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Therapy As Craft

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SO2012-1Healing Clients One Brick at a Time

By William Doherty

In this era of medical necessity and evidence-based therapies, it’s easy to lose sight of a basic truth. We heal not through prescriptions and procedures, but through talking and listening.

Most of us went into the practice of psychotherapy after years of having friends tell us that we were easy to talk to about their personal problems. They didn't say we were the smartest or the coolest, but we were the ones people turned to when something went wrong with a relationship or their parents were driving them crazy. Taking the hint, we ended up making careers out of being skilled conversational partners to people in emotional trouble.

In this era of medical necessity and evidence-based therapies, it's easy to lose sight of the basic truth that psychotherapy is a special form of conversation: we heal not through prescriptions and procedures, but through talking and listening. Diagnoses and therapeutic models give us markers and road maps, but we have to put them into words, sentences, silences, looks, and gestures--the stuff of human interaction. However, we can get so focused on assessments and strategies that we don't pay enough attention to the core craft of our work: the spoken word. Surgeons cut and suture; therapists converse.

In workshops, I like to show a tape of a conflicted couple in which the wife, during a first-session diatribe about how emotionally distant her husband is, slips in these words: "I want my husband back." I ask the audience what they'd do next--what exactly they'd say, and to whom. Typical answers reveal a reluctance to get specific and a desire to talk strategy: "I'd try to get the wife to get in touch with her hope," or "I'd help the husband hear what his wife is saying." I keep repeating: "Whom would you address first and what words would you use?" Sometimes I have to be firm: "The floor is only open to two responses: whom and with what specific words?"

As we unpack the conversational options, it becomes clear that the outcome of the session, and perhaps of the therapy, could depend on what's said next. Nearly everyone in the room understands conceptually that the angry wife has expressed a vulnerable longing for her husband, and that the therapist's strategy should be to highlight that longing and the hope that it reflects. I break down the choices: say something to the wife or the husband, make that either a statement or a question, go cognitive or affective. Here are examples that have come from audiences:

Cognitive question to the wife: "Could you say more about what you mean when you say you want your husband back?"

Affective question to the husband: "How did you feel just now when you heard your wife say she wants you back?"

Then there are nonverbal options: for the therapist to be cool (using a calm, neutral voice, keeping the body still and relaxed) or more intense, as in my favorite response, saying softly and with emotion to the wife, "Susan, I just heard you say something that really struck me. In the midst of all the pain and hurt you feel in this marriage, you still long for Jeff. You want him back with you." The rationale here is that you want to turn up the heat on her hope before you do anything else with what she said. It'd be a mistake to ask the husband to respond before Susan goes deeper into her positive feelings for him; after all, everything else she'd just said was critical of him.

We continue the role play with ideas for how to get the husband involved in this pivotal moment. Once again, we have many options: cognitive statement or question, affective statement or question, cool or hot, having him respond to the therapist, or asking him to say something directly to his wife. It's like a basketball player leading a fast break: do you pass the ball, to whom, and at what time? Or do you take the ball to the basket yourself? In basketball and therapy, you have microseconds to decide--and your choice can have outcome-determining consequences.

Some choices, like asking the husband to turn to his wife and respond in any way he wants to her remark about wanting him back, carry risks of derailing the therapeutic moment, and perhaps the therapy, if it's the first session and the couple is on the brink. The husband is apt to respond with something like, "You sure have a strange way of letting me know you still care." The husband now looks like a jerk, and the wife shuts down, firmer in her belief that he's emotionally unavailable. On this clinical fast break, the therapist has passed the ball too far out ahead of a teammate, who kicks it out of bounds and looks bad.

Here's what I tell audiences is a better approach at this moment in the conversation: after the wife has stayed with her softer feelings for a moment or two, the therapist leans toward the husband and says softly, "Jeff, I know this has been a hard time for you in the marriage, and you've been feeling Susan's anger. What's it like now for you to hear her say that she longs to be connected with you again?" I'd have him respond to me, rather than his wife, because if he mixes positive and negative feelings, I can help him focus on the positive ones before I reengage his wife in the conversation.

Therapy as Craft

We rarely talk about therapy on the ground like this: what words at what time and with what tone and body language? Maybe we assume that if therapists are trained in good models of therapy or in the common factors of all successful therapy, they'll just know how to execute the skills. But what if we think of therapy as a conversational craft that we hone over a career with our clients and with a community of conversational healers? The term craft (a Germanic word for "power" or "ability") describes a skill set for producing useful things. Crafts are traditions passed down; we learn our craft from apprenticeship with masters. Crafts have communities with standards for whether the work is done well and the product meets practical needs. Carpenters recognize good and bad housing construction. Even therapists with different models can recognize good therapeutic craft when they see it, just as musicians who play different instruments or in different genres recognize good musicianship when they hear it.

The craft idea differs from two other images handed down to us: the therapist as scientist-practitioner and the therapist as artist. The first was born in 1949 with the Boulder model of clinical psychology. To the dismay of many academics, the scientist-practitioner model never took hold in community-based practice. Although few therapists would argue that research in areas such as psychotherapy efficacy, neuroscience, and attachment theory (to name a few) are irrelevant to the practice of psychotherapy, the treatment room is miles away from the science lab. The alternative conception, of the therapist as artist, was popular during my training. The best therapists were conversationally creative: think Carl Whitaker, Salvador Minuchin, and Virginia Satir. But art doesn't have to be useful, and artists today are expected to thumb their noses at tradition and convention. In Woody Allen's classic line from Bullets over Broadway, "An artist creates his own moral universe." Psychotherapy may be a creative exchange, but by contrast, we work as part of a community of healers, and it matters whether our clients get better. We're not each our own moral universe.

So if psychotherapy is a conversational craft, not mainly a science or an art, what are the tools of the craft? They include words, gestures, statements, questions, listening, pausing, and the nonverbals that go with them. (Of course, there's a knowledge base, too, for the craft of therapy, but here I'm focusing on the tools.) Then there are metaconversational tools, such as pacing versus leading the client, heating up the conversation versus toning it down, staying with a subject versus shifting focus, keeping the conversation productive, recalibrating when the therapy is no longer productive, and using additional tools for multilateral conversations with couples, families, and groups.

For example, heating up a conversation can take the form of using colorful and challenging metaphors. Instead of pointing out for the umpteenth time that a wife was indulging in indirect, negative communication with her husband, here's what I said: "Susan, I want to tell you what I just saw. I saw you pick up a hand grenade, calmly pull out the pin with your teeth (I mimicked the motion), and toss it into your husband's lap--and then you seemed surprised when it blew up--BANG!--and he shut down once again." The key to this being effective was the twinkle in my eye and a sense of near admiration in my voice for the offhanded artistry she showed in pulling this off. She had to laugh at herself, and I laughed with her. By contrast, I could have challenged her with more clinical (and blaming) language, such as saying something like, "That was pretty passive-aggressive, Susan," thereby bringing the wrong kind of defensive heat to the conversation. If this seems overwhelming, well, it is--for beginners. Even as an old-timer, I'm always nervous before seeing new clients, because I don't take for granted that we'll achieve a therapeutic level of conversation.

I made a craft mistake yesterday that scared me. I was seeing a couple for Discernment Counseling, a way of working with couples considering divorce in which they spend time deciding whether to continue on the divorce path or devote six months of therapy to an all-out effort to restore their marriage to health. It was the second session, and I was talking with the husband alone. When he launched into what I sensed was going to be a lengthy monologue on his wife's failings, I tried to interrupt and steer him back to looking at himself. He must have felt that I was telling him his feelings were wrong, because I hadn't said two words before he cut me off and became enraged. No one, he shouted, was going to tell him he didn't have the right to feel angry at his wife. Not the last goddam therapist, not his wife or adult daughters, and certainly not me. He was so worked up that I felt a pang of fear for my safety. I'd misjudged his openness to have me structure how he talked about his hurt and anger.

I switched to a calm, listening stance, focusing my attention on his pain and not allowing my nonverbals to communicate fear or distress. (I recall Jay Haley teaching a nice piece of craft: when you feel threatened by a client, act the opposite nonverbally, open and calm--which signals safety to the client.) The storm soon passed. I knew it was important for me to pace him better, but I told myself that I shouldn't overreact and play it too safe. So I challenged him several times, but with better skills. After waiting for him to pause, I'd say, "I have a thought about what you're saying that you may or may not agree with. I'm wondering if . . . ." I gave him permission to disconfirm my statements and maintain his sense of self-protection.

Near the end of the session, he told me that the angriest he'd gotten in his whole life was at a therapist who, after he said he was feeling guilty about how he'd behaved in his marriage, rubbed his bearded chin and said, "Guilt: I'm not hearing guilt." If that happened as reported, it was a megamistake by the therapist (the client refused to return to therapy). Mine was a smaller mistake, although potentially serious. Without knowing the client well enough, I'd tried to lead him without enough pacing of his feelings, and I'd done so by interrupting him without waiting for a natural pause.

In this situation, the advantage for me in thinking about my work as a craft is that I knew immediately that I'd made a technical mistake. Of course, I learned a lot about my client from what happened, but too often, when our clients act dysfunctionally in sessions, we veteran therapists focus on them and not enough on ourselves--on what we did or didn't do, or on what we can learn. How did my client's previous therapist respond to the therapy-ending outburst? He called the wife to tell her that her husband had narcissistic personality disorder.

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3 comments

  • Comment Link Monday, 22 October 2012 19:42 posted by Bruce Teall

    I think that the identification of psychotherapy as a craft is an extremely important one. I fear, however, that the current business model that treats therapy as a commodity with the therapist's educational level being the only determinant of reimbursement rates — at least within panels/geographic areas — is working against us. As it gets tougher and tougher to make a living wage as a practitioner, the time needed to become a true master craftsman is more and more difficult to find or justify.

  • Comment Link Monday, 01 October 2012 12:42 posted by Kemila

    One of the most interesting reads for long. Thank you.

  • Comment Link Saturday, 15 September 2012 08:00 posted by jeffrey von glahn

    Kahneman and Klein (2009. Conditions for intuitive expertise: A failure to disagree. American Psychologist, 64(6), 515-526) write about "skilled intuition." This ability can only develop in a setting that has stable relationships between input and response. The authors cite firefighting and medicine as examples. Psychotherapy is certainly one. Long-range forecasting of the value of a stock or of an election are not examples.