Soft Shock Therapy

The Art of Speaking the Unspeakable

Magazine Issue
March/April 2014
A marionette

We’re now so firmly in the era of standardized, manualized, empirically validated, insurance-friendly, client-soothing psychotherapy that it’s easy to forget the radical origins of our field. In late 19th-century Vienna, Freud shocked conservative, straight-laced, bourgeois society with his radical ideas (i.e., the psychic challenges adults face mostly stem from childhood sexual traumas) and treatments (i.e., all talk, all the time). Similarly, even if all the creative, new movements in the field—behaviorism, Gestalt therapy, humanist psychology, cognitive behavioral therapy, family therapy—weren’t equally revolutionary, in their day they all had at least a certain out-of-the-box quality. Today, however, it often seems that the only unbreakable rule for doing therapy is never to surprise, never to be anything other than soothing, neutral, nonconfrontational, usually non­directive, and pleasant, and never to shock anyone—not clients and certainly not the insurance companies that reimburse their treatment.

But there are times when clients are deeply stuck, not just in the unhappy circumstances of their pain—the failing marriage, the unrelenting depression, the crippling anxiety—but in the unshakable sense that nothing they do will make any difference. Having tried and tried and tried to make things better—usually, of course, by engaging in the same ineffective behavior over and over again—they give therapy a go. Often, they’ve seen several therapists; sometimes they’ve even been in therapy of one sort or another, talking about their “insoluble” problems, for years.

In fact, most of the clients I now see are consultations referred by desperate therapists who haven’t been able to move things forward. If I’m not going to give these clients a version of the same old thing that hasn’t worked before, I have to do a kind of therapy that some would consider provocative, even outlandish. I must come up with a new perspective, a new kind of strategy, one that the clients don’t expect.

Most of these clients—even though they may be successful in certain areas of their lives—are stuck feeling that their negative emotions are uncontrollable, their relationships unchangeable, their circumstances unalterable. They’ve come to believe in the ineradicable unchangeability of their unhappiness: thus it has always been; thus it will always be. It follows that they’ve lost all sense of perspective, all capacity to see any possible humor or lightness in their problem or in their lives. Emotionally and cognitively, they’re trapped in their own sad story.

In these cases, the approach that I’ve found most useful is a kind of soft shock therapy in the form of a humorous paradoxical directive. By consciously and knowingly directing clients to do something preposterous and absurd, but uniquely suited to them and their dilemma, I aim to upend their expectations of therapy and life. Before you recoil in horror, know that I never ask them to do anything immoral, illegal, dangerous, or humiliating. But I do ask them to do things that’ll help them find the humor in their tragedy, and I always explain the rationale behind my directive.

Tragedy and humor are closely interconnected. Freud is noted to have said there’s no such thing as a joke, meaning that humor is the way humans deal with the saddest, most tragic circumstances of life. By using humor to help clients reconstruct their problems—almost make parodies of their own dilemmas—I help them acquire a healing distance from their woes, learn to take themselves less seriously, and gain more perspective about themselves, even more wisdom.

Playful, humorous strategies can be like therapeutic life preservers, which keep both therapist and client afloat until both can get back to shore. Often humor can help clients gain different, more useful perspectives, helping them regard their stories less as melodrama and more as comedies of error, less as tragic romance and more as epic adventure. People frequently become helpless when things don’t go a certain way or meet certain expectations. But humor is a natural way to accept that surprising things happen, readying people to adapt to new life conditions and learn to tolerate or even enjoy them. In this sense, humor is a trigger for change because it reboots the emotions and enables us to look at our situation with fresh eyes.

Following a technique used by stand-up comedians, therapists can set up a serious, even solemn atmosphere and then give an unexpected, humorous directive. One of the ways I use this technique in therapy is with a typical problem presented by husbands: they complain that their wives want to talk constantly about unpleasant matters, be it money, in-laws, the children, or their lack of intimacy. At dinner together, on a walk, during a visit with friends, even on vacation, the wives bring up the same issues. Of course, they want to be heard; being heard makes them feel understood and loved. But the husbands become overwhelmed by the negativity that seems to permeate every interaction and end up incapable of hearing their wives at all. The tenor of these “conversations” is all too familiar: the wife nags endlessly while the husband repeatedly tries to change the subject or sinks into sullen unresponsiveness, which just makes matters worse.

In these situations, I’ll typically explain how important it is to contain these unpleasant conversations to a specific time and place, instead of letting them invade the couple’s entire life. I ask the couple to decide on a day and time, once a week, when they’ll meet for lunch. I tell them to bring notebooks in which they’ll have listed their issues and to take turns discussing them, knowing that the issues may not be solved and that this might be one of many conversations that they’ll have in the future. It’s important that these meetings always be on the same day at the same time, and that they happen in a public place, like a restaurant, so the couple doesn’t start screaming at each other. I tell them that these issues won’t be discussed at any other time, unless it’s a dire emergency. When they’re both nodding solemnly in unison, agreeing to the weekly meeting, it’s time for the comic punch line.

I tell the husband that if the wife forgets the agreement and begins to discuss one of these matters outside of the special meeting, he should begin to take off his clothes. He might first remove his tie, his watch, his shoes, his socks, and continue undressing, no matter where they are, for as long as the wife continues to talk about the issues. He should continue to undress, even if it means that he’ll end up naked in public.

Typically, the husbands laugh and say something like “I can do that.” The wives usually laugh too, and the atmosphere of the session lightens. This is an outrageous strategy, but it works to break the pattern of negative interactions and turns them into playful exchanges. Humor involves outrageous behavior, and so can therapy. Plus, I don’t think I’ve ever had a husband who had to remove more than three or four items of clothing.

Healing Hatred with Paradox

A woman came to see me because she was obsessed with hateful thoughts about her ex-husband. Her marriage hadn’t been happy. After years of enduring his stonewalling, his put-downs, and his coldness, she’d decided to divorce him. He didn’t want the divorce, but soon after it was finalized, he married a much younger woman and moved into a beautiful house. His new wife didn’t have to work, while my client had to work hard and struggled with money issues. Now she couldn’t stop hating her ex-husband and wishing all kinds of evil upon him. Since she’d always thought of herself as a kind person, she didn’t like having these thoughts.

I told her that it was okay to experience hatred for her husband: the problem was that the hatred invaded her whole day when it should be contained to a specific time, leaving her free to experience joy and other positive emotions at other times. She agreed, although she said she’d prefer to experience no hatred for her ex-husband at all. Of course, I preferred that as well, and hoped that my paradoxical strategy would eliminate the hatred altogether. But I didn’t share this. Instead, I simply said that since that ideal outcome didn’t seem possible just yet, she should try this new plan.

“I want you to get up every morning 20 minutes earlier than usual and sit in a special chair that you will use only for this purpose,” I directed. “During those 20 minutes, you’ll think only about your hatred for your husband. Your mind will probably wander, but you’ll have to bring it back and concentrate on only thinking and experiencing the hatred. It’s like meditating: at first it’ll be difficult, but then it’ll get easier.” I explained this in a kind and serious way, saying that this is an established strategy for containing a negative emotion to a specific time and place.

She came to see me two weeks later and told me that she wasn’t thinking hateful thoughts about her ex-husband all the time anymore. She’d followed my instructions, until her mind had begun to wander to thoughts of hatred toward me, the therapist, for having made her do this every morning. She said this with a mischievous smile, and we both laughed.

Of course, this strategy stems from Viktor Frankl’s paradoxical intention: in the context of working to eliminate a behavior, one asks the client to engage in more of it. Frankl, for example, would ask a patient who was afraid of having a heart attack to have a heart attack right there in his office. The patient would typically laugh at the absurdity of this request, and Frankl would say this laughter was precisely what he was after: it indicated the patient’s ability to take himself and his fears more lightly. In the case of my client, consciously spending 20 minutes every day trying hard to have hateful thoughts about her husband began to seem absurd, even ridiculous—which in effect broke the spell. Once her sense of humor had been aroused by engaging in the directed behavior and we could laugh about it together in the office, her need to ruminate hatefully about her husband disappeared.

A Cure for Panic

Breaking a pattern of interaction in absurd and humorous ways can often reverse years of conflict and suffering. Once, for example, a therapist asked Richard Chouhy, my student and now colleague, for a consultation with a woman she’d treated for panic and anxiety over the preceding decade with no results. Marianne’s panic attacks would start early in the morning every day, last all day, and often be accompanied by intestinal cramps and diarrhea. At those times, she’d brood about dying and would be overwhelmed by fear. Virtually paralyzed with dread, she couldn’t take care of the house or the children, so her mother and her mother-in-law would take turns stepping in.

For the initial consultation, Chouhy invited Marianne’s husband, Marc, to come with her. The couple was attractive and charming. They’d known each other since childhood, and it was obvious there was a great deal of love between them. Chouhy asked Marc how he’d attempted to help Marianne, and Marc described how he’d done everything in his power to help her: he’d listened to her, talked to her, reassured her, given her love, and taken care of her in every way he could think of. Chouhy listened carefully and then said, “Perhaps it’s time to do something different.”

“Like what?” asked Marc. “I’m willing to do anything to solve this problem.”

“Since what you’ve been doing hasn’t been working, perhaps we should consider doing something that’s quite the opposite, don’t you think? What do you typically say to Marianne before you leave for work every morning?” he asked.

“I tell her that I love her, and I say I hope she feels better and has a better day,” replied Marc.

“What could you say that’d be the opposite of that?” Chouhy prompted.

“That I don’t love her.”

“That’s good, but what about something really strong, really awful?”

“I could say ‘Drop dead!” said Marc.

Marianne gasped in amused surprise.

“That’s good, very good,” Chouhy encouraged. “What about something even stronger?”

“Drop dead, witch! Once and for all, drop dead!”

“Very good. Anything else you could add?”

“Yes,” said Marc, turning to Marianne, “and if you die, I’m marrying again!”

“I don’t think this is very nice,” said Marianne, now not finding this amusing, “and I don’t see how anything like this could work.”

“Every morning before you go to work,” said Chouhy, “I want you to say to Marianne, ‘Drop dead, witch, and if you die, I’m marrying again!’ and you must say it with feeling. Can you do that?”

“Yes, I can,” said Marc, smiling mischievously at Marianne.

“This is rude and won’t help me,” Marianne insisted.

Turning to Marianne, Chouhy said in a kind voice, “You know it’s time for something different, so let’s just try this for a few weeks and see what happens.”

Chouhy ended the session after that. Timing is important, and some directives are more effective when they’re not discussed too much. Nonetheless, Chouhy’s thinking about this directive was simple. Marianne would have a panic attack every morning right after her husband expressed his love and concern. Psychiatrist Milton Erickson taught that when you make one small change in the context in which a symptom occurs, then everything changes. In this case, Chouhy wanted to make a small but utterly surprising change to see what other changes it would bring.

A few days later, Chouhy got an emergency phone call late at night from Marc. Marianne had become upset, screamed at her mother and mother-in-law, and carried on in such a way that the whole family had been scared. Chouhy invited everyone, including the two grandmothers, to come see him the next morning. By the time they’d arrived, Marianne was completely composed. She explained to Chouhy that Marc had told her to drop dead, called her a witch and so forth, and it had made her think about her situation.

Marianne had always wanted to study and work, but when she married, she was told by both her mother and mother-in-law that she was expected to take care of her husband, the home, and the children, and nothing else. She’d resented this deeply, but had said nothing throughout the course of her marriage. Turning to the two grandmothers, she said firmly, “It’s over now. I’m going back to school, and that’s it.”

When Marc was able to criticize her for the first time, and to do so in an exaggerated, intense way, he broke his own habitual pattern for dealing with her and so enabled her to break her habitual pattern of illness and misery. It turned out that Marianne had been punishing the two grandmothers, her husband, herself, and her children because of her resentment. When Marc stopped seeing her as a helpless victim, stopped trying to reassure her, and actually called her a witch, she was able to stop being a victim and asserted herself. After a short initial phase of being even more upset and miserable, Marianne herself realized what she had to do. Two years later, she was studying psychology in school, happy in her marriage, and living without panic attacks.

A Risqué Intervention

The element of the unexpected and incongruous is important to both humor and therapy. But to make a good joke or a good paradoxical intervention, something about the payoff has to be appropriate and jarring at the same time. Take this joke, for example: a man is sitting at a drive-in movie theater and notices in the truck in front of him a dog that’s crying. The man thinks this is amazing because the dog is crying at an extremely sad movie. After the movie is over, the man goes to the owner of the dog and says, “I can’t believe how intelligent your dog is. It’s amazing that he’s crying at this really sad movie.” The owner of the dog says, “I know, I don’t understand it because he hated the book.”

The good directive, like an effective punch line, is perfectly fitted to the circumstances: it’s not just illogical nonsense, but invites a perspective on what’s happening that’s subtly, yet clearly, a bit skewed. It’s like placing clients in front of funhouse mirrors: they see themselves and their behavior in both familiar and strange and distorted ways. The experience gives them an instructive perspective on themselves and what they’re doing.

Take the case of Natalie and her husband, for instance, who came to my office and explained that they’d been happily married for 20 years, had no children, and enjoyed doing many things together, like hiking, traveling, cooking, socializing with friends, and building their dream house. They considered themselves best friends, as well as spouses. When I asked what the problem was that they would like to resolve, they looked at each other in silence, each expecting the other to say something.

“Is it something to do with sex?” I asked.

“Kind of,” said Natalie.

“Does it have to do with enjoying sex?” I asked the husband, Josh.

“Sort of,” he answered.

The conversation went on like this for quite a while. “What about infidelity?” I finally asked. “Are one or both of you having an affair?”

Natalie immediately said “yes” at the same time that Josh said “no.” Turning to Natalie, he said, “I never had an affair.”

“But you had sex,” said Natalie angrily.

“We never had intercourse, and I never spoke to the woman,” said Josh.

After some more confusing discussion, as Natalie began to cry, Josh finally explained that he’d paid a dominatrix to beat him and that the sessions had ended in masturbation. After a few sessions, Josh had told Natalie about his newfound sexual preference. They were, after all, best friends, and he didn’t want to hide anything from her. She was considerably upset, but once the initial shock had worn off, she tried to help him by playing the role of the dominatrix herself. Her heart, however, wasn’t in it, and Josh didn’t like her doing it.

To add to their problem, Josh had done something incredibly stupid. He’d decided that he shouldn’t have to pay someone to dominate him when he could surely find someone who’d do it for free, just for the pleasure of it, so he’d placed an ad on a website with a nude picture of himself. Natalie, in the meantime, had been gathering evidence against an employee in her company in the hopes of being able to transfer her to another department. After Natalie had succeeded in pushing the transfer through, the woman showed up at her farewell lunch at the office with Josh’s ad and his nude photo. Natalie was not only humiliated, but lost security clearance in the company, and she was now in danger of being fired. Clearly, Josh was not organizing his sexual activities in a way that was safe for Natalie or for him. As they told me this story, Josh looked remorseful and Natalie seemed deeply hurt.

“I have a solution,” I said to Natalie, “and it’s not for your husband to give up his sexual preferences.”

“What then?” asked Natalie. “I don’t want to lose my husband. We have so many good things together, and I still love him.”

“From now on, Natalie, you’re going to be in charge,” I said. “I want you to find Josh a dominatrix who’s both safe and legal. To be legal, I think you’re going to have to travel to Nevada to do this, but I know that money is no object for you. You’re going to research this extensively and find the right person, someone he could enjoy and yet someone you trust. Then I want you to be present at all times. You’re going to be the one to pay this person, and you’re going to remain in the room to make sure your husband remains safe.”

They both looked at me wide-eyed, almost in disbelief, but I knew the intensity of the therapeutic intervention had to match the drama of the presenting problem. I also knew this directive would work no matter how it was taken: straightforwardly or paradoxically. In other words, if the couple complied with the instructions, then they’d share a sexual life that, while a bit unusual, would at least keep them engaged and would allow Natalie to have some control; however, if Josh developed a dislike for this activity (because it involved putting his wife in charge, which would drastically change the nature of the relationship with the dominatrix), it’d end future indulgence. Either result would be a satisfactory solution.

A few months later, I got a call from Josh, who was almost tearful. He said he wanted to tell me that he’d never be involved with a dominatrix again. When I asked what had happened, he explained that Natalie had found a dominatrix who was an aerobics instructor. The two women had become close friends and had recently decided that Josh needed to get into shape. In their last session, the dominatrix had ordered Josh to jog on the treadmill and do pushups and jumping jacks while she beat him. Afterward, Josh was hurting all over and could hardly walk.

“Couldn’t you tell her to stop?” I asked. “Isn’t there a safe word for that kind of situation?”

“I had two women dominating me,” said Josh. “I couldn’t tell them to stop, but I will never be with a dominatrix again.”

Everyone who has worked with unconventional sexual preferences knows how difficult it is to change them. I don’t think I’d have been able to convince Josh to abandon his preferred practices; however, the small change of including his wife—which led to including physical exercise—was enough to turn him off completely from the activity.

Again, this intervention came from an Ericksonian idea: a therapist starts a small change in the context, not knowing where it’ll lead, and the change can have huge repercussions. Sometimes the therapist guides the change, but sometimes all the therapist has to do is wait for the repercussions to happen. Later, I heard that Josh and Natalie were doing well and enjoying common interests together, just as they always had.

My Daughter the Artist

Parents typically love their children and want the best for them, but they often don’t understand how a particular child needs to be loved and what is really best for him or her. Often the role of the therapist is simply to help parents understand their child and give the kind of love that the child needs. Again, this help can come in the form of soft shock therapy, as it did with a family who consulted me about their 22-year-old daughter, Myra.

Myra lived in a different city but routinely called all her family members in the middle of the night, talking at length about her anxiety, depression, and self-hatred. She frequently cut herself, prompting a panic that’d land her in the emergency room. She was a dramatically beautiful young woman with long black hair, black clothes, and many silver chains. Every gesture she made expressed despair, futility, and doom. When I met with her and the family, she sat slumped over in the chair, her head in her hands.

I learned that Myra hated her part-time job as a receptionist, and that all she wanted was to be an artist, particularly a painter. But she had little money and no medical insurance. When things got really bad, her father helped her out financially, but lectured her weekly about the importance of building a strong work ethic, getting a good job, saving her money, and being more responsible with her finances. This was the dynamic of their relationship, and it never led to any change. The father would lecture, she’d say she’d try, but nothing leading to any type of change would happen. In fact, every attempt her father made to help her seemed to make matters worse—in part because he wanted her to be somebody else, and in part because they were caught in a pattern of interaction in which he was determined to show her what he knew was best for her and she was determined to show him that she couldn’t be helped.

The whole family—her divorced parents, stepmother, and two older siblings—had flown in from different cities to see me for two days. As I observed them, I realized that they all, except Myra, were goal-directed, hard-working people, especially the father, a wealthy businessman. It was as if Myra had dropped into this family from another planet. They couldn’t understand her, but knew that what they were doing to help her—the long, late-night conversations, the father’s intense lectures—wasn’t working. I got them to agree that they needed to take a totally different approach, perhaps even an opposite approach. I told them that I’d think about what that could be and expressed my appreciation for how much they all loved Myra and wanted to help her to be happy. I also said that Myra needed a consultation with a psychiatrist friend of mine, since I feared that the medications she was taking were making her worse.

The consultation with the psychiatrist, a Gestalt therapist, took place the next day, and he reported to me that he’d interviewed both Myra and her parents, and had asked many questions about her behavior as a young child—how sensitive she was to sounds and colors, what toys she preferred, how she expressed her emotions. He’d then brought the family together and announced a diagnosis of “artistic temperament.” This was a personality trait that she’d exhibited since early childhood, and it couldn’t be changed or repressed. It was who she was. He also planned with Myra how he was going to wean her from her medications.

When the family came back to my office, surprised and confused by the diagnosis, I said, “I totally agree with the doctor. Myra is an artist, and you’ve been trying to change her into what she’s not, instead of nurturing who she really is. I know your intentions are good, but she’s the only artist in the family, so you don’t have the experience of what it’s like to deal with an artist. Artists need an angel, someone to support them financially and encourage them in their work. And Myra is so fortunate that her father can be that angel for her.”

My thinking was that if Myra could feel that her father loved her unconditionally, that she didn’t have to be self-supporting or hard working to have his love, she’d develop the maturity and self-confidence that she so badly needed. Love has huge healing power. There was no question that the father loved Myra, but he wasn’t giving her his love in the way she needed to get it.

I turned to the father and said, “From now on, you’re going to support her financially so she can devote herself to her art, and you’re going to support her according to your own social class, not so she lives in poverty. You’re going to provide for her every need.”

Myra’s eyes were wide open. The father was stunned. This was the last thing he expected from me. I could tell he was thinking that by following my directive he’d be enabling lazy, obnoxious behavior.

The stepmother asked, “What about tough love? Aren’t we supposed to teach young people to be independent and self-reliant?”

I said, “That doesn’t apply to people with an artistic temperament.” Then I became specific, instructing the father to pay off all of Myra’s credit cards, have her car repaired, make sure she has medical insurance, and so forth. The father agreed. He was an intelligent, successful man, and he knew that what he’d been doing wasn’t working, so he was willing to try this radically different approach.

After this agreement, there was no more cutting and no more trips to the emergency room. A few months later, Myra called me one day, tearful about a boyfriend who she suspected was going to break up with her. I asked how old this boyfriend was. She said 25. I said, “Twenty-five? That’s a boy. You need a 40-year-old man who’ll invite you to Paris for the weekend and have his assistant make the arrangements.”

Myra laughed and said, “You’re right, Cloe. I need a rich, older man. I’m okay. I just needed to hear your voice. You always make me laugh.”

Three years later, I heard that Myra had gone back to school and was finishing her master’s degree in fine arts. There’d been no more family dramas.

The Therapist as Miss Marple

As I see it, a good therapist is primarily a kind of detective, a Miss Marple (Agatha Christie’s elderly lady sleuth) with a degree in social work or psychology. Our mission is to burrow in and find out who our clients really are and the sources of their problems—even when they themselves aren’t entirely sure or aware of what drives them (which is often the case). This kind of work requires, more than many forms of therapy, an ability to pick up on the sometimes hidden-in-plain-sight idiosyncratically funny details of their situation.

There’s no way to do this ethically and effectively without first forging a strong therapeutic relationship built on mutual respect, trust, and appreciation—a relationship in which clients feel deeply seen, heard, and understood. None of my clients would even consider my “silly” directives, much less try to follow them to the letter, if they didn’t feel I cared about them and had some insight into what troubled them. Without that level of mutual regard, this kind of work would be a travesty, and I’d have no clients. They do what I ask on trust—trust that I know and care about them enough not to harm them, even inadvertently.

Built on thoughtfulness, deep attention, and obvious regard for the clients, these kinds of directives work because they wake people up from their misery-trance. You can see the new spark in their eyes, almost hear their brains start to buzz with more liveliness. Garrison Keillor, host of A Prairie Home Companion, once said that “God writes a lot of comedy. The trouble is, he’s stuck with so many bad actors who don’t know how to play funny.” In a sense, these paradoxical directives are a bit like acting class: the clients may start out as melodramatic tragedians, but during this process they learn how to do pretty good stand-up comedy!


Photo © Caspar Benson / Getty

Cloe Madanes

Cloe Madanes is one of the originators of the strategic approach to family therapy. She’s authored seven books that are classics in the field: Strategic Family Therapy; Behind the One-Way Mirror; Sex, Love, and Violence; The Secret Meaning of Money; The Violence of Men; The Therapist as Humanist, Social Activist, and Systemic Thinker; and Relationship Breakthrough.