Inspiration Vs. Perpiration in the Therapy Room
by David Waters
It was the kind of tense stalemate between an angry, critical father and an increasingly withdrawn teenage son I’d seen many times through the years. Greg was a single parent who seemed to regard every exchange with his shy, 14-year-old son, Tad, as an opportunity for a “corrective experience.” But they were both bright and articulate, and therapy started off with both of them readily agreeing to spend more time together.
Having contact isn’t the same as making contact, however. Greg routinely ended up angry and disgusted with his son, rarely missing an opportunity to find fault, much like his description of his own father’s behavior. Rather than focusing on Tad, Greg spent many of our sessions talking about how bad his father had been. In short, therapy wasn’t going anywhere.
Finally, in one session, I decided to get Greg’s full attention. As he launched into yet another rant about his father, I said, “Forget your damn father, Greg, and focus on helping your son!” I tried to say this with just enough mock exasperation that I wouldn’t sound like a critical dad myself. I went on, “You came here because you couldn’t connect with your son, but every time you approach him, you get tangled up in all your old anger toward your father. It’s time to cut it out! Your father’s already done enough harm. Don’t let him come between you and your son.”
Greg was stupefied, and incredulous. “Forget my father ? Stop having these feelings ? What the hell kind of therapist are you?”
“Good question,” I replied. “I’m the kind of therapist who hates to see the same painful pattern repeated over and over, and, today, I’m a therapist who hates to see long-dead fathers ruin the bond between their sons and grandsons. So your father isn’t welcome in this room, for the time being. I don’t want to hear a word about him until further notice. I want all of your attention on your son, and on the present. I want you to focus on doing what your father couldn’t do, instead of repeating what he did.”
This wasn’t a well-rehearsed therapeutic routine. It was improvisation, with a purpose: to flip an all-too-repetitive moment into what I like to call a Big Moment, a therapeutic event that raises the stakes and deepens the possibilities, creating the climate for a conversation that might otherwise never happen. In this case, I knew from Greg’s response–a mix of startled anger and hesitance–that I’d gotten his attention with my statement in a way I hadn’t been achieving with therapy-as-usual.
As a younger therapist, I’d have thought that this moment with Greg was an unadulterated triumph. I’d have basked in the feeling of new energy between us that I sensed when Greg was caught off guard, and I’d have assumed that Greg had been stimulated to consider a new way of behaving. Basically, I’d have thought my job was all but done and transformation was just around the corner. For, as a younger therapist, I was convinced that the challenge of really getting the client’s attention couldn’t be overstated. In those days, I didn’t ask questions about the larger context of a Big Moment–how it could be employed in the totality of a client’s life. I believed there were just two kinds of cases: your usual, low-level-of-attention cases, in which clients put in their time, did their homework, and incrementally moved out of their old ruts, and the far more interesting, high-attention-level cases, in which clients embarked on a project, a therapeutic undertaking that seized clients’ imaginations with the potential to alter them on every level. I also believed that these two types of cases were mutually exclusive.
I’m writing now to document my discovery that they are, in fact, not mutually exclusive, but that both approaches, combined, produce the best results. This is a story of learning the hard way.
Big Moment Addiction
I used to get very excited when I thought that clients were about to embark on what I called a project–a course of action that crystallized a problem into a unifying undertaking; a Big Moment extended over time. Here’s an example.
Tammy’s family came to see me after moving to Charlottesville, Virginia, to get 16-year-old Tammy away from Tony, the boyfriend-from-hell who’d slept with her and later given them all a pregnancy scare. But moving the family hadn’t changed gorgeous, talented, spoiled Tammy’s feelings about ne’er-do-well Tony. While the parents lectured and cried, she stayed absolutely glued to her dream of true love. This in spite of her admission that Tony cheated with other girls and had walked away when she feared she was pregnant, saying, “It could be anybody’s.”
When I couldn’t get the family off a fruitless repetition of the same battle over changing their daughter’s mind about Tony, I decided to see Tammy alone. In these individual sessions, I appealed to the princess in her–a major feature, to say the least. I asked her how a guy should treat a girl in general. Her answer included every romantic clichÃ© from flowers and jewelry to spaniel-like devotion. I had to fight the temptation to point out that Tony hadn’t met a single one of these criteria. Instead, I asked her to muse about how it looks when a guy comes through, how it looks when he doesn’t, and how a girl can tell the difference.
As Tammy became increasingly involved in our discussions, a project emerged: Tammy would go on a field trip back to her previous hometown to see whether Tony could pass this test of how a guy should treat a girl. I didn’t bring up this excursion directly, because she needed to come up with the idea and structure the “test” herself. When she did, I was very skeptical, and made her think through every ramification. She listened to me and plotted her “data collection” with an energy and verve I’d never have thought possible in the early, listless stage of our work together. I began to see a maturity and level of insight I hadn’t suspected she was capable of. Once she’d considered every aspect of the visit, we planned how to go to her parents with this outrageous idea.
When she did approach parents, they hit the roof, as we’d expected. But she was able to convince them that she really had to see for herself whether Tony was a creep. So, with lots of preparation, we sent her back to spend the weekend seeing her old boyfriend.
The week of the experiment, her parents and I had our hearts in our mouths. Then Tammy came back reporting that Tony was “okay,” but there was now a noticeable shift; she no longer seemed to feel any real excitement about him and had no plans to continue the relationship. The project seemed to have gotten her into a new mode of thinking–critical and observant, rather than mushy-headed and romantic. The more she talked about Tony, the clearer it became that she didn’t particularly like him. We all breathed a sigh of relief, and I felt great that the project had worked so well.
But then the unexpected happened. After the project was over, Tammy dropped back into her funk. She got into meaningless struggles with her parents and lost the spark that had made her an attentive, excited collaborator. I couldn’t get her interested in taking on any other challenges and, ultimately, lost the family to their resigned sense that they’d done all they could. After our creative leap, it seemed, no real change happened.
Why didn’t it work? Why did I lose Tammy’s interest? While the trip to see Tony had captured her imagination, once that adventure was over, she was again staring out the window and asking whether the session was up yet. Tony wasn’t the white knight she’d imagined, but she remained obsessed with finding one. This quest was far more interesting to her than working on boring issues of self-worth and empowerment, which had been important only in the context of the “Tony test.” I couldn’t translate the excitement generated by our project into an ongoing interest in growing up. So what I’d thought of as the beginning of the work turned out to be the end.
Now I understand that I was expecting too much of a 16-year-old. She’d faced a challenge and met it, and this increased her awareness. She wasn’t going to grow up according to my timetable. I was paying more attention to my goals than to her life and her teenageness. Perhaps I should have suggested that she and the family digest the experience, and that we meet again in six months to compare notes. Almost certainly, she’d have pursued another white knight with similar results. Then, with work, I might have been gotten her to perceive the repetition and begin to root out the white knight myth. But I was so enthralled with our Big Moment, our project, that I couldn’t get focused on how to keep her interested in growing up. Once the excitement of the project was over, both Tammy and I got bored with the grunt-work of change. I failed to understand that if I wasn’t excited with gradual growth, I couldn’t expect excitement from my clients.
Learning to Fly
What first made me fall in love with being a therapist was the idea that I could make a living by having conversations that cut through everyday pretenses, got directly to the heart of the matter, and helped people change their lives. This was profoundly appealing to someone who came from a reticent, emotionally avoidant, WASP family that was devoted to the creed “If you do have to feel something, for God’s sake don’t let on.” Unfortunately, I entered grad school in the late stages of the psychoanalytic hegemony, when therapeutic impact was thought to derive from the therapist’s ability to remain silent for years–not exactly what I had in mind. As a result, my early supervisors diagnosed me with poor impulse control. My play-therapy supervisor used to say to me, “Dave, ‘play’ refers to the child, not the therapist!”
But I wanted to make things happen! I was too impatient to wait while a child came up with his own version of a game, so I’d help him out a little by teeing it up for him. After watching him roll the same car back and forth in the sand tray for three sessions, I’d say something like, “Let’s race the cars around the track and see which one goes faster.” I just knew that this would give me good data about how he dealt with competition (read: Oedipal drama). But my supervisor didn’t agree, insisting that I merely reflect and validate the child’s play, however poky it might be.
Adult therapy went pretty much the same way. That supervisor would say things like, “That was an excellent interpretation, Dave, but six months too early.” And I’d think, “I’m supposed to sit on that idea for six months?!” They didn’t understand: I wanted to earn my keep–a lifelong anxiety–and have clients get excited about what we were doing. It was less about my ego (a not inconsiderable factor) and more about my need to prove, to myself and my clients, that this work could make a difference. I believed that the possibility of breakthrough should always be at the forefront. But in most of the therapy I saw and experienced, there was little place for novelty and few indications of real impact. It made no sense to me to move so cautiously through the valuable therapeutic hour.
Luckily, just as I was starting out in the profession, the whole field of therapy began to shift. A cacophony of raucous new voices started drowning out the quiet, refined tones of the psychoanalytic old guard. In this heady new world, my impulse-control problem suddenly became an asset. Spontaneity, energy, imagination, daring were now therapy’s new watchwords. The low-decibel collective drone of analytic therapy morphed almost overnight, it seemed, into encounter groups and T-groups with exotic and radical ways of working, often led by people without much knowledge and expertise. The basic idea seemed to be that restraint was old-fashioned and unnecessary, and that people needed encouragement to listen to their healthy, but usually ignored, impulses. I still recall my Student Health Therapy Group petitioning me to meet as a nude encounter group, in order to “get past the charade of self-presentation.” My supervisor nixed the proposal in a heartbeat (more’s the pity), but it still represents for me the freewheeling zeitgeist of the period.
Even psychoanalysis, that conservative bastion of methodical control that had set the rules for so long, experimented. There were schools like Direct Psychoanalysis, in which, for example, the therapist would bombard a psychotic patient with interpretive feedback to break through defenses. “So you want to fuck your mother?” the direct analyst would ask the patient, often repeatedly, as the patient got more and more upset. I couldn’t imagine how it could work, but it was certainly exciting to see even the hoariest old schools of thought join the creativity parade.
To me, the most radical and interesting innovation was family therapy, with people like Jay Haley and Salvador Minuchin and Carl Whitaker doing things that scandalized the therapeutic old guard. Imagine my excitement when I discovered this brand-new, brave new world! At the family therapy workshops and externships I began attending, film clips would be shown of dramatic breakthroughs and amazing turnarounds. Minuchin would create stunning metaphors on a stage, in vivo, that visibly changed the family. Harry Aponte would have an outright battle with a child or an adult about their part in the problem. Whitaker would say crazy things. One time, he said to a recently discharged young man, who was looking at a chair before sitting down for a family session, “Don’t sit there, I think there are little pieces of shit all over it.” The man bonded with Whitaker immediately.
As I sat in workshops and watched these little miracles happen, feeling terribly mundane and unimaginative by comparison and wondering whether I’d ever have what it took to say and do such remarkable things, I got hooked on the Big Moment. Like many others in the field, I became enamored of the point in therapy when the problem is transformed or the solution is achieved in a flash. The creative breakthrough became the moment of therapy for me. Everything else led up to it, supported it, or built on it.
All of a sudden, I felt a new freedom as a clinician. I stopped waiting for people to bring things up and started leading the way; I stopped settling for small gains and started pushing for more, trusting that there’d be more. True, what I did might not seem thrilling now, but against the backdrop of total analytic quietude, it seemed daring and exciting.
Once, for example, I pushed a timid, intimacy-phobic husband to give his wife “a real hug” at the end of a hard session. He gave her a tepid, A-frame hug worthy of a distant cousin. Although hug therapy was already a radical departure for me, I made myself tell him it wasn’t good enough and ask him to give her a real, “I’m-crazy-about-you,” hug. He claimed it was Â a real hug, and told me to leave him alone. That didn’t deter me. I asked his wife if the hug felt “real” to her. In her nice gentle way, she indicated that she was eager for more contact. He tried again, and three minutes later, when they were definitely getting the hang of it, I slipped out. I wasn’t going to upstage Minuchin with work like this, but I think it helped more than a few of my clients find some new potential in themselves. I know I did.
The Limits of Creativity and Change
That was then, and this is now. Today as a profession–and as a society–we’re much more fearbound and rule conscious than we used to be. Many professionals live in terror of making a mistake, getting sued, and being politically or socially or bureaucratically incorrect. It’s become a lousy atmosphere for creative leaps and Big Moments, or even for reaching beyond “approved” forms of interaction. Yet the sacred space of the therapy room is the ideal place to really exercise your creativity. What individuals can accomplish together in a private, protected undertaking is as amazing as it ever was.
In spite of the current restrictive atmosphere of fear permeating the therapy profession, I’ve hung on to my early passion for change and impact. However, Tammy and many other clients have taught me that after a breakthrough moment in therapy, it can often be quite difficult to interest a patient in the work necessary to maintain the gain or put the new ideas to work. All too often, patients drawn to the Big Moment have started immediately looking for the next one, rather than focusing on the hard work of applying and embodying more fully what the Big Moment had revealed. In this way, patients are no different from us–just as we go to workshops hoping to learn how to do magic, patients often come to therapists hoping to have magic practiced on them. Slow, hard struggle is much less appealing.
The danger is that the therapist and/or the patient can get hooked on creating the Big Moment and lose the will for the hard work that can slowly change unfulfilling habits. The real challenge, I began to realize, isn’t just to create interest and intensity in a session, but to incorporate the movement generated by sessions into habits of thought, feeling, and action that patients can establish as part of their lives.
Having become disillusioned with the Big-Moment approach to therapy,Â I made a classic mistake of overcorrection. I began to look longingly at the CBT manuals and their methods for hammering home therapeutic gains. I became envious of the clear protocols presented by workshop veterans of one school or another. Even totally programmed therapies like EMDR began to seem appealing. I started distrusting my creative impulses and began to seek out some reliable way to really change people.
Of course, this kind of search for new tools and more dependable methods is common in this field, a profession in which it’s so easy to develop doubt about one’s effectiveness. An older psychiatrist I admired a lot once described therapy as “the only profession that gives you five or six chances a day to feel like a failure.” At this stage in my career, my self-doubt became so strong that even when things went well, I’d often ask myself, “Would it have gone that way anyway? Did the therapy make a difference, or was I just on the scene when the improvement happened?” I’d hear my friends describe great outcomes and wonder if I’d ever helped anyone that much.
Then I began to place my bets on the more formal, structured rigor of getting people to actually do what we were talking about. In couples therapy, for example, I’d always spent a lot of effort helping people connect in my office through physical contact, honest revelation, and taking chances with each other in ways they couldn’t do without me. Call it Relational Creativity 101. But it never included much by way of homework, carefully checking back about what actually happened, or discussing what had helped most in getting someone to really do things differently. So I decided to start placing more emphasis on giving couples small but consistent actions they could take home and build on.
I began giving a homework assignment I called the Shape-Up, inspired by what happens on the docks every morning when stevedores gather around to divvy up the day’s responsibilities and make sure everyone is pulling their weight. I asked couples to have a Shape-Up time every evening when the second person came in the door. They were to meet, shoo the kids away, and take just 5 to 10 minutes to check in with each other: How was your day? What do you need to get done tonight? How can we help each other? What happened today that we both need to know about, especially kids-wise? What other preoccupations are you carrying?
I soon found, however, that even after a wonderfully connected session, many couples only managed to do the Shape-Up once or twice. Even when I exhorted them to build this ritual into their lives and they agreed enthusiastically, they often got sidetracked and never went back to it. I began to wonder why I could get couples over a huge barrier in the session, but couldn’t help them make a small, day-to-day adjustment.
Certainly, part of the reason was that I wasn’t at home with them to encourage and enforce change. But I also realized that scheduling the daily Shape-Up felt too small and inconsequential, too ordinary to make a difference to them. People will reach deep for a moment of high drama and poignancy, but won’t go upstairs to make the small contact that might change the course of an evening–and cumulatively, over time, a relationship.
So I decided to make much more of the small follow-up steps with clients –to try to get the level of involvement from them at home that I could get in the office for big changes or enactments. But it’s hard to get people to pay the same attention, take small steps seriously, and really commit to gradual change. It was a replay of how I felt about the difference between the energy of making small changes required to get out of a rut and that of undertaking a project when I first did therapy. They couldn’t get very interested, and, at first, I felt a little foolish following up our breakthroughs with nickel-and-dime exercises. It felt rote and unimaginative, not creative enough. But I noticed that when clients did take the exercise seriously enough to follow through on it daily, it often made a bigger difference than the Big Moment.
If I were showing tapes at a workshop, like everyone else, I’d be more apt to show the point at which I was able to create the dramatic change than the difficult negotiations needed to get couples to sign on for the Shape-Up. But clearly, there’s a place for both models–breakthrough and working-through–in our work. The Big Moment is good for getting people’s attention, but we always need to bear in mind what we’re getting people’s attention for. The role of the creative leap in therapy is to establish a strong involvement with an issue and engage clients fully in the difficult and laborious business of change. But however valuable creativity can be in setting up the conditions in which transformation may take place, change itself requires repetition and commitment to altering habits and revisiting an issue over and over and over again. People often need a startling moment of awareness to build the small changes around, but the startle itself usually won’t suffice to shift lifelong patterns
Consider the case of Kelly and Jack, who’ve been married 20 years, during much of which they’ve agreed on only one thing–they don’t want a divorce. They both felt “truly married for life,” even if that life was a big pain in the butt. They fought more or less nonstop–mostly niggling little put-downs, punctuated by occasional nasty battles. One particular source of conflict was how to raise the kids, and every evening was a pastiche of disagreements and rolled eyes over the right way to do things. I tried to mediate and deflect their arguments; I got them agreeing on better ways to work with the kids; I tried to institute the Shape-Up. In short, I worked to help them make a lot of small changes that could have made a difference, but didn’t.
One day recently, they were starting to repeat the old mantras of criticism and disgust, in their usual playful manner, when I had an idea. “Slide over on the couch, Jack, and put your arm around her,” I requested. He moved one inch and laughed. I pushed on this request for several minutes, in an atmosphere of growing tension. They both said it was artificial and forced and not worth bothering with, but I held my ground. The tenseness increased. Finally I said, “You just can’t do it. Admit it. You’re afraid to get really close. You’re both scared of intimacy, and you maintain this game of playful meanness as a substitute; but you’re not comfortable with actually being close.” They froze.
Neither said anything for what felt like 30 or 40 seconds, and I wasn’t sure whether they felt attacked or helped. Then Jack said, very slowly, “It’s absolutely true. I can’t get close to her. I sometimes admit to myself that I’ll pick on her and start a fight if things are getting too cozy.” Kelly was surprised by this admission, but then copped to the same pattern. “I know I can always get his back up by talking money.”
The younger me would have felt like we’d cracked the case, and moved on from there toward the next breakthrough. But as a veteran of far too many Big Moments that ultimately led nowhere, I realized that what had just happened was merely an indication that Jack and Kelly needed to spend time doing all the little things required to break that pattern. Fear of intimacy and their unconscious contract to stay together but not close became the focus of our therapy sessions. Then we began working on the small steps needed to change these ingrained patterns.
We went back over the Shape-Up, the rules of engagement around the kids, and the ways they could help each other out. We looked repeatedly at how to deal with the moments in which they have to choose how to be with each other. We talked about their having the courage and presence of mind to do something different. We examined the roots of their avoidance of intimacy, with an emphasis on patterns of thinking and reacting, and how to change those. The shock and dismay they felt at seeing the issue starkly became a touchstone for making these small changes.
We now had a project together that synthesized the Big Moment and the day-to-day work of getting out of a rut. Without the big issue in our sights, I wasn’t able to keep them focused on moving toward something better. But at the same time, without the small changes and the ongoing attention to doing little things differently, the creative leap we’d shared was an interesting insight, but wouldn’t have changed anything.
In these days of Managed Care and Therapeutic Minimalism, my biggest concern about therapy is that we don’t ask enough of it. Too often, we don’t push ourselves or our clients hard enough to make the changes that make a real difference in people’s lives. It’s taken me more than 30 years to realize that it’s the combination of two strange bedfellows–imagination and repetition–that holds the key to change.
I still cherish and nurture my ability to sometimes make a dramatic intervention that gets my clients’ attention, but today, when it works, I immediately recognize that I have a new task: keeping it in our sights. How do we tie it in to the day-to-day realities of life and get our insight to play out in real ways? Often that’s harder to do than the original breakthrough, but that’s what makes our job as therapists challenging. I realize now that, for many years, I was letting myself off the hook too easily by thinking, “Now that I showed them the way, my work is done.” Today I know that good therapy requires a whole second sequence that builds on insights and carries clients forward in a variety of ongoing, daily events.
To move clients out of their ruts, their numbness, and their stuck places, we need to get their attention and start their adrenaline going at a rate that wakes them up and helps them to experience the fullness of life again. Creative Big Moments can be indispensable for this. They also get us out of our own ruts and make us feel more alive, making them a great antidote to the pitfalls of this profession and the perils of burnout. Intense, vibrant, liminal, human interaction–experience that goes off an edge and soars–is wonderful stuff for everybody involved. It’s something to strive for in therapy, to recognize and cherish when it occurs, and to help clients build upon in their daily lives. But the Big Moment needs many little moments to make it stick.
That may sound like an underwhelming conclusion, but something else I’ve learned as a therapist and a man is that the simplest things to say can be the hardest to do, and can take the better part of a lifetime to learn.
David Waters, Ph.D., is a professor of family medicine, psychiatric medicine, and psychology at the University of Virginia in Charlottesville, Virginia. He’s practiced family and marital therapy for 30 years. Contact: email@example.com. Letters to the Editor about this article may be e-mailed to firstname.lastname@example.org.