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2003 January/February (3)

Friday, 02 January 2009 11:14

Why Is This Man Smiling?

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Why is This Man Smiling?

A Self-Described Grouch is Trying to Turn Happiness into a Science

by Mary Sykes Wylie

Martin Seligman reports spending much of his life as a "walking nimbus cloud enduring mostly wet weather in my soul." Former president of the American Psychological Association and about as famous as any research psychologist is likely to get, he admits he never much liked doing therapy. He usually felt relieved when sessions ended ("I was always itching to leave the room," he says) and thought he wasn't much good at therapy, anyway. So how did this admittedly depressive man of science--someone who'd rather conjure up research projects than meet real, live clients face to face--come to be known as the "father" of something called positive psychology, a movement that could change the face of psychotherapy as we know it?

For those who haven't looked at a psychology journal or even a newspaper for several years (Seligman's work has been featured on the front pages of The New York Times, Time, Newsweek, U.S. News and World Report , and USA Today ), positive psychology--the hottest new trend in the field right now--is basically the scientific study of what makes people happy and good. Its proponents believe that positive psychology not only has the potential to shake clinical research to its roots, but may directly challenge some of the most basic attitudes that psychotherapists bring to the practice of their work.

Accenting the Negative

To understand just how novel this perspective is, positive psychologists ask you to consider the field's history. For 50 years, they say, professional psychology ought better to have been called victimology, so obsessed has it been with the study of what's wrong with people--what's wrong with their emotional lives, their relationships, their physical brains, why they fail and feel bad and do terrible things to each other. The entire so-called mental health establishment has become a giant public edifice dedicated to mental illness --from the National Institute of Mental Health (which only funds studies geared to treating mental diseases) to the Diagnostic and Statistical Manual of Mental Disorders ( DSM ), an 800-page, quasi-scientific classification of human unhappiness, to virtually every textbook a student therapist reads in training.

In the meantime, what makes for good, healthy, and happy human functioning has not only been ignored, but considered an unscientific and virtually disreputable academic pursuit, like researching astrology or psychic phenomena. "We know a great deal about the psychology of conformity, cowardice, and prejudice," says Laura King, associate professor of psychological science at the University of Michigan, "but we don't have a good take at all on generosity or heroism--why, for example, ordinary people on flight 93 on 9-11 could become heroes in rising up against the hijackers."

 

However promising the new science of positive psychology, it probably wouldn't have achieved its current high level of visibility and apparent success without the formidable Seligman persona behind it. "Marty is a big, big person, with a big personality, a powerful, booming speaking voice, and an authoritative style," says King. A can-do kind of guy, he has established something of an empire devoted to positive psychology. Among other accomplishments, he has set up a scientific foundation, three distinct research centers and a training institute to promulgate the faith, launched a book series, led numerous conferences featuring various academic stars, gotten the American Psychological Association behind his efforts, fired up platoons of young research psychologists around the country, and generated enough grant money to fund a host of studies in universities around the country of what, empirically, constitutes the good, the true, the wise, the spiritual, and even the merely pleasurable in human affairs. To cap it off, he has gone beyond the academic world to attract national attention for positive psychology with his just-published book, Authentic Happiness , a neat counterpart to Learned Helplessness , the book that helped make his reputation more than 25 years ago. Not too shabby for a movement that's only about four years old.

A few tiny shadows dog this expansive and, well, optimistic enterprise, however. First, some humanistic psychologists grumble that there's nothing remotely new about positive psychology--they've been ploughing the same field for 40 years, ever since pioneers like Carl Rogers, Abraham Maslow, Rollo May, and others broke with psychoanalytic tradition to emphasize their clients' potential for growth, wisdom, love, pleasure, and creativity. Then there are the critics from within academic psychology, who say that positive psychology isn't and never can be real science. These skeptics argue that the terms of positive psychology are too vague and susceptible to individual interpretation ever to be defined, let alone measured, by the methodologies of empirical science.

Learning to Feel Good

Seligman, now Fox Leadership professor of psychology at the University of Pennsylvania, was catapulted to prominence in the field as a graduate student in the mid-1960s, when he and several colleagues discovered the phenomenon of learned helplessness in dogs. They found that dogs given shocks while restrained and unable to escape soon "learned" that trying to escape pain was futile. Even when the restraints were removed, the dogs refused to run away from the shock, or go on to learn any other tasks, but simply remained where they were, whimpering and passively enduring whatever happened to them. This and other experiments confounded standard assumptions of behavioral psychology--that animals (including humans), when conditioned, respond noncognitively, reflexively and involuntarily to pain and pleasure, trying to avoid the first and get at the second. Seligman's work showed that even dogs could actually learn a generalized state of expectancy that went beyond a response to any particular stimulus and paralyzed their capacity for any action.

 

If dogs can learn to feel too helpless and hopeless to make any effort to change their plight, Seligman wondered, why not people? The theory of learned helplessness--the acquired attitude that "nothing I do matters, or ever will"--along with systematic techniques for treating depression developed by psychologist Aaron Beck, gave a tremendous boost to the nascent movement of cognitive psychology, emphasizing the vital role thinking played on subsequent feeling. What we learn to expect from ourselves and others can determine our emotional experience of the world and how we deal with life. Over the past 25 years, cognitive behavioral methods for treating a range of clinical problems, grounded in this perspective, have come to constitute the core of empirically-supported therapy practice.

For Seligman, the next step after developing the concept of learned helplessness was obvious: if people can be taught to feel bad , perhaps they can also be taught to feel good . He began work on what would be his real vocation: not just studying optimism and well-being, but devising successful methods for teaching the skills of optimistic thinking to potentially depressed adults and children. "Seligman showed that you can literally change the minds of pessimistic people in a relatively short time, thus getting really good outcomes for preventive therapy," says psychiatrist and resilience researcher Steve Wolin. "It was elegant work."

In 1995, Seligman acted as consultant on a huge national survey done by Consumer Reports , which showed that most of the respondents felt they benefitted very substantially from therapy, and those whose therapy lasted the longest felt they had benefitted the most. Although academicians roundly denounced the survey for its lack of scientific rigor, psychotherapists loved Seligman for it. In 1996, thousands of clinical psychologists helped elect him president of the American Psychological Association by the largest margin in the organization's history.

As APA president, Seligman brought positive psychology front and center to the attention of field. The spotlight, however, also provoked criticism. In response to the special 2000 issue of the American Psychologist on positive psychology, a group of irate humanist psychologists charged that positive psychologists had "hijacked" the humanist movement, "stolen its premises," ignored its predecessors, "derided its history," denied its legitimacy and "cancelled" its right to be considered a ­serious player at the mainstream psychology table. Solution-focused and resilience-oriented therapists also protested that they, too, have long underplayed pathology and focused instead on helping clients bootstrap themselves up on their own strengths and abilities.

 

The Science of Happiness

What sets Seligman apart is his determination to ground positive psychology in tough-minded, grown-up science. Unlike the humanists, who wanted to jettison standard research techniques as too mechanistic and reductionistic to measure experiences like happiness, creativity, spirituality, and the like, Seligman and company want to subject these soft concepts to the hard science of empirical tests and statistical analysis, take them out of the woozy realm of pop psych and inspirational platitudes and give them intellectual backbone. They've produced reams of reports that, on paper, reduce inchoate ideas about happiness into orderly categories and subcategories. So far, they define three major branches of the positive-psychology tree: subjective happiness (positive emotions and mood), human excellence (positive personal strengths and virtues, like optimism, wisdom, and knowledge, courage, spirituality, love and humanity, justice and temperance) and positive institutions (democracy, family, a free press). At universities around the United States, researchers are beavering away, trying to ground amorphous concepts in valid research designs to determine what they mean operationally and how they objectively affect the way people behave.

Compared to studies of psychopathology, these sun-drenched efforts can sound quixotically cheerful--Academic Psychology Meets Mary Poppins. Different "pods," as they are called, of positive psychology researchers are studying, for example, the factors associated with a happy, satisfying Christmas, the emotional consequences of overconsumption and greed (one major focus of the movement is "finding alternatives to materialism"), and the impact of feelings of awe and transcendence on cardiovascular physiology. Other projects seem more mainstream: how positive traits and life events promote immunity and health; how positive emotions and social interactions protect students from loneliness and depression (a prospective study of Stanford University's entering class of 2000); what sorts of school-based interventions can promote ­optimism, hope, perseverance/resilience, courage and duty/citizenship in students.

This blossoming of research projects doesn't cut any ice with academic critics, who maintain that much of positive psychology still remains on the squishy side of scientific legitimacy. In an upcoming issue of Psychological Inquiry , psychologist Richard Lazarus and several colleagues take positive psychology to task for shallow and overly casual research methods, oversimplifying the meaning of basic concepts, ignoring individual differences and changes over time in individuals, and failing to show real causal relationships among emotions, health, and well-being. Positive psychologists respond that every one of the critiques leveled at them could just as well be made of virtually all psychology research (the behavioral sciences aren't physics, after all) and that, if anything, positive psychology has gone overboard to make its studies as unimpeachable as any research in the field has ever done.

Critics are particularly unconvinced by Seligman's classification schemes, his assumption that foggy, philosophical terms can someday bear the weight of empirical science. How can inescapably qualitative concepts like "wisdom," "joy," "judgment," "courage," and the like be rigorously defined, much less objectively analyzed and quantified? Even more to the point for therapists, how can such vague entities become relevant to any practical, down-to-earth interventions with real clients? Steve Wolin remembers being astonished when he first saw the list of qualities--wisdom, courage, humanity, justice, temperance, transcendence--Seligman intended to turn into universally valid scientific constructs. "This is all well and good," he wrote in an e-mail message to Seligman. "But this is not what my patients are interested in. My patients are interested in sex, shopping, drugs and rock 'n' roll."

 

Wolin thinks Seligman is so focused on the definitions of universal strengths and virtues--untainted by relativistic, culture-bound, everyday human context--that these terms risk languishing in the realm of meaningless abstraction. "People use their human strengths like creativity, humor, relationship in specific contexts, to overcome particular adversities, hardships, and struggles--but Marty doesn't seem to be interested in that--he's interested in their pure, Aristotelian essence. I want to see his work make sense to those of us in the trenches. How can I use what he is doing?" In response, Seligman and his colleagues concede that positive psychology is still baby science, but point to such achievements as devising eight-week training workshops that, when given in controlled studies to school children and college students at risk for serious depression and anxiety, reduced the development of symptoms as shown in follow-up studies three years later. With hundreds of young adults and schoolchildren at risk for depression, their research has shown that learned optimism programs used preventively halve the rate of depression and anxiety disorders over long-term follow-up.

Good Character

Positive psychology may remind people of "positive thinking," the feel-good/get-happy movement most often associated with uplift gurus like Norman Vincent Peale in the 1950s. But positive psychology has a paradoxical side, which could only emerge from the mind of a born pessimist, someone deeply familiar with the dark side of life. Seligman not only knows firsthand about human unhappiness, he has come to accept and respect it. "Evolution stamped dysphoria pretty indelibly into the psyche of the human species," he said in a Slate online debate with evolutionary psychologist Stephen Pinker last October. "It was the dysphoric hominids that survived the bad weather of the Pleistocene, not the blithe ones." Sadness, anger, and anxiety are built into the human frame--some frames more than others--and no amount of therapeutic tinkering or positive affirmations is going to turn a natural-born Grinch into Goldie Hawn.

If negative emotions are a necessary part of human nature, so too are the positive ones--with one big difference: it's probably far more feasible, not to mention more pleasant, to expand and build up our capacity for good feelings than it is to eliminate the bad ones. The underlying message of positive psychology is that we can to some extent make ourselves happier, even when we can't entirely rid ourselves of our miseries.

But this happiness-building project is not a walk in the park (though a walk in the park may be a very good happiness-building project). Feelings of joy, contentment, love, awe, even physical pleasure don't consistently "just happen," particularly to those of us who, like Seligman, are more naturally inclined to emotional twilight or even foggy drizzle than brilliant sunshine. These good feelings evolved as emotional rewards humans got for the kinds of activities that make decent civilization possible--hard work, cooperation, self sacrifice, child care, learning, teaching, seeking transcendent meaning in ordinary life. In other words, pleasure and satisfaction most often don't come without previous expenditures of will power, courage, applied intelligence, and damn good attitude. Not normally found in psychology textbooks or therapeutic interventions, nor reducible to popular self-help bromides, these qualities used to be encapsulated by the term good character .

 

Indeed, Seligman writes in Authentic Happiness , "the notion of good character is a core assumption of positive psychology." Which brings us to a surprising feature about Seligman the scientific psychologist--his deep commitment to a very old philosophical quest: understanding the nature of goodness and virtue. He asks questions that would have been familiar to thinkers in Athens 2500 years ago: what constitutes the good life? how do we define happiness and pleasure? what role do virtue, morality, and ethics play in finding happiness?

For individuals pondering these imponderables, wondering how to make them relevant to their personal lives, Seligman offers both a question and a route to the answer: what personal abilities, strengths, and potentials within our own natures can we draw on to create the good life? Seligman has devoted himself to giving this age-old project the full treatment of modern science. In the end, he believes that happiness is a pursuit, as Thomas Jefferson suggested, not an automatic benediction; it doesn't come easily or without struggle for most people. Seligman has been known to say at the end of his talks, "All my work can be boiled down to the one-word answer to a single question. The question is: 'What is the word in your heart?' Is it yes? or is it no? "

In the following interview with Networker editor Richard Simon, Seligman explores the implications of positive psychology for the psychotherapy field.

Mary Sykes Wylie

Psychotherapy Networker: As a therapist and researcher who has spent three decades trying to build a bridge between the world of science and the world of everyday practice, are you impressed with the hard evidence of psychotherapy's effectiveness?

Martin Seligman: Not really. Over the past 20 years, it looks to me like we have hit something I call the 65-percent barrier.

 

PN: Meaning?

MS: If I average all the therapy outcome studies that I've ever read--which by now is probably in the four figures--and I take the percent relief provided by both drugs and psychotherapy across all the disorders, I'd say the average improvement is around 65 percent. That means that, by and large, we produce only mild to moderate relief.

PN: So let me make sure I understand what you're saying. If cure is 100 percent--a touchdown--then 65 percent is a field goal?

MS: Yes. And also that, overall, about 65 percent of the people who come in for therapy see some degree of symptom relief. And 50 percent is what a placebo typically does. And by placebo, I mean either a drug with no known effect on a particular condition or, in the therapy context, an interaction that isn't designed to have specific treatment effects. In other words, both through drugs and psychotherapy, we're dealing with doing 30 percent better than placebo. Of course there are wonderful cases in which there are complete cures, and I'm a collector of those, and you can find those in some of my books. But the average is 15 to 20 percent better than the placebo.

Now that prevents a lot of suffering and you could argue that it's worth the $20 billion investment in drug companies and the psychotherapy industry. But let's look at it in another way. Over the past 25 years, I've been regularly revising a formal textbook about abnormal psychology that has gone through five editions. Over that time, the 65-percent figure hasn't changed. That means to me that we may have reached the limit of progress for our current approaches through psychopharmacology and psychotherapy.

 

PN: Do you see a lot of difference between the results of drug studies and therapy studies? Are the two approaches generally comparable in their effectiveness?

MS: It all depends on what you're treating. For things like obsessive-compulsive disorder, I think psychotherapy's better. For panic disorder, I think psychotherapy's better. For depression, I think they're about equal. For bipolar depression, I think the drugs are better. I can take you through each one of these, but what is important is that I haven't seen a lot of change over our lifetime, and that says to me that some natural limit has been reached by these procedures.

PN: Why do you think that collectively the therapy field has hit this wall?

MS: First of all, I think that negative emotions that are the product of evolutionary constraints are a big part of the reason there are limits to our therapeutic effectiveness. Evolution has been very concerned to give us only limited conscious control over our survival mechanisms. From an evolutionary perspective, negative emotions like fear, anger, and even depression are just too closely tied to survival, and voluntary attempts to gain exert control over them have upper limits.

PN: For example?

MS: Take phobias. I think they are evolutionarily prepared to help us avoid situations that may be dangerous. Some phobias are curable, but if you are agoraphobic, behavior therapy may make you less avoidant and less afraid, but I don't think you're ever going to really love going to a big shopping mall. I think the dirty little secret of biological psychiatry is that it's given up the notion of cure. All the medications being prescribed for depression and anxiety and other negative states are all cosmetic and palliative--when you stop taking them, you're back where you started. Similarly the advances in psychotherapy have been palliative. For example, the most that cognitive therapy can do is help a depressed person dispute the inner critical voices, but there's nothing in cognitive therapy about getting rid of the voices.

 

On the other hand, Freud and the psychodynamic therapists really had a vision of cure. But after 100 years of therapy, it's hard to find much evidence for that sort of cure. Of course, if you believe some of the great clinical anecdotes, when a client gets enough emotional catharsis and insight into the source of a problem, it's gone. That's a cure. And there are enough cases on record to think that that happens some of the time, although no one's ever been able to bottle it. So bottling it up would be the great advance. My guess about the future would be that if we see major advances in therapy, it won't be on the palliative side. I think we've kind of run out of tricks to relieve symptoms.

PN: So where are the advances going to come from?

MS: I think the positive side of life is where the big potential for growth lies. Because positive emotions are much less tied to survival issues, they are much more plastic. When you begin to deal with the human capacity to create things that weren't there before, you are moving out of pre-wired survival mechanisms into a different arena.

PN: So, concretely, what does that mean for the future of psychotherapy?

MS: Working on weaknesses and doing remediation is an uphill battle. After all, words like "intervention" and "therapy" are all appropriate to working out of weaknesses. Let's say we're conducting this interview about my weaknesses. I think it would be an uphill battle and neither of us would have a very good time, and we'd both be waiting for the interview to be over. But when you approach people about what they're good at, they like to talk about it. Time really zips along when the subject is how to use more of what you're good at in your life. What I'm saying is that spending more and more time on strengths is not only a rapport-building technique, it's a natural therapeutic buffer against our troubles.

 

PN: What you mean by a "buffer?"

MS: Okay. Take me. I consider myself a depressive, so I could see that in a different life course, I could wind up a basket case, but, fortunately, there are a few things that I'm really good at--verbal skills, writing, listening to both sides of an argument--that kind of thing. And I've chosen a life course--marriage, a way of parenting, a job--in which I get to maximize my strengths, and therefore I think I'm protected against depression. And I think, in general, our best protections against the kinds of conditions listed in DSM are our strengths.

In the Consulting Room

PN: So how might you then apply that kind of positive psychology approach in a therapist's consulting room?

MS: Let's imagine that a waitress who's got moderately high depression comes to see you and, after she goes through a litany of complaints, you conclude that the core of it is how much she hates her job. You do a very careful assessment to determine her highest strength, which turns out, among other things, to be her social intelligence. At that point, the task becomes helping her to recraft what she's doing at work to better use her strengths. So although she hates being patronized and hates carrying heavy trays, she redefines her job to make her customers' encounter with her the social highlight of their evening. And while she doesn't succeed in that all the time, that keeps her level of challenge and interest up to give her an experience of flow at her work, which now becomes fun, something she's good at.

PN: The concept of flow seems to come up again and again in your work. Say more about it.

MS: Flow, of course, is my friend Mike Csikszentmihayli's signal contribution to psychology. It refers to those activities in which time seems to stop, the moments when you find yourself doing exactly what you want to be doing and never wanting it to end. For most people, perhaps the key to the good life is developing interests and discovering activities that enable you to experience flow regularly in your life. You can probably best understand flow by understanding the reverse. From the first day I took up skiing to the day I gave it up five years later, I was never in flow. Skiers call it "fighting the mountain." So instead of the flow experience, of being comfortable letting yourself ski downhill, I was always worried about falling and trying to figure out what I should be doing. Right now, I think too much of the experience of psychotherapy, for both therapists and clients, involves fighting the mountain.

 

PN: And that's where what you call positive psychology comes in.

MS: Yes. Positive psychology is a lot more like the flow experience of downhill skiing, and it's my hope for getting therapists out of the remedial business. Positive psychology doesn't involve manipulation or much of what we think of as standard therapeutic interventions. You don't need to use clever techniques to get people to change. The focus is on helping people identify what they're really good at, with the premise that doing what they're really good at buffers them against their weaknesses. So when a person finds out that they're really extraordinarily kind and they like being kind, and you suggest to them, "Maybe in your daily life you should take opportunities to display kindness more often." And when they start to do that more, it's self-reinforcing. So, in my case, I don't know how to dress, and if you tried to make me a snappy dresser, I wouldn't have any fun doing it. But even if I don't dress well, I talk well. So it kind of makes of up for the fact that my socks don't match.

PN: Lots of therapists today are turned off to DSM and share your position that therapy should focus on clients' strengths. What's distinctive about positive psychology?

MS: That's a good question. I'm still working on a full answer to it. Basically positive psychology is devoted to giving a solid scientific legitimacy to the interest in strengths. For a weakness-based psychology, we've got a DSM . We've got all kinds of ways of measuring things like depression, and we concentrate on training people in graduate school how to undo the weaknesses people bring to therapy. But up until now, we haven't had a classification of the strengths that make a real difference in people's lives, and we haven't explicitly trained people in interventions that produce well-being. Most therapists decide if a client is depressed by seeing if they have five of nine symptoms, but, from the viewpoint of the science of therapy, it will make a tremendous difference if we had a systematic nosology of strengths that gave them equal weight with DSM diagnoses.

So we've developed a 800-page classification of strengths and virtues that will soon be published by the American Psychological Association that I hope will become psychology's un- DSM . It's what we need to bring us out from under the yoke of medicine, which is about undoing illnesses, not buffering strengths. Now undoing illnesses is fine, but it's just part of what the therapist's job should be.

Along with a classification system, we've developed a panoply of validated assessment tools for measuring the positive side of life. We started with tests for strengths and virtues, but there are also tests for well being, tests for amount of meaning in life, tests for strength of relationships, tests for gratitude, tests for forgiveness, tests for optimism. Those are all free on the web (www.authentichappiness.org). So there are now all kinds of materials to help clinicians measure where a person's weak and to find out where they're strong.

 

PN: What about treatment applications?

MS: What we're doing now is developing a set of positive interventions that we've been testing on normal people and ninth grade-students to see what difference they make. One example involves gratitude. One of the best correlates of life satisfaction is gratitude. So we ask people to take someone in their life that they've never properly thanked and write a testimonial to that person and then visit that person to deliver it. Personally, I'm a pretty ungrateful sort, but I've done that assignment and it had a profound effect on me.

PN: Can you say something about that experience?

MS: I did my own gratitude exercise on the morning of my 60th birthday. My wife and I had invited 50 people to celebrate with us and when I woke up that morning I suddenly had a very clear realization about two different ways of looking at your life--the autobiographical and the biographical. It became so plain to me that my story about myself had been very  autobiographical-- I got this award, I wrote this article, I did this, that, and the other thing. It was all about my fighting one obstacle after another and overcoming it. It was filled with I and about accomplishments as something I did . And, of course, that's so common--our  own will and our own actions are often in the forefront of the drama of our lives, and we put into the background things like the sacrifices of parents, the loyalty of friends, like a wife who reads every word you write and critiques it, children who create a background of happiness, a mentor who, in the beginning of your career, approves everything you do until just the right time comes and then starts to critique it. But as I thought about all the people coming to my birthday party, I found myself filled with gratitude and moving from an autobiography of an I to a biography, in which my life was a part of many more lives that had me possible.

PN: Do you think that therapy can encourage people too far in the direction of the autobiographical consciousness that you're describing?

MS: Our evidence is that gratitude is strongly related to subjective well-being, and so a question for therapists is how they can better promote gratitude. But at the moment, the area of interventions is the least validated in positive psychology. The validation of diagnostic categories is way ahead of evidence-based interventions. That's why I want to encourage your readers to dream in this direction. They're much better at developing interventions than researchers like me, who spend so much time sitting in front of computers.

 

Science and Therapy

PN: It sounds like you're encountering one of the limitations of science. The strengths of science is in measurement and being systematic, but you're saying that there's a big role for the creativity of the clinician in what you're trying to develop.

MS: Absolutely. Before yeoman scientists can go to work and see if things really work, you need the imagination of clinicians to provide something to test.

PN: Do you think that positive psychology will one day do away with psychotherapy as we have known it?

MS: Not at all. Positive psychology is not remotely intended as a replacement for all of therapy. I've been a therapist for 35 years and I'm proud of it. Whatever its limitations, I think therapy has important effects. What I'm describing as positive psychology's contribution is intended as another arrow in the therapist's quiver. I feel the same way about it as I do about drugs--it's another arrow in our quiver. More specifically, teaching our clients optimism, gratitude, forgiveness, identifying their signature strengths, and moving them in the direction of recrafting their lives to use them everyday--these are some of the new arrows for the positive clinician.

PN: But all in all, you sound like a bit of a skeptic when it comes to therapy and the results it has achieved so far.

MS: No, no. I'm tremendously impressed by the 50-percent symptom relief that most therapists are able to bring about using so-called "nonspecific" treatment factors. What they're really talking about are things like listening and taking an interest in people. The secret of therapy as a profession is that it draws in people who are just naturally good at helping other people screw their heads on straight. We could probably put most therapists through four years of learning how to make great coffee and they would still help 50 percent of their clients, whereas if we took the kind of people who I play poker with, I don't think the results would be anything like that.

 

So I think whatever we're doing in selecting and training clinicians, and whatever they do in the consulting room, is 50 percent of the wonderful stuff that helps people. So far science has added another 15 or 20 percent to it. That's good, too. But the biggest thing the psychotherapy field has going for us now is the people who do it, who without using science a lot of the time, bring about change 50 percent of the time, and sometimes do much better.

While the clinician's job is to alleviate troubles, I also think the development of things like character, positive emotions, and strengths are an end in themselves, completely independent of alleviating troubles. But the science isn't there yet. We don't yet have clear empirical demonstrations that if you work hard on developing your strengths, then your troubles fade into the background. When we get that kind of data, it could change the future for psychotherapy.

Richard Simon

Mary Sykes Wylies, Ph.D., is a senior editor of the Psychotherapy Networker HASH(0xc85a294)

Richard Simon, Ph.D., is the editor of the Psychotherapy Networker . Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

Friday, 02 January 2009 11:13

The Pragmatics of Hope

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The Pragmatics of Hope

What to Do When All Seems Lost

by Yvonne Dolan

It was a completely full morning flight to Los Angeles. Despite the post 9-11 security procedures, our United Airlines flight was actually leaving on time. Everyone, passengers and crew alike, seemed in pretty good spirits. Then I noticed the man seated across the aisle. He was hunched over, his face in his hands, the muscles in his back shaking. He nodded almost imperceptibly when the attendant gently touched his shoulder and reminded him to fasten his seat belt in preparation for takeoff.

A few minutes into the flight, I heard the muffled sound of sobbing. After a few minutes, I leaned across the aisle and asked, "Are you okay?" He shook his head. "Is there anything I can do?" Again, he shook his head.

A little later, a flight attendant walked down the  aisle, noticed the man's sobbing, and asked, "Do you need anything?" He shook his head and cleared his throat.

"My wife and all four of my kids were killed last night in a car accident. I'm on my way back to Hawaii to make the funeral arrangements. I moved over here [the flight had originated in Chicago] for my work." His voice broke. "They were going to join me when the school term ended. "

"I don't know what to say, sir," the attendant said gently. "I'm so sorry. Are you sure there isn't anything I can get you?" Again, he shook his head. "I just need to get through the next two flights, so I can do what needs to be done. Our family is all flying over from the mainland for the funeral and I'm going to have to pick them up and make arrangements. I was up all night last night after they called me, so I'm going to try to get some sleep."

 

"Ring the call bell if you need anything, sir, "the attendant murmured. As she walked away, the man looked across the aisle at me. "I just need to focus on what needs to be done. That's the only way I can get through this." Then he folded the airline blanket across his chest and closed his eyes.

To most people, this man would hardly qualify as "hopeful." His misery and his story make it easy to conclude that he was, literally, without hope. Easy, but wrong. True, he undoubtedly felt hopeless, but he was not hopeless, he had not succumbed to despair. Even in the face of his catastrophe, he was taking small, tentative but active, steps back toward the realm of life. By focusing on what he needed to do in the immediate future--get some sleep, pick up his relatives, and begin making arrangements--he was assuming a future, a time for which plans needed to be made, people contacted, tasks met, even if, for now, that future encompassed only the next few hours or days. Despite his acute grief, he was saying, in effect, "this is impossible, but I'll find a way to get through it."

Making his plans didn't change what had happened or his feelings about it, but it gave him some small measure of control in otherwise uncontrollable circumstances. It also provided him with a rough map for what would undoubtedly be a brutal journey through a wilderness of suffering. For the time being, he was alive and coping; he hadn't been defeated by despair, and that in itself was a harbinger of hope to come.

There's Hope in Activity

As therapists, we've been trained to think that we should focus primarily on emotions. We often elicit negative emotions, believing that they must be purged before there'll be room for hope and other positive emotions. We're particularly anxious to assuage trauma survivors, whose desperate, unbearable pain seems to demand immediate relief. We frequently assume that all clients must feel hopeful and believe that life is meaningful before they'll make much progress in therapy or in life.

 

But the fact is that in the wake of catastrophe, it's often impossible to summon up the least glimmer of hope or faith or sense of life's meaning. How, for example, can you suggest to someone whose child has been shot in a schoolyard, who has lost a home to a hurricane, or who's been raped as a child by family members that there's hope for the future, that they'll feel "better" someday? To clients who have suffered such profound trauma, it's ludicrous to suggest that they can be coaxed into feeling hopeful about the future.

In these cases, the trauma therapist may be in something of a bind. Trying to "drain off" negative emotions by focusing on the pain--asking clients to rehash what happened or to speak repeatedly about their terrible feelings--is likely to make them feel worse. Just asking such clients an open-ended question about their emotional state--"How do you feel today?"--may exacerbate already terrible feelings or call forth a sense of numbness and apathy.

But favoring positive emotions and subtly trying to subdue negative ones can backfire. Asking these clients to imagine a time when they won't feel suicidal or reframing their trauma as an opportunity to "grow" can trivialize their suffering and inadvertently insult them. These efforts may also strike them as manipulative, as though the therapist is trying to maneuver them into a hopeful response they're not ready for.

How do we get beyond this impasse? We can begin by looking again at the ways people have found consolation and support in the thousands of years   before psychotherapy was developed. Throughout history, human beings have found rough relief and a modicum of comfort in the immediate obligations and habits of ordinary, daily life. The greatest incentive to go on coping lies in their relationships with other people, not only those who comfort and support them, but those who depend upon them. Sometimes, the simplest act can have profound power. I learned recently of a Red Cross survey given to disaster survivors, asking them to name the most helpful "intervention" they'd experienced right after the disaster. Many said they most appreciated being given a cup of coffee by an aid worker. It wasn't fancy trauma therapy, but I suspect the familiarity and ordinary helpfulness of the act implied to survivors that, in spite of catastrophe, normal life was still going on. In receiving a cup of coffee lay some small kernel of hope for the future.

 

In my 25 years of treating traumatized people, I've found that in these crisis situations dissecting negative emotions or trying to rev up positive ones isn't the most useful step we can take. This isn't to say we should avoid discussions about how clients feel--far from it. But talking with clients about what they're doing and how they're coping provides not only a framework for them to talk about how they feel, but a real-life scaffolding for the eventual construction of more positive emotions. Hope follows action, rather than the other way around. Helping clients become aware that what they're doing--even if it's "merely" coping and "just" getting by--can be the first step toward rebuilding their sense of agency and control.

I first began thinking about the healing power of activity and its "hope-implicit" quality when I was a young therapist-in-training, working in a shelter for abused and runaway teenagers. Every one of these kids had experienced severe and prolonged abuse, and virtually all suffered from acute post-traumatic stress. As an all-night staff person, my job was to help them get to sleep--an almost impossible task because for my charges sleep was a realm of nightmares and flashbacks. Talking with them about their traumas just heightened their distress, and asking them "positive" questions--about what they wanted to do with their lives, what they liked, what would make them feel safer--didn't engage them.

Desperately casting around for a solution, I began to ask more specific questions about the immediate future. "What would you like to do tomorrow? What do you need to get that done? How will you know tomorrow night that you had a decent day?" Several said they wanted to contact brothers, mothers, or friends to find out if they were okay. Others said they wanted to go outdoors; they'd been cooped up inside for too long. Still others said they wanted to wash their hair, take a bath, get clean clothes. This doesn't sound like therapy, nor does it provide much in the way of emotional breakthroughs. But it worked. Talking about practical, immediate plans calmed them down and helped them sleep. I believe that the practical details of their lives reminded them that they were more than their traumas, and gave them concrete realities that, at least momentarily, jostled them out of their inner turmoil.

Drawing on my shelter experience, I work with trauma clients to help them identify actions they can take to keep going. But sometimes trauma clients no longer have a sense of who they are and why they should continue living--except that they feel they have to go on for the sake of their kids, their grandchildren, their spouses, or even the person they've lost. Many clients who cannot imagine going forward for themselves can summon up some last ounce of strength on behalf of those they love.

 

Focusing on Day-to-Day

Germaine, came to see me after her adolescent son had been killed in a gang-related shooting. She'd just lost her job, was drinking heavily, and was almost paralyzed with grief. She entered therapy not to make herself feel better, but so that she could go on living for the sake of her other two children.

At that point, nothing I could say would make her feel better. I told her how sorry I was for what happened to her son, and how painful I imagined this must be for her whole family. "How have you managed up until now?" I asked. This focused her on what she was doing and offered her an indirect opportunity to express her feelings. Germaine said she'd been going to a support group, and while it helped to get dressed, get out of the house, and be with others, the overall experience wasn't particularly useful. "I feel like I'm being swallowed up by how much it hurts, like I could, literally, drown in the pain."

Germaine was a former crack addict, but had been clean for six years. She'd resisted taking drugs again, but she was drinking heavily. "These feelings aren't ever going to go away," she said. "And just talking about it isn't going to cut it. I have to have some sort of concrete plan of what I'm going to do to fill up the time or I'll die of grief. What am I going to do?"

Of course, I didn't know the answer. But clients often have within themselves the budding solutions to their own dilemmas, though they may not recognize it at the time. Germaine had come up with a potential way out of her hell when she said she needed a "concrete plan" of action. I thought we should try to construct one. I asked her if there had been anything at all that had helped to make these past few months a little bit more bearable. She was silent for several minutes, staring at the floor.

 

"It helps when I make a list," she said finally. "Some days, when I get up in the morning, I make a list of what I need to do and, somehow, those days seem to go a little bit easier--maybe because I have a plan, sort of like a map for getting through the next few hours. When I don't have my list, it's a lot worse. I can just sit and cry all day."

I asked her how the list helped. She said that it wasn't so much the list itself that helped, but that the act of making it put her completely in the present. Listing the most mundane chores--"go to grocery store," "pick up Michael's shoes from repair shop," "make kids' lunches for tomorrow"--and then doing them helped her "get back to living, at least for the time being," she said. In a sense, she could do hope before she could feel hope. This focus reflects a great human wisdom found in many major spiritual traditions: that being consciously mindful, maintaining full awareness of what's going on in the present can bring some solace and peace when all else fails.

It struck me that concentrating on her list-making and following through with the tasks when she felt so terrible must have taken extraordinary effort. "How did you do it?" I asked.

"I guess I just made up my mind."

"But just how did you make yourself get up in the morning?"

"I told myself I had to do it."

"What did you do to convince yourself?"

"Well, I gave myself a lot of shit, as I lay there, telling myself it was a lousy thing to do to my kids--just let them fend for themselves while I wallowed in bed."

 

This pursuit of minutiae can have a powerful impact on the client. In answering the questions, Germaine acknowledged her own agency and strength. If I were to praise her, no matter how sincerely, for managing to get up every morning, it might have sounded condescending. Focusing her attention on what she was doing for herself helped her to recognize her own strength and her ability to keep going despite her pain.

I saw Germaine weekly for a year and a half, keeping the focus on her own efforts. One of the most powerful and respectful ways to help clients actively find new meaning for their lives is to ask them to imagine someone who loves them telling them what they're accomplishing. When I asked Germaine what she was doing right, she responded like many depressed and grieving people that she wasn't doing anything right. So, I rephrased the question, "Well, imagine that your kids are remembering what you did during this past week. What would they say you'd done right?" After a pause, she said, "I guess they would say that I'd put a meal on the table every night, and that I took them to church on Sunday, and that we went to the movies one evening." Once, I asked her what a favorite aunt, who was deceased, might have said to her. For the first time, she smiled softly and said in a small voice, "She would tell me I was doing good, taking care of the kids and all, and that she was proud of me for not hitting the bottle at the end of the day."

Session by session, Germaine gradually began to immerse herself in the mundane stuff of daily life, and her despair seemed to lessen over time. But  she seemed to grow more anxious about her children. She worried that she hadn't been a good enough mother, expressing guilt for neglecting them while addicted to crack. She wondered if she'd been responsible for her son's death. Now, though still grieving for the one she'd lost, she felt increasingly frightened for the other three, and anxious about her own capacity to guide them through childhood.

"Suppose that you dream that many years have passed and your children--who are now adults--are sitting around the kitchen table with you, telling you that you did a great job as a mother and describing all the things you did completely right while raising them," I said. "Now, suppose you wake up and can't remember the dream, but find yourself doing all the things they said made you a great mother. What would be the first things your kids would notice you doing?"

 

Germaine closed her eyes and smiled. "I would go to every parent-teacher meeting. And I would make sure they told me where they were going to be every hour of the day--even if they fought me on it. And I would help them with their homework. And I would push them to finish school. I would keep on loving them, and let them know how much I loved them every day." Because she was already beginning to do some of these things, it slowly dawned on her that she was already becoming the kind of mother her kids needed.

By asking this type of question, the therapist makes a kind of hypnotic suggestion that communicates--indirectly, without ever denying the client's ongoing pain--that there is something significant to hope for. If the question is worded right, the client will answer it not by expressing a wish for the impossible, but by setting out realizable goals. I didn't ask Germaine the kind of question that would provoke her to wish for her son to be alive again. Instead, she could wish for something entirely achievable, through her own efforts--something that would help her become the mother she wanted to be.

Starting with Baby Steps

Though focusing on mundane tasks in the present can seem impossibly beside the point for someone who has suffered a life-shattering event, it can help build, inch by inch and then yard by yard, a pathway out of despair and into the fullness of life. A Japanese doctor told me a story about how powerful this kind of mindfulness can be. Mr. Tanaka, a recently retired patient of his, had been admitted to a hospital after trying to commit suicide. For nearly 50 years, Mr. Tanaka had suffered from severe back pain as a result of tubercular meningitis he'd contacted at 15. He'd endured 30 operations, to no avail. Every treatment--physical therapies, nerve-blocks, drugs--had failed. Indeed, the pain was getting worse and he was now confined to a wheelchair. Stuck at home and in constant pain, he'd lost all hope and had attempted suicide. The doctor asked him how he'd managed to get through his painful life to that point.

"Well, I'm a very optimistic man at heart, and that has helped me," Mr. Tanaka answered. "While the pain was awful, I just buried myself in work, which relieved it a tiny bit. I also believed the pain would become much less some day--and that made me optimistic. But now that I know I'll never have relief, I feel there is no hope."

Not knowing what else to offer, the doctor grabbed at this lifeline. "Could you do something for me?" he asked Mr. Tanaka. "When you feel even a little bit more comfortable, please notice and remember the occasion, and notice why and how it occurs."

 

Each time he saw Mr. Tanaka over the next few weeks, the doctor encouraged him to notice when his pain was less severe. For six weeks, nothing. But one day, Mr. Tanaka came in smiling. "Since you began asking me to notice times I feel better, I've been thinking about it. A couple of days ago, on the way home from the dentist, I stopped in the park by the riverside. I ate sandwiches and fed the crumbs to the pigeons. They started going after the crumbs, and I really enjoyed watching them. In fact, I became so absorbed in watching them that I didn't have any pain at all while I was there!"

The doctor encouraged him to continue noticing other times he became so involved he didn't notice the pain. Gradually, Mr. Tanaka noted more and more activities during which the pain disappeared. He also noticed that the pain didn't seem to be getting any worse. He began gardening and fishing and even took a short trip with his wife. Seven years later, the doctor told me, Mr. Tanaka was still improving.

Strangely enough, the "distraction" of living fully in the present seems to be the only real cure for the terrible things life can do to us, the only real source of hope in hopeless situations. As therapists and healers, we can't make people feel hopeful, nor can we reverse the tragedies that make them feel hopeless. But we can help them slowly begin building, out of life's own materials, a place in which hope can nest.


Yvonne Dolan, M.A., specializes in trauma treatment. She is the author or coauthor of 5 books, including Resolving Sexual Abuse. Address: 7137 Knickerbocker Pkwy., Hammond, IN 46323. E-mails to the author may be sent to yvonne@yvonnedolan.com. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

 

Tuesday, 30 December 2008 13:35

The Good, the Bad and the Ugly

Written by

 

The Good, the Bad and the Ugly

Turning Ambivalence into Possibility

by Bill O'Hanlon

Nearly a decade ago, I treated a man named Abel, who was severely obsessive. He taught in a college communications program and loved words, but he'd become so obsessed with how human beings communicate that he could no longer put together words and meanings. He loved to read, but he could no longer concentrate because he obsessed about page margins and typefaces. He obsessed about art, sex, and his own writing. If one obsession went away, another took its place, from the moment he woke up till the moment he went to sleep. Nothing he tried brought any relief.

I thought hypnosis might help with his symptoms, but Abel, who'd unsuccessfully tried practically every form of therapy, including hypnosis, didn't think so. I assured him that I used a different approach to hypnosis, and he agreed to give it a try. During our second hypnosis session, he was symptom-free for about 15 minutes, and he continued to be for about 2 hours afterward. Even though he didn't entirely believe he'd been in trance, he was impressed and happy that something finally had helped.

In the third session, I began once more with hypnosis: "Okay, you can keep your eyes open, or you can close them, or they might open and close on their own," I said. Abel closed his eyes. "And as you're sitting there, you may be thinking you're not going to be able to go into trance. You can have that thought--that's okay. You may be thinking that this trance isn't going to work. You can think that--that's okay. You may be distracted by one of your symptoms, maybe by the tension in your jaw or your neck. You may even think you're too tense to go into trance--that's okay. You can be tense and you can still go into trance and you might relax as the moments go on. You don't have to relax to go into trance. You may be obsessing--that's okay. You can just let yourself feel what you feel, think what you think, experience what you're experiencing, and not think what you don't think, not experience what you don't experience, not feel what you don't feel, and you can still go into trance."

At that point Abel's eyes popped open. "That's it," he said. "Do more of that. That's what helped me last time."

"You mean do more trance?" I asked.


"No, no. I don't think I'm going into trance. But what you're doing now is exactly what I need. Do more of that."

"What do you mean?" I asked again.

"The way you're talking now is what's helping me. Because, somehow, when you talk that way, I get the sense I can't do anything wrong. It's the only time in my life when I can't do anything wrong. I long for that sense."

While Abel's symptoms didn't completely disappear, from this point on, he began to make progress in therapy. For the first time in years, he could relax his obsessive vigilance and begin to live his life instead of endlessly worrying about the details around life's edges.

Erickson and Not-Doing

I first learned this permissive approach watching Milton Erickson's work in the late 1970s, particularly the way Erickson used hypnosis and challenged standard ideas about hypnotic techniques and affects. Many considered hypnosis a rigid procedure, which could be effective only if certain exacting conditions were met: a person had to be physically and mentally relaxed to go into a trance; once in a trance, the person was supposed to be unaware of his or her surroundings except for the hypnotist's voice. So rigid were the requirements for succeeding at being hypnotized that many people believed they didn't have the ability to "go under" the hypnotist's spell.

Erickson's view was different. For him, trance was more of a not-doing than a doing. He understood that the hypnotist had to take the pressure off people, and make them realize that they didn't have to experience specific mental and physical stages in a particular order to go into trance. He invited people to just allow their own experiences to happen as they happened, without having to force anything. He used language that neutralized the mind's tendency to break experience down into dualistic opposites--this or that, right or wrong, correct or incorrect.


In a sense, he gave his clients permission to experience simultaneously or in rapid succession contradictory emotions and states of mind and body, emphasizing that no reaction excluded any other, and that all were "right." From Erickson, I learned to make statements like: "You can listen to and hear everything I say and you don't have to. You may remember what I say and you may not. You don't have to believe anything about this."

Abel's response to this approach--that it made him feel he couldn't do anything wrong--crystallized something for me. Here was a way to break up unconscious logjams; permissions enabled clients to experience two seemingly contradictory states simultaneously. The structure of hypnotic language freed people from the tyranny of having to choose, and choose correctly, what to feel and how to proceed. I began to appreciate the extraordinary power of permission, with or without hypnosis, particularly with my most challenging cases.

So I began focusing on how to most productively include the good, the bad, the ugly, and the in-between of my clients' experience to help them expand their sense of possibilities in life. But this was the mid-1980s, the height of the popularity of various forms of solution-based therapy, and people would sometimes come up to me at my workshops and say, "I really like your positive approach," thinking they were complimenting me, in spite of the fact that I wasn't particularly interested in accentuating the positive.

Around the same time, therapist David Nylund told me that the staff at his clinic had noticed a problem with therapists who were too focused on highlighting the positive. As they watched from behind the one-way mirror, they were struck by how often they saw therapists straining relentlessly to keep clients focused on solutions and solution-talk. Often, the effect was that clients became more and more frustrated and alienated, while the oblivious therapists continued asking about what was going better. Nylund and his colleagues named this phenomenon solution-forced therapy.

So, in my training workshops, I began emphasizing the importance of not excluding those thoughts and feelings that didn't look like solutions to anything. As valuable as it is to help people focus on solving their problems, it's equally important to validate people's experiences, however negative. The essence of good therapy is to be able to descend with people into their hell and at the same time keep one foot in the land of hope and possibility. I once heard a radio interview about research conducted with people who'd survived jumping off the Golden Gate Bridge. The only common factor among them seemed to be that on the way down each of them had had more or less the same thought: Hmmm. Maybe this wasn't such a good idea.


As therapists, we must recognize the complexity and ambivalence at the core of human experience. Inevitably our therapy theories invite us to oversimplify, and solution-focused therapists aren't the only ones guilty of that: the client's problem is "cathected introjects"; she needs to "express her feelings"; he needs to "take responsibility for his life"; clients have to "reexperience their abuse to heal from it." Whatever ideas we therapists get are going to be helpful in some situations with some clients, but they necessarily diminish and impoverish our clients' inner realities. Recognizing this, we need to remind ourselves that whatever conclusions we come to about our clients, it's always more complicated than that.

The Power of Permission

People run into problems when their lives are dictated by rigid beliefs that make the stories they're living out too restrictive. One common set of beliefs is about what you must or should do. For example: "I must always be perfect," or "I should always smile and be happy," or "Females should take care of others' needs." Another common set of beliefs is about what you can't or shouldn't do: "I can't be angry," or "Big boys don't cry."

Permission counters these commands and prohibitions. The therapist who offers permission goes beyond accepting clients as they are and moves into encouraging them to expand their life stories and their sense of themselves. In effect, the therapist who offers permission is saying, "There's more to you than this story you've lived out up to this point." Permissions can introduce choice and possibilities into circumstances that have been limited by necessity and impossibility.

How do permissions work in practice? Some years ago, I worked with a woman who'd been sexually abused by a cousin in childhood. He routinely brought her to orgasm, which she liked and felt bad about--because she didn't like him and felt manipulated and coerced by him. As an adult, she never got sexually excited or had orgasms until she became involved in S&M in her early twenties. After a frightening experience in which she was almost killed, she left the S&M scene.

Now, after many years of therapy, she lived with her fiance and was still unresponsive sexually. She'd begin to get sexually excited, and then get frightened and go numb. She'd accepted that this was the way things were with her. Once, at a professional conference, she'd started chatting with a fellow attendee and had gone into an elevator with him. As the doors closed, sparks seemed to jump between them and they had sex in the elevator. She was surprised that she was doing this wild thing, and even more surprised to have an orgasm during the short encounter.


In our therapy, she realized she was operating under two beliefs: "You shouldn't enjoy sex, because it's bad," or, "You're bad if you're sexually excited or have an orgasm." Because she'd been coerced to be sexually aroused, she'd developed the idea that she had to be sexually aroused and have orgasms in any sexual situation, whether she felt like it or not. I gave her two permissions: "It's okay to have sexual pleasure and not be punished. It's also okay not to be sexually aroused and okay not to have sex." I started interspersing into our conversations permissions such as, "You can be a good person and be sexual." And "You don't have to be bad to be aroused." But also, "You don't have to have sex, if you don't feel like it." And, "You don't have to have orgasms when you have sex."

How did she begin putting these permissions into practice? She decided to let her partner know she became afraid or numb when they were having sex. She'd tell him she needed to stop and talk, or not have sex right then. He was understanding and appreciated that she was honest with him, rather than just forcing herself to go through the motions. The fact that he responded so well confirmed for her that she did not have to have sex or have an orgasm. Her new freedom actually enabled her to have orgasms with her fiance more often.

Although you can give the permission to or the permission not to, giving both permissions at the same is often most effective: "It's okay to be sexual, and you don't have to be sexual." If you give only one permission for one type of response, clients may feel pressured to experience only one part of the equation, or they may find the other side emerging in a more compelling and disturbing way.

In certain situations, it's important to give permission for feelings, not actions. For instance, "It's okay to feel like cutting yourself, and you don't have to feel like cutting yourself." Needless to say, never give permission for harmful, destructive behavior.

Other times, it's helpful to give a client permission to do two things at once. Such was the case with Josie, whom I'd seen for a few sessions when she came in very agitated. She said she had something to tell me, but was terrified to talk about it. I told her it was okay not to tell me until she was comfortable enough to do so. Josie responded that she had to tell me, or she felt she'd be wasting her time and money in therapy. I told her to go ahead and tell me in whatever way felt right.


She seemed to struggle for a while and then said, "I can't tell you. I'm too afraid." We went back and forth like that until I began to understand Josie's dilemma and said, "Okay, I know this may not make sense, but what I'm going to say can be understood somewhere deep inside. You can find a way to tell me and not tell me at the same time."

In response, Josie closed her eyes and her hands began to move in elaborate movements that reminded me of "hand dancing" I had seen done by Thai performers. After some time, she opened her eyes and smiled, obviously relieved. "There," she said, "you were right. I told you and didn't tell you at the same time. My hands told you the whole story of my abuse. Now I can tell you in words."

"That's good," I thought to myself, "because I didn't get the hand thing at all." Josie went on to tell me what had happened to her. Although she knew it was irrational, she'd feared that if she told me, she'd somehow be responsible if I had a car accident or a heart attack. Telling her story was a great relief to her. Once she could find a way out of her bind, she could embrace the possibility of breaking her "curse."

The Power of Inclusive Thinking

Sometimes the key to helping someone who seems hopelessly stuck is to invite them to experience two seemingly contradictory feelings or states without putting them in conflict. What's central is the use of the word and: "You can feel tense, and you could relax. You might think you can't change, and you might be surprised to discover that you're changing. You want to change, and you're so afraid to change." This contrasts with how most people unconsciously put things together: "I have to feel this or feel that. I feel this, but I should be feeling that." Instead of reinforcing one-dimensional definitions of ourselves, such permissions go beyond mere acceptance to actively encouraging clients to simultaneously experience thoughts and feelings that they consider irreconcilable. It's as if the therapist is saying, "Your story has become too small for you. Give yourself permission to begin to envision and live out a larger story."

I remember doing therapy with a woman who'd been severely and persistently abused as a child. She lived six hours away and we met every month or so for three-hour sessions. She'd struggled with suicidal impulses for years, and the work we were doing was leaving her emotionally raw. She called one day and told me she couldn't go on in the therapy. "You're getting too close, and I feel too vulnerable," she said. "Plus you're too far away, and I can't come easily for an emergency appointment if I need one."


"I understand," I replied, "and I think this isn't a good time to end treatment. So let's talk for a minute and see if we can get you through until the next appointment. You can find a way to be vulnerable and protected. And you can regulate the distance and closeness to make it work for you. I can be right there with you while I'm here. You can be right here with me while you're there. I can be as far away as you need me to be and as close as you need me to be. And I can be far away and close at the same time." I went on in a similar vein for a few minutes--trying to establish in her a direct feeling sense that she could have her cake and eat it, too. It seemed to work. "Okay. You're right," she said. "I can do that. I'll see you next appointment."

As therapists, we must always be sensitive to the enormous life-restricting pull of either/or thinking. This abused client believed she had to be either vulnerable or safe. But there were situations in which this particular client had been able to be both vulnerable and safe. She said she felt that I was getting too close. I suspected just the opposite as well: she felt that I was too far away, emotionally as well as physically. So I included both possibilities, instead of one or the other.

Typically, when people are stuck, it's like two people trying to go through a door at once. The two are present simultaneously: I want to change, and I'm afraid to change. Inclusion expands the doorway, leaving room for both--and perhaps more--aspects of self to move freely. Merely giving language to this double presence by inviting people to recast their life stories to match their expanded sense of themselves, is often enough to free them from the insidious internal demand to see themselves and their reactions monolithically.

Not long ago, I consulted at a hospital with a woman who was depressed, suicidal, self-mutilating, and defiant.

"How long have you been so depressed?" I asked.

"Since I was 8 years old," she said.

"That's a long time. I'm surprised you've lasted this long."


"Well, two times over the years I almost succeeded in killing myself."

I was curious about how she'd kept herself alive. She told me she'd struggled against the depression so long because in some ways she wanted to live and find a way out of depression. Nobody really understood that, she added, because she was always talking about killing herself.

A few weeks earlier, I'd seen Mike Wallace on 60 Minutes interviewing a woman with a degenerative illness, who was fighting through the courts for the right to die. Wallace asked her why she was suicidal. She replied, "I'm not suicidal. I just don't want to live like this, and I want the right to choose to die." Wallace insisted that, since she was fighting for the right to die, she must be suicidal. "No," she replied, "I love life. I just don't want to live like this. I love life."

I told the woman at the hospital the story and said, "You've lived all this time because you want to live. You've made it this far, by luck, or because the angels were watching over you, or because someone cared for you at times, but mostly because you just kept yourself going. You want to die and you want to live, but you definitely don't want to live like this."

"That's it exactly," she said. "No one has understood that. I'm suicidal and I'm not!"

Now you might say that these women really didn't want to die. But I think that's the cheap version of their reality. They did want to die in a certain way, and (there's that word again) they were still alive, which spoke powerfully for their desire to go on living. Only by recognizing the complex truth of the matter, taking it seriously, giving words to and accepting these dual realities can this permissive, inclusive method work. So clients really do want to live. And the reality that you must come to terms with is that they may really die.

Practicing What We Preach

If the approach I've been laying out here was purely a matter of logic, theory, and better clinical outcomes, its principles would be more widely demonstrated in therapists' consulting rooms. But embracing clients' multiple realities inevitably leads therapists to face emotional issues in their own lives, issues that make an inclusive approach much more than a merely intellectual exercise. At least that's what my own experience has taught me. It's been one thing to give clients permission to accept their ambivalence, but quite another to do that in my own life.


Some years ago, my wife Steffanie was stricken with a painful and life-threatening illness. By 1997, she was bedridden, gaunt, and in extreme physical pain. While the doctors could offer many diagnoses, they had no viable treatments. Many told her there was nothing more they could do. Others referred her for assessments or treatments she'd already tried. She was despondent and convinced she was going to die.

I would hear none of it and found it impossible to support her hopelessness. So I unswervingly emphasized the possibilities for treatments yet to be developed, and the need to keep a positive attitude to support her immune system. I thought, of course, that this would be helpful to her, but it often had the effect of sparking terrible arguments between us.

She would tell me, "You want me to feel better, and I don't feel better. What you're saying just makes me feel worse and more alone." But at some level, I felt that if I didn't expend all my energy in fighting her pain and hopelessness, I would be giving in to it, even making it worse. I was terrified that if I accepted her reality, she was doomed and I would lose her.

Finally, help came from an unusual quarter. We'd recently moved to Santa Fe, New Mexico, and rented a house out in the country. It turned out there were some problems with the well because of leaks and some toxic materials stored in the house. I called the landlady, explained the situation, and told her that we intended to move out. The landlady didn't want us to move and, in addition to making the needed repairs, had a suggestion that could only happen in Santa Fe (or perhaps Sedona): she proposed hiring a "house psychic" to do a reading on the house and deal with the problem at a more cosmic level. Skeptical and a bit bemused, Steffanie and I decided we had nothing to lose and agreed to let the house psychic do her thing.

After a few Feng Shui-type suggestions, the house psychic did a reading for us that revealed, she said, that in a previous life Steffanie and I had been a couple living on a large estate in ancient Italy. Steffanie was the heir and I, as the new husband, had taken over managing the estate. But because I had little experience in such things, I was running the estate into bankruptcy and stubbornly refusing to listen to Steffanie, who unsuccessfully kept trying to tell me what to do. In our past life, the psychic told us, our stalemate ultimately had led to tragedy for Steffanie and I'd spent the rest of my life regretting I hadn't listened to her.


I know, I know--only in Santa Fe! But whatever its value as a past-life story, the psychic's tale was so parallel to our situation that it had an electric effect on me. I realized that I hadn't been listening to Steffanie. However inclusive I'd tried to become as a therapist, at home, I'd been determined to screen out her "negativity." As I might have predicted had I had any distance from our situation, the more "positive" I got, the more desperate Steffanie became.

Something about the psychic's making me see how stubbornness can led to tragedy made me think about my own family story. I suddenly made the connection to growing up in a household in which the unwritten injunction was "don't get sick." We kids had to be essentially on our deathbeds to be allowed to stay home from school or work. If we did stay home, we were never coddled. There was no television or other distractions. My mother, a tough farm girl, would leave some 7-Up and soda crackers by the bedside and check back every few hours to make sure we were still alive. No doctors, no medications. It was as if sympathy would somehow reinforce the illness.

From fear that Steffanie might die, I'd been reenacting an old family drama. I saw that I had to quit trying so hard to make everything okay again. I needed to let myself just be with Steffanie in her hell. I remember going into our bedroom and just lying down and holding her for a long time, without saying much of anything. Then, we quietly spoke about the pain she was in. Later, she told me that it was the first time she hadn't felt left alone in her despair. From then on, something shifted between us. I realized that accepting her hopelessness didn't mean I had to give up my own hopes for our future. I could hold them both. Soon, Steffanie began to talk about future plans and other small dreams that indicated she hadn't given up. I could, in turn, speak to her about my fear of losing her and being left alone. She's still far from well, but the tension between us has been replaced by a sense of connection and an awareness of my tendency to "go positive."

It's relatively easy for most of us to think inclusively with our most functional clients, but much harder to do so with those who are difficult and demoralized, or when our own psychological hot buttons are being pushed. But being a therapist means taking the time to get all the pieces of people's reality, spoken and unspoken. At the most basic level, we must discover how to perform the balancing act of simultaneously giving up the need to see clients change while holding open the possibility of change. This attitude requires us to face our own fears (of lawsuits, suicide, failure) and be still with the client's pain, immobility, glaring absence of change, and , at the same time, we must be able to see the "and"--that something more, unrecognized and unspoken, happening beneath the dead calm of an apparently inert sea.

Bill O'Hanlon is a therapist, author, and workshop presenter. His latest books include Do One Thing Different; Try and Make Me; Collaborative, Competency-Based Counseling and Therapy; and Even From a Broken Web. His book A Guide to Inclusive Therapy is due in early 2003. Address: 551 West Cordova Road, Suite 715, Santa Fe, NM 87505. Website: www.brieftherapy.com.