A Psychotherapy Veteran's Thoughts on Treatment Methods
by Ms. Bonnie Burton
As a psychotherapy "veteran" who has seen a variety of therapists adhering to an assortment of theoretical orientations in the past 30 years, I am at times both amused and disheartened by the rancor and polarization between the traditional analytic "how dare you question my neutral and abstinent stance" camp, and their opposing but often equally obstinate contemporaries, the "let's all be warm and fuzzy" club.
Therefore, I wish to ask a question of both sides, and, to be fair, of anyone in the middle:
Remember us, your patients? Have you asked US what works and how we feel about what you are doing?
Let's see a show of hands. How many of you are squirming?
I have had more therapy relationships than friendships in my lifetime, which sounds pathetic but is probably due to a number of issues, including my disorder and previously inappropriate treatment. (No black or white thinking today! See, doc? I AM making progress!) Sadly, though, not once in all these years has a therapist asked me if I felt his or her approach was effective, or if I might like to try something a little different. I have, on occasion, been TOLD we were going to try an alternate approach, but I have never been asked.
For the record, in case any of you were wondering, the answer to MY request to do something different was "No." My therapist believes he's simply being consistent, which of course is an important ingredient in any therapy. I, however, tend to think that's above and beyond his duty to provide consistency. A more appropriate adjective would be "stubborn."
That said, I would like to share -- yes, I said "share" -- my thoughts with those of you who are willing to listen.
First, this may come as a shock to some of you, but from many patients' perspectives, the neutral, non-reactive therapist is actually far from neutral, because the absence of a natural reaction to the patient is, in fact, still a reaction. Now, I know some of you have already figured that out (did I mention I read a lot?) but here's a secret -- some of US have figured that out, too. It didn't take me 30 years to realize that if I say something to my therapist that produces laughter in other people, and my therapist doesn't laugh but instead simply continues to look at me, the absence of a response still constitutes a reaction on the part of my therapist. It's just not the reaction I expected.
The therapist, in choosing not to react, has, in fact, reacted both subtly and profoundly. My therapist's "non-reaction" is not lost on me. His refusal to "indulge" me has quite an effect on how I proceed in the session, because I then begin to silently question his lack of response. Did he misunderstand what I said? Did he intentionally ignore me? Was he even paying attention? Did I offend him? My friends thought it was funny, so why didn't he? Those are but a few of the many possible reactions I might have when my "neutral" therapist, believing it is undesirable for me to see his reaction or to know what he feels, does not react with a reciprocal response to a relational need. This sets in motion a desire in me to change my behavior in relation to my therapist, which effectively negates his neutrality. I might decide that he doesn't think I'm funny, and therefore I will refrain from showing him a natural part of myself in the future. I might feel humiliated for desiring "gratification" and thus become less willing to risk expressing my needs. I might also feel misunderstood and angry, and might not return for another session, particularly if I am already disillusioned with other aspects of therapy.
Neutrality, then, is not only an illusion, but a potentially destructive force in the therapeutic relationship. This is particularly true if the patient places significant emphasis on the therapy relationship as being a healing relationship. However, neutrality may be just as destructive when the primary pursuit is insight, because if neutrality and abstinence send parts of the patient into hiding from the therapist, transference cannot be interpreted, and insight cannot be appreciated.
If, on the other hand, my therapist reacts with laughter, I am more likely to feel understood and to continue the session showing him my genuine self. I am also--and this is a biggie--more likely to return. (Incidentally, my therapist does have a pretty good sense of humor, which has often served him well in his dealings with me. Only on rare occasions has he given me his "now is not the right time" stare, and when he has, it's usually because I've given him plenty of reason to do so).
So, now that I've primed the pump here, it's time for the important questions, the ones that will provoke both the happy analytic campers and the huggable relational club.
Does my therapist's laughter constitute unnecessary gratification? Or does it simply mean he has provided a necessary component, a sense of mutuality, to our therapy relationship? Research on the therapeutic alliance has shown that it is the patient's perception of the alliance, not the therapist's, that is most accurate in predicting outcome. If the patient's perception of neutrality and abstinence is such that it weakens the alliance, it really does not matter what the therapist believes, because the patient is unlikely to progress if she feels her needs are not being met in the therapy relationship. So fight all you want, guys, because -- are you ready for this--:
What matters isn't how YOU feel; what matters is how WE feel!
Now, don't some of you feel just a little bit silly?
How ironic it is that in the name of neutrality and abstinence, we patients are frequently reminded that therapy is about US and about how WE feel, but when the topic turns to determining what works or what we need, our feelings take a backseat -- if any seat at all -- to the wishes and theories of the therapist.
So here's a new vocabulary word for you guys to toss around. The word is... EMPOWERMENT. Believe it or not, it's good for us! Remember that word, because I'm going to ask you about it later.
Similar questions can be asked about other reactions on the part of the therapist as well.
What's a therapist to do if a patient is crying? Does he sit in stone-faced silence in an attempt to allow the patient to fully experience her own feelings, or does he prove that there's a human being inhabiting his body by offering her a tissue? If his intent, through neutrality and abstinence, is to allow her to fully experience her feelings, can the therapist be sure that's actually happening? And even if it is happening, and it leads the patient to an awareness of earlier experiences with a primary caregiver, does that in and of itself imply that the crying experience was "good" for the patient, or might it have created unnecessary pain for the patient, who now experiences the therapist as being cold and uncaring, much like her earlier caregiver? If the therapist reacts by handing the patient a tissue -- thereby showing compassion instead of abstinence and neutrality -- is that too considered gratification, or is it simply a natural human response to a person in pain? Under which circumstances is the patient more likely to express those feelings to her therapist in the future -- if the therapist is perceived as being uncaring, or if he is seen as a genuine human being who is responsive to her feelings and emotional expressions?
Now, this next bit will sound for a minute as if I'm contradicting what I've been saying, so bear with me. In my own experience of crying during a session, my therapist's silence actually did lead to a new awareness about myself. His leaving me alone with my feelings did, in fact, help me fully experience the pain of early memories, which might not have occurred if he had interrupted the experience. This led me to conclude, at least for awhile, that his neutrality and abstinence had been entirely beneficial.
But don't point the "I told you so" fingers yet, abstinent analysts. Notice I said "for awhile." It has now been more than three years since that display of emotion, and I have repeatedly found that anytime the tears begin to flow in a therapy session, what I remember first is not how I felt as a child -- it's how I felt as a patient in the "here and now" -- the anguish of feeling desperately alone in the presence of my therapist, and I consequently attempt to push those feelings aside. This has, in part, led me to conclude that there just might be a better way.
It is possible that if my therapist had handed me a tissue, or even asked if there was something I needed from him, that I would not have felt as much of the pain of childhood memories. However, I later came to realize that I wasn't feeling only that pain; I was also confused and hurt and bewildered by not receiving a natural human response from my therapist. Just as the offer of a tissue might have contaminated and lessened the experience of "reliving" the trauma, my therapist's lack of response also contaminated the experience by exacerbating my pain. What he perceived as a reliving of the original experience was more than that -- it was a combination of reliving the experience AND once again experiencing the pain of psychological abandonment by someone who was supposed to care about me. Maybe a response would have temporarily "removed me" from the past... but I would have also been more willing to go there again in the future.
I am not advocating a "one size fits all" therapy, or a form of therapy at either of the extremes. I have had destructive experiences with therapists who became too involved, who lost the ability to separate their issues from mine, and the amount and kinds of self-disclosure in those situations were not at all helpful in my treatment. I am also aware that for different patients, different kinds of therapy relationships feel most helpful. Some patients may prefer more distance than closeness, more "neutrality" than obvious involvement. I do believe, however, that in many situations, especially when the therapy relationship is utilized as a significant aspect of healing, patients could benefit immensely from less abstinence and neutrality, and from more relatedness.
This does not have to preclude exploring the past. Remember, guys, it's not all black or white. Perhaps, in a genuine reciprocal encounter, where the therapist reacts naturally while placing the patient's needs above his own, an exploration of how the patient felt when the therapist reacted could follow. This could be the catalyst for subsequent exploration of both present and past relationships. The therapist could ask how the patient might have felt and reacted if he had either remained "neutral" or responded in an unexpected manner, encouraging the patient to engage in active self-reflection. Above all, it would give us, the patients, some control over the treatment process.
Remember the vocabulary word? EMPOWERMENT would allow us to have an opportunity to make some decisions too, while collaborating with our therapists on what is or isn't helpful. Our input is valuable. In many cases, none of you therapists, not those on the left or the right or any of you in between, can even make a diagnosis without our input. Remember, unless you have a direct line to our thoughts and feelings (and if you believe that, there's probably a diagnosis for you, too), what you know about us is what we tell you. And what we tell you depends in large part on the alliance as WE see it.
So here's a suggestion Listen to your client, be willing to accept that your way may not be the ONLY way, and above all, practice what you preach! There is one belief you all seem to share regardless of your theoretical persuasion -- that what matters isn't how YOU feel, what matters is how WE feel. If that's so true, why don't you ask us?
Bonnie Burton lives in Saratoga Springs, NY. You can contact her at Cloudsplitter015@aol.com
Read a counter-point by Garry Cooper, LCSW
Read a counter-point by Dr. John Riolo
