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2005 November/December

2005 November/December (4)

Friday, 02 January 2009 11:36

Rediscovering the Mystery

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Rediscovering the Myth

For John O'Donohue, Therapy Is a Journey into the Unknown Self

by Mary Sykes Wylie

Psychotherapy's preoccupation with personal troubles can seem like a self-indulgent luxury in the harsh Irish countryside near Conamara, where poet, philosopher, and former priest John O'Donohue makes his home. According to a commonly told local story, one day during World War II, two German fighter planes circled overhead. One pilot radioed the other asking, "Should we bomb it?" Looking down, the other pilot radioed back, "I think it's been bombed already." As O'Donohue, a tall, rangy man with amused eyes and a sudden, piercing laugh, puts it, "This landscape absolutely minimizes any kind of supposed significance of human words or thought; your pet ideas unravel very fast. It can be so desolating that it makes you feel how nomadic and transient you are--all this was here hundreds of millions of years before humans-come-lately arrived. It makes you aware of our own arrogance, human orphans as we are, who think the whole of existence is all about us."

His Irish upbringing among rural, traditionally reserved people, has enabled O'Donohue to bring an outsider's perspective to our therapy-obsessed culture's insistence on revealing all the intimate details of our own lives and uncovering those of other people. "Americans have a sweet and touching need to personalize everything," he remarks with affectionate irony. "I found that, in America, if I put too much sincerity into the question, 'How are you?' I could unleash an entire biography. In my village, you wouldn't ask a full-frontal question to anybody--you'd read the signs in the person, take stock of him or her, keep your distance, and then, maybe, you might get a glimpse of what was going on inside." For good measure, he adds, quoting poet Rainer Maria Rilke, "I won't go to a psychologist because I'm afraid that if my demons leave, my angels will as well."

Nevertheless O'Donohue has begun to build up a small but devoted following in the therapy world, a following that mushroomed dramatically at last spring's Networker Symposium in Washington, D.C., where, in spite of the fact that few people had ever heard of him initially, his appearances became the talk the meeting. His poetry reading on the meeting's opening day in particular became such a word-of-mouth sensation that it later sparked a run on the conference taping service. When O'Donohue's new fans discovered that the reading hadn't been taped, the occasion itself became something of an instant legend: afterward, stories about it passed along from those who'd been there to those unfortunates who hadn't been so lucky, leaving the latter feeling they'd missed the biggest event at the conference. Fortunately, Symposium attendees will have another chance to hear John O'Donohue, who'll be a keynoter at the 2006 conference.

This said, the reasons behind O'Donohue's impact are a bit mysterious. He spoke about beauty, creativity, poetry, the divine. He delivered exuberant lyrical riffs--"blasts" he calls them--on the meaning of true identity; the holy power of language; the divine gift of imagination; the dialectic between visible and invisible, presence and absence, longing and belonging; the fundamental mystery of the self. He laced his almost incantatory flow of words with his own luminous poems, though the line between his poetry and everything else he said wasn't easy to draw. It wasn't even always entirely clear afterward what O'Donohue had been talking about--these were less logical discourses than extravagant wordfests. So how did he so deeply move an audience usually impressed far more by practical clinical tools than rhapsodic flights of the imagination?

 

Therapists in the audience had less to say about the information O'Donohue conveyed than about how he managed to open their inner beings to an entirely new way of perceiving the world. "He said such astonishing things, like 'When we move away from our houses, do our houses miss us?'And the shift he created, literally, smacked you in the face, demanded that you go somewhere in your mind you hadn't been before," says Richard Goldberg, a clinical social worker in Bethesda, Maryland. "It's as if he's come from some different, remote place, and he somehow touches you in that same remote place that you'd forgotten you had inside yourself," said Virginia psychologist Charles Cerutti. Lisa Tillman, a therapist in Baltimore, Maryland, thought that "something happens in people's brains when they hear language so precisely tuned into the soul. He has the ability to make that happen." Of course," she added, echoing several other people, "it didn't hurt that he also had an Irish brogue."

O'Donohue seemed to tap into a yearning in his audience not often addressed in today's therapeutic culture. At a time when the pressure is on to do ever briefer, more technical, symptom-focused, "evidence-based," standardized therapies, to make ever greater use of psychopharmacological agents, to slavishly follow DSM diagnostic categories, and to rationalize every moment of a clinical encounter, he reminded his listeners what a noble, even sacred, calling therapy can be. Quoting Plato's Symposium, he said that "one of the greatest privileges of the human being is to become a midwife to the birth of the soul in another person." This is what therapy is about, he added--"helping people retrieve what has been lost to them; wakening and bringing home their fundamental wholesomeness." Therapists are like poets or priests, he noted: they draw on the power of words in the profoundly creative work of bringing people fully alive to themselves, awakening in them the human capacity for divine imagination that "dreams our completion."

But perhaps most of all, O'Donohue reawakened his listeners to the fundamental mystery that surrounds our existence. "In focusing on how people work, we've lost a sense of reverence for the deep mystery of who they are. We have lost sight of the mystery in the primal fact of human presence--that we are here at all." He suggested that the most important dimensions of human experience are those we can't see and grasp and measure, which demands the most reverent attention from a therapist. "I'd love a return to that old way of considering human identity not just as biographical drama, but as sacred mystery."

A scholar, bestselling author, internationally known speaker, and corporate consultant, O'Donohue is clearly both successful and comfortable in the 21st century. And yet he also seems to be something of an historical throwback--like a 19th-century nature poet or 13th-century mystic, living in an 18th-century cottage, surrounded by 1st-century Celtic ghosts. Although he resists our modern tendency to reduce personal identity to the mere external facts of biography, we can't help but wonder how this interesting human anomaly came to be.

 

The Making of a Poet

O'Donohue grew up in a premodern world of rural peasantry that would be almost unrecognizable to most Americans or Western Europeans today. The oldest of four children, he was born on a farm in Conamara--his father was a farmer and stonemason--surrounded by animals, in a community that probably hadn't changed much in hundreds of years. His family had no electricity until he was nearly 10, and, in the evening, the oil lamps and candles created a small island of softly flickering light encircled by a penumbra of shadow fading off into deep, mysterious darkness. "It seemed to me, as a child, that the area of light was really an abbreviation of the dark presence of the house, and that there was a huge interim world between where light ended and true darkness began."

Outside the house where O'Donohue's family lived, nature was a constant, living presence, both intimate and vast, in which it must have been easy to imagine the existence of whole colonies of primal, wayward spirits, not at all submissive to human schemes and intentions. Although O'Donohue's family wasn't overtly "religious" in any rigidly doctrinaire way, he says, there was a great sense of spirituality in the house, along with a family ethic of nonjudgmental kindness. His mother was humorous and often irreverent, "with a wild kind of mind, very sharp, very bright," while his father seems to have been something of a mystic himself. "My father was the holiest man I ever knew; more in the presence of God than anyone I've ever met," recalls O'Donohue. "He could be great fun, and was very attentive, but his spirit was tuned into the divine, his mind and heart lingering there. If he was working in a field alone in the mountain, or on one of the open gardens we had, when you brought him up a tea or that, you'd often hear him praying before you'd see him. Being with him, you knew he had it--his presence was like a doorway opening to the divine. He also had a great sense of the transience of things, and a wariness of getting entangled in the world, which I guess kind of came over me, too. 'Life is like a mist on the hillside,' he used to say, 'look, and it's there. Look again, and it's gone.' "

O'Donohue went away to a boarding school at 12, and then, at 18, to St. Patrick's College Maynooth, Ireland's national seminary--one of the largest and most celebrated learning centers in Europe--where he began training for the priesthood. Why the priesthood? Certainly, it wasn't something his family had pressured him to do. "The idea of making money never appealed to me," he explains. "Ever since I was very young, like my father, I had the same informing intuition of transience--that everything is passing--and I wanted to do something that would make things eternal in some way. I considered medicine, but then thought that if I didn't have a go at the priesthood, I'd always be kind of restless about it; it would always follow me."

But O'Donohue almost gave this path up during the first year of seminary, when he faced "six months of complete aridity," as he calls it. "I was there studying to be a priest because I wanted to participate in the huge, infinite intimacy with the divine, but I fell into a state of feeling complete, terrifying nothingness. I began to doubt that there was any divine at all--there was just nothing there. I began to believe I'd been duped." He now remembers this terrible trial as one of his first great lessons in the tough struggle of true spiritual growth, which isn't necessarily a feel-good course in personal uplift. "I learned that there's a huge difference between feeling and presence  in the world of the mystical," he says. "When you feel absolutely nothing, or only absence, that can be actually the most refined form of presence. While I was going through it, I just knew it was a desert, but revisiting it, I begin to see it as a huge pruning of the spirit--like a false skin of protectiveness falling away."

 

While O'Donohue was never exactly a docile parish priest, he never thundered his rebellion against what he disliked. Instead, he staged a quiet, determined, persistent campaign in opposition to what he felt were some of the church's most egregious failings, including its rigid hierarchy, its fear of the feminine, and its hostility to sexuality. "I thought that sexual morality was people's own business, not the church's, and never believed in the demonization of the body," he says. "The most honest thing in human presence is the body--more honest than the mind, which is often twisted. I spoke in sermons about the lyrical beauty and innocence of the body, and tried to help people get away from the idea that sexuality was sinful, arguing instead that, for all the ambivalence we feel about sexuality, it was a creative, beautiful, and good thing in life."

Four years after he was ordained a priest, he went off to Germany to get a Ph.D. from the University of Tübingen, where he wrote a dissertation in German on the notoriously difficult philosopher Friedrich Hegel. "Through the grace of ignorance, I had no idea when I began just how difficult it was going to get," he recalls. "It was pure work, total work, work and work and work. That we don't know the future is our greatest protection. If I'd seen the amount and depth of the work I'd have to do, both learning the language and writing about Hegel, I don't think I could have done it." Nonetheless, after four years inside what he calls "the white monastery of Hegel's thought," he completed the dissertation and saw it published in 1993 and favorably reviewed by a slew of German, French, Spanish, and English critics.

In 1990, he took up the more quotidian concerns of leading a parish in County Clare. He also threw himself into a 10-year, ultimately successful, struggle to save Mullaghmore, a beautiful, unspoiled mountain in the Burren area from development as a major tourist site. At the same time that he was working to protect this ancient, natural place, he was also rediscovering another ancient birthright--Celtic culture and mythology--which, itself, was echoed and reflected in the Gaelic language, and even in the stories, anecdotes, references, and expressions used by his family and neighbors. Many people in this part of Ireland (including O'Donohue) still speak Gaelic, a language freighted with historical and social significance. Even regulation English, when spoken by the local people, reflects, says O'Donohue, "the colorful ghost of our real language, which was stolen from us by our colonizers." Furthermore, the souls of these Celtic forebears, their descendants still living in the villages, working in the fields, all somehow belonged to and seemed to have emerged from--even merged with--the palpably living, breathing, perhaps conscious and watchful, landscape itself.

During the 1990s, O'Donohue began putting this vision of Conamara's people and landscape to words, publishing his first book of poetry, Echoes of Memory, in 1994, and a second, Conamara Blues, in 2000. In both books, human love, longing, grief, memory, and faith are witnessed through the prism of, and haunted by, the brooding, timeless presence of nature. O'Donohue had begun writing poetry at about 18 or 19 on an impulse, he says, "stirred by experience too rich for normal words." It seems fair to say that, for him, language itself is in some sense holy. He cites the famous passage from the gospel according to John--"In the beginning was the Word, and the Word was with God, and the Word was God"--adding that he feels that poetry is as close to divinely inspired utterance as human beings can produce.

 

O'Donohue describes his own fraught encounters with the ungovernable muse of poetry as something like wrestling with angels. "I have a great terror of the white page. I hate going to my desk in the morning, because it's all or nothing when you sit down. When you submit yourself to this kind of rigor, of finding the form for something, what absolutely begins to emerge is something you'd never anticipate, something you can't control-- it knows it needs to come through. In some sense, everything you've ever experienced knows more about itself than you ever will. When I'm touched by a certain experience and start trying to go after it by writing it down, I often find it goes off in another direction completely, and, frequently, I find another experience is concealed there behind the first, but only now just showing itself. There's wildness, passion, spontaneity, and freedom in it. Poems are the most sublime individualities, living actualities. They aren't about anything, they are the thing itself--they just are ."

By 1995, O'Donohue began what he calls the "long journey to resignation from the priesthood." He now says that the best decision he ever made was to become a priest, and the second best decision was to resign from the priesthood. The priesthood refined and directed his inherent sense of reverence and spirituality, opened new intellectual worlds, made him lifelong friends, and introduced him to the work of thinkers and mystics that would help shape the contours of his mind. But by the mid-'90s, he was finding it ever harder to openly and honestly represent church positions he found increasingly untenable. He also crossed swords with a new bishop, who, O'Donohue says delicately, "wasn't overburdened with hospitality toward the kind of vision I had." Specifically, he insisted on assigning O'Donohue to full-time duties as a parish priest, which wouldn't allow him any time to write, and there was no possibility of compromise.

Even though O'Donohue could see no other path but to leave, it was a wrenching break. "I made the decision very slowly, over a long time--and it was a very lonesome time. What I loved most was celebrating the Eucharist. That's where the action is--the place where divine and human meet in ultimate togetherness. Sacrificing that was, for me, the loneliest, most forsaken thing."

But shortly after taking this portentous step, he was freed to write, and write he did. His book Anam Cara, about Celtic spirituality and its relevance for the postmodern era, was published in 1997. It became an international bestseller and has been translated into 20 languages. Another book, Eternal Echoes, was published in 1998, and it, too, became a bestseller in Europe, Australia, and America. In his most recent book, Beauty: The Invisible Embrace, published in 2004, O'Donohue explores the physical, emotional, and spiritual experience of beauty and protests the commonplace notion that beauty is an extraneous luxury, which "practical" people can do without.

 

An Unlikely Friendship

O'Donohue's introduction to the therapy field came through his unlikely friendship with neuropsychiatrist Daniel Siegel, known for his book  The Developing Mind and his pathbreaking efforts to help therapists develop an understanding of how the brain develops and changes in response to human relationships. As Siegel was working on his book, an intricately constructed synthesis of evolutionary biology, neuroscience, and developmental psychology, with forays into attachment research, cognitive science, the study of emotion, and complexity theory, he came across O'Donohue's poetry. Recalls Siegel, "It seemed to me that he described, in a beautifully poetic way, the human mind in a state of inner coherence or neural integration--which is my subject--and how both solitude and relationship can act in tandem to bring a sense of mental and emotional wholeness."

Siegel cited Anam Cara in his own book and tried to contact Donohue directly, without success. Several years later, he saw a poster for a 10-day retreat O'Donohue was giving in Ireland and, as a birthday present, sent his wife--who's of Irish descent--to the retreat. She came back exhilarated, saying that it had changed her life. A few months later, she returned the favor and sent Siegel to a week-long conference led by O'Donohue, this time, on the coast of Oregon. Between O'Donohue's talks, the poetry jam sessions, the meditations and long walks together on the beach, O'Donohue and Siegel got to know each other. Each seems to feel he's found in the other a true "soul friend"--the meaning of the Gaelic words Anam Cara --a teacher, affectionate companion, and spiritual guide who completes the other's unfinished self in some way.

As the two men talked, they discovered a common interest in "poetry and the brain, poetry  in the brain, poetry of the brain"--the details of which weren't entirely clear. It was clear, however, that Siegel's insights about interpersonal neurobiology dovetailed with O'Donohue's lyrical and mystical sensibility, and that both recognized intuitively the connection between the hard facts of neurobiology and the more illusive reality of emotion, imagination, creativity, and spirituality. For Siegel, O'Donohue is "living poetry," the walking incarnation of profound neural integration of the "logical, linear, literal left brain and the somatic, visual, emotional, ambiguity-loving right. Listening to him evokes a profound state of integration in us."

For his part, O'Donohue has been amazed to discover from Siegel just how inherently mystical and poetic the physical brain actually is. "In my ignorance, I presumed that the brain was a fixed, closed object of control, execution, and measurement--a kind of central headquarters for thought and so forth," he says. "But, actually, I learned from Dan that your experience shapes the kind of brain you have, and the brain you have shapes your experience. There's this amazingly intimate and subversive mutuality between your mind and brain. All the mirroring you do of the world--your gathering of information and communications, your sense of yourself--all occurs within this huge poetic, organic matrix. The brain is actually a poetic reservoir that loves possibility and makes connections we normally think would never be made. It's a lattice of subtle meshing that holds the fragile dust of spirit together to make the 'whoness' of who we are."

 

Both partners in this unusual pairing of brain scientist and poet-mystic share a disenchantment with the usual rigid dualism assumed to exist between the hard, objective logic of science and the soft, subjective imaginings of spirituality and art. They've begun to take their joint show on the road, giving workshops together, each spinning curlicued improvisations off the thoughts and insights of the other. For Siegel, speaking as a therapist and scientist with his own lyrical sensibility, the essence of good therapy is to establish with clients a deeply attuned, responsive relationship that helps a brain state of neural cacophony become a harmonious polyphonic choir, which is "flexible, adaptable, coherent, energized, and stable." For O'Donohue, the therapist, like the poet or priest, doesn't "fix" people, or "manage" them, or make them more "functional," but inspires and guides them on journeys only they can undertake into the deep territory of their unknown selves.

"The idea isn't to give people answers, or lead their bark of longing into a safe, dull, protected harbor," says O'Donohue, "but to make them aware of the depths of possibility in their hearts and lives; help them remove the barriers that keep them from being the people they were meant to be. In therapy, people tend to ask the 'how' questions-- how do you express anger, how do you deal with others, how do you show your personality, how have you become who you are. What's more interesting is the question of who. HASH(0xcafa0f8) Who are you really? The essence of who you are is ultimately mysterious, ungraspable and numinous--completely different from every other structure of matter. When people get into therapy, or when they need healing, their real hope is that they'll come to the secret frontier in themselves, some unknown source of energy and healing in themselves, where the divinity of 'whoness' is protected. This is a spiritual quest." O'Donohue clearly yearns for an era that seems to have just about vanished from the Western world--except perhaps in the Irish equivalent of Brigadoon where he hangs out. "I was born in a rural, peasant community and grew up in the midst of a folk consciousness, rooted in the land, which had taken hundreds of years to emerge and was much more subtle and mysterious than anything in Freud's Introductory Lectures. If you live in a community like this, people don't show themselves to you directly, but only in an oblique, suggestive way." He feels that the lack of respect in American culture for true privacy, for the fundamental ineffability of the deep self, has spawned an obsession with surface appearances that feeds our ravenous celebrity worship. Says O'Donohue. "I think that the pervasive loneliness of our times is related to this obsessive adoration of ever-changing surfaces--the computer screen is a good metaphor--and an addiction to keeping up a bright facade. People look so good on the surface that you'd never suspect how lost they are underneath."

Remembering the mysterious shadowy space between light and dark in his childhood home, he wonders if the momentous shift to electrical lighting, with its severe, glaring, unshadowed light, has transformed the way modern people actually view the world and each other. This "neon consciousness," as he calls it, can't tolerate ambiguity, darkness, mystery. But trying to shine a glaring, blinding flashlight into the deep center of a person's being will not, in the end, reveal anything worth seeing. "Severity of light banishes all shadows. In terms of human interiority, if you bring an electric neon band of light to shine on the inner world of thought and imagination, you'll never write a poem or compose a piece of music or paint a picture or make a sculpture. If you try to see through to the bottom of a person's being, all you'll find is a false bottom, an ersatz kind of depth, with no nourishment in it, no fecund darkness; the real depths won't show up. The excitement of creativity is something that emerges from the darkness quite mysteriously. If you completely wipe out the darkness, nothing can come forth."

In fact, it's at the threshold between knowing and not knowing, between complete mystery and full disclosure, between invisibility and visibility, at the boundary between dark unconscious and the light of awareness, O'Donohue suggests, that imagination has its fullest play. He describes a mountain near his home, with fog hiding its summit. "You know it's there, but you cannot see it with the eye. This is a wonderful living metaphor for the imagination. Around every life are these adjacencies--these huge, invisible presences that you can't pick up with the human eye, but that you can connect to viscerally and affectively through the power of imagination. This is the threshold where polarities can enter into conversation with each other, and take us to new levels of complexity, differentiation, and integration."

 

The Old Becomes New

Essentially, all John O'Donohue is doing is asking us to reflect on some of the same old questions mystics and spiritual guides have asked throughout the ages: Who are we? Where have we come from? Why are we here? What do we truly want? These are the grand, old chestnuts of philosophy and spirituality. We may still even vaguely remember them, like faint echoes from an earlier, more archaic time. And yet, somehow, through his astonishing way with language and incandescent presence, O'Donohue makes these old echoes ring again; makes the questions seem urgent, critically important, not only to our happiness, but to our very existence. Listening to him, we feel something stirring inside, something quickening, as if some buried yearning were being awakened. "There are certain rhythms and sounds of language that have their own atmosphere," he says. "What affects you is the atmospherics of language. The weather of language gets inside you. It's something intangible and illusive, but intimate and transforming." Lightly, even gaily, with what seems like no effort whatsoever, he creates a kind of climate change within every person whose heart and mind isn't terminally climate controlled.

How does he do this? The short answer is that John O'Donohue is an artist and this, to the extent of their talent, is what artists do. As an artist, he spins straw words into golden language, delivers them with all the brio of a born performer, enables us to experience the archaic world in a new, thrilling way. Perhaps one key to his appeal to therapists is that he does them the honor of suggesting that, at their best, they, too, have the power to be artists, midwives of the imagination, guides to the lost beauty their clients can no longer see in themselves. The other key may be that in a field increasingly focused on solutions and influenced by positive psychology, O'Donohue expresses an unflinching belief, deeply embedded in all the great spiritual traditions, that suffering isn't only inevitable in human life, but may also be a great opening to transcendence. He quotes again from Plato, "'All thought begins with the recognition that something is out of place,'" and adds, "Arriving into conception, into the womb, and then into birth is a primal act of rupture and disturbance, and all through human experience, that fracture doesn't let us be completely ourselves." If this is true, then the inherently human state of being "out of place" in the universe is the source of all our suffering, but also of the human imagination--born of the need to repair or transcend the primal rupture.

At the heart of O'Donohue's appeal is his ability to evoke the astonishing mystery of the human presence on earth--our peculiar, difficult place between earth and heaven. "We humans are the strangest creatures," he says. "Outside my window, all the time, this raggle-taggle group of white mystics known as Conamara sheep wanders back and forth, showing no level of metaphysical disturbance at all. They're as completely at one with the places they're in as the stones and lakes and mountains. We are the only creatures who are in-between. We're of the earth, but don't belong to it, because we strain after the heavens; and yet the heavens aren't fully in us. So this wonderful, restless, eternal longing in us has us always on a quest."

Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .

Friday, 02 January 2009 11:34

The Poetics of Progress Notes

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The Poetics of Progress Notes

Using Your Imagination with Tough Cases

by Brad Sachs

Like many therapists, I know what it's like to dread having to write up case notes after my sessions, and how tempting it is to find ways to put off the task. But through the years, I've discovered that because of the many overlaps between psychotherapy and writing, broadening the definition of what it means to "write up case notes" can actually heighten my awareness of what's happening in my work.

While we're generally trained to focus on preparing notes that are clinical and objective, confining ourselves to this format severely restricts the creative potential of the process. It's interesting to consider, in fact, that although many clinicians encourage their patients to keep a journal, draft real or imaginary letters to family members, and compose poetry, few clinicians use creative writing in their own work.

The act of writing is, in its most elemental form, an act of self-discovery. At its core, it brings into awareness a conversation between what's alive and what's dying in ourselves, what's limiting and free, what's observable and shadowy. Writing isn't just a transcription of what we know; it can also reveal to us what we don't know, what we don't know that we know, and what we don't want to know. When it comes to progress notes, delving into our reluctance to write about a particular client has the potential to help us think about a case in new and clinically valuable ways, rather than simply making us feel guilty.

There are many ways to write progress notes that tap a therapist's imagination and enhance what goes on in therapy. One is what I call the Reverie Poem. As clinicians, all of us have had the experience of having our minds drift during a session. With practice and self-discipline, most of us learn to gently nudge ourselves out of our reveries. But another approach involves being more attentive to our inner meanderings to see whether they lead to useful clinical clues.

I was once treating a woman, Wendy, with whom I was having great difficulty empathizing. Despite the litany of quite legitimate complaints she had about her life--a callous, philandering father; a mother who was simultaneously clingy and rejecting; a thwarted escape from her family into a dismal marriage with a remote alcoholic who absolved himself of almost all childrearing responsibilities--during sessions, I'd almost instantly find myself reflecting upon anything but what she was saying.

 

Writing up my sessions with Wendy was a further exercise in futility. I remembered very little about what she'd said as I struggled to implement some kind of treatment plan. Then, after one particularly frustrating session, I wrote the following poem to try to make sense of the trancelike musings that overtook me in Wendy's presence:

Three Minutes of Therapy

It's like I can't feel

I can't even feel

The feeling of not feeling

The O'Keeffe on my wall

Its glowing wombs

When I'm with my kids

It's as if I'm not with them

They could be anyone's kids

The mocha drink in the fridge

I'm like my own mother with them,

So cut off, so remote

It's 9:53

I despise her

But I'm just like her

It's all I can do to get through the afternoons

And I'm desperate for my glass of wine

Sometimes two

A glass of red wine

The late afternoon sun

Will I ever return to Italy?

dizzy with wine

Until I can get them off to bed

And then the emptiness

The sandwich I made for my lunch

So much earlier this morning

It's just me and my husband

Did I bring the rice?

Although he's so busy with the computer

I can avoid him more easily

Than the kids

My daughter fell asleep before I got to say goodnight to her

Last night

Because I was too busy on the phone

asleep before he even gets upstairs

And then he's gone before I wake up

9:55, halfway through

months, I guess,

I don't even think about it anymore

I don't even think he thinks about it anymore

Yes, I believe the rice is there,

I know I brought it

divorce, but would I be better off?

What would it accomplish?

The O'Keeffe on my wall

The glowing, empty wombs . . .

 

Reading the poem afterward, I became aware that my personal wool-gathering had to do with profound emptiness --the wombs in the O'Keeffe painting on my wall, the incessant focus on food and drink, the absence of contact with my own child (playing the role of my patient's callous father, "philandering" with whomever I'd been on the phone with when my daughter was ready and waiting for me to tuck her in). I realized that it was my own fears of encountering my patient's profound emptiness that kept me so disengaged from her.

Reading the poem inspired by my session with Wendy crystallized for me how dutiful she was. She was essentially raising her two children as a single mother while tending to her adolescent-acting husband. She volunteered at the children's school and was team manager for her girls' lacrosse teams. She also regularly fielded her mother's calls for medical advice and made herself available to drive her to appointments, even though they lived almost an hour apart.

Perhaps, it occurred to me, her responsibilities were so oppressive that they were oppressing me, prompting me to avoid attending to her by allowing my own attention to roam. My reverie may have been serving the same purpose for me that her drinking did for her--allowing for a momentary break from a suffocating reality. After this insight, I was able to rouse myself from my previous torpor and focus on our sessions with more clarity. I helped Wendy begin to examine her ambivalence about setting limits with her children, her husband, and her mother. I encouraged her to start looking for ways to nourish and gratify herself that didn't rely entirely on meeting others' needs.

Thinking more about her own needs, she joined a senior swim team, and insisted that her husband be home the two evenings a week she practiced to supervise the girls' homework and nighttime routine, which, to her surprise, he agreed to do. She made some calls to a senior-support services center in her mom's neighborhood, and found that they offered free transportation for local seniors' medical appointments, which unburdened her as well. She also began attending Al-Anon meetings.

 

In retrospect, my poetic exploration of my own absentmindedness enabled me to enter Wendy's psychic landscape more fully than I'd have otherwise been able to. Connecting with her in this new way changed the whole direction of our work together.

Since then, I've explored other ways of using writing to offer fresh perspectives on a case. Sometimes I've written a reverie-based poem, along the lines of the one I wrote about Wendy, but from the patient's viewpoint, imagining the subnarrative that might be going on within her during a session. Other times I've interviewed my inner censor in an effort to ascertain why I'm reluctant to write about a patient, posing questions like:

What do you want from me?

What do you want to keep me from ?

Who do you remind me of?

Who does this patient remind me of?

How might we become partners, rather than adversaries?

What keeps me separated from my patient, making me unable to write about him/her?

How could I honor you and still write what needs to be written?

What would I lose by being freed to write about this patient?

What would I gain by being freed to write about this patient?

 

Therapists have often asked me whether it's ever a good idea to share their creative progress notes with their patients. I've never done so, although I've been tempted to many times. I suppose it's a judgment call, much like any form of personal disclosure during treatment--there are times when it's certainly warranted and can be quite illuminating, but it also can be hazardous.

Whether shared with patients or not, though, whenever therapists find new and imaginative ways to invest in clinical documentation, the process generally pays handsome dividends. In some sense, it's really just another form of clinical supervision, but one in which the supervisor is inside us. n

Brad Sachs, Ph.D., is a family psychologist in Columbia, Maryland, and the father of three children. He's the author of The Good Enough Child: How to Have an Imperfect Family and Be Perfectly Satisfied . His poetry books include Blind Date; In the Desperate Kingdom of Love ; and I Have Told You This to Make You Grieve . Contact: brad@bradsachs.com. Letters to the Editor about this article may be e-mailed to letters@psychnetworker.org.

Friday, 02 January 2009 11:33

The Art of Therapeutic Conversation

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The Art of Therapeutic Conversation

by Jay Efran and Mitchell Green

In a memorable scene in Fiddler on the Roof, the main character, Tevye, pretends to have been awakened by a nightmare that he concocts to convince his wife to change her mind about who their daughter should marry. As he describes this "dream," dancers and singers act out the story, accompanied by a small band of strolling musicians. In the original Broadway production, this scene was always a crowd-pleaser. In the revival, however, Zero Mostel (as Tevye) found a way to turn it into a showstopper. In the new version, as he recounts his tale, the audience watches him become increasingly distracted by the deafening cymbal crashes of the nearby percussionist. Suddenly eyeing a solution, Tevye grabs for the nearest bed pillow and hurls it at the musician. It lodges between the cymbals just in time to stifle the next crash. This improvised bit of comedy elicited such howls of laughter from the audience that it was permanently incorporated into the show.

Such consummate pieces of stagecraft are the lifeblood of a theatrical production. However, because they develop organically out of the "conversation" of actor, role, and audience, they're virtually impossible to plan. (Mostel didn't "find" the pillow bit until he'd played Tevye hundreds of times.) For similar reasons, effective psychotherapy interventions can't be fully scripted in advance. Like Mostel's innovation, therapy's most effective moments are improvisations that arise out of the conversational flow between client and therapist. Indeed, every therapeutic journey is unique, involving unexpected twists and turns. These aren't signs of the therapist's lack of skill or treatment failure; they constitute the very heart of the process.

From this perspective, the growing emphasis on treatment manuals and empirically validated methods is a step in the wrong direction. Yes, the public needs to be protected from quacks, and managed care organizations certainly want some assurance that their money is being spent wisely. In the final analysis, however, the effectiveness of a client-therapist pairing is a function of their collaborative dialogue--a process that resists standardization. Undoubtedly, one can specify general principles and guidelines, and therapy can be anchored in a contract that defines roles and sets boundaries. However, therapy also requires a certain creative ambiguity that can't be reduced to stock exercises or "bottled" like an antidepressant.

The past three decades of research on psychotherapy have added little to Lester Luborsky's famous 1975 "dodo bird verdict," that "everybody has won, and all must have prizes." In other words, with only a few circumscribed exceptions, every empirically tested therapy has shown roughly the same level of (some would say mediocre) results. As Mark Hubble, Barry Duncan, and Scott Miller note in The Heart and Soul of Change in 1999, the vaunted list of empirically supported approaches amounts to little more than a recognition that some methods have been tested and others haven't.

 

Even in the case of heavily researched treatments, such as Marsha Linehan's Dialectical Behavior Therapy (DBT), we still know almost nothing about how particular components of the approach operate. All we really know is that the potpourri of methods Linehan assembled--skills training, mindfulness techniques, phone contacts, group sessions, etc.--works somewhat better for certain types of emotional problems than the ragtag assortment of treatments generally available. It's possible, even likely, that the advantages in outcome the DBT studies report are mainly attributable to the skills and enthusiasm of handpicked, crackerjack research teams and the comparative abundance of resources available to them. Thus far, we haven't seen the kinds of dismantling studies that would enable us to understand more about how DBT works.

Unfortunately, manualized treatment protocols, designed to make treatments replicable, create a false impression of objectivity. For instance, we know many who've worked on manual-driven projects and who report, off the record, that they were only able to adhere to the manual for the first few sessions--during the intake phase. After that, the content of their sessions became increasingly variable and idiosyncratic, tailored, as one might have predicted, to the exigencies of the developing client-therapist dialogue. In some of these studies, the therapists dutifully continued to administer the prescribed exercises, but they also felt obliged to slip in side conversations that more directly addressed their client's needs. Unfortunately, such procedural deviations rarely make their way into the published literature. Therefore, readers are left with the false impression that the manualized procedures are easy to implement and reliably produce the desired result. Manuals may not be entirely worthless, but they certainly don't tell the whole story of what transpired between client and therapist.

Several years ago, we watched a manual-driven group treatment from behind a one-way mirror. Time after time, group members were actively discouraged from discussing issues that concerned them because these didn't fit the session's prescribed agenda. The leader kept complaining that the group had to move on because they were "falling behind the schedule." Ironically, it was those forbidden "disgressions" that group members later remembered as the most valuable aspects of the sessions. At a feedback session with an outside evaluator, members were quick to say that they liked being in the group and profited from meeting the other members, but had little use for the leader's heavy-handed attempts to administer "the treatment."

Even the best manuals tend to devolve into a series of vague instructions, such as "continue checking the client's homework," "review the previous week's gains," or "identify other instances of catastrophic thinking." Such directives hardly achieve the goal of insuring standardization. Most such studies emphasize group statistics, ignoring the therapist variability that exists even though each client is supposed to be receiving the same treatment. In fact, much of the field's scientific sweat equity has been invested in studies of therapy's lowest common denominator--group findings from hothouse projects of canned therapies, using inexperienced graduate-student therapists and highly selected populations. The shame is that these studies convey an erroneous message about what works, focusing attention on particular techniques and away from the kind of conversational improvisation that good therapy requires.

 

We can trace the current conundrum we're in--over the difficulty of making real therapy fit into a scientific paradigm--to the "slow-acting poison pill" that former American Psychological Association president George Albee says the mental health profession ingested several decades ago. With this pill, we swallowed the deeply flawed medical/psychiatric assumptions about diagnoses and dosages, culminating in the unrealistic expectation that forms of psychotherapy can be administered with the reliability of, let's say, a surgical protocol. The belief that this level of consistency can be obtained derives from a serious confusion of models--what philosopher Gilbert Ryle called "a category mistake." In other words, psychotherapy has been misclassified; it should never have been considered a treatment in the first place. Rather, it's a specialized form of inquiry--more philosophical journey than medical procedure.

In fact, if Jungian James Hillman had his way, the therapy enterprise would be categorized "as an art form rather than a science or a medicine." At root, therapy is just two people conversing. That would be evident if you peeled back the layers of mystification and simply listened to a therapy tape. "Consciousness," says Hillman, "is really nothing more than maintaining conversation, and unconsciousness is really nothing more than letting things fall out of conversation."

The derivation of the word conversation is worth examining: it comes from vertere (to turn) and con (with). This is a perfect metaphor for the therapeutic process. As Hillman describes it, you "walk back and forth with someone . . . turning and going over the same ground" from a variety of directions until "what we already feel and think [has been converted] into something unexpected." To be effective, therapeutic talk must have an edge: "It opens your eyes to something, quickens your ears, . . . and keeps on talking in your mind later in the day," adds Hillman, and, hopefully, for days to come. Instead of talking of cures, the therapist's job is to "cure our talk."

A week ago, a client came in for her first session. She described the frustrations of having engaged in years of self-improvement efforts--meditation classes, body disciplines, empowerment groups--only to find herself as confused as ever about whether to stay in her marriage and if a career shift might bring greater fulfillment. At that moment, I found myself contradicting Socrates, telling her that sometimes the unexamined life is worth living. That statement struck a chord. She lit up, laughed, relaxed into her chair, and said, "Thanks for saying that."

 

My remark couldn't have been preplanned and wouldn't necessarily have been appropriate for either a different client or even the same client at a different time. Like a thousand other such bits of conversational ingenuity, it worked because of its positioning in the ongoing dialogue--it was exquisitely responsive to the several layers of meaning contained in the client's communication.

It's practically impossible to explain how such comments are generated or exactly what clients make of them, yet the immediate reaction and subsequent discussion in this case made it clear that comments such as these catalyze important shifts in perspective and advance the collaboration inherent in therapy. Like Mostel's bit of chicanery, such spontaneous remarks are not learned from manuals and can't be dispensed on demand, yet they're the essence of the therapist's conversational craft.

Our recent informal survey of real-world practitioners--the folks who actually make their living seeing clients--suggests that most therapists don't use cookbooks, don't place their faith in techniques, and don't pay much attention to what's on the latest list of validated treatments. Moreover, the longer they've been in practice, the less their treatments resemble the rule-bound procedures they learned in school. Experienced clinicians intuitively follow Hillman's advice to avoid fixed positions, realizing that any prejudgments can "stop conversation dead in its tracks"--leading to a sterile monologue rather than a productive dialogue. When that happens, you might just as well send a memo.

Jay Efran, Ph.D., is emeritus professor of psychology at Temple University. He's the coauthor of  Language, Structure and Change: Frameworks of Meaning in Psychotherapy and of The Tao of Sobriety . Contact: jay.efran@verizon.net. Mitchell Greene, Ph.D., is clinical director of Main Line Clinical Associates in Wayne, Pennsylvania. Letters to the Editor about the article may be e-mailed to letters@psychnetworker.org.

Friday, 02 January 2009 11:31

The Big Moment

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The Big Moment

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 cliché 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   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,  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: dbw@virginia.edu. Letters to the Editor about this article may be e-mailed to letters@psychnetworker.org.