Therapy and Transformation

What Are We Promising Our Clients?

Magazine Issue
January/February 2018
A unicorn flies through a hoop and changes color

Like many therapists, I went into this field to do more than help people get over their current psychological or relational problems. There’s nothing wrong with problem solving, but in the 1970s, in the wake of the human potential movement and the advent of the family systems movement, the therapy profession seemed to be about something deeper: big changes in the direction of wholeness, self-actualization, and authentic connection. Part of the initiation of us young trainees entering the field back then was absorbing the notion that therapy was supposed to be about transformation, and to really be helpful, we had to undergo transformations ourselves. After all, we were prophets of a new wisdom tradition suited for the modern era, and our clients could only go as far down that wisdom path as we’d gone ourselves.

Of course, not everyone accepted the idea that therapy needed to be about large goals; we called these folks behaviorists, and we felt a bit sorry for them because they seemed like technicians who lacked a grander vision. We liked the early cognitive therapists better because they moved fast and aimed for cognitive restructuring, but they were, well, too practical and skeptical about human potential. (There were no marathon cognitive encounter groups.) The debates about transformation—what it was and how to achieve it—were between the analysts and the other approaches that believed therapy could be an immediate “growth experience”: the humanistic therapists, the family systems therapists, and a variety of body-mind, Gestalt, and existentialist therapists, to name a few.

In other words, the question was not whether transformation was possible, but whether it could be best achieved from deep analytical work or from the new, faster forms of therapy that focused more on the present. As a Baby Boomer of late 20th-century America trained in a blend of humanistic and family systems models, with the underlying assumption that everyone embodied great human and relational potential ready to be released in therapy, it was clear where I stood.

Trauma and Addictions Conference

These memories came back to me when I heard the theme for the 2018 Psychotherapy Networker Symposium: “The Many Paths to Transformation: From Problem Solving to Deeper Healing.” My first reaction was Cool, that’s an inspiring theme. My next reaction: Hmm. Really? If client transformation depends on the growth of the therapist, I found myself wondering, in all my experiences with therapy over the years, whether I’d been transformed?

I like to think I’ve changed and grown in positive directions over the course of my life, but transformed? Not so much, even after extensive therapeutic experiences in my training years. The same seems true for my therapist colleagues: we all look recognizable to one another after decades of seminars and case consultations. We seem to have the same insecurities (the analysts would say “neuroses”) we always had, albeit with the edges smoothed over. Those of us with boundary or control issues still seem to have them, but they don’t bite us as much. If I were to let out my more judgmental side, I’d even say that therapists who’ve told me about their own transformation—after completing their analysis or family-of-origin work—were testifying about a degree of advanced enlightenment that I didn’t see in them. It’s like in the spiritual realm: if someone implies they’re a saint, that’s probably an immediate rule-out for sainthood.

Not that I haven’t seen big transformations in my four decades as a therapist. An early case was with my client Carol, who came to me after two rounds of hospitalizations related to the stress of a failed marriage, an alcoholic and controlling husband, and a rigid evangelical Christian congregation that wouldn’t support her desire to leave her marriage. Raised to be a good religious girl who followed male authority, Carol hadn’t developed a solid sense of self. After her husband had refused to get help for his drinking or for the marriage, she’d asked him to leave, which he reluctantly did. But as the sole financial support for the family (with two preteen children), he insisted on returning to the house whenever he wanted and waging a campaign to return permanently, which Carol eventually allowed. This became a pattern, from which her hospitalizations were her only reprieves.

Six months before seeing me, Carol had joined a conservative Christian church as a way to change her life. Because her husband wasn’t a Christian, her minister and fellow church members supported her desire to get a divorce. But then her husband joined the same church, and all support for the divorce was removed, as he was now a Christian seeking healing. He used “finding the Lord” as a way to get her to let him return. (I’d invited him into a therapy session with Carol and saw him clearly as an insecure, needy, and controlling man who’d do anything to keep Carol—except confront his own problems.)

At first, as Carol sat small and waiflike in a chair in front of me, I felt an internal pull to rescue her from her husband and her religious congregation—a road I knew I couldn’t take without perpetuating her sense of insignificance. (News flash: strong, secular male therapist saves weak, desperate woman from evil husband and oppressive faith! Nope.) Instead I worked patiently on her boundaries, and ours. A minimal goal, the one she’d come in asking for, was to help her stop repeating the destructive cycle that led to her decompensating and being hospitalized—something that further weakened her prospects of seeing herself as a solid adult woman.

The turning point in our therapy was a session that dealt with her religious views. Her husband and several members of the congregation were telling her that it was not Christian of her to be angry at her husband. Here was a trap: in the past, when she’d let go of her anger, she’d felt pity for him and had taken him back. As she struggled in our session about how to be a good Christian woman and still hold onto her protective anger, I called on my knowledge of the Bible and challenged the idea that anger was inconsistent with Christian virtue, inviting her to think about the story of an outraged Jesus throwing the money changers out of the Temple. Did he seem angry? Yes, she replied. And did the money changers think his anger was fair to them? No, probably not. The takeaway: anger isn’t necessarily wrong, and you can’t let the person you’re angry at be the only judge of whether yours is justified. She visibly relaxed in her chair, looking bigger even as she did so.

The rest of the story began there and then. She was able to see her husband’s latest manipulation more clearly, and to understand that he’d tricked her congregation as well. Once she told her husband that she was done with him, wouldn’t apologize for her anger, and was proceeding with the divorce no matter what he and the congregation felt about it, he dropped out of the church and contacted a lawyer. Carol felt empowered for the first time in her life, and her anxiety and depression lifted. When I ran into her several years later, she was working as a coordinator at a youth services center, where she showed great skill in making young people feel welcome. She told me she felt like a different person. She was divorced, handling coparenting as well as she could with a difficult ex-spouse, working in a job she loved, and was in a new relationship that felt worlds apart from her marriage. Yes, she was transformed.

Carol represented for me the most common way that transformation emerges in therapy: when circumstances in the client’s life outside of therapy are at a tipping point, and therapy assists in a breakthrough into new territory where personal resources and circumstances converge to make someone’s life or relationship very different and much healthier. I’ve seen it with people who got off drugs and found a new community. I’ve seen it with members of Alcoholics Anonymous. And with people who found a spiritual direction for their lives, as in the case of a young male client who struggled with using women and being known as a “player” until he found a religious faith, which, on top of his psychotherapy work, led to a breakthrough that gave him a deeper sense of moral values and allowed him to have more authentic relationships in his life.

But most therapy cases don’t lead to dramatic changes. A lot of clients just want to get past an episode of depression they’re suffering through, or learn to manage chronic anxiety in a more constructive way. Or a couple wants to stop fighting and enjoy each other more. In Freud’s terms, these clients just want to love and work. In fact, the average length of psychotherapy in the United States is less than eight sessions, hardly enough time for deep work on self. And in terms of measures of psychological well-being as a result of therapy, the outcome research shows comparable (and modest) gains for clients, regardless of the therapeutic method used. So on average, we help clients get past some problems and improve their well-being, with some fading of effects over time from a single dose of therapy.

Our yearning for transformative impact has also run into the realities of the medical model we got into bed with in the 1980s. Most therapy now starts with a medical diagnosis and treatment code. Medicine, in case you haven’t noticed, isn’t so much about deep, pervasive health and healing, but about containment of chronic conditions and restoration of baseline health for acute conditions. Maybe that’s why the medical insurance leaders have embraced cognitive behavioral therapy (CBT) more than other form of treatment: it’s brief, symptom focused, and evidence based. It’s not about creative restructuring of psychological and relational living.

Which ironically is why CBT and its variants haven’t really captured the imagination of therapists, even if they begrudgingly admit that many CBT techniques work well. Therapists still seem attracted to models that promise deeper healing, for clients and themselves. It seems that only such ambitious approaches to therapy become part of the core identity of therapists who embrace these models as personally enriching, a guide to deeper human functioning, and a way of being that’s changed their own lives and can change the lives of their clients. Thus, some therapists testify about how they’ve integrated psychodynamic or attachment-based therapies into their lives, not just a set of tools for therapy. Others accept the requirements of employers and insurance companies to offer therapy with more circumspect goals. Some walk away from the pursuit of therapy as a kind of personal quest and take up the more practical-minded approach of coaching, which disclaims goals of deep transformation entirely.

So our choice of clinical approach is about more than therapeutic goals; it’s about our core identities as professional helpers. Are we more like shamans or family doctors? Are we explorers of human depths or more like Siri on your iPhone, just directing you from one place to another? Dante’s Beatrice leading him through the levels of heaven, or J. K. Rowling, who delights but doesn’t rattle your existential bones? Do we represent a wisdom tradition for the modern age—with something important to say about human suffering and human flourishing—or are we orthopedic surgeons of the psyche? And if we’re some of all of these things, how in the world do we find a coherent identity in this confusing and polarizing 21st century?

The Downside of Seeking Transformation

Any goal in psychotherapy beyond relief of suffering and dysfunction is infused with personal and cultural values that are usually not explicitly articulated by the creators of therapy models themselves. And since psychotherapy is a thoroughly Western invention, most images of the good life are individualistic, rather than communitarian. We resonate more with “to thine own self be true” than with “we the people.” Personal life is valued way more than public life. Family life is a venue for individual development more than a place of dedication for its own sake, as it is in many other cultures. Our ideals for marriage and intimate relationships are mostly a product of the late 20th century: egalitarian, emotionally intimate, sexually fulfilling, with some ambivalence about commitment when those ideals aren’t being realized.

It’s not that these values are wrong (sign me up for most of them), but that they’re unacknowledged and therefore put forth as objective truths. Therapy isn’t like fixing a broken bone or managing heart disease—where cultural values are less prominent. It embodies many Western cultural values and ideologies. Once we get past the initial goals of therapy—alleviating pain and helping people love and work again—we’re into the realm of philosophy of the good life. The problem, of course, is that our clients are usually clueless about where we might lead them. Does the therapist believe that deeply attached relationships are the key to human flourishing, or maybe differentiation is more important? (Bowlby vs. Bowen as a human ideal.) Is family worth staying connected to despite the pain it causes? What about the longing for more sexual fulfillment when it seems unlikely to occur within one’s marriage? And what about the tradeoff between civic commitments and a balanced personal life?

At least with religion, the various stances on morality and human destiny are made explicit. With therapy, clients would have to be cultural anthropologists to decipher what a therapy model says about the big questions of life—even though these assumptions are embedded in every model of therapy—and detectives to figure out where a particular therapist stands.

The therapy outcome research and my own experience have made me a skeptic about whether any clinical approach is good at getting clients consistently to the promised land of transformation. Instead, I’ve come to the conclusion that therapy is better understood as being about breakthroughs—small, medium, and large—rather than about transformation. Maybe the starting point for all therapies is a modest breakthrough, getting past stuck points so people can restore their functioning or find a better way to face life’s challenges than they have in the past. And then, in ways we can’t predict, sometimes this breakthrough becomes part of a confluence of personal and contextual forces, mostly outside of what happens in the therapy room, that transforms lives.

I see this approach in the newer therapies that didn’t come out of the either/or era of symptom relief or creative change. Contemporary neuroscience-informed therapies aim to help quickly at the level of everyday functioning, and then some people go much further toward mind–body–spirit integration. Some of today’s trauma-based therapies make no apologies for targeting immediate symptom relief and also offer something deeper for those who yearn for it. Couples therapy models like EFT and the Gottman model, for instance, start with current dysfunctional impasses and offer couples much deeper connection when they’re open to it. Different forms of acceptance therapies emphasize change and then the acceptance of what may never change—which paradoxically can open up new vistas for growth.

I think about Jeff and Laurie, who came to me for help with the challenges they were experiencing with Laurie’s adult daughter, LuAnn, who was on drugs and manipulating her mother into supporting her unhealthy lifestyle. LuAnn was verbally abusive to Laurie—which led to Jeff stepping in and huge subsequent family meltdowns. All of this was occurring a year into Jeff and Laurie’s marriage. Still very much in love but scared they’d end up losing each other, given all the tension, they seemed desperate for my input on how to not let LuAnn ruin their marriage. As a parent himself, Jeff understood that Laurie couldn’t just walk away from her daughter, but he was furious about the manipulation and coercion going on. Laurie was befuddled about how to handle her daughter and keep her marriage intact. I liked this couple very much, felt bad for them, and had to keep myself from demonizing the daughter in my mind. In fact, I told myself that she was the one in the family who was most at risk.

In many ways, this was a straightforward family systems and couples therapy case, complicated by the fact that Jeff and Laurie were both counselors and got into each other’s psychological space too much. I helped them clarify boundaries with each other and with LuAnn—with each other by being clear who was the parent here, and with LuAnn in terms of setting limits on her moving in and out of the household and insisting on financial emergency payouts when she was in trouble. I also helped Jeff and Laurie stay present during disagreements, rather than him either intellectualizing or shutting down, and her telling him what he was thinking and feeling.

When they were coping better with a joint plan for dealing with LuAnn, along with a more functional way to talk with each other during conflict, Jeff and Laurie could have ended therapy. Lots of couples would have, with the offer to come back in the future if they got stuck again. But they wanted to stay and go deeper in their relationship. They knew that family-of-origin and first-marriage issues had surfaced in their crisis, and they wanted this marriage not just to make it, but be a source of joy. So we spent a lot more time helping them be emotionally vulnerable and intimate, with good boundaries, which they’d never learned.

A big breakthrough happened in a session when Jeff, after feeling emotionally abandoned by Laurie, stayed present and said, “I don’t want to run away from you right now, and I don’t want to keep telling you how you’re messing up. But right now, I don’t what else to do.” For a guy who liked to have all the answers, it was a touchingly vulnerable admission of confusion. On her end, Laurie’s first impulse was to rescue him by telling him how he could best handle the moment, but as she glanced my way, she caught herself, looked at Jeff with soft eyes instead of anxious ones, and said, “I don’t know either, but I love you and we can get through this.”

Jeff and Laurie eventually went from biweekly to monthly sessions to keep from backtracking as more emergencies occurred with LuAnn, and to keep going deeper. They taught me about the deep interconnection between attachment and differentiation—that the closer a couple gets emotionally, the more they have to work on self, and vice versa. I sometimes felt as if I were an orchestra conductor with two fine musicians who wanted to keep improving as soloists and a duo. Although not immune to the challenges of married life, this couple did leverage a life crisis to use therapy as a way to transform themselves.

A Guide to Thinking about Transformation as a Goal of Therapy

Okay, here’s how I end up thinking about all of this.

Don’t assume that transformation is desired by clients or necessary for successful therapy. You’ll feel disappointed too often, and you may communicate that to your clients. On the other hand, it’s probably safe to assume that clients want to break out of the stuck place they currently occupy. Where a breakthrough ends up is outside of anyone’s knowledge in advance.

Accept that the more you make transformation your goal, the more value-based and nonobjective you are. Having said that, as therapists, we do have a wisdom tradition (with some scientific basis) about what human flourishing looks like in the 21st century, based on a complex understanding of self and a deep connection to others while maintaining the individual self. As I’ve argued elsewhere, we’re only recently looking at aspects of human flourishing involving commitment that’s both personal and public, which can offset our individualistic focus.

So in the end, it makes sense to take clients as far as they want to go (and can afford to go) toward transformation, as long as we separate our hopes for our clients from their goals for themselves, and as long as we understand that we’re just one of many wisdom traditions (from religion to philosophy) that have their own beliefs about what human flourishing looks like, and as long as we’re willing to acknowledge and work on the blind spots in our tradition, including the tendency to explain human problems at the micro level and ignore larger social forces. As Winston Churchill liked to say, “We all suffer from the defects of our virtues.”

During an interview for my first therapy job in 1976, I was asked what metaphor I’d use to describe my role as a therapist. I blurted our “healer,” which seemed to please the search committee because I got the job. I still like that metaphor but, as the decades have gone by, I’ve come to know that healing has more dimensions than I was aware of then. A big part of my work nowadays is helping couples on the brink of divorce understand (through an approach I call discernment counseling) what’s happened to their marriage and decide whether to divorce or try to repair it. This is short-term work; if they decide on repair, I refer them out for couples therapy. But I love joining these couples in the crucible of their hope and ambivalence.

In this and other areas of my work, I focus on breakthroughs to help free people up to take the next step on their journey. Big, powerful transformations—the kind of thing that makes their friends say, “Wow, you seem like a different person”—well, these take a convergence of time, context, and forces outside my abilities and even outside my clients’ current abilities. Nobody can make transformation happen; we can only be open to it. My favorite theologian defines the divine in similar terms: it’s the force that transforms us in ways that we can’t transform ourselves. Our job as therapists is to create the container from which this experience may emerge.

On a less grand note, I sometimes share with clients a maxim from John Weakland, one of the founders of family therapy, in a line quoted in his New York Times obituary. “Before successful therapy,” Weakland used to say, “it’s the same damn thing over and over. After successful therapy, it’s one damn thing after another.” Maybe that’s a form of transformation after all.

William Doherty

William Doherty, PhD, is professor of family social science and director of the Minnesota Couples on the Brink Project at the University of Minnesota. He’s the author of the forthcoming book, The Ethical Lives of Clients: Transcending Self-Interest in Psychotherapy