Case Study

Manners Matter

Respecting the etiquette of effective psychotherapy

Daniel L. Buccino
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From the July/August 1997 issue

Whenever I talk about my belief in the link between etiquette and successful psychotherapy, people exclaim “Manners?! You mean how to set the table?” In fact, manners are a vastly underutilized resource in helping people manage the deep currents of stress and anxiety that bring them to therapists’ offices. Rather than an archaic, artificial code of conduct, manners are the means generations of people have used to establish their social relationships, long before the invention of psychotherapy. The following case demonstrates how my attention to my own therapeutic manners and my patient’s concern about a serious breach of etiquette in her family led to a surprisingly efficient and satisfactory treatment outcome.

When the case manager at the managed care company told me about Rose, I knew I was getting a difficult referral. Despite all the pleasantries, the subtext was, “This woman is driving her internist crazy, and you’d better fix her up, calm her down and get her off his back as soon as you can!” Rose was a divorced, Italian American woman in her fifties who was complaining of severe and persistent headaches, for which her primary care physician and two specialists could find no organic basis. Medications had not been helpful, and Rose was beginning to complain of fatigue and dizziness and demanding to be considered for permanent disability. Having been steamrollered by somatically preoccupied patients before, I thought, “Oh, great, what am I supposed to do? Stand in the way of her mad dash for disability?”

Rose was a strong-willed, independent-minded assembly-line worker who could have stepped off the screen of Prizzi’s Honor. She smoked like a chimney, cracked gum sassily and swore like a sailor in a low, husky voice. Prior to the onset of her symptoms, she had been a stellar employee who had never complained of any psychological problems. She had always relied on her close-knit family, especially her mother, the extended family’s matriarch, for support. Now, however, her mother thought Rose was “acting like a baby,” and that Rose should just endure her pain the way she herself always had–silently and stoically. But the real problem, Rose explained, was that her mother, as well as others in their extended family, were angry at Rose’s son, who had just gotten married, and they were, according to Rose, “taking it out on me.” Rose’s symptoms had developed shortly after her son’s wedding.

Rose was devoted to her only child, Richie. Despite recurring familial struggles and shifting allegiances, which were actually part of her family’s connections (“We’re not arguing, we’re discussing!”), Rose and Richie held privileged positions in the family–Rose as the eldest child of the matriarch and Richie as not only Rose’s only child, but the oldest male in his generation.

Rose explained that Richie’s wife, Jane, had not yet sent out wedding thank-you cards, four months after the wedding. Intensely aggrieved by this etiquette breach, Rose “picked a fight with Richie” about some money she had lent him, and now she thought they “would never speak to each other again!” Referring to the thank-you cards, Rose said, “After all I’ve done for him, and this is how he disrespects me! It makes me look bad.”

Prior to his marriage, Richie had lived at home, and his marriage was a difficult separation for Rose. Further, he married a non-Italian “girl” whose family was far more involved in planning the wedding than Rose had been. Rose said that these small slights had made her feel “tense and disrespected” prior to the wedding, and the late thank-you notes were “the straw that broke the camel’s back.”

I saw the obvious links between Rose’s headaches and the wedding, but I resisted the urge to interpret. I was convinced that by employing my own therapeutic good manners of simple warmth, genuineness and empathic, goal-directed suggestions, I could help Rose create her own solutions that would most likely not look like anything I might have imagined or suggested at this point.

Rather than moving in to explore directly Rose’s difficulty in letting her son go, I chose to focus on what might seem like the superficial issue of good manners and thank-you notes. When I’d asked Rose what her goals for treatment were, she’d said that she wanted to be headache free and able to work again. However, since her story kept coming back to her son, I decided to sidestep the somatic complaints and look for ways to help Rose reconcile with Richie. I trusted the solution-focused assumption that a small change in one area will lead to larger changes in other areas, so, minding my good therapy manners and employing a patient-centered, solution-focused treatment strategy, I listened as Rose talked about the etiquette of extended Italian American family weddings and her feelings of “disrespect” that were symbolized in the late thank-you cards.

I asked Rose how she would advise another family in a predicament like hers, in particular regarding the thank-you note issue. Rose started by talking about not only the disrespect, but how the rudeness of the late thank-you notes made “the whole family look bad.” She knew that she had raised Richie “better than that.” Rose decided that since she was “too emotional” to talk to Richie, she would write him and tell him directly that she thought that it was very important for her and the family’s good name that the thank-you notes go out very soon. Rose wrote the letter, in which she gave Richie a lesson on the importance of gratitude, along with some technical pointers on writing the notes, and shared her own feelings of anger, sadness and shame. After she mailed it, Rose said, “Well, even if they don’t do anything with it, it helps me to have gotten it out like that!”

Richie seemed to get the message and soon began to write some of the notes himself, which inspired Jane to complete the others. The cards relieved a great deal of the intergenerational resentments. Richie’s reluctant but eventual adherence to the basic rules of etiquette demonstrated that he still respected the values his mother had taught him and that he had not completely abandoned her. The simple solution addressed many deep undercurrents regarding separation and family structure in a way that satisfied and was visible to everyone.

I will never forget Rose’s cogent summary of the importance of being able to rely on a code of conduct when faced with tough situations: “Manners are so easy. And you can always fake them!”

What Rose had wanted was for things to be different (her headaches and her son) and by doing things differently via manners, the deeper issues of her somatic complaints and her family relationships were resolved. Focusing on manners was a way to take action, not just engage in endless talk. And by my noticing and amplifying her solution in one area of life, Rose’s sense of competence spread into other areas and her headaches began to fade. We were finished in just three sessions over six weeks.

It’s been close to two years since I saw Rose last. In a recent follow-up, she was at work as vigorously as before, essentially headache-free and enjoying time with Richie and Jane.

By thinking seriously about good manners as a small part of a common-sense, solution-focused therapeutic repertoire, by minding our own manners and helping patients mind theirs, we can draw on generations of ritual and tradition to help us say the right thing at the right time to the right person, thereby avoiding resentment, estrangement and, in some cases, needless psychotherapy.


Case Commentary 1

By Kathy Weingarten

Daniel Buccino clearly believes that good manners can not only help people navigate their social relationships, but that they can also simplify the challenge of doing good therapy. However, this case demonstrates that while good manners may be a resource, they are as slippery and value-laden as any of our other efforts at communicating. The questions remain: good manners, according to whom, in what context, for whom and when?

Buccino offers a straightforward description of what he thinks constitutes therapeutic good manners: “simple warmth, genuineness and empathic goal-directed suggestions,” to help clients achieve their goals at their own pace. Without transcript detail–or, perhaps, without being Rose–it is hard to evaluate whether Buccino meets his own criteria for good therapeutic manners; a short case study report is unlikely to convey a clinician’s warmth and genuineness. However, there is enough data presented to consider whether or not the therapist followed the client’s self-described goals at her pace.

Rose stated that her goals were to be headache free and to return to work. Buccino writes that since she kept talking about her son, he decided to “sidestep the somatic complaints and look for ways to help Rose reconcile with Richie.” Earlier, he informed us that he had seen the “obvious links” between Rose’s headaches and the wedding, but that he had “resisted the urge to interpret” out of his therapeutic good manners.

I agree that it is good manners to resist interpreting, but I also think it is good manners to be transparent about the reasons for choosing a particular therapeutic tack, in this case, sidestepping the somatic complaints. Without letting Rose in on my thinking, I would be worried that she would find it odd that instead of talking about her severe and persistent headaches, we are discussing weddings and thank-you cards.

Buccino has a rationale for deciding to focus on the etiquette of wedding thank-you notes: he trusts that a small change in one area of Rose’s life will lead to larger changes in other areas. Although I have no quarrel with this assumption, my own preference would be to share this assumption with Rose. I would want to enlist her as a codeveloper of the therapeutic strategy rather than to make a unilateral decision about what might be therapeutic to discuss. My own version of therapeutic good manners involves cocreating the agenda with my clients. I continually ask them if our talk is going in a direction that feels productive. If not, we discuss how to redirect the conversation.

Like Buccino, I also eschew interpretation, but I am very much in favor of sharing my thinking. That means it behooves me to think thoughts that I will be comfortable sharing. Fortunately, abandoning theories that pathologize persons in favor of conceptual models that separate persons from the problems from which they suffer enables me, usually, to think thoughts that I can easily disclose to clients. Thus, my “good manners” extend not just to what I do with clients but to what I think about them also.

Therapists’ good manners are as sensitive to contextual factors as anyone else’s. Clearly influenced by the case manager of the managed care company that referred this case, Buccino introduced us to Rose emphasizing several negative qualities. He let us know that before meeting Rose he labeled her as “somatically preoccupied” and as a person who might “steamroller” him in order to make a “mad dash for disability.” This description illustrates how hard it is to maintain one’s good manners when one works within a system that cares more about its bottom line than about its customers’ well-being.

This case also raises questions about the etiquette of who gets to decide what something means in the consulting room. Repeatedly in this case, Buccino, rather than Rose or the two of them together, defines the meaning of Rose’s experience. It is Buccino who decides that Rose is having difficulty in “letting her son go” and that there are “deep undercurrents regarding separation.” He does not tell us that this is language that he and Rose constructed together to account for her experience, and I suspect that it is not. Rather, it is an interpretation that he is only sharing with his professional reader audience. My preferences are to arrive at these understandings collaboratively with clients and my experience is that when meanings are codeveloped, change is more likely to be sustained.

Perhaps the fundamental difference between Buccino’s approach and mine is that I believe that change is anchored in new meanings. Consequently, I believe that it is my job to ask questions that engage people in understanding what their actions reveal about their values, purposes and commitments. Were I to have worked with Rose, I would have asked her what she thought the importance of family members’ showing respect for each other tells her about her values? Does she admire this in herself or is it something she would want to change? Are there other people in her life–in the present or the past–who value this as well? How have they showed their commitment to these values? Would they have been surprised or proud of her for writing the letter to Richie? How can she imagine following up on the letter to extend the message that she hopes the letter has sent?

The conversation that would likely follow from questions such as these would shift the emphasis away from the letter itself and place it instead on the relational context within which the letter was conceived, written and sent. Writing the letter would become linked with other knowledge Rose has about herself and other significant people in her life.

Manners, too, are always linked to a relational context and as such, it seems to me, their meanings are never fixed. I am afraid that good manners, after all, will not get us out of the relativistic relational soup we always find ourselves in.


Case Commentary 2

By Bill O’Hanlon

Rose came to therapy because she had debilitating headaches that were interfering with her work. A solution-focused approach would have primarily involved investigating with Rose times when headaches were lessened or absent, or having her imagine what she would be doing differently if the headaches were gone. Buccino’s approach strikes me as less solution-focused and more akin to the strategic tradition of the therapist taking the expert position and deciding where the client needs to go and on what the client needs to focus. In the strategic approach, the therapist often has ideas about the “true” problem without letting the client in on that thinking. Here, Buccino believes that Rose is a “somatically preoccupied patient” who might “steamroller” him in “her mad dash for disability.” According to Buccino, her true issue, which he politely keeps from her, is that she is a typical “Italian mother” who has “difficulty in letting her son go.” The problem stems from her son’s getting married. So Buccino decides to “sidestep” the somatic complaints and focus instead on the mother’s issues with her son, since she had spoken about them quite a bit.

Another approach to this situation would have been to address Rose in a more tentative and collaborative way, saying something like: “I know you came in here for your headaches and the work problem, but since you have talked quite a bit about your son and how upset you and the other family members are about his situation, maybe we should include that, too. Or perhaps we should focus on that, since it may have something to do with the headaches. Perhaps it wasn’t a coincidence that your headaches started around the time of his wedding. One idea could be that you–like most parents, especially single parents–have a tough time adjusting to major life changes with a child, like when they get married or leave home. What do you think?”

There is a glimpse of this collaborative approach when Buccino asks Rose what advice she might give another family facing the crisis of not having thank-you notes written. One can’t fault success: Rose did resolve her problem. However, one gets a sense that Buccino uses manners primarily as a strategic device to bypass “resistance” and get people to solve what he considers their “real” problems (in this case, not headaches, but somaticizing and the inability of a mother to let go of her son). To me, a solution-based approach to therapy naturally involves good manners because one has turned away from these projected ideas about people and listens to clients’ ideas about their problems and preferred methods of resolving them. Manners are a pale imitation for genuine faith in, connection to and heartfelt caring for your clients.

Author’s Response

I am grateful for the feedback provided by my colleagues Kathy Weingarten and Bill O’Hanlon. Weingarten’s points lie at the heart of both good manners and good psychotherapy. We must not impose our cultural beliefs, etiquette standards or interpretations on our patients. We must seek to validate multiple perspectives, learn from other realities and investigate alternative strategies for health and healing. I attempted this with Rose by letting her full story unfold, which included her concerns about the thank-you notes. The letter and the thank-you notes were not interventions I introduced to the system, but rather opportunities to collaborate with Rose in her construction of a solution.

With regard to O’Hanlon’s commentary, I was interested in Rose’s headaches, but, given that her medical workups had ruled out a physical problem, I decided not to reinforce the focus on her medical condition and instead listened for other possibilities for solution-building. Many cases turn out not to be about what they seemed to be about initially. This case was not about headaches or separations; it was, quite simply, about thank-you notes. The thank-you notes may have served to bring together headache and separation issues, but that would be my interpretation. 

Daniel L. Buccino, L.C.S.W., B.C.D., is cofounder and codirector of the Baltimore-Washington Brief Therapy Institute, Inc., and is on the faculties of the Johns Hopkins University School of Medicine and the University of Maryland School of Social Work. 

Kathy Weingarten, Ph.D., is codirector of the Program in Narrative Therapies at The Family Institute of Cambridge, an assistant professor of psychology at Harvard Medical School and in private practice in Newton. She has written The Mother’s Voice: Strengthening Intimacy in Families, edited Cultural Resistance: Challenging Beliefs About Men, Women and Therapy and coedited Reflections on Feminist Family Therapy Training.

Bill O’Hanlon has authored or coauthored 13 books. He lives in Santa Fe, New Mexico, and teaches workshops internationally.