Spitting in the Client’s Soup

Don’t Overthink Your Interventions

Magazine Issue
March/April 2015
An illustration of two people sitting in an office with a bowl of soup between them

Therapists sure have a knack for creating complications. In the search for simple explanations for their clients’ suffering, they tend to find an attachment injury behind every relationship issue, a traumatic event to account for any symptom, and brain research to support every clinical maneuver. New problem categories continue to be devised. For instance, the list of possible types of trauma has now expanded to include insidious trauma, intergenerational trauma, vicarious trauma, microtrauma, and betrayal trauma. Recently, just-world trauma has been added to the list. This is when an event shatters a client’s belief in a benevolent world in which good deeds are rewarded and wrong-doings punished. But isn’t this what we used to call growing up?

Of course, new therapeutic specialties and novel variations on existing approaches keep cropping up. Among the latest are cognitive-processing therapy, trauma-focused cognitive behavioral therapy, mindfulness-based cognitive therapy, trauma-sensitive group yoga, attachment-focused family therapy, and even forgiveness therapy. The neurobiology craze has many therapists offering clients lecturettes on neuroplasticity and myelination, and one Networker author reports showing them PET scans, presumably to prove that therapy really does change the brain. Of course, so does drinking your morning coffee.

The field is as fractionated as ever. And as new and reworked methods continue to attract adherents, the disquieting question remains: are these emerging methods any more potent than the existing strategies? Is all of this specialization and complexity really necessary? Is there any evidence that one theory or therapeutic strategy is really better than the rest? Perhaps client problems are simpler than we (or they) have suspected. Perhaps this chaotic array of specialized techniques can be reduced to a more manageable and straightforward set of principles and methods.

Marsha Linehan, the originator of dialectical behavior therapy (DBT), was once asked if she had any advice for novice therapists. She suggested that they be themselves and stop trying to act like therapists, reminding them that this entire venture is nothing more than “one human being trying to help another human being.” We think she just might be onto something.

Imagination and Healing

A perennial hazard for therapists is succumbing to the allure of novel procedures and fancy theories, particularly those that promise quick and dramatic cures. For perspective on this trend, let’s delve briefly into the creation of the Perkins Tractor—a peculiar form of healing now relegated to the dustbin of history. This device, invented in 1796, consists of two three-inch pointed metal rods, which presumably had the power to draw off “noxious electrical fluid” and thereby cure individuals of whatever ailed them. They were quite popular in their day and sold for high sums in both the United States and abroad. Even George Washington owned a set. We might still be using tractors today if it wasn’t for the work of John Heygarth, a clever British physician who duplicated Perkins’ results with a fake wooden tractor and published his findings under the prophetic title On the Imagination as a Cause and as a Cure of Disorders of the Body.

In that era, proponents of Anton Mesmer’s theory of animal magnetism were touring Europe to demonstrate the wondrous effects of magnetic forces. For instance, they showed that a person’s laughter could be changed to tears just by shifting the way a magnet was pointed. Similarly, when the magnet was rotated 180 degrees, an individual hallucinating the color red would instead see the complementary color (blue-green). Eventually, the belief in these magnetic phenomena was undercut by double-blind experiments with electromagnets that could be turned on or off or have their polarity reversed surreptitiously, thereby depriving both the mesmerist and his subject of any cues about when different effects were to be expected. Under those conditions, the behavior of subjects became random.

As outlandish as these approaches seem today, those who practiced them were neither fools nor charlatans. Most of them believed fervently in what they were doing and felt a duty to bring their discoveries to the attention of the public. Our modern understanding of placebo effects would seem to indicate that their certainty about their beliefs contributed significantly to the effectiveness of their methods. In other words, tractors and magnets worked because people expected them to work. It would be nice to think that we’ve outlived those days of hokey healing rituals and misguided theories. However, even Jerome Kagan—the highly respected Harvard developmental researcher—recently suggested that every clinician read (or reread) Jerome Frank’s Persuasion and Healing.

In that classic, Frank suggests that all therapies hinge on just four essential elements: a confiding relationship with a helping person, a healing setting, a rationale or myth that accounts for the patient’s symptoms and prescribes a plan for resolving them, and a ritual that both patient and therapist believe will work. Frank doesn’t specify whether that healing ritual should involve pointed rods, rotating magnets, waving arms, tapping feet, compiling thought records, massage, or special breathing exercises. In fact, he argued that any ceremony believed in by both parties might do the trick.

Grounds for Skepticism

Some of the seeds for my own (Jay’s) skepticism about the validity of the field’s cherished traditions and popular practices were planted shortly after I received my doctorate, when the influence of psychodynamic theory had begun to wane and behavioral approaches were in the ascendency. The medical faculty of the University of Rochester, where I was teaching, invited Joseph Wolpe—the creator of systematic desensitization—to present a grand rounds, during which he portrayed his approach as a new method for treating fears that could bring psychiatry out of the dark ages.

The psychiatrists on the medical school faculty were furious. They accused Wolpe of foisting a superficial method of symptom relief on an unsuspecting public. They argued that because Wolpe’s method totally ignored the deep-seated roots of problems, it would generate horrible cases of “symptom substitution” or worse. Ironically, at a grand rounds the following year, one of the junior psychiatrists had the temerity to ask the old-timers if any of them had ever actually witnessed a case of symptom substitution in any of their patients. Not a single hand was raised. This is an example of how readily mental health mythologies, once created, are passed along from one generation to the next with little reexamination.

After Wolpe’s visit, I tried systematic desensitization for myself, experiencing only modest success. However, I then read about an alternative model—Thomas Stampfl’s implosive therapy. It was also touted as producing excellent and rapid results. Although both methods were purportedly based on learning theory, they involved diametrically opposed procedures. In systematic desensitization, the goal was to keep the client as relaxed as possible while he or she gradually imagined more fearful images. The strong relaxation response was supposed to “counter-condition” the initially weaker phobic response. Implosive therapy, on the other hand, required raising the client’s fear level as quickly as possible and then encouraging him or her to sustain that intensity until the process of extinction kicked in. In short, Wolpe’s method emphasized relaxation, while Stampfl’s emphasized arousal.

As a number of us pondered the differences between these methods, some academic learning theorists began weighing in, expressing doubts about whether, in fact, either procedure was an accurate translation of learning theory principles. That controversy motivated us to design a formal experiment somewhat analogous to Heygarth’s fake tractor demonstration. We invented a bogus treatment, purposely designed to violate all the known laws of learning.

We hooked snake- and spider-phobic subjects up to elaborate recording machinery and seated them in front of a tachistoscopic screen on which images of the feared object were presumably being projected. We told them that they wouldn’t actually see the images because these were being flashed at speeds “too fast for the conscious mind to perceive” but at an ideal rate for effective “unconscious deconditioning.” In reality, there were no images—the subjects were watching flashes of light while being given mild shocks at random intervals. We then showed them fake graphs indicating that the procedure had been highly successful. Obviously, this was before the days of stringent consent forms and institutional review committees.

Our results, published in the Journal of Abnormal Psychology, demonstrated that our bogus treatment worked as well as standard systematic desensitization, suggesting that Wolpe’s method might just be another healing ritual—a clever way to convince subjects that they could overcome their fears. In other words, Perkins’s tractor and Mesmer’s magnets all over again.

These days, few clinicians practice either systematic desensitization or implosive therapy. Given that those methods once held such great promise, why have they disappeared? Part of the answer is that this is a fickle field, in which new gimmicks come along, grab our attention for a while, and then fade into oblivion, only to be replaced by still newer and snazzier interventions. Presumably, if either of these methods were as powerful as originally advertised, they’d have become standard practice and eclipsed other methodologies, just as antibiotics had replaced bloodletting. At least part of the problem is that we work in a field in which the path to money and fame lies in invention. Moreover, there’s enormous pressure to claim that we have special ways of relating to clients and special reasons for doing so.

Debunking Myths

In the absence of clear winners in the therapy sweepstakes, clinicians practice a stunning array of unsupported and half-baked approaches. Even components of mainstream methods, such as the cognitive components of CBT, continue to fare poorly in dismantling studies, in which you take apart the elements of a treatment package to see which are actually necessary and which don’t add value. The bulk of such studies show that techniques such as disputing maladaptive thoughts contribute little to the method’s outcome. Moreover, there’s no evidence to suggest that CBT clients think any less logically than the rest of us.

Although research shows that DBT, if administered by a well-trained and supervised staff, works better with borderline clients than the generic care available in the community, even Marsha Linehan freely admits that there’s still no evidence proving which aspects of her protocol are effective or necessary. For all we know, the procedures that give DBT its edge may be the birthday cards her therapists send to their clients or the “I’m just thinking of you” phone calls they make.

Perhaps the most enduring but unsubstantiated theoretical belief among therapists is the timeworn notion that difficulties in adulthood stem from childhood misfortunes. Almost all therapy approaches, from psychoanalysis and Imago therapy to the emotion-focused and sensorimotor methods, embrace some version of this dogma. Given its venerable pedigree, this belief in the potency of childhood events is one of the most difficult to deconstruct. Nevertheless, as a general clinical hypothesis, it’s deeply flawed.

The simple truth is that a preponderance of the evidence mitigates against assigning any great importance to childhood experiences and memories—processed, unprocessed, or reprocessed. Martin Seligman, the former president of the American Psychological Association, puts it this way: “Childhood events—even childhood trauma—and childrearing appear to have only weak effects on adult life. Childhood, contrary to popular belief, does not seem, empirically, to be particularly formative.

So, contrary to popular belief, we are not prisoners of our past.”

In their book, We’ve Had a Hundred Years of Psychotherapy—And the World’s Getting Worse, James Hillman and Michael Ventura argue that this mythology persists partly because our culture has bought into an idealized image of the pure, innocent, and wholesome child. Therefore, it follows logically that any troubles the adult experiences must be due to corruptions in that child’s upbringing. Because it’s in tune with our cultural paradigm, the belief that adult problems are the residue of a faulty upbringing is an easy sell to both therapists and their clients. In this regard, they’re members of the same cultural “club” and therefore unwittingly reinforce each other’s beliefs. Nevertheless, two distinct lines of evidence mitigate against accepting the “my parents are why I’m such a mess” ideology.

First, research supports Frank’s third proposition, that the effectiveness of treatment has little to do with the validity of the interpretations clients are offered. In fact, one of the most robust research findings in the psychological literature is that all therapies—with only a few minor exceptions—produce the same level of results, regardless of the particular insights they promulgate. In other words, no particular interpretive contents—including those that emphasize the importance of childhood experience—can be considered a major factor in therapeutic outcome. CBT gets good results without delving into childhood memories, and mindfulness approaches often work quite well without assigning CBT-style homework. Nevertheless, proponents of various approaches continue to preach the necessity of strictly adhering to complex and specialized procedures of dubious validity.

Research repeatedly shows that a major factor determining outcome is the strength of the therapeutic alliance—analogous to Frank’s “confiding relationship.” Moreover, when a strong client–therapist alliance exists, clients almost always fall into line with their therapist’s worldview. Those that don’t tend to go elsewhere. This is why therapists often say, only partly in jest, that Jungian clients produce Jungian dreams and Adlerian clients produce Adlerian dreams.

The second line of evidence against the centrality of childhood experience is the research on the role of hereditary factors in shaping adult personality. Information about this neglected determinant started to become widely available in the 1980s, when Thomas Bouchard founded the Center for Twin and Adoption Research at the University of Minnesota. Bouchard first became interested in identical twins while watching an episode of the Johnny Carson show that featured the so-called “Jim twins.” These twins, both named Jim at birth, were separated at four weeks of age and reunited (through chance circumstances) when they were 39. The similarities and coincidences in their lives are remarkable. Despite having been raised in different households with no knowledge of each other, they turned out to have similar habits, fears, careers, and hobbies.

In turn, Bouchard located more than 120 additional pairs of twins reared apart, discovering that uncanny similarities were the rule, rather than the exception. Twins who know each other are generally less similar than those reared apart, because those who grow up together are usually motivated to emphasize their differences.

Identical twins raised apart not only have the same fears and anxieties, they often deal with them in the same way. For instance, two women who were frightened of wading in the ocean both developed the habit of backing into the water so that they could make a hasty retreat if necessary. Because they were raised by different parents, such concordances can’t be attributed to attachment histories, traumatic events, or child-rearing patterns. Similarly, it’s been shown that adopted children behave more like their biological parents than either their adoptive parents or their step-siblings, again raising doubts about the importance of upbringing as a direct cause of adult concerns.

Therapists like to point to the so-called “cycle of violence,” in which children of abusive parents grow up to abuse their own offspring. However, this phenomenon has been badly misinterpreted because genetic factors weren’t entered into the equation. The truth is that the majority of abused children don’t become abusers; and for the minority who do, the genetic overlap between parent and child is sufficient to account for their behavioral similarity.

What does all this mean? Despite an enormous amount of evidence to the contrary, mental health professionals continue to base their practices on flawed socialization research, outdated developmental studies, and self-perpetuating clinical myth­ology. Absent from the clinical scene is any serious consideration of the central role of hereditary in shaping character and determining relationship patterns. As Seligman notes, well-designed longitudinal studies inevitably lead to the conclusion that in explaining adult mood, personality, and daily functioning, one can expect “huge effects of genetics, large effects of recent life events, and small or no effects of childhood events.”

Of course, Americans hate this idea, preferring to believe that we can all become whatever we want. And therapists have even more motivation for maintaining this narrative because it’s good for business. Unfortunately, it simply continues to shackle the profession with unwarranted confusion and complexity. It causes many clients to dwell on aspects of their past that ultimately make little difference in plotting a productive future.

At the same time, real differences in temperament are ignored. Quite aside from differences in child-rearing, people have different happiness set points, degrees of reactivity to environmental triggers, levels of affability, and so on. Moreover, clients are much better off when these variations are frankly acknowledged as biological propensities and integrated into their sense of self, instead of being automatically pathologized as attachment difficulties, sibling rivalry, or long-forgotten childhood insults that must be subjected to special treatments.

Therapy as Conversation

Our own clinical work is firmly rooted in the simple proposition that all therapy sessions—even those that incorporate massage, imagery exercises, behavior rehearsal, or homework—are conversations between two or more people. A few years ago, at a Networker Symposium, psychiatric gadfly Thomas Szasz was asked how many patients he’d treated over the course of his long career. “None,” he replied, explaining that he had no “treatments” to offer. “However,” he added, “I have certainly enjoyed conversing with many troubled individuals.” Unfortunately, the notion that therapy is merely a conversation about life makes many therapists more than a bit uneasy. The medical model and insurance company forms seem to require that we arm ourselves with technical terms and adopt arcane procedures. And these days, if what we do can be linked to findings from the neurobiology lab, so much the better. We’re loath to admit that therapy might be as simple as people sharing and exchanging experience through the use of words and symbols.

Of course, good therapy is more than just ordinary chitchat. To be effective, it has to go beyond an endless recital of complaints, a dull report of the week’s events, a narcissistic advertisement for self, an exchange of pleasantries, or the dispensing of stock homilies. In Hillman’s words, the therapeutic conversation should “open your eyes to something [and] quicken your ears.” To achieve this, Hillman argues that therapists must be allowed to “speak with irony, even ridicule and cutting sarcasm.” Hillman calls this kind of conversation psychoshock—little jolts that “make a situation suddenly seem altogether new”—the kind of dialogue that reverberates in your head, possibly for days to come. This kind of conversation can’t be preprogrammed, which is why therapy can never be fully manualized. On the other hand, the kinds of principles Frank suggests appear to provide useful guidance to therapists, focusing on basics and increasing the probability of having a productive dialogue with clients.

We want to emphasize that in describing how we operate, we’re neither proposing a new form of therapy nor offering any novel therapeutic gimmicks. We believe the field already has plenty of these, and we’ve tried virtually all of them. Instead, we want to describe a modest method for doing therapy without unnecessary complications while still giving clients what they seem to want and need.

Decluttering the Therapeutic Canvas

Our first suggestion is to approach doing therapy from as simple, clean, and far-reaching a worldview as possible. We call this beginning with nothing, meaning that we clear our heads of assumptions and take as little as possible for granted. Perhaps British psychiatrist Wilfred Bion was getting at something similar when he advised entering the consulting room “without memory or desire.”

A few years ago, the Philadelphia Inquirer interviewed Eiko Ishioka, the Japanese designer who did the costumes for the opening ceremonies of the Beijing Olympics. In the interview, she said that all she had in her apartment was a chair, a glass table, and big windows. “Empty space is very important for me,” she said. “When I start to work with a new project, I must throw away all my achievements in the past and have a blank canvas and think about it from zero.” Therapists, too, would be wise to find ways to declutter the therapeutic space.

When the therapeutic canvas is cluttered, therapists are likely to become embroiled in the client’s story and distracted by their own concerns about how to intervene, often failing to see the broader prospective that might enhance therapy’s impact. In the words of family therapist Doug Flemons, their impatience to answer the wrong question means that they never quite get to the more powerful and productive questions that lie ahead. Small-scale fixing blinds them to the possibilities of large-scale creating. The truth is, exactly as Einstein warned, “you can rarely solve a problem on the level on which it was created.”

Perhaps the best way to avoid being ensnared in assumptive cobwebs is to remind ourselves that, as they say in the East, “it doesn’t matter, and it doesn’t matter that it doesn’t matter.” This aphorism has two parts, both of which are equally important—not only does life (and what we make of it) not matter, but it’s also perfectly fine that it doesn’t matter. The problem is that when you tell people that nothing matters, they tend to defiantly cross their arms and threaten to stop doing whatever they’re doing at the time. After all, if it doesn’t matter, why shouldn’t they just take a backseat and watch the world go by? Of course, those who adopt that stance reveal that they’ve only grasped the first part of the equation. In other words, they think that it matters that it doesn’t matter.

We’ve found that this bedrock principle—that nothing matters, and that’s just fine—is almost always useful in preserving our sanity as therapists. Moreover, it’s often immediately applicable to a client’s problems. Years ago, I (Jay) saw a depressed client named Evan, who was suffering from what most of us would consider a mid-life crisis. He’d concluded that his current job as a financial advisor was completely meaningless. I quickly pointed out that he’d accidently “stumbled” onto half of one of life’s major truths. Yes, he’d realized that his current circumstances were meaningless, but he’d failed to notice that so were everyone else’s.

I proceeded to show him that even those occupations he considered prestigious and significant were, when examined in terms of the big picture, fundamentally as unimportant as his own occupation. In fact, even without a background in philosophy, one can argue persuasively either that every job in the world is extremely important or that none are. The position that turns out to be difficult to defend is the notion that some occupations are meaningful and others are not. It’s like saying that birds are important but trees aren’t. After all, I pointed out, when you come right down to it, surgery is really just high-class plumbing. Moreover, a surgeon is basically useless when your basement is flooded. Under those circumstances, plumbers suddenly rise to the ranks of the great and powerful.

Of course, Evan believed—as many of us do—that meaning and satisfaction reside in our jobs. I suggested that it’s more useful to consider that meaningfulness has more to do with how you do your job. In other words, you’re the source of satisfaction, rather than the job. From this perspective, you’re powerful enough to bring satisfaction to any job you choose. In the same way, the Japanese tea ceremony isn’t fundamentally about tea: it’s about the beauty and elegance that individuals choose to bring to the ceremony. Similarly, in Japanese Morita therapy, depressed and anxious clients are tutored in how to do even the smallest tasks with loving attention.

One of Evan’s original concerns was that others had somehow selected “better” occupations than he had. Thus, at the start of our work, he was seriously considering changing careers. I told him that he was absolutely free to do that, but I predicted that if he did, he’d be right back in a few years, complaining that his new vocation had failed him. Our conversation helped him put aside the fear that he was missing out on something that others were enjoying and he ultimately decided to stay put, creating new goals for himself and finding great satisfaction in tutoring the younger employees in his firm. Coincidentally, I ran into him just a few months ago—20 years after we did our work together. He was still working in the same profession, and he thanked me for dissuading him from precipitously shifting careers.

My work with Evan fulfills at least three of Jerome Frank’s four conditions for successful therapy. We had a strong relationship and a clear therapy contract, and I proposed a different rhetoric for his troubles, with different implications for future action. Of course, the “ritual,” if there was one, was mostly in the form of a Socratic dialogue, rather than something fancier. And the work didn’t require thought records, homework, or an elaborate exploration of his past.

As in this case, the notion that life has no intrinsic or objective meaning (which some initially find disturbing) contains good news: the cosmic meaninglessness of it all provides exactly the right kind of empty canvas onto which we’re free to create and declare our own sets of meaning. It helps us see that we have the capacity to generate new meanings if and when the old ones have outgrown their usefulness. If life came with predetermined meanings, creating our own would be a trickier proposition. On the other hand, the meanings we concoct are double-edged swords: we often find ourselves tripping over our own creations, forgetting that we’re the ones who put them there. In fact, it’s that hodgepodge of reified and ossified beliefs that clients bring to therapy, no matter where they came from, that makes the clinician’s job both challenging and necessary.

Life Isn’t Personal

There’s a second broad philosophical principle that we find useful in keeping the big picture in mind—that life isn’t personal, even when it absolutely looks as if it is. Few of us get up in the morning and try to figure out how to make ourselves and those around us miserable. We’re all doing the best we can. Most of us come by our problems honestly, trying to get as much as we can of what we want while avoiding most of what we don’t want. Once you give up the belief in obscure childhood determinants, you discover how much client unhappiness is rooted in ordinary life dilemmas.

Finding a good fit with others can be a tricky matter, but it’s even trickier when you get stuck in the belief that life is personal—that people or circumstances are out to get you. The truth is that the way people treat you is the way they would treat anyone who represented to them whatever you happen to represent to them. As human relations coach Stewart Emery puts it, “you’re just an extra from central casting.” Other people are in the process of being themselves, and you just happen to be an individual standing there.

Even love isn’t personal. Although we can make up plenty of plausible-sounding explanations, we really have little idea why love happens. We didn’t necessarily plan it that way, and we can’t necessarily do much about it. It’s just about how we happen to fit together with our partner. It isn’t logical or convenient, and the fact that it sometimes results in pain doesn’t mean that it’s derivative of some obscure childhood memory or traumatic event. We may be sorry that it happened with one particular person and not another, but that’s just the way it is.

In the final analysis, both love and relationship satisfaction are always a matter of fit. The problem is that so much of life seems personal, so we have to recognize that nature doesn’t care about us: we haven’t been singled out for special abuse. As writer Esther Dendel reminds us, “It takes a certain maturity of mind to accept that nature works as steadily in rust as in rose petals.” And, at the risk of inducing additional “just-world traumas,” the way things are is just the way they are—the universe is neither benign nor malevolent. It’s just going about its own business.

By adopting this simple but, for many people, odd perspective, we’re often able to help clients approach long-standing struggles and conflicts from fresh and more productive angles. A few years ago, I (Rob) worked with a client who’d been torturing himself for years over what he considered an intolerable and unforgivable family transgression, making his family miserable in the process.

Tony was the oldest of three brothers and had come to believe that his youngest brother had deliberately outmaneuvered him for control of the family business. The truth is that the younger brother hadn’t set out to destroy or humiliate Tony; he was simply good at business and had a clear vision for how the business could keep up with changing times. Nevertheless, Tony felt cheated out of his birthright. In his mind, he’d been wronged and robbed, and the only move left open to him was to declare war on his brother and insist that his wife and children join him in this vendetta. His insistence was threatening to destabilize his family in the face of an important upcoming family event—a wedding.

Tony believed that dropping his righteous indignation and outrage, even enough to allow his immediate family members to attend the wedding and fraternize with the enemy, meant nothing less than total capitulation and defeat. Arguing with Tony would’ve been useless; after all, that was precisely what everyone in his family had been doing, and it had only served to harden his position. Instead, I sympathized with Tony over his perceived loss of power and status in the family and affirmed his right to want to feel at least as powerful and important as his younger brother. I just suggested that he might consider going about this a different way, since his current strategy didn’t seem to be going so well.

Having gotten his attention, I further suggested that if he really wanted to reclaim power and esteem within the family, he might consider not being so predictable and try doing something a bit surprising. For example, what would happen, I mused, if at the wedding, and in direct contradiction to everyone’s expectations, he assertively strode over to his brother at the wedding, looked him square in the eye, shook his hand warmly, and thanked him for coming, indicating that it was good to have the whole family together again?

Understanding that he felt he’d been displaced as head of the family, I was suggesting that instead of boycotting the event, he take advantage of the gathering to act as the patriarch of the family, which he so desperately wanted to be. “Who cares what your little brother is doing?” I asked. “He’s just doing the one thing he knows how to do, which is business. He can’t fix this family thing—he doesn’t know how to. You’re the only one with the know-how and the power to do that.”

Within seconds, Tony had grasped the novelty of this idea. Considering the perceived personal affront as unimportant gave him the room to once again be a man of consequence in his family’s eyes. He loved it, and put the plan into action. Several weeks later, when I saw Tony and his wife together for another session, she came bearing cake, which she said she offered in gratitude for this unexpected and miraculous shift in her husband’s position and demeanor.

Beware of Treating Abstractions

One person who recognized the importance of getting caught up in either the client’s soap opera or your own was Harvey Jackins, the creator of Reevaluation Counseling. When a session with one of his clients would get bogged down, he typically suggested that they take a break and get a Coke from the basement soda machine. By the time they got back up to the therapy room, the tempo of the conversation would often shift in a positive direction. The trip to the soda machine provided just enough perspective to break the logjam. Jackins suggested that clinicians must always be “two-footed”—keeping one foot in the problem, so that they’re aware of what’s at stake, and the other foot outside the problem, so that they can maintain a suitably broad outlook. We suppose that the requirement that analysts in training have their own personal analysis is intended to serve a similar purpose. However, because their analyses are with members of the same club, this practice sometimes has the reverse effect—narrowing rather than broadening the individual’s viewpoint.

Not only do clients come in with a host of beliefs, images from the past, fixed attitudes, and false causal assumptions, therapists often add their own explanatory fictions to the mix, introducing hazardous abstractions such as ego-strength, frustration tolerance, insecure attachment, automatic thoughts, negative schemas, unprocessed memories, and so on. Even common clinical terms such as anxiety and depression can be more of a hindrance than a help. Whenever possible, we suggest that therapists pin down the meaning of ambiguous terms and translate professional jargon into ordinary language. For example, let’s imagine that a bear is chasing you. You run to the door but find that it’s locked. Therefore, you experience what psychoanalyst Roy Schafer called blocked action. When action is blocked, the resulting state of arousal is often labeled anxiety or fear. If you have your cell phone with you, you might quickly text your therapist to report that you’re in urgent need of anxiety relief. However, what you really need is information about bears. If you can handle the bear, your anxiety will take care of itself. If you can’t handle the bear, anxiety will be the least of your worries.

The confusion arises because mental health “bears” are harder to see than their real-life counterparts. Thus, it seems reasonable to many clients and therapists to talk about decreasing or eliminating anxiety (or increasing self-esteem or improving frustration tolerance). However, the smart money is on locating the psychological bears and determining what can be done about them. Terms like anxiety, self-esteem, and ego-strength are explanatory fictions of limited utility. We recommend that therapists get in the habit of focusing on specific beliefs and circumstances, not linguistic abstractions. More often than some therapists like to think, translating a problem into ordinary English goes a long way in permitting a solution to become apparent.

Generating a New Game

One of the few essentials of successful therapy is that it must instigate a fresh conversational perspective. In James Hillman’s terms, there has to be that jolt of novelty. Or, to use Alfred Adler’s colorful language, the therapist must somehow “spit in the client’s soup.” After that, the client is free to go right on eating, but nothing is likely to taste quite the same.

In practice, what this means is that we’re careful not to adopt the client’s view of the problem right out of the box, or even to put too much stock in what they say they want. When a client comes to us and asks for help in being less anxious, we don’t say, “Okay, we’ve got a treatment for that.” We’re more apt to want a clearer explanation about what the client means by anxiousness, and why we should be concerned with getting ridding of it. Taking this position keeps the conversation from heading in the usual direction that so often seems promising at the outset but soon leads down a number of fruitless blind alleys and therapeutic rabbit holes. Instead, it pushes it in unexpected and more dynamic directions.

Years ago, I (Jay) worked with a couple. The husband had promised several times to stop seeing his paramour, but to no avail. His wife was still hoping to save the marriage, but was being torn apart by his indecisiveness. When I met separately with the husband, he said that although he loved his wife, he found the thought of giving up his lover unbearable.

I was encouraged by the fact that both spouses seemed to love each other. They had sought help together and were both deeply invested in the welfare of their 5-year-old daughter. They’d also both rejected the advice of two other therapists. One was a therapist who’d insisted that their childhoods held the key to the problem. However, he could offer no practical advice about what they should do about their current situation. The second therapist had taken a highly moralistic stance toward the husband’s transgressions, which both spouses found objectionable.

I proposed an unorthodox experiment. I suggested that the couple separate for three months. During that time, the wife was to grant her husband full permission to live with his girlfriend. At first, this idea struck both of them as slightly preposterous. However, they were open-minded enough to give it a try, perhaps because they couldn’t think of a better alternative and because they were both exasperated by the status quo. The husband agreed that at the end of the three months, he’d decide whether to continue the marriage or file for divorce.

Of course, now that the affair was no longer forbidden fruit, its appeal waned. Living with someone in an efficiency apartment is far different from meeting for secret dates in romantic settings. The context had changed, and the husband soon discovered that his girlfriend had habits he disliked, such as leaving clothes on the floor and dishes in the sink. He also realized that he’d misjudged the level of compatibility between them. By the end of the three-month trial period, he’d made up his mind: if his wife would still have him, he’d return home. It was a simple shift in context—a new way of thinking about the problem—that did the trick. The new context generated a different process, which, in turn, automatically generated a different set of thoughts, feelings, and behaviors. The intervention was oblique with regard to the usual club rules.

Practically speaking, as therapists, we’re always asking ourselves what the client’s current worldview prevents them from considering—what’s the road less traveled? What rules are they taking too seriously?

What concepts have narrowed their framework? What options are they missing that our intervention might forcefully bring to light? Not every such intervention will hit pay dirt. As every practitioner knows, an intervention that works beautifully with one client may have no effect on the next. Every conversation has unique properties. This is an intrinsic characteristic of every dialogic process, not a procedural error. Therefore, therapy always requires a certain amount of guesswork. However, learning to listen for missing or occluded options is a therapeutic skill worth cultivating, and frankly, it’s not that difficult.

What’s the Rush?

I (Jay) was asked by a hospital to see a young man on an emergency basis. Joseph was contemplating suicide and, until that point, had been in treatment with one of their staff psychiatrists. Unfortunately, when Joseph arrived for his appointment, he was told that his therapist was “unavailable.” But he soon discovered the truth—that the very person who’d been trying to convince him that life was worth living had just made her own suicide attempt and was now in a coma.

When Joseph came to see me, he took the position that if his therapist was trying to end it all, why shouldn’t he do the same? I replied that as far as I was concerned, he had every right to do so. In fact, every one of us does, including his therapist. After all, if we don’t have that right, what rights do we really have? Aren’t we allowed to smoke—which some consider just a slow way of killing oneself? What about overeating, bungee jumping, or jaywalking?

I pointed out that if Joseph thought I was there to talk him out of killing himself, he had another thing coming. Perhaps his regular therapist had that goal, but I was operating from a different philosophical position. As we talked about this, I asked him if he’d ever been to Brazil. “No,” he said, looking at me as if I was mildly deranged. I explained that if I was going to kill myself there are things I might want to do first. For example, I might want to try parachute jumping or hang gliding. I might want to travel to South America to see some of the sights. After all, what was the rush? Was there a Tuesday special on suicide that I hadn’t heard about? Was this Tuesday better than the following Thursday? I also cautioned that if he were going to do himself in, he should make sure it’s what he really wants, because do-overs are unlikely.

Of course, because of his history at the psychiatric clinic, I knew that he preferred to discuss suicide rather than do it. It was the topic that had preoccupied him and his therapist for many sessions. However, in my view, their discussion wasn’t going anywhere because he and his therapist were both card-carrying members of the same “you’re not allowed to kill yourself” club. My approach disregarded those club rules entirely, enabling the conversation to move into new territory. Another one of the few fundamental principles worth retaining as a therapist is the notion that if the current strategy isn’t working, it’s necessary to do something different.

So Joseph and I discussed the fact that although he knew how Act One had turned out, he had little information about how Act Two might unfold. Sure, it might end up being just as dismal as Act One. On the other hand, it might turn out differently, especially if he could harness some of the life lessons he’d learned in Act One. I indicated that if he was willing to stick around for a few months, I’d be happy to chat about possible Act Two “scripts.” He agreed, and in our work over those next several months, he never again brought up the subject of suicide or showed any interest in discussing the topic. Evidently, in Adler’s terms, I had successfully spit into that client’s particular soup.


Over psychotherapy’s history, the search for new therapy techniques and fancier gimmicks has led the field lurching down one blind alley after another. In our view, the odds are that the field’s current preoccupation with attachment patterns, trauma histories, mindfulness exercises, and neurobiology will have as little additional benefit as yesterday’s tractors and magnets. From our perspective, therapy is undeniably a form of conversation, not a medical treatment. Moreover, as an interpersonal encounter, it can never be fully scripted or manualized. Its value, as Jerome Frank suggests, hinges on a few basic principles that have been known for a long time. There has to be a solid relationship with a helper, some sort of healing procedure, and a rhetoric that sounds sensible and generates hope for the future.

Unfortunately, in our profession, it’s more alluring to explore new gimmicks than acknowledge that our success largely hinges on simple, commonsense factors. Yet it’s the mystifications of theory and technique that tend to make the job seem difficult, often causing even experienced therapists to feel lost in a quagmire of competing alternatives. As British therapist Peter Lomas notes in his book Doing Good? Psychotherapy out of Its Depth, even when they’re hopelessly stuck, some therapists fail to ask themselves what they might do in their own lives under similar circumstances. After all, this is supposed to be some special activity called therapy—not ordinary life.

In our own work, we’ve formalized a basic set of principles to keep us grounded. As we’ve noted, these include adopting the broad philosophical stance that nothing ultimately matters and life is never personal. This recipe includes chucking our own preconceptions for long enough to hear which “club” allegiances and conflicts blind the client to viable possibilities. We then seek ways to submit such options for the client’s consideration. At the same time, we want our clients to grasp that they’re the storytellers, not just the particular story they’ve been telling: they’re the movie theater, not just the particular film that happens to be playing at the moment.

Along with Lomas, we argue that too many therapists operate under a “tyranny of convention” and that an effective therapist is simply someone “who [listens] without prejudice, is free from an attempt to fit us into a formula, and who would not condemn us or convey a sense of superiority.” As he puts it, therapy should create “an atmosphere in which risks can be taken, fun can be had, closeness is possible, and the relationship feels alive.” Although that may not be a description that establishes an alluring new brand of treatment, fills up workshops, or sells lots of books, after many years of practicing our often confusing profession, we’ve found that it captures the essence of effective psychotherapy as well as anything we’ve come across so far.



Frank, J. D. (1973). Persuasion and healing: A comparative study of psychotherapy (rev. ed.). Baltimore, MD: Johns Hopkins University Press.

Hillman, J., & Ventura, M. (1992). We’ve had a hundred years of psychotherapy—and the world’s getting worse. San Francisco, CA: Harper.

Lomas, P. (1999). Doing good? Psychotherapy out of its depth. New York, NY: Oxford University Press.

Marcia, J. E., Rubin, B. M., & Efran, J. S. (1969). Systematic desensitization: Expectancy change or counter conditioning? Journal of Abnormal Psychology, 74, 382-387.

Seligman, M. (1993). What you can change and what you can’t. New York, NY: Fawcett Columbine.

Illustration © Richard Weiss

Jay Efran

Jay Efran, PhD, professor emeritus of psychology at Temple University.  He received the Pennsylvania Psychological Association’s 2009 award for Distinguished Contributions to the Science and Profession of Psychology and is co-author of Language, Structure and Change and The Tao of Sobriety.


Rob Fauber

Rob Fauber, PhD, is associate professor of psychology and associate director of clinical training at Temple University.