshort of physical holding,tocomforther.Perhaps,Isuggested,Ihadbeenback- ingaway fromher inrecentsessionsbecause of concernthatI had beentooseductive bypromisingmuchmore reliefthanI wouldeverbe able todeliver.Ibelievedthatthiswasthe con- textformy impersonal statementabouther“situation.”It wouldhave beensomuchbetter,Itoldher, tohave simply beenhonestaboutmyachingto console herandmy confusionabouthow toproceed. If you make a mistake,admitit.Anyattemptat cover-upwill ultimatelybackfire.Atsome levelthe patientwill sense youare actingin bad faith,andtherapywill suffer.Furthermore,an openadmissionof errorisgoodmodel-settingforpatientsand anothersignthat theymatterto you. CHAPTER 10 Create a NewTherapyforEach Patient There isa greatparadox inherentinmuchcontemporarypsy- chotherapyresearch.Because researchershave alegitimate needtocompare one formof psychotherapytreatmentwith some othertreatment(pharmacological oranotherformof psychotherapy),theymustoffera“standardized”therapy—that is,a uniformtherapyforall the subjectsinthe projectthat can inthe future be replicatedbyotherresearchersandtherapists. (Inotherwords,the same standardsholdas in testingthe ef- fectsof a pharmacological agent:namely,thatall the subjects receive the same purityandpotencyof a drug andthat the exactsame drug will be availableforfuture patients.) Andyet that veryact of standardizationrendersthe therapylessreal and lesseffective.Pairthatproblemwiththe factthat somuch psy- chotherapyresearchusesinexperiencedtherapistsorstudent therapists,anditisnot hard to understandwhysuchresearch has,at best,a mosttenuousconnectionwithreality. Considerthe taskof experiencedtherapists.Theymust establisharelationshipwiththe patientcharacterizedbygen- uineness,positive unconditionalregard,andspontaneity.They urge patientstobegineachsessionwiththeir“pointof ur- gency”(as Melanie Kleinputit) andto explore withevergreater depththeirimportantissuesastheyunfoldinthe momentof encounter.Whatissues?Perhaps some feelingaboutthe ther- apist.Or some issue thatmay have emergedasa resultof the previous session,orfromone’sdreamsthe nightbefore the session.Mypointisthat therapyisspontaneous,the rela- tionshipisdynamicandever-evolving,andthere isacontin- uoussequence of experiencingandthenexaminingthe process. At itsverycore,the flowof therapyshouldbe spontaneous, foreverfollowingunanticipatedriverbeds;itisgrotesquelydis- tortedby beingpackagedintoaformulathat enablesinexpe-
• 27. rienced,inadequatelytrainedtherapists(orcomputers) tode- liverauniform course of therapy.One of the true abominations spawnedbythe managed-care movementisthe evergreater reliance onprotocol therapyinwhichtherapistsare requiredto adhere toa prescribedsequence,aschedule of topicsandexer- cisesto be followedeachweek. In hisautobiography,Jungdescribeshisappreciationof the uniquenessof eachpatient’sinnerworldandlanguage,a uniquenessthatrequiresthe therapisttoinventanew therapy language foreachpatient.PerhapsIam overstatingthe case, but I believe the presentcrisisinpsychotherapyissoserious and therapistspontaneitysoendangeredthataradical correc- tive isdemanded.We needtogoevenfurther:the therapist muststrive to create a newtherapyforeach patient. Therapistsmustconveytothe patientthattheirparamount task isto builda relationshiptogetherthatwill itselfbecome the agentof change.Itis extremelydifficulttoteachthisskill in a crash course usinga protocol.Above all,the therapistmust be preparedto go whereverthe patientgoes,doall thatis necessarytocontinue buildingtrustandsafetyinthe rela- tionship.Itryto tailorthe therapyfor eachpatient,tofindthe bestwayto work,and I considerthe processof shapingthe therapynotthe groundworkorprelude butthe essence of the work.These remarkshave relevance evenforbrief-therapypa- tientsbutpertainprimarilytotherapywithpatientsinaposi- tionto afford(or qualifyfor) open-endedtherapy. I try to avoidtechnique thatisprefabricatedanddobestif I allowmychoicesto flowspontaneouslyfromthe demandsof the immediate clinical situation.Ibelieve “technique”is facilitativewhenitemanatesfromthe therapist’suniqueen- counterwiththe patient.WheneverIsuggestsome intervention to my superviseestheyoftentrytocram it intothe nextsession and italwaysbombs.Hence I have learnedtopreface mycom- mentswith:“Do nottry thisin yournextsession,butinthissitu- ationI mighthave saidsomethinglike this.…”My pointis that everycourse of therapyconsistsof small andlarge sponta- neouslygeneratedresponsesortechniquesthatare impossible to pro-gramin advance. Of course,technique hasadifferentmeaningforthe novice than forthe expert.One needstechnique inlearningtoplaythe pianobut eventually,if one istomake music,one musttran- scendlearnedtechnique andtrustone’sspontaneousmoves. For example,apatientwhohadsufferedaseriesof painful lossesappearedone dayather sessioningreatdespair,having justlearnedof herfather’sdeath.She wasalreadysodeepin grief fromherhusband’sdeatha fewmonthsearlierthatshe couldnot bearto thinkof flyingbackto her parents’home for the funeral andof seeingherfather’sgrave nexttothe grave of herbrother,whohad diedat a youngage.Nor, onthe other hand,couldshe deal withthe guiltof not attendingherownfa- ther’sfuneral.Usuallyshe wasanextraordinarilyresourceful and effective individual,whohadoftenbeencritical of me and
• 28. othersfortryingto “fix”thingsfor her.But now she needed somethingfromme-—somethingtangible,somethingguilt- absolving.Irespondedbyinstructinghernottogo to the funeral (“doctor’sorders,”Iputit).InsteadIscheduledour nextmeetingatthe precise time of the funeral anddevotedit entirelytoreminiscencesof herfather.Twoyearslater,when terminatingtherapy,she describedhow helpful thissession had been. Anotherpatientfeltsooverwhelmedwithstressinherlife that duringone sessionshe couldbarelyspeakbutsimply huggedherself androckedgently.Iexperiencedapowerful urge to comfort her,to holdherand tell herthateverythingwas goingto be all right.I dismissedthe notionof ahug—she had beensexuallyabusedbyastepfatherandIhad to be partic- ularlyattentive tomaintainingthe feelingof safetyof ourrela- tionship.Instead,atthe endof the session,Iimpulsivelyofferedtochange the time of hernext sessiontomake itmore convenientforher.Ordinarilyshe hadtotake off work to visit me and thisone time I offeredtosee herbefore work,earlyin the morning. The interventiondidnotprovidethe comfortIhadhoped but still proveduseful.Recall the fundamentaltherapyprinciple that all that happensisgristfor the mill.Inthisinstance the pa- tientfeltsuspiciousandthreatenedbymyoffer.She wascon- vincedthatI didnot reallywanttomeetwithher,that our hourstogetherwere mylowpointof the week,andthat I was changingherappointmenttime formyown,nother,conve- nience.Thatledusintothe fertile territoryof herself-contempt and the projectionof herself-hatredontome. CHAPTER 11 The TherapeuticAct,Notthe TherapeuticWord Take advantage of opportunitiestolearnfrompatients.Make a pointof inquiringoftenintothe patient’sview of whatishelp- ful aboutthe therapyprocess.EarlierIstressedthattherapists and patientsdonotoftenconcur intheirconclusionsaboutthe useful aspectsof therapy.The patients’viewsof helpful events intherapyare generallyrelational,ofteninvolvingsome actof the therapistthatstretchedoutside the frame of therapyor some graphicexample of the therapist’sconsistencyandpres- ence.Forexample,one patientcitedmywillingnesstomeet withhimevenafterhe informedme byphone thathe wassick withthe flu.(Recentlyhiscouplestherapist,fearingcontagion, had cut shorta sessionwhenhe begansneezingandcough- ing.) Anotherpatient,whohadbeenconvincedthatIwould ultimatelyabandonherbecauseof herchronicrage,toldme at the endof therapythatmy single mosthelpfulinterventionwas my makinga rule to schedule anextrasessionautomatically whenevershe hadangryoutburststowardme. In anotherend-of-therapydebriefingapatientcitedaninci-
• 29. dentwhen,ina sessionjustbefore Ileftonatrip,she had handedme a story she hadwrittenandI had senther a note to tell herhowmuch I likedherwriting.The letterwasconcrete evidence of mycaringandshe oftenturnedtoitfor supportduringmyabsence.Checkinginby phone toa highlydis- tressedorsuicidal patienttakeslittle time andishighlymean- ingful tothe patient.One patient,acompulsiveshoplifterwho had alreadyservedjail time,toldme thatthe mostimportant gesture ina longcourse of therapywasa supportive phone call I made whenI wasout of town duringthe Christmasshopping season—atime whenshe wasoftenoutof control.She feltshe couldnot possiblybe soungrateful astosteal whenIhad gone out of my wayto demonstrate my concern.If therapistshave a concernabout fosteringdependency,theymayaskthe patient to participate indevisingastrategyof how theycan be most supportedduringcritical periods. On anotheroccasionthe same patientwascompulsively shopliftingbuthadso changedherbehaviorthatshe wasnow stealinginexpensiveitems—forexample,candybarsor ciga- rettes.Herrationale forstealingwas,asalways,thatshe need- edto helpbalance the familybudget.Thisbelief waspatently irrational:forone thing,she waswealthy(butrefusedtoac- quaintherself withherhusband’sholdings);furthermore,the amountshe savedby stealingwasinsignificant. “What can I do to helpyounow?”I asked.“How do we help youget past the feelingof beingpoor?”“We couldstart with yougivingme some money,”she saidmischievously.Where- uponI took outmy walletandgave herfiftydollarsinanenve- lope withinstructionstotake outof it the value of the itemthat she was aboutto steal.Inotherwords,she was to steal from me ratherthan the storekeeper. The interventionpermittedher to cut short the compulsive spreethathadtakencontrol of her, and a monthlatershe returnedthe fiftydollarstome.From that pointonwe referredoftentothe incidentwhenevershe usedthe rationalizationof poverty. A colleague toldme thathe hadonce treateda dancerwho toldhimat the endof therapythat the most meaningful actof therapywashisattendingone of herdance recitals.Anotherpa- tient,atthe endof therapy,citedmywillingnesstoperform aura therapy.A believerinNewAge concepts,she enteredmy office one dayconvincedthatshe wasfeelingillbecause of a rupture inher aura. She laydownon mycarpet and I followed herinstructionsandattemptedtoheal the rupture bypassing my handsfromheadto toe a fewinches.above herbody.Ihad oftenexpressedskepticismaboutvariousNew Age approaches and she regardedmyagreeingtoaccede to herrequestas a signof lovingrespect. CHAPTER 12 Engage in Personal Therapy
• 30. To my mind,personal psychotherapyis,byfar,the most importantpart of psychotherapytraining.Question:Whatisthe therapist’smostvaluableinstrument?Answer(andnoone missesthisone):the therapist’sownself.Iwill discussthe rationale andthe technique of the therapist’suse of self from manyperspectivesthroughoutthistext.Letme beginbysimply statingthat therapistsmustshowthe wayto patientsbyper- sonal modeling.We mustdemonstrateourwillingnesstoenter intoa deepintimacywithourpatient,aprocessthat requiresus to be adeptat miningthe bestsource of reliabledataaboutour patient—ourownfeelings. Therapistsmustbe familiarwiththeirowndarkside andbe able to empathize withall humanwishesandimpulses.A per- sonal therapyexperience permitsthe studenttherapisttoexpe- rience manyaspectsof the therapeutic processfromthe pa- tient’sseat:the tendencytoidealize the therapist,the yearning for dependency,the gratitudetowardacaring and attentive lis- tener,the powergrantedtothe therapist.Youngtherapists mustwork throughtheirownneuroticissues;theymustlearn to accept feedback,discovertheirownblindspots,andsee themselvesasotherssee them;theymustappreciate theirim- pact uponothersand learnhowto provide accurate feedback. Lastly,psychotherapyisapsychologicallydemandingenter- prise,andtherapistsmustdevelopthe awarenessandinner strengthto cope withthe manyoccupational hazardsinherent init. Many trainingprogramsinsistthatstudentshave a course of personal psychotherapy:forexample,some Californiagrad- uate psychologyschoolsnowrequire sixteentothirtyhoursof individualtherapy.That’sagoodstart—butonlya start. Self- explorationisalifelongprocess,andIrecommendthattherapy be as deepand prolongedaspossible—andthatthe therapist entertherapyat manydifferentstagesof life. My ownodysseyof therapy,overmyforty-five-yearcareer,is as follows:a750-hour, five-time-a-weekorthodox Freudian psychoanalysisinmypsychiatricresidency(withatrainingana- lystinthe conservative BaltimoreWashingtonSchool),ayear’s analysiswithCharlesRycroft(ananalystinthe “middle school” of the BritishPsychoanalyticInstitute),twoyearswithPat Baumgartner(a gestalttherapist),three yearsof psychotherapy withRolloMay (aninterpersonallyandexistentiallyoriented analystof the WilliamAlansonWhite Institute),andnumerous brieferstintswiththerapistsfromavarietyof disciplines, in- cludingbehavioral therapy,bioenergetics,Rolfing,marital- coupleswork,anongoingten-year(atthiswriting) leaderless supportgroupof male therapists,and,inthe 1960s, encounter groupsof a whole rainbowof flavors,includinganude marathongroup. Note twoaspectsof thislist.First,the diversityof approaches. It isimportantfor the youngtherapisttoavoidsectarianism and to gainan appreciationof the strengthsof all the varying therapeuticapproaches.Thoughstudentsmayhave tosacrifice
• 31. the certaintythat accompaniesorthodoxy,theyobtainsome- thingquite precious—agreaterappreciationof the complexity and uncertaintyunderlyingthe therapeuticenterprise. I believethere isnobetterwaytolearnabouta psy- chotherapyapproachthan to enterintoitas a patient.Hence,I have consideredaperiodof discomfortinmylife asaneduca- tional opportunitytoexplore whatvariousapproacheshave to offer.Of course,the particulartype of discomforthasto fitthe method;forexample,behavioral therapyisbestsuitedtotreat a discrete symptom—henceIturnedtoa behavioristtohelp withinsomnia,whichoccurredwhenItraveledtogive lectures or workshops. Secondly,Ienteredtherapyatmanydifferentstagesof mylife. Despite anexcellentandextensive course of therapyatthe onsetof one’scareer,an entirelydifferentsetof issuesmayar- rive at differentjuncturesof the life cycle.ItwasonlywhenI beganworkingextensivelywithdyingpatients(inmyfourth decade) thatI experiencedconsiderableexplicitdeathanxiety. No one enjoysanxiety—andcertainlynotI—butIwelcomed the opportunitytoexplore thisinnerdomainwithagoodther- apist.Furthermore,atthe time Iwas engagedinwritingatext- book,ExistentialPsychotherapy,andIknew that deeppersonal explorationwouldbroadenmy knowledge of existential issues. Andso I begana fruitful andenlighteningcourse of therapy withRolloMay. Many trainingprogramsoffer,aspart of the curriculum, an experiential traininggroup—thatis,agroupthat focusesonits ownprocess.These groupshave muchto teach,thoughthey are oftenanxiety-provokingforparticipants(andnoteasyfor the leaders,either—theyhave togetahandle onthe student members’competitivenessandtheircomplex relationships outside the group).Ibelieve thatthe youngpsychotherapist generallyprofitsevenmore froma“stranger”experiential groupor, betteryet,an ongoinghigh-functioningpsy- chotherapygroup.Onlybybeinga memberof a groupcan one trulyappreciate suchphenomenaasgrouppressure,the relief of catharsis,the powerinherentinthe group-leaderrole,the painful butvaluable processof obtainingvalidfeedbackabout one’sinter-personalpresentation.Last,if youare fortunate enoughtobe ina cohesive,hardworkinggroup,Iassure you that youwill neverforgetitandwill endeavortoprovide sucha therapeuticgroupexperience foryourfuture patients. CHAPTER 13 The TherapistHas Many Patients;The Patient, One Therapist There are timeswhenmypatientslamentthe inequalityof the psychotherapysituation.Theythinkaboutme farmore than I thinkaboutthem.I loomfar largerintheirlivesthantheydoin mine.If patientscouldaskanyquestiontheywished,Iamcer-
• 32. tainthat, for many,that questionwouldbe:Doyoueverthink aboutme? There are manywaysto addressthissituation.Forone,keep inmindthat, thoughthe inequalitymaybe irritatingformany patients,itisat the same time importantandnecessary.We wantto loomlarge in the patient’smind.Freudonce pointed out that itis importantforthe therapisttoloomso large inthe patient’smindthatthe interactionsbetweenthe patientand therapistbegintoinfluence the course of the patient’ssymp- tomatology(thatis,the psychoneurosisbecomesgraduallyre- placedbya transference neurosis).We wantthe therapyhour to be one of the most importanteventsinthe patient’slife. Thoughit isnot our goal to do awaywithall powerful feel- ingstowardthe therapist,there are timeswhenthe transference feelingsare toodysphoric,timeswhenthe patientissotor- mentedbyfeelingsaboutthe therapistthatsome decom- pressionisnecessary.Iamapt to enhance realitytestingbycommentinguponthe inherent crueltyof the therapysitu- ation—the basicnature of the arrangementdictatesthatthe pa- tientthinkmore aboutthe therapistthanvice versa:The patient has onlyone therapistwhilethe therapisthasmanypatients. OftenIfindthe teacheranalogyuseful,andpointoutthatthe teacherhas manystudentsbutthe studentshave onlyone teacherand,of course,studentsthinkmore abouttheirteacher than she aboutthem.If the patienthashadteachingexpe- rience,thismaybe particularlyrelevant.Otherrelevantprofes- sions—forexample,physician,nurse,supervisor—alsomaybe cited. AnotheraidI have oftenusedistoreferto my personal experience asapsychotherapypatientbysayingsomething like:“Iknowit feelsunfairandunequal foryouto be thinking of me more than I of you,for youto be carryingon longcon- versationswithme betweensessions,knowingthatIdonot similarlyspeakinfantasytoyou.Butthat’ssimplythe nature of the process.I had exactlythe same experience duringmyown time intherapy,whenIsat inthe patient’schairandyearnedto have my therapistthinkmore aboutme.” CHAPTER 14 The Here-and-Now—Use It,Use It,Use It The here-and-now isthe majorsource of therapeuticpower,the pay dirtof therapy,the therapist’s(andhence the patient’s) bestfriend.Sovital foreffective therapyisthe here-and-now that I shall discussitmore extensivelythananyothertopicin thistext. The here-and-now referstothe immediate eventsof the therapeutichour,towhatis happeninghere (inthisoffice,in thisrelationship,inthe in-betweenness—the space betweenme and you) andnow,in thisimmediatehour.Itisbasicallyan ahistoricapproachand de-emphasizes(butdoesnotnegate the
• 33. importance of) the patient’shistorical pastoreventsof hisor heroutside life. CHAPTER 15 Why Use the Here-and-Now? The rationale forusingthe here-and-now restsuponacouple of basicassumptions:(1) the importance of interpersonalrela- tionshipsand(2) the ideaof therapyas a social microcosm. To the social scientistandthe contemporarytherapist,inter- personal relationshipsare soobviouslyandmonumentally importantthatto belaborthe issue istorun the riskof preach- ingto the converted.Suffice ittosaythat regardlessof ourpro- fessional perspective—whetherwe studyournonhumanpri- mate relatives,primitive cultures,the individual’s developmental history,orcurrentlife patterns—itisapparent that we are intrinsicallysocial creatures.Throughoutlife,our surroundinginterpersonalenvironment—peers,friends,teach- ers,as well asfamily—hasenormousinfluenceoverthe kindof individualwe become.Ourself-imageisformulatedtoalarge degree uponthe reflectedappraisalswe perceive inthe eyesof the importantfiguresinourlife. Furthermore the greatmajorityof individualsseekingther- apy have fundamental problemsintheirrelationships;byand large people fall intodespairbecause of theirinabilitytoform and maintainenduringandgratifyinginterpersonal relation- ships.Psychotherapybasedonthe interpersonal model isdi- rectedtowardremovingthe obstaclestosatisfyingrelationships. The secondpostulate—thattherapyisasocial microcosm— meansthat eventually(providedwe donotstructure ittoo heavily) the interpersonalproblemsof the patientwill manifest themselvesinthe here-and-now of the therapyrelationship.If,in hisor her life,the patientisdemandingorfearful orarrogant or self-effacingorseductive orcontrollingorjudgmental ormal- adaptive interpersonallyinanyotherway,thenthese traitswill enterintothe patient’srelationshipwiththe therapist. Again,this approach isbasicallyahistoric:There islittle needof extensive history-takingtoapprehendthe nature of maladaptivepatterns because theywill soonenoughbe displayedinlivingcolorinthe here-and-nowof the therapyhour. To summarize,the rationale forusingthe here-and-now is that humanproblemsare largelyrelational andthatan individ- ual’sinterpersonalproblemswill ultimatelybe manifestedin the here-and-nowof the therapyencounter. CHAPTER 16 Usingthe Here-and-Now—GrowRabbitEars One of the firststepsintherapyisto identifythe here-and-now equivalentsof yourpatient’sinterpersonalproblems.Anessen-
• 34. tial part of youreducationisto learntofocus onthe here- and-now.Youmustdevelophere-and-nowrabbitears.The every- day eventsof eachtherapyhourare rich withdata:consider howpatientsgreetyou,take a seat,inspectorfail to inspect theirsurroundings,beginandendthe session,recounttheir history,relate toyou. My office isina separate cottage abouta hundredfeetdown a windinggardenpathfrommy house.Since everypatient walksdownthe same path,I have overthe yearsaccumulated much comparisondata.Most patientscommentaboutthe gar- den—the profusionof fleecylavenderblossoms;the sweet, heavywisteriafragrance;the riotof purple,pink,coral,and crimson—butsome donot.One manneverfailedtomake some negative comment:the mudonthe path,the needfor guardrailsin the rain,or the soundof leaf-blowersfroma neighboringhouse.Igive all patientsthe same directionstomy office fortheirfirstvisit:Drive downXstreetahalf mile past XX Road,make a right turnat XXXAvenue,atwhichthere’sa signfor Fresca(a local attractive restaurant) onthe corner. Some patientscommentonthe directions,somedonot.One particularpatient(the same one whocomplainedaboutthe muddypath) confrontedme inan earlysession:“How come youchose Fresca as yourlandmarkrather thanTaco Tio?” (Taco Tiois a Mexicanfast-foodeyesore onthe opposite cor- ner.) To grow rabbitears,keepinmindthisprinciple:One stim- ulus,manyreactions.If individualsare exposedtoa common complex stimulus,theyare likely tohave verydifferentre- sponses.Thisphenomenonisparticularlyevidentingroup therapy,inwhichgroupmemberssimultaneouslyexperience the same stimulus—forexample,amember’sweeping,orlate arrival,or confrontationwiththe therapist—andyeteachof themhas a verydifferentresponsetothe event. Why doesthathappen?There isonlyone possible expla- nation:Each individualhasa differentinternal worldandthe stimulushasa differentmeaningtoeach.Inindividual therapy the same principle obtains,onlythe eventsoccursequentially rather thansimultaneously(thatis,manypatientsof one ther- apistare, overtime,exposedtothe same stimulus.Therapyis like alivingRorschachtest—patientsprojectontoitpercep- tions,attitudes,andmeaningsfromtheirownunconscious). I developcertainbaseline expectationsbecause all mypa- tientsencounterthe same person(assumingIamreasonably stable),receive the same directionstomyoffice,walkdownthe same path to getthere,enterthe same roomwiththe same fur- nishings.Thusthe patient’sidiosyncraticresponse isdeeplyinformative—aviaregiapermitting youto understandthe pa- tient’sinnerworld. Whenthe latch on myscreendoor wasbroken,preventing the door fromclosingsnugly,mypatientsrespondedinanum- berof ways.One patientinvariablyspentmuchtime fiddling withitand each weekapologizedforitasthoughshe had bro-
• 35. kenit.Many ignoredit,while othersneverfailedtopointout the defectandsuggestI shouldgetitfixed.Some wondered whyI delayedsolong. Eventhe banal Kleenex box maybe arich source of data. One patientapologizedif she movedthe box slightlywhenex- tractinga tissue.Anotherrefusedtotake the lasttissue inthe box.Anotherwouldn’tletme handherone,sayingshe could do itherself.Once,whenIhadfailedtoreplace anemptybox,a patientjokedaboutitforweeks(“Soyourememberedthis time.”Or,“A newbox!You mustbe expectingaheavysession today.”).Anotherbroughtme apresentof two boxesof Kleenex. Most of mypatientshave readsome of my books,andtheir responsestomywritingconstitute arichsource of material. Some are intimidatedbymyhavingwrittensomuch.Some ex- pressconcernthat theywill notprove interestingtome.One patienttoldme that he reada bookof mine insnatchesinthe bookstore anddidn’twantto buyit,since he had “alreadygiven a donationat the office.”Others,whomake the assumptionof an economyof scarcity,hate the booksbecause mydescriptionsof close relationshipstoother patientssuggest that there will be littlelove leftforthem. In additiontoresponsestooffice surroundings,therapists have a varietyof otherstandard reference points(forexample, beginningsandendingsof hours,bill payments)thatgenerate comparative data.Andthenof course there isthat mostelegant and complex instrumentof all—the Stradivariusof psy- chotherapypractice—the therapist’sownself.Ishall have much more to say aboutthe use and care of thisinstrument. CHAPTER 17 Searchfor Here-and-NowEquivalents What shouldthe therapistdowhenapatientbringsupan issue involvingsome unhappyinteractionwithanotherperson? Generallytherapistsexplorethe situationatgreatdepthand try to helpthe patientunderstandhis/herrole inthe transaction, explore optionsforalternative behaviors,investigate uncon- sciousmotivation,guessatthe motivationsof the otherper- son,and searchfor patterns—thatis,similarsituationsthatthe patienthascreatedinthe past.Thistime-honoredstrategyhas limitations:notonlyisthe workapt to be intellectualizedbutall too oftenitisbasedon inaccurate data suppledbythe patient. The here-and-now offersafarbetterwayto work.The gen- eral strategyisto finda here-and-nowequivalentof the dysfunc- tional interaction.Once thisisdone,the workbecomesmuch more accurate and immediate.Some examples: Keithandpermanentgrudges.Keith,along-termpatientanda practicingpsychotherapist,reportedahighlyvitriolicinter- actionwithhisadultson.The son,for the firsttime,hadde- cidedto make the arrangementsforthe family’sannual fishing
• 36. and campingtrip.Thoughpleasedathisson’scomingof age and at beingrelievedof the burden,Keithcouldnotrelinquish control,and whenhe attemptedtooverride hisson’splanning by forcefullyinsistinguponaslightlyearlierdate anddifferentlocale,hissonexploded,calling hisfatherintrusive andcon- trolling.Keithwasdevastatedandabsolutelyconvincedthathe had permanentlylosthisson’slove andrespect. What are mytasks inthissituation?A long-range task,to whichwe wouldreturninthe future,wasto explore Keith’sin- abilitytorelinquishcontrol.A more immediate taskwasto offersome immediate comfortandassistKeithtoreestablish equilibrium.IsoughttohelpKeithgainperspective sothathe couldunderstandthatthiscontretempswasbutone fleeting episode againstthe horizonof alifetime of lovinginteractions withhisson.I deemeditinefficientforme to analyze ingreat and endlessdepththisepisode betweenKeithandhisson, whomI had nevermetandwhose true feelingsIcouldonly surmise.Farbetter,Ithought,to identifyandworkthrougha here-and-nowequivalentof the unsettlingevent. But whathere-and-nowevent?That’swhere rabbitearsare needed.Asithappened,IhadrecentlyreferredtoKeithapa- tientwho,aftera couple of sessionswithhim, didnotreturn. Keithhadexperiencedgreatanxietyaboutlosingthispatient and agonizedfora longtime before “confessing”itinthe pre- vioussession.KeithwasconvincedthatIwouldjudge him harshly,thatI wouldnotforgive himforfailing,andthatI wouldneveragainreferanotherpatienttohim.Note the sym- bolicequivalence of thesetwoevents—ineachone,Keithpre- sumedthata single actwouldforeverblemishhiminthe eyes of someone he treasured. I chose to pursue the here-and-nowepisodebecauseof its greaterimmediacyandaccuracy.I was the subjectof Keith’s apprehensionandcouldaccessmyown feelingsratherthanbe limitedtoconjecture abouthowhissonfelt.Itoldhimthat he was misreadingme entirely,thatIhad nodoubtsabout his sensitivityandcompassionandwascertainhe didexcellent clinical work.Itwasunthinkable forme toignore all mylong experience withhimonthe basisof thisone episode,andI saidthat I wouldreferhimotherpatientsinthe future.Inthe final analysisIfeel certainthatthishere-and-now therapeutic workwas far more powerful thana“then-and-there”investi- gationof the crisiswithhissonand that he wouldremember our encounterlongafterhe forgotanyintellectual analysisof the episode withhisson. Alice andcrudity.Alice,asixty-year-oldwidow desperately searchingforanotherhusband,complainedof aseriesof failed relationshipswithmenwhooftenvanishedwithoutexplanation fromher life.Inourthirdmonthof therapyshe tooka cruise withherlatestbeau,Morris,whoexpressedhischagrinather hagglingoverprices,shamelesslypushingherwaytothe front
• 37. of lines,andsprintingforthe bestseatsintour buses.After theirtripMorris disappearedandrefusedtoreturnhercalls. Ratherthan embarkon an analysisof herrelationshipwith Morris, I turnedtomy ownrelationshipwithAlice.Iwasaware that I, too,wantedoutand had pleasurablefantasiesinwhichshe announcedshe haddecided to terminate.Eventhoughshe brashly(andsuccessfully) negotiatedaconsiderablylower therapyfee,she continuedtotell me how unfairitwasthatI shouldcharge herso much.She neverfailedtomake some commentonthe fee—aboutwhetherIhadearneditthat day, or about myunwillingnesstogive heranevenlowersenior- citizenfee.Moreover,she pressedforextratime bybringingup urgentissuesjustasthe hour was endingorgivingme itemsto read(“on yourown time,”asshe put it)—herdreamjournal; articlesonwidowhood,journalingtherapy,orthe fallacyof Freud’sbeliefs.Overall,she waswithoutdelicacyand,justas she had done withMorris,turnedour relationshipintosome- thingcrude.I knewthatthishere-and-now realitywaswherewe neededtowork,andthe gentle explorationof how she had coarsenedherrelationshipwithme provedsouseful that monthslatersome veryastonishedelderlygentlemenreceived herphone callsof apology. Mildredandthe lack of presence.Mildredhadbeenabused sexuallyasachildand hadsuch difficultyinherphysical rela- tionshipwithherhusbandthathermarriage wasin jeopardy. As soonas herhusbandtouchedhersexuallyshe begantore- experience traumaticeventsfromherpast.Thisparadigm made it verydifficulttoworkon herrelationshiptoherhus- bandbecause itdemandedthatshe firstbe liberatedfromthe past—adauntingprocess. As I examinedthe here-and-now relationshipbetweenthe twoof us I couldappreciate manysimilaritiesbetweenthe way she relatedtome and the way she relatedtoherhusband.I oftenfeltignoredinthe sessions.Thoughshe wasanengaging storytellerandhadthe capacityto entertainme atgreat length,I founditdifficulttobe “present”withher—thatis,linked,en- gaged,close toher, withsome sense of mutuality.She ram- bled,neveraskedme aboutmyself,appearedtohave little sense orcuriosityaboutmyexperienceinthe hour,was never “there”relatingtome.Gradually,asI persistedinfocusingon the “in-betweenness”of ourrelationshipandthe extentof her absence andhowshut outI feltbyher, Mildredbegantoappre- ciate the extenttowhichshe exiledherhusband,and one day she starteda sessionbysaying,“Forsome reason,I’mnot sure why,I’ve justmade a great discovery:Ineverlookmyhusband inthe eyeswhenwe have sex.” Albertandswallowedrage.Albert,whocommutedoveran hour to myoffice,hadoftenexperiencedpanicattimeswhen he felthe had beenexploited.He knew he wassuffusedwith angerbut couldfindnoway to expressit.Inone sessionhe de-
• 38. scribeda frustratingencounterwithagirlfriendwho,inhis view,wasobviouslyjerkinghimaround,yethe wasparalyzed withfearaboutconfrontingher.The sessionfeltrepetitiousto me;we had spentconsiderabletime inmanysessionsdis- cussingthe same material andI alwaysfeltIhad offeredhimlittle help.Icouldsense his frustrationwithme:he impliedthat he had spokentomany friendswhohadcoveredall the same basesI had andhad ultimatelyadvisedhimtotell heroff orget out of the relationship.Itriedtospeakforhim: “Albert,letme see if Ican guessat what youmightbe ex- periencinginthissession.Youtravel anhourto see me and youpay me a gooddeal of money.Yetwe seemto be repeat- ingourselves.Youfeel Idon’tgive youmuchof value.Isay the same thingsas your friends,whogive ittoyoufree.You have got to be disappointedinme,evenfeelingrippedoff and angryat me for givingyousolittle.” He gave a thinsmile andacknowledgedthatmyassessment was fairlyaccurate.Iwas prettyclose.Iaskedhimto repeatitin hisownwords.He didthat withsome trepidation,andIre- spondedthat,thoughI couldn’tbe happywithnothavinggiven himwhat he wanted,Ilikedverymuchhisstatingthese things directlytome:It feltbettertobe straighterwitheachother,and he had beenindirectlyconveyingthesesentimentsanyway.The whole interchange proveduseful toAlbert.Hisfeelingstoward me were an analogof hisfeelingstowardhisgirlfriend, andthe experience of expressingthemwithoutacalamitousoutcome was powerfullyinstructive. CHAPTER 18 WorkingThroughIssuesinthe Here-and-Now So far we have consideredhowtorecognize patients’major problemsinthe here-and-now.Butonce thatis accomplished, howthendo we proceed?Howcan we use these here-and-now observationsinthe workof therapy? Example.Returntothe scene I describedearlier—the screen door withthe faultylatch,andmy patientwhofiddledwithit everyweekandalwaysapologized,toomanytimes,fornot beingable toclose the door. “Nancy,”I said,“I’m curiousaboutyour apologizingto me.It’sas thoughmy brokendoor,and mylaxityingettingit fixed,issomehowyourfault.” “You’re right.I knowthat. AndyetI keepondoingit.” “Anyhunchesaboutwhy?” “I thinkit’sgot to dowithhow importantyouare and how importanttherapyisto me and mywantingto make sure I don’toffendyouinanyway.”
• 39. “Nancy,can you take a guessabout how I feel everytime youapologize?” “It’sprobablyirritatingforyou.” I nod.“I can’t denyit.But you’re quickto saythat—as thoughit isa familiarexperience toyou.Isthere a historyto this?” “I’ve heardit before,manytimes,”she says.“Ican tell youit drivesmyhusbandcrazy.I know I irritate a lotof peo- ple andyet I keepdoingit.” “So, inthe guise of apologizingandbeingpolite,youend up irritatingothers.Moreover,eventhoughyouknow that, youstill have difficultyinstopping.There mustbe some kindof payoff foryou.I wonder,whatisit?” That interview andsubsequentsessionsthentookoff ina numberof fruitful directions,particularlyinthe areaof herrage towardeveryone—herhusband,parents,children,andme. Fastidiousinherhabits,she revealedhow unnervedthe faulty screendoormade her. Andnotonlythe door, butalso myclut- tereddesk,heapedhighwithuntidystacksof books.She also statedhowveryimpatientshe waswithme fornot working fasterwithher. Example.Severalmonthsintotherapy,Louise,apatientwho was highlycritical of me—of the office furnishings,the poor colorscheme,the general untidinessof mydesk,myclothing, the informalityandincompletenessof mybills—toldme about a newromanticrelationshipshe hadformed.Duringthe course of heraccount she remarked: “Well,grudgingly,Ihave toadmitI’mdoingbetter.” “I’m struckby yourword ‘grudgingly.’Why‘grudgingly?Itseemshardforyouto say positive thingsaboutme and about our worktogether.Whatdo youknow about that?” No answer.Louise silentlyshookherhead. “Just thinkout loud,Louise,anythingthatcomesto mind.” “Well,you’ll getaswelledhead.Can’thave that.”“Keep going.” “You’ll win.I’ll lose.” “Win andlose?We’re ina battle?Andwhat’sthe battle about?Andthe underlyingwar?” “Don’t know,justa part of me that’salwaysbeenthere,al- waysmockingpeople,lookingfortheirbadside,seeingthem sittingona pile of theirownshit.” “Andwithme?I’m thinkingof howcritical youare of my office.Andof the pathas well.Youneverfail tomentionthe mudbut neverthe flowersblossoming.” “Happenswithmyboyfriendall the time—he’ll bringme presentsandI can’thelpfocusingonhow little care he has takenwiththe wrapping.We got ina fightlastweekwhenhe bakedme a loaf of breadand I made a teasingcommentonthe slightlyburntcornerof the crust.” “You alwaysgive thatside of youa voice andyou keepthe otherside mute—the sidethatappreciateshismakingyou
• 40. bread,the side thatlikesandvaluesme.Louise,gobackto the beginningof thisdiscussion—yourcommentabout‘grudg- ingly’admittingyouare better.Tell me,whatwoulditbe like if youwere to unfetterthe positive partof youand speakstraightout,withoutthe ‘grudgingly’?” “I see sharkscircling.” “Just thinkof speakingtome.What doyou imagine?” “Kissingyouonthe lips.” For several sessionsthereafterwe exploredherfearsof closeness,of wantingtoomuch,of unfilled,insatiableyearn- ings,of her love forherfather,andher fearsthat I wouldboltif I reallyknewhowmuchshe wantedfromme.Note inthisvi- gnette thatI drewuponincidentsthathadoccurred inthe past, earlierinourtherapy.Here-and-nowworkisnotstrictlyahis- toric,since it mayinclude anyeventsthathave occurred throughoutone’srelationshipwiththe patient.AsSartre putit, “Introspectionisalwaysretrospection.” CHAPTER 19 The Here-and-Now EnergizesTherapy Work inthe here-and-now isalwaysmore excitingthanwork witha more abstract or historical focus.Thisisparticularlyevi- dentingroup therapy.Consider,forexample,anhistorical episode ingroupwork.In1946, the state of Connecticutspon- soreda workshoptodeal withracial tensionsinthe workplace. Small groupsledbythe eminentpsychologistKurtLewinanda teamof social psychologistsengagedinadiscussionof the “back home”problemsbroughtupbythe participants.The leadersand observersof the groups(withoutthe group members) heldnightlypost-groupmeetingsinwhichtheydis- cussednotonlythe content,but alsothe “process”of the ses- sions.(Notabene:The contentreferstothe actual wordsand conceptsexpressed.The “process”referstothe nature of the relationshipbetweenthe individualswhoexpressthe words and concepts.) Newsspreadaboutthese eveningstaff meetings,andtwo dayslaterthe membersof the groupsaskedtoattend.After much hesitation(suchaprocedure wasentirelynovel) ap- proval wasgranted,and the group membersobservedthem- selvesbeingdiscussedbythe leadersandresearchers. There are several publishedaccountsof thismomentous sessionatwhichthe importance of the here-and-now wasdiscovered.All agree thatthe meetingwaselectrifying;mem- berswere fascinatedbyhearingthemselvesandtheirbehavior discussed.Soontheycouldstaysilentnolongerandinter- jectedsuchcommentsas“No, that wasn’twhatI said,”or “howI said it,”or “what I meant.”The social scientistsrealized that theyhad stumbledontoanimportantaxiomforeducation (andfor therapyas well):namelythatwe learnbestaboutour- selvesandourbehaviorthroughpersonal participationininter-
• 41. actioncombinedwithobservationandanalysisof thatinter- action. In grouptherapythe differencebetweenagroupdiscussing “back home”problemsof the membersanda groupengaged inthe here-and-now—thatis,adiscussionof theirown process—isveryevident:The here-and-now groupisener- gized,membersare engaged,andtheywill always,if ques- tioned(eitherthroughinterviewsorresearchinstruments),re- mark that the groupcomes alive whenitfocusesonprocess. In the two-weekgrouplaboratoriesheldfordecadesat Bethel,Maine,itwassoonevidenttoall thatthe powerand al- lure of processgroups—firstcalledsensitivity-traininggroups (thatis,interpersonal sensitivity)andlater“T-groups”(train- ing) and still later“encountergroups”(Carl Rogers’sterm)— immediatelydwarfedothergroupsthe laboratoryoffered(for example,theorygroups,applicationgroups,orproblem- solvinggroups) intermsof members’interestandenthusiasm. In fact,it was oftensaidthatthe T-groups“ate up the restof the laboratory.”People wantto interactwithothers,are excited by givingandreceivingdirectfeedback,yearntolearnhow they are perceivedbyothers,wanttosloughoff theirfacadesand become intimate. Many yearsago, whenI wasattemptingtodevelopamore effectivemode toleadbrief-therapygroupsonthe acute inpa- tientward,I visiteddozensof groupsinhospitalsthroughout the country andfoundeverygroupto be ineffective—andfor preciselythe same reason.Eachgroupmeetinguseda“take- turns” or “check-in”formatconsistingof members’sequen- tiallydiscussingsome then-and-there event—forexample,hal- lucinatoryexperiencesorpastsuicidal inclinationsorthe rea- sonsfor theirhospitalization—while the othermembers listenedsilentlyandoftendisinterestedly.Iultimatelyformu- lated,ina texton inpatientgrouptherapy,ahere-and-nowap- proach forsuch acutelydisturbedpatients,which,Ibelieve, vastlyincreasedthe degree of memberengagement. The same observationholdsforindividualtherapy.Therapy isinvariablyenergizedwhenitfocusesonthe relationshipbe- tweentherapistandpatient.EveryDayGetsa Little Closerde- scribesan experimentinwhichapatientandI each wrote sum- mariesof the therapyhour.It was strikingthatwheneverwe readand discussedeachother’sobservations—thatis,when- everwe focusedonthe here-and-now—theensuingtherapy sessionscame alive.