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12 Questions of a Good Therapy
What is good therapy?
12 questions of a good therapy
by Peter Fox, Clinical Psychologist
Good, better, best down to lousy, dangerous and evil. 'Good' and 'is' appears loaded with values and pre-conceptions. Like peanuts, good for one life threatening for another. 'Is' a witch and burnt in one era 'Is' a herbalist and praised in another. Good can conjure up bad with just the flip of a coin: good therapist bad therapist, good therapy bad therapy. Why not good client bad client? I hear them called 'difficult'. The question itself, therefore, has problems, so I will answer the question with a series of questions.
What 'is good' therapy contains the difficulty that follows some of our help seeking behavior. 'I'm a good person aren't I' or 'I'm not that bad'. 'I've got one bad leg' and 'meet my better half'. Problems are maintained by our attempts to solve them, especially through language traps like 'is' and 'good'. Instead, try the 'how?' questions like 'how do you know good therapy?'; 'how do you know you're good/bad/ineffective?'; 'how do you know you're depressed/sad/unhappy?' and 'teach me how I could develop and maintain a bad leg or depression'. How elicits concrete, operational language rather than glib statements like 's/he is angry with me' that get us into trouble in our heads and with each other. To every complex situation there is a simple depiction that is wrong. This applies to: 'he is a man', 'she is black' and 'I am in therapy' - how do you know you are in therapy? Just attending a session each week doesn't do it. 'It's the only hour in the week when I can laugh my head off, enjoy periods of thoughtful silence and decide on small goals I can accomplish between weeks' begins to describe what therapy 'is'. The same applies to 'we are in a relationship, married' - just living together for 20 years doesn't touch it.
A 'what is good therapy' question in operational language could sound wordy like: 'which therapy with which therapist at what stage in their career, involving which client with what significant others, over what time?' and so on. Language like that makes the brain work out. It exercises neural circuits where questions such as 'what is ...' and 'good is....' can scramble clear thinking and effective action. Operational language expresses English without the verb 'to be'. Try writing a letter or speaking for a couple of minutes without using was, were, been, being, am, are, is and be. We get very lazy in our thinking relying on the verb to be. It provides the simplest, usually most unproductive answer to why questions and it's great for pre-judging any situation and our selves without building mental muscles.
No matter how fuzzy and feel good, tough minded or confronting, body oriented or cross cultural we therapists describe our work, the reality resides in a business relationship. The therapist IS a fiduciary: 'one entrusted with duties on behalf of another; the law requires the highest level of good faith, loyalty and diligence of a fiduciary, higher than the common duty of care that we all owe one another.' From a legal standpoint that duty begins as soon as we pick up the phone or chat in the street! No matter how we mystify what happens in therapy, such as a policy of 'trust in what happens, in the unknown, go with the flow, it's all good', therapists would be mad not to keep a careful record of what happens in each session that allows for plausible deniability should their actions or inactions lead to harm and a later law suit for damages. This is even more important when we are unjustly accused by a vexatious complainant.
Our clients do not owe us a duty of disclosure; it is our duty to elicit pertinent information. We can't claim, 'they never told me they were suffering from a diagnosable condition'. We all deal with these fiduciary burdens in different ways. A minimalist approach might be solution orientated or brief therapy. It starts and ends with a specific problem and gets the client in and out in a specified time. Though, one of my teachers told me that each session is solution orientated and there can be many years of such sessions. Solution oriented focuses on the melody line. Other therapists deal with the fiduciary duty in an orchestral approach to therapy. It has all the bells and whistles and takes a little longer. Others cover the duty by sticking close to the canon of scientifically proven treatments. And then there are the timeless, limitless therapies like Woody Allen's. He makes me laugh and cringe. Allegedly he did not take to therapy his decision to sleep with his step daughter and then marry her - 'it never came up' he is reported as saying.
'Music happens between the notes' Duke Ellington Therapy creates spaces between the client's words and movement so that they can fill in the blanks. Some of us want a therapy recipe with a guarantee, but an effective therapist charms the imagination and refuses a cure. Some of us are trained and expected to only provide evidence based treatments such as cognitive behavior therapy for specific conditions such as depression. However, a good singer can turn a lousy song into a chart buster and a lousy singer can trash a perfect song. It's the same with any brand of therapy - 'good' or 'bad', evidence based or not. Therapist, client, their support systems and their culture make the difference. Our job is to interrupt our client's interruption to their natural state of health, connection and well being. Frank Pittman describes therapy as an adversarial relationship. 'Good therapy is not a chaste love affair between buyer and seller of psychotherapeutic services. The therapist and the customer don't even have to like one another. The therapy may be working best when you don't like your therapist, when you get the firm impression that your therapist doesn't like you very much either, and when you are being told that you have to do something you don't want to do if you are ever to feel good about yourself.'
The more a therapist meets and greets the client's own theory of change the more influential the therapy. Clients often sing up their own therapeutic solutions outside the range of movement of the therapist. Many powerful interventions are discovered this way, then packaged and crushed by an organization that promotes them. You could argue for example, that the last Gestalt therapist was Fritz Perls. Later 'Gestalt' therapists do their own thing and keep that fresh with their own personal growth and innovation.
Therapy brings the person into a direct experience of themselves; And as a couple or family or community, into direct experience of each other. That is a jaw dropping, ah-ha experience without jargon - 'so that's what you've been on about for years! I get it. No wonder we've been misunderstanding each other.' That comes more easily with a therapy that is light on theory and rich in direct experience. Not with the pre-processed explanations of a therapy model, nor through each other's pre-packaged ideas of what makes the other tick. Therapy asks us to come into a direct relationship with who we are. To be helped to experience the sensations of fear directly, rather than be told 'you are feeling fear'. To witness our children's or our partner's body tensions, breath and heart beat, to feel it under our hands, to breathe with them and smell the odor of despair, the taste of anger rather than take a shortcut, interposing a label like depression, which means different things in every person's experience.
Studies of therapists show their relationship skills and personal style have a greater impact on the outcome of therapy than the modality of treatment they provide. David Orlinsky and Helge Ronnestad have a large scale international study of what therapists bring to treatment. Early results indicate therapists experience the process of doing therapy in two distinct states of mind named healing involvement (alive, engaged and productive) and stressful involvement (bored and anxious). These two states occur in different proportions over a career giving rise to four practice patterns: effective practices (50% of therapistsí surveyed, high healing low stress), challenging (25% of therapists, high healing high stress), distressing (10% of therapists, low healing high stress) and disengaged (15% of therapists, low healing low stress) practices. (Psychotherapy Networker May/June 2005) In my experience, we tend not to realize we are in the dysfunctional bottom 25% until after we have returned to effective practices. Sometimes that occurs after something major goes wrong in our lives, which corrects the imbalance and wakes us up. This is a recommendation for effective ongoing supervision and therapist receiving regular therapy health check ups. 25% of those surveyed above were in therapy at the time of the survey from all over the four types of practices.
There are well over 500 body-mind therapies and over 20,000 self help titles listed on amazon.com. All are influenced by the rhythm and language of movement (e-motion) in which they arise, colored by each culture's social construction of pain, of cure and of growth. 'Most of us have been indoctrinated into particular theories and methods based on the accidents of our training. But the one thing all perspectives have in common is that they are ultimately the underlying operating principles of the human brain' Professor Louis Cozolino. The ongoing findings of neurobiology will increasingly impact on how we do therapy (as well as how we explain its effects). For example, 90% of serotonin in the body is produced in the belly. Serotonin re-uptake inhibitors are a class of modern anti-depressants, but what if you could increase the serotonin supply to the brain (rather than inhibit its re-absorption in the brain) simply by myofascial abdominal massage, belly dancing or hoola hooping directed at stimulating that endogenous resource? Would that shrink the 9 million prescriptions of anti-depressants each year in Australia? Or radically change cognitive behavior therapy (CBT), both of which claim to be evidence driven?
Therapy probably evolved because language and movement organize the brain in fundamental ways. With therapy both spoken and unspoken, we rewrite the story of our lives while simultaneously building neural networks and reorganizing the neural integration of past experience in life-mind-body. Effective therapy and therapy's effect includes expressing a story that integrates the left hemisphere's drive for logical, sequential narrative about significant events and the right brain's ability to emotionally build a mental map with the cognitive processes and inter-relationships of the people in those events. (Generally speaking, with right brain functions we drive a car and with left brain functions we follow the directions, read the signs, and anticipate traffic hazards.)
Stories told in Jungian and past life therapies can be recognized by their structure and narrative style. Dance, music and movement therapies, deep tissue massage, CBT and holotropic breath work all have their own narrative form. Each presents a transformation and brain integration of the particular modality. Our story makes a whole from the fragmented experiences of pain, confusion, growth and transformation. Re-writing, re-telling, re-singing, newly loving, and re-owning the story simultaneously reorganizes the neural network that held the experience frozen in time and place.
It may help to think of our life-mind-body (including brain, nervous and endocrine systems) as a dynamic fluid, that exhibits plasticity, changeability, transformation and inter-connectedness. The model of an isolated, hard wired, machine like a computer no longer represents what we are discovering in research and witnessing in healing. Both body and mind exhibit incredible plasticity after injury. Listen to the stories of people who survive head injury, life threatening illness and catastrophe. They tell of our capacity to re-shape ourselves, our identity, our lives and even the lives of those with whom we connect.
Other people's body movements are mirrored in the self. We have mirror neurons, which in experiments with monkeys, fire when the monkey picks up an object but also fire in exactly the same way when the monkey sees another monkey or a human pick up the same object. Similar results are observed studying human brain waves. (Chapter 10 'Imagination and the Meaningful Brain' by AH Mode 2003 and also here). Through this fluid mechanism we can feel ourselves into another's gestures. It is likely that empathy and language evolved from gestures and the resonance of our mirror neurons.
Highly evolved therapists exhibit almost incomprehensible empathy and mimetic skills. I think of Milton Erickson, polio afflicted in a wheel chair who would observe and mirror the heart rate and blood pressure of his clients during his apparently rambling inductions. Having come alongside the client's current autonomic process, together with language patterns he would in effect lead their nervous system's mirror neurons in the direction of desired change, often completely out of his client's awareness. Moshe Feldenkrais who with just a slight shift in breath or a touch on the shoulder, could return a person to freedom of movement in their body. Stage magicians like Franz Bardon developed similar abilities to cue and for his purpose, misdirect audience attention so that they did not see the disappearing object fall into his lap, even when he explained and showed them in slow motion how the trick was done and then repeated it as usual. It's not all smoke and mirrors. It's neurons.
'[w]e are somatic creatures, living in bodies, having emotions, bathed by sensations, at times bubbling and simmering, at times dawdling and eddying, hot and cold, nervous and calm, fearful and yearning, hungry and satiated. From 'A Scream Goes Through The House' by Arnold Weinstein.
I continue to surprise myself and my clients when on some occasions, I interrupt our conversation and reach across to take their pulses, ask to see their tongue, read their irises, notice breath through mouth or nose, watch skin color and texture, smell odor, sense the atmosphere they brought into the room and so on. Some of these actions are noisy, intrusive approximations to a hoped for seamless reading of the exquisite, transparent life within thee, in me and between us as we engage in therapy. Sometimes this leads to a comprehensive health plan and other times it helps to tune us into the unspoken dimensions of being.
Were we therapists as seamless in this reading and influence as our heroes, I expect my clients would experience all of their poignant and their tragicomic life embraced, all welcomed fully into the healing place, engaged wholly in direct experience of themselves, as if this trusted stranger knew them in times and places they hardly know themselves. Not mind reading but a meeting resonating with full body, mind and place, which supports their journey wherever it may lead them. For the time being, I and many of my colleagues are a bit clumsy and well into the future we'll be described as therapy dinosaurs. For the time being, awakening to spirit and body as we do our own personal work and keep growing in this knowledge of ourselves and each other is the best we can do.
With more knowledge comes more gratitude, increasing responsibility and a widening duty to do no harm. To thank life for every day we're given in being useful to another. And not for example, in my agenda, to offer our clients individual therapy without also including and being seen to include their significant others and their bodies - and ours as well. I don't mean bring everyone into therapy including our partners and our children as well as theirs, but they are all affected by and affect our work behind the closed door of a therapy session. We have a duty to extend our care to those directly outside the room, the ones who greet our clients when they come home. Everything we have learnt in human ecology and quantum mechanics says that we and everything with the planet are interconnected and indivisible, as hard as we might try to act other wise. 'Every outward thing we do is inner work.'
Ineffective therapists and ineffective therapies will continue because that is in the nature of life's experiment - it never knows which mistake will bear healthy, abundant fruit. Hopefully, the klutzes be easier to recognize because they continue to carry worn out hearts and lazy minds. These simple questions devised by Arnold Lazarus are worth asking ourselves about our therapists.
Signing on to the ethics of a professional organization is no guarantee that a particular therapist or therapy is informed, responsible, or even sane. 'What your therapist doesn't know can hurt you' says one 'bad therapy' site. Here are 20 easy steps for violating ethical standards. For example 17. It's not unethical as long as there's no intent to do harm. 18. It's not unethical as long as we don't intend to do it more than once. 19. It's not unethical as long as we're very important. 20. It's not unethical as long as we're busy.
By the time you've reached this item 13, the Judas number that is rarely listed on the lifts of multi story buildings, you're probably asking 'so what is good therapy and how do I find it?' Isn't that how all entertaining lectures end their talk - they propose a question dispose of it and then, despite all they have said, satisfy the audience with a feel good answer to take home, go to bed and rest in the sure knowledge that everything in the world is going according to a plan - even therapy? My Jewish heritage won't allow me to do that. Answer a question with a question. For more questions, visit my website.
Copyright Ziji Fox 2005 All Rights Reserved