Metatone raised three questions in comments on my earlier post here :
1. Is the common factor in talk therapies that work the regular contact with a relatively non-judgemental/sympathetic person who seems to be paying attention?
2. Is the common feature of all the talking therapies that they represent a process (thinking of process over outcome) and that largely any process is an improvement on no process?
3. Is it true of, a benefit of, talk therapy that it provides a language for things, a way of talking about them, that was otherwise lacking?
I’ve paraphrased the questions to some extent and might have gotten away from what was actually being discussed. I hope not too far away. In turn:
1. Common factors between effective forms of talk therapy.
It turns out, as I mentioned in the previous post, that it’s hard to establish through testing ANY features of ANY talk therapy that are definitively useful. That might be because we just haven’t been able to define a series of tests that we are currently capable of delivering that would establish such a thing. Or, it might be that talk therapy doesn’t work, at all, and that any improvement experienced by the client is down to reversion to the mean, outside factors, changing circumstances or the wisdom of age. Heaven forfend.
Each therapy has its own rough idea of how things might be expected to proceed, all being well. In CBT, the client counters the thoughts and beliefs that underlay negative emotions. As they get better at this, over a period of weeks, they feel better bit by bit. In psychodynamic counselling, which can last years, the building client-therapist relationship creates a safe testbed for all of the client’s beliefs and assumptions about his relationships with other people – the therapist becomes a confidante, a mirror and a source of advice and commentary. The client finds their own better way through all of this.
So go the manuals. But if the manuals were always right, there’d be none of those heaving shelves of case studies.
My own experience of this was pretty stark. I had only one case in ten years go by the book. In every single other case, things went differently. Over time, I came to notice patterns in what was happening. Common factors did exist. They just weren’t where training told me to look for them.
I’m probably not the person to ask about whether it’s about sympathetic attention of someone appearing to take interest. At any rate, I find it a hard question to answer. What made my therapeutic relationships work or not work were intangibles – who in their life did I remind them of? Did they instinctively like me, or did I turn them off from the outset? Sometimes, the relationship would start off well, and then get closer as the sessions passed, and this, if there was anything, seemed to matter. Some that had started well stalled, and once stalled, never recovered.
Moreover, even when the relationship was going well, there would always be the question at the back of the client’s mind of money. Did I really care, or was I an actor, pretending interest in order to earn a living? Some vocalised this, some, I’m guessing, kept it to themselves. Frankly, the money was never good enough to be any kind of motivation, but any monetary exchange suffices to raise the issue.
2. Is any process is an improvement on no process?
Yes, I think so. It’s not an answer in itself, but it’s important nonetheless.
By process, I mean (1) a structure by which I as a therapist believe things operate, and (2) a procedure one can present to a client as a roadmap and route to a solution to problems they can see no way past on their own.
I came to suspect that most of the problems that were presented to me were the result of people not accepting some of their own feelings.
Imagine a Great War trench under bombardment. In it, imagine an officer whose father and grandfather were both career soldiers and war heroes. Now his own war is underway, and he wants desperately to live up to them. Like them, he must be brave, a leader, an example. Down come the shells. One over there, another – damn! that was close! He can’t believe how scared he is. He wants to turn and run. Get to the coast, get a ship.. But all around him are resolute faces. How much braver these common men are! What a coward he is! I must be brave.. but he’s frightened, frightened through.
Sixty miles away, upstairs in a moonlit nursery, his daughter, not yet six, stands at the open window. The air carries the bombardment to her, distant thunder. Her Daddy is very much on her mind: childish instinct tells her that what she can hear is bad news for him. In her imagination, she feels him hurting, and his hurt makes her cry as she listens. Her mother isn’t sleeping either, and comes in, gathers her, rocking: there now, there now…
Both the officer and his daughter were scared. But the officer didn’t think it was OK for him to be scared. For him, courage meant lack of fear. He felt fear: he was wrong to feel fear. He was wrong, there was something wrong with him: he was less the man than his forefathers who’d neglected to tell him only a fool doesn’t feel fear. Instead, as he stood, a small child, at the top of the stairs, they’d urged him to jump down: come on.. you’re not scared! You’re not scared, a big brave boy like you!
The officer took a lesson from his fear: that he was an inferior man. His fear was prima facie evidence of his flawed status, of his failure to continue a line of heroes.
Whatever the CBT he didn’t live long enough to undergo might have told him – e.g. challenge the belief that you are inferior because you are afraid – the bottom line was his regressive questioning of his own emotions.
I’d give that officer some chance of undergoing the experiences we label together as PTSD. At any rate, the cases of PTSD I saw all had a common theme: not just traumatic events, but a rejection of the feelings experienced during those events or a negative reevaluating of those feelings later on. I’d give him some chance of developing depression. But I’d have few fears for his daughter as a direct result of her experience that night.
I’m placing weight here on the meaning people give to their feelings, not the feelings themselves or their strength. I’d look for that in a client. What did their feelings mean to them?
The very fact that they were there indicated that they were having feelings that they didn’t want to have. Help me, I ‘m experiencing panic and proper people don’t experience panic… Some people experience panic but don’t think any worse of themselves for it – but it’s unlikely that they’ll be experiencing panic attacks in the horrible, often random way that we refer to when we discuss panic in clinical terms.
So there’s process in terms of a therapist having an idea of what’s going on, where a client sometimes won’t – why am I panicking? because I’ve really no idea and I’ve tried everything. There’s also process in terms of a comforting programme to undergo. I’m talking to an expert now: I can – to some extent – relax and hand the problem across. Trust and first impressions on the client’s part matter here – many of my clients thought that what I was telling them sounded unlikely, but were willing, having met me, to give me the benefit of the doubt.
I don’t, for instance, think that phobias are about the focus of the phobia and some sort of traumatic experience involving it. I don’t think phobia is about extreme fear. Fear’s in the mix, sure – but it’s only one of a number of emotions at full pitch that are involved. What I think doesn’t matter: every phobic client did think it was about fear of the phobia’s object(s). They expected to prove me wrong, but, for now, I had a plan for them, I sounded at least halfway intelligent, and they were here now: I was better than nothing.. It’s a relief for people to be doing something, anything, about a longstanding problem that has resisted all their own efforts.
3. Providing a language for things
When you’re a stranger to something, an expert’s familiarity with the territory is hugely comforting, if occasionally humiliating: the RAC man doesn’t take his eyes off you as he reaches an empty hand behind him into the engine, tweaks something, and the car roars into life..
The therapeutic equivalent might be to shine meaning on what had looked random and malicious. Showing that there is a way of looking at it, rationally, sensibly. Giving evidence that it can come to an end, can be overcome or outmanouvered. Showing that there is a way in which it fits into the grander scheme of things.
But meaning can be elusive. A client once came to me shining at the start of our tenth session, saying that “everything had fallen into place” about their life in the intervening days. And your panic attacks? Oh, those.. (thinks) no, no panic attacks. None for a while. Doesn’t matter, really. I’m just never going to let myself be treated like that again. It’s not on. I didn’t see that before, but it’s not on.
What’s that about? Well, it’s not about training yourself to relax, learning to recognize your triggers and cutting down on coffee, is it? If I’m right, and some symptoms are a consequence of interplay between a person’s core personality and their own rejection of their own feelings, then that client had come to accept and affirm their feelings, on their own, when I wasn’t there, thus breaking an ugly cycle.
But there are other instances when finding a form of words to describe someone’s experience provides them with a new and – at last, useful – way of looking at it. My therapeutic supervisor would talk about a type of client who had in essence grown up being their family’s scapegoat. All of the family’s faults and shortcomings would be projected onto that individual who, in order to cope and to maintain a belief in their family’s good and loving nature, absorbed the lot. All the client would know would be an enduring guilt and tiredness, a lack of trust in their own feelings and a sense that it was unsafe to express themselves.
So often, working with depressed people, I found myself thinking this is all about pecking order, and you’ve been trained all the way to the bottom. But “pecking order” had little appeal for people: my supervisor’s “scapegoat” rang many more bells. It introduced the thought into tired minds that perhaps I’m not as bad as I think I am. Once that thought’s there, the rest often follows.
Not always, though. When we change our view of ourselves, the people we live among don’t, not necessarily, and may indeed have a lot invested in our staying as we always were. It can feel safer to go along as we always have than make a break for light and freedom. Alice Miller has written a host of books, but I’ve always felt one paragraph from one of her earliest was sufficient to sum up the whole dilemma. From The Drama of Being a Child:
It is one of the turning points in therapy when the patient comes to the emotional insight that all the love she has captured with so much effort and self-denial was not meant for her as she really was, that the admiration for her beauty and achievements was aimed at this beauty and these achievements and not at the child herself. In therapy, the small and lonely child that is hidden behind her achievements wakes up and asks: ‘What would have happened if I had appeared before you sad, needy, angry, furious? Where would your love have been then? And I was all those things as well. Does this mean that it was not really me you loved, but only what I pretended to be? The well-behaved, reliable, empathic, understanding and convenient child, who in fact was never a child at all?