Survival Guide To Psychotherapy 2009
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A SURVIVAL GUIDE TO PSYCHOTHERAPY
Sergio Rodriguez-Castillo California Institute of Integral Studies August 2009 In order to use the mutual experience, one must have in one’s bones a theory of the emotional development of the child and the relationship of the child to the environmental factors D.W. Winnicott
One should always start out on the wrong foot. Carl Whitaker
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
Contents Foreword:............................................................................................................................................. 3 I. The Client ......................................................................................................................................... 4 1. It is all about the client..................................................................................................... 4 2. Learn about the client....................................................................................................... 4 3. Clients want to heal........................................................................................................... 4 4. Follow the client.................................................................................................................. 4 5. Clients already know the answer.................................................................................. 5 II. The Therapy ................................................................................................................................... 5 6. Therapy as a Relationship and a Holding Environment. ...................................... 5 7. Listen....................................................................................................................................... 5 8. Let the affects flow. ........................................................................................................... 6 9. Don’t push the river........................................................................................................... 6 10. No right, wrong or simple answers.......................................................................... 7 11. Encourage responsibility............................................................................................. 7 12. Don’t decide for the client.......................................................................................... 8 13. Validate the client’s feelings. .................................................................................... 8 14. Be empathic..................................................................................................................... 8 15. Be nondefensive............................................................................................................. 9 16. Do not judge your clients............................................................................................ 9 17. Symptoms are metaphors. ....................................................................................... 10 18. Objectionable clients. ................................................................................................. 10 19. Beware of labels ........................................................................................................... 11 20. All is present in the session. .................................................................................... 11 21. Therapy is a process................................................................................................... 11 22. Cut back on interpretations...................................................................................... 12 23. Appreciate silence. ...................................................................................................... 12 24. Be totally present but don’t turn into a full-time therapist. ......................... 12 25. Acknowledge the anxiety in the room.................................................................. 13 26. Believe your clients’ stories, but with a grain of salt. .................................... 13 27. Notes-taking................................................................................................................... 13 28. Be grateful...................................................................................................................... 13 29. Intersubjectivity............................................................................................................ 13 The Therapist.................................................................................................................................... 14 30. Do not confuse your role with you......................................................................... 14 31. Watch your own feelings & fantasies ................................................................... 14 32. Work in yourself............................................................................................................ 15 33. Your job is not to teach, save or rescue you clients. ...................................... 15 34. Don’t try to fix, cheer up or fine-tune your clients.......................................... 16 35. Don’t try to know it all. .............................................................................................. 16 36. Neither better, nor worse.......................................................................................... 17 37. Personal Modeling........................................................................................................ 17 38. You’ll make mistakes.................................................................................................. 17 39. Be honest, transparent and candid....................................................................... 17 40. You are a human being.............................................................................................. 17 41. Be yourself...................................................................................................................... 18 42. Humor............................................................................................................................... 18 Bibliography...................................................................................................................................... 19
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Foreword: I wrote this paper originally as par of my preparation to begin my psychotherapy practicum on fall 2006. Although some my view and understanding of psychotherapy have evolved as I gain experience both as a professor and a clinician, I am happy to see how most of what I wrote back then still holds true to me as the bedrock of my therapeutic practice. Almost needles to say that what follows are highly personal lessons; they deal with my issues and with those aspects of therapy that concern me the most (my own “issues” as we therapist like to say). I have tried to be as comprehensive as I can, but again, the focus is in what I need to keep in mind; therefore, many of these suggestions may not make much sense to other practitioners. Likewise, what follows reflect both my understanding of psychotherapy and they approach it is taught in CIIS’ Integral Counseling Psychology program. I am not claiming in any way that these principles are “the” way psychotherapy works, only and humbly the way I understand it. Although I would not want to get into a debate about the general validity of my conclusions, I’d love to know your thoughts and reactions about it. You can contact me through the www.ciis.edu website. Finally, it is worth mentioning that, although I have included a bibliography at the end of this guide, I am afraid that it only represents a very small piece of the material consulted for this work. I have incorporated ideas from many readings, classes, conversations, etc. The concepts, ideas and “tips” about how to “survive” as a beginning therapist, how to deal with the clients and what to do and what not to do come from many of my teachers and mentors. As a result, it would be impossible to list and give credit to all of them. All I have done is to put them together to create this survival guide. Paraphrasing Anthony De Mello, my task has been that of a weaver and the dyer, so I take no credit at all for the cotton and the thread. My hope is that these principles maybe as helpful to others as they have been for me. Love, Sergio
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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A SURVIVAL GUIDE TO PSYCHOTHERAPY I. The Client 1. It is all about the client. Everything, even the client’s opinion has about you, has very little to do with you. The client improvement (or worsening) is more his/her doing than yours. Avoid feeling that you are instrumental in assisting the client to enjoy life more fully (the need to be needed) or giving yourself credit for the client’s growth. You are not that important. Psychotherapy is not so much about what the therapist does or says, but how the clients experiences (the Selfobject experience) what is being (or not being) said or done.
2. Learn about the client. Learn about her 1 life, hobbies, family, interests, world, idiosyncrasy, habits, the way she relates to others, what “pushes her buttons”, expectations for therapy, how does she feels about herself, about significant others, about therapy, etc. Encourage the client to talk about her feelings, thoughts and fantasies, including those about you and your feelings thoughts and fantasies. Learn to develop, from the first meeting, a sincere interest and appreciation for the client.
3. Clients want to heal. When the eye is unobstructed, the result is seeing; when the ear is unobstructed, the result is hearing; ... When the mind is unobstructed, the result is wisdom; When the heart is unobstructed, the result is love. If you could get rid of illusion, you would be happy. 2
Clients want to get better, to solve their problems, to be happy; they just do not know how. Acknowledge their courage in trying, be empathetic and supportive to their efforts and patient with their (some times seemly unending) wandering away of the “real” issues. Hold them in their process. Help them by pointing the way they stand in their way and how to remove obstacles for growth. We are witnesses, not guides. Relax; you are only a facilitator, not the protagonist of the story.
4. Follow the client. Let your communication be, Yea, yea; Nay, nay: for whatsoever is more than 3 these cometh of evil.
Start with what you have. Ask “what is going on?” “Where is the distress?” Clients know what they want to talk about and deal with. 1
In order to make the writing and reading easier (and since I am the one writing), I will write using the masculine for the therapist, while alternating the gender of the client. 2 Anthony De Mello 3 Mt 5:37
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
The therapist never writes the agenda for change, clients do. Beware, in as much as possible, of your unconscious agenda and ask where is it coming from? Whatever happens is good; fear is good, anger is good, resistance is good, openness is good. All is well. There is no plan.
5. Clients already know the answer. ...the maximum help you can give patients is to foster reliance on their own resources rather than yours. 4
Even if they do not know it. Help them discover those answers within. Your main responsibility as a helper is to assist others in finding their own answers. Align with the client’s healing powers (their unconscious plan to get better).
II. The Therapy 6. Therapy as a Relationship and a Holding Environment. See therapy as a reliable and understanding relationship where two people work together towards free spontaneous growth. It is not about clever interpretations, but the therapist’s ability to develop a safe environment for the client, encouraging her to try her own solutions, walking together in the therapeutic relation, where two persons meet, relate, and by means of it, healing occurs. Think of the therapy room as a setting, a potential space 5 and a sacred holding environment, where client and therapist assemble to grow and (in Winnicott’s terms) to play.
7. Listen. We have two ears and one mouth so that we can listen twice as much as we speak. 6 The greatest compliment that was ever paid me was when one asked me what I thought, and attended to my answer. 7
Listen well, listen carefully, listen with your whole self, listen to what is being said (discrepancies included), to what is not being said, to how is being said, why is being said and when is being said. Everything counts, from the way the clients greets you, how and where he seat, how he begins the session, the topic he chooses to talk about, the questions he asks, to the way he says goodbye. When the client asks a question, ask yourself, what is he really asking? What is the question behind the question? When focused in listening we are less prone to 4 5 6 7
Strupp & Binder D.W. Winnicottn Epictetus Henry David Thoreau. © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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react, to jump into conclusion. Is a bit like meditation, if we are able to remain in the present moment (not reacting, not making inferences or drawing conclusions), we will be able to see and hear what is really going on. We might be able to realize even what the client really is telling us, behind all his words and affects.
Listening is an art not easily come by, but in it, there is beauty and great understanding. 8 Listening means immersing oneself in the world of another human being; allowing oneself to resonate to the spoken and unspoken message.
So when you are listening to somebody, completely, attentively, then you are listening not only to the words, but also to the feeling of what is being conveyed, to the whole of it, not part of it... You can only listen when the mind is quiet, when the mind doesn't react immediately, when there is an interval between your reaction and what is being said. Then in that interval there is a quietness, there is a silence in which alone there is a comprehension which is not intellectual understanding. Listening has importance only when one is not projecting one's own desires through which one listens. Can one put aside all these screens through which we listen, and really listen? 9
8. Let the affects flow. To urge the patient to suppress, renounce or sublimate her... transference would be, not an analytic way of dealing with them, but a senseless one. It would be just as thought, after summoning up a spirit from the underworld by cunning spells, one were to send him down again without having asked him a single question. 10
Do not try to placate anger or console a cry. Help your clients to go deeper in the direction they are going (but do not push them; intensity does not necessarily equal progress).
9. Don’t push the river. Psychotherapy must proceed at its own pace and any effort to speed it or slow it because of the character of the therapist can only be destructive. 11
Avoid the “this hurts me more than it hurts you” critical attitude: Clients are whiney, clinging, depending children and need to mature. Life is tough and every man is for himself. The sooner they learn this, the better. Should not we force them to grow up? Keep shattering their vain hopes, stepping onto their clinging fingers for them to see reality. Of course, it will hurt us more than it will hurt them, but it is for their own good; right? Wrong. At times, it seems hard not to be critical to clients. Of course it is easy 8
J. Krishnamurti J. Krishnamurti, Book of Life 10 Sigmund Freud 11 Carl Whitaker 9
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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to get the impression that clients make their lives harder than necessary, they should know better. They are full of resistances and defenses, they behave childlike and illogically. We should point this to them, right? Wrong. Clients are just blind not to realize that whatever is going on in therapy is not about us, it is about their parent, mother, brother, sister, whatever. They are not sophisticated enough to see this, but luckily for them we are. Should not we point it to them every time they do it? Wouldn’t we do well in explaining them that they are kidding themselves, that they would be better of facing the facts? Wrong. Being critical as above, we become the latest version of the clients’ parents, teachers and preachers, telling them how inept they are. Pointing out what they do wrong would not help and instead will reinforce the precise assumptions underneath the behavior (the pathogenic beliefs) that they are trying to eradicate. Respect the client’s views and struggles. Whenever you thin that you know better what she should be doing; seriously consider the possibility that it is her who knows best and work hard to try to discover the ways in which she is right. Whatever words we utter should be chosen with care for people will hear them and be influenced by them for good or ill. 12
Be thoughtful, considerate and gentle. Respect the client’s pace. You will not be doing her any favor by pushing or forcing her to realize something (even if it has been clear for you since day one). Don’t push the river.
10.
No right, wrong or simple answers. The truth is rarely pure and never simple. 13
In psychotherapy (and maybe in everything in this world) there is no absolute truth, right or wrong. Things are useful and useless (in Patañjali’s Yoga klista and aklistah); and even these are relative to each client’s specific situation and moment in life. What may be seen as an undesired resistance in one client may be a healthy selfpreservation mechanism for another that has kept him “together”. Keep in mind that defense mechanisms are unconscious means of selfprotection. There are no simple answers or solutions to any of the client’s problems. The client is –at the very least– as a complicated human being as you are.
11. 12 13
Encourage responsibility.
The Buddha Oscar Wilde © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Most people do not really want freedom, because freedom involves responsibility, and most people are frightened of responsibility. 14
Be realistic when establishing goals. Don’t do for the client what she can do for herself. Don’t make promises of solving problems or create false expectations (don’t seduce the client). If you take onto yourself the responsibility your clients need to learn to direct their lives, you’ll be blocking rather than fostering their growth. Allocate the responsibility where it belongs, with the client. Our job is to gently assist them to learn to make choices independently and have the courage to accept the consequences of those choices. The therapist is engaged in the art of making subtle suggestions, many of them more by our deeds that by our words. Point to the client whenever she does in the therapeutic relationship the behavior she is working on. When making observations, use “parts” instead of general statements.
12.
Don’t decide for the client.
Never make decisions for the clients or guide them to the conclusion you think is best (even if you think you are right). Instead help them to own their actions, their feelings and face reality (but don’t push them). Resist the temptation to give advice. Your task is to help clients discover their own solutions and recognize their own freedom in action, not to deprive them of the opportunity to act freely.
13.
Validate the client’s feelings. Approaching a person with the intention of really being honest often reminds me of taking a cold shower. The anticipation is frightening, the initial impact shocking, and the outcome, refreshing, cleansing, and invigorating. 15
Remember that the client may feel inadequate, deficient; even by the fact of coming to a therapist. Communicate to him (by deeds more than words) that he is Ok, that you are not judging him and that you unconditionally accept him.
14.
Be empathic. The patient, as I finally grasped, insisted –and had a right to insist- that I learn to see things exclusively in his way and not at all in my way. 16
Empathy is not a technique but an attitude. Put yourself in your client’s place. You’ll learn more about your client by allowing yourself to feel what she is feeling than by trying to figure her out. Empathy does not necessarily imply love, affection or compassion; it can be 14 15 16
Sigmund Freud Schutz, William; Elements of Encounter, p. 100, Joy. Heinz Kohut © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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expressed in disagreement or in accord, and that it does not imply a fusion with the client. Alternatively, it can be achieved by actively arousing, or letting oneself be pervaded by an absorbing human interest in the person one wills to understand. It implies approaching the client with understanding, respect and wonder, 17 to establish a relationship. Whenever you don’t understand, ask the client for help, when you think you understand, check with her.
15.
Be nondefensive. Better curious than furious.
Whatever feelings clients express about you, be interested, encouraging and without judgment. Acknowledge the client’s reactions and assume that they are accurate. Always be willing to ask yourself what you did to provoke any particular response, and be willing to encourage the client to talk about it. Whatever the stimulus, do not preen when praised and do not punish when attacked 18 . Don’t attempt to justify yourself or to dismiss the client’s reasoning with an interpretation.
16.
Do not judge your clients. Don't judge a man until you walk a mile in his moccasins 19 .
Remember that the freedom to express feelings depends on the assurance that they are value-fee, that they will draw neither blame nor praise. How could you judge a client? Remember that most probably you would be doing the exact same things had you growth in his family and had his life. “Empathy is vicarious introspection, a method for inquiring into the subjective experience of another...” 20 Get interested not judgmental. Kohut teaches that it is hard to change and grow until someone has really seen (and I would add understand) where we are now. Look down at me and you see a fool; look up at me and you see a god; look straight at me and you see yourself. 21
In as much as you are able to keep in mind constantly that you are just like the client (perhaps maybe luckier), you ought to be able to stop from judging and instead unconditionally accept him. Again, a religious simile might help to clarify this point. It has been suggested that the most remarkable feature of Jesus was the fact that he knew that, as a human being, he was not better than the rest of us. Highly evolved people everywhere share such feature. If they do not judge, 17 18 19 20 21
In an I-Thou fashion. Michael Kahn Native American adage Heinz Kohut. Charles Manson © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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how could you? The concept can be taken even beyond, to the spiritual realm of “oneness”. If you keep in mind that neither the client nor you are your “personae”, but parts of the whole (just like two drops of water in the sea), what is there to be judged? If you can see through the illusion of separateness and acknowledge that we are all one, there is nothing to like or dislike about the client. Being all one, who is the one judging and who is being judged?
17.
Symptoms are metaphors. Neurosis is the inability to tolerate ambiguity. 22
Symptoms are artistic creations of the psyche, a magical attempt to alter an unbearable reality. There is always a good reason for whatever the client does. Reframe symptoms as efforts to grow. Every symptom has a reason, a meaning, there is wisdom in them. A symptom is a solution; ask yourself a solution to what? What is its purpose or function? Symptoms are symbols pointing at something; but in as much as possible, think of horses, not zebras 23 . Honor the symptom, since it is doing something for the client. What is the client getting out of it? Try to focus in the roots, not in the leaves, but do not ignore the leaves either (which is what is visible anyway).
18.
Objectionable clients. I am human and let nothing human be alien to me. 24 . Everything that irritates us about others can lead us to an understanding of ourselves. 25
What to do with a client that you just find unacceptable? (whether because you dislike her, because her presenting problem overwhelms you, etc). There is really not such thing as an unacceptable client/problem (within the limits of your own physical integrity). If you find it hard to accept someone with unlovely qualities, think of the person as being up against those qualities inside. One can accept the person while disapproving the action. Just as with children, even when they do “wrong” we keep in mind that they are only children and as such, they are not evil, just do not know better. In other words, the fact that one censures the behavior; does not mean that one condemns the child. Think about what the client’s being through. Find the scare child within her. Connect to her humanness. If there is something you particularly dislike about the client or you would like to change in her, first take a good look within and find out if 22
Sigmund Freud Galloping footsteps should evoke suspicion of horses before zebras. More obvious hunches should be entertained before rarer ones. 24 Terence 25 Carl Jung 23
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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it not something that could better be changed in you.
19.
Beware of labels
As well as diagnosis, syndromes, disorders, acronyms and the like. Although it might be useful to develop some preliminary hypothesis, do not get attached to them. Every person, every situation, every problem is unique. Accordingly, there is not such thing as a text-book neurotic, teenager, mid-life crisis, divorce, depression, etc. The moment you label somebody as a “bipolar”, “ADHD”, “depressive”, etc. you’ll stop looking at the person and only see the label, you will loose the unique individual before you and only see psychopathological symptoms. In that very moment, you’ll stop seeing the person and start disregarding anything that does not fit with the diagnosis. This is a well-known fact, applied to our profession. Krishnamurti 26 used to say that the day we teach a kid that a fluffy, colorful moving object is called “a sparrow”; he/she has lost something 27 . From that day on, every time he/she sees a new (and unique) similar fluffy thing, he/she will say, “Oh, another sparrow, I know sparrows”.
20.
All is present in the session. Life isn’t mind over matter, it is present over past, and present over future. 28
The client will bring into the session whatever he is dealing with outside. Focusing in the relationship (while keeping in mind the client’s history, background and context) will help you both to elucidate what is really going on. “So, how are you and I doing today?” At the moment of the encounter between therapist and client, the client’s whole world is present; all the significant relationships, basic hopes and fears; all are present and focused on the therapist. Make and effort to check into the “here and now” each session.
21.
Therapy is a process. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer. 29
Psychotherapy is a walking together, a constant unfolding, a process that accelerates the development of a person, a series of experienced events that catalyze the natural growth of the psyche. Enjoy the ride with the client as she unfolds. ...let go and submit to the therapeutic process rather than trying to run it. …recognize our helplessness and focus not on how to do the work but on how to let the work happen, how to restrain our impulses to block the process… accept a far humbler (and more difficult) role than that for which our academic training prepared us. We must witness rather than guide, enter into the patient’s pain rather that cure it. … We must be willing to be confused and 26 27 28 29
As quoted by Anthony De Mello That is the awe for its uniqueness. Carl Whitaker Rainer Maria Rilke © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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lost if we are to accompany someone into chaotic, uncharted areas of [the patient’s] soul”. 30
It is the search that matters, the asking of the questions. Therapy, as life, is a journey, not a destination. The process itself is healing, even if certain goals are not achieved. 31 Life is an unanswered question but
let's believe in the dignity and importance of the question. 32
22.
Cut back on interpretations Psychotherapy is not making clever and apt interpretations; by and large it is a long-term giving the patient back what the patient brings…[I]f I do this well enough the patient will find his or her own self and will be able to exist and to feel real. 33
Our role is not to make clever interpretations, but to let the client explore, play and be creative with whatever he is bringing to therapy. Kohut explains how interpretations are irrelevant, since it is the client’s experience of the relationship (being understood and seen) what has a real impact. Must probably client are not even interested in listening to “brilliant” interpretations.
23.
Appreciate silence. See how nature - trees, flowers, grass - grows in silence; see the stars, the moon and the sun, how they move in silence...we need silence to be able to touch souls. 34
Befriend silence; become comfortable in it, inside and outside the therapy room. If during the session, what does it tell you? Who provoked? Observe the process and how it fills (or not) the room. Doing nothing is doing something. Sometimes is good and even necessary to leave the patient alone, and not insist that every little thing means something (even if deep down you know it does).
24.
Be totally present but don’t turn into a full-time therapist.
Your clients deserve (and are paying for) your full undivided attention during the session, but do not carry them on your shoulders once the hour is over. Avoid losing yourself in your clients, learn to “let clients go” and do not carry around their problems until you see them again. You will certainly think (and even worry) about them during the day, but do not be their therapist 24x7. Trust that they have the capacity to live their lives and make their own decisions outside the session. Likewise, don’t “therapize” your partner, family and/or friends. Be the best therapist you can be for your clients, but leave that “persona” in 30 31
Sullivan, B.S. Especially when the number of sessions is limited. 32
33 34
Tennessee Williams
D.W. Winnicott Mother Teresa of Calcutta © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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the therapy room.
25.
Acknowledge the anxiety in the room A journey of a thousand miles begins in the first meeting.
Anxiety prevents the person’s internal communication system from functioning appropriately. The client most likely feels anxious and you should be too (especially in the first session). Normalize the situation without belittling the client’s feelings. Acknowledge his courage in being there, and provide some assurance that it was the “right move”, that she is not crazy and that there is hope.
26.
Believe your clients’ stories, but with a grain of salt.
Remember that people (you included) don’t always tell the truth. Even if they are being as honest as they can possibly be (and many times they will not be that honest), you are only listening to your client’s side of the story. Keep looking at clients in an I-Thou way, honoring their self-exploration efforts, while acknowledging that there are many things going on during the session. Many times, even if we want to, we cannot tell the truth because we ignore our real motives, which have been repressed long ago, buried in the darkest cave or our mind (our shadow). Our unconscious is always there, like a puppet-master, pulling strings of which we are not even aware. How can our clients be fully honest with us when we cannot even be honest with ourselves? And since we all do it, nobody should be condemned for it. All the same, always remember that, in the session, reality is not as important as the client’s perceptions.
27.
Notes-taking.
Do not take notes during the session but do not rely on your memory either. At the end of each session, write about the main issues discussed, your feelings and unfinished business. Use a few minutes before the session to review such notes.
28.
Be grateful.
The privilege of entering into another’s life is among the highest a person can ever get. Be thankful of the honor of being a witness of the client’s struggle and story and a confidant to her. Our clients trust us with what is most valuable for them, their life stories, their fears, their feelings and desires. It is a privilege and a responsibility to be the recipient of such treasures. Honor and respect that and vow to do your best to assist them to find their own answers.
29.
Intersubjectivity. The meeting of two personalities is like the contact of two chemical
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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substances: if there is any reaction, both are transformed. 35 You are me, and I am you. Isn't it obvious that we “inter-are”? 36
In the therapy room, as the client begins to go deeper into himself, so too does the therapist into his own self in a series of reciprocal transactions. The therapist is not an objective viewer, removed of what is going on in the session; as such, he cannot be the arbiter of reality. The truth we believe about ourselves, the world and the client, is no more (though no less) ‘real’ than that of the client. All we can ‘know’ is our own psychic reality. The client is affecting you (and you would do well in welcoming this) at least as much as you are affecting him.
The Therapist 30.
Do not confuse your role with you. By acceptance I mean a warm regard for him as person... ...no matter what his condition, his behavior, or his feelings. 37
Transference is powerful. It is about you, but do not take it personal. Remember that the client hate, admiration, sexual desire, etc., may have less to do with you than with her past and ways of organizing experience. Don’t let yourself be destroyed or demoralized by the patient, even when she ignores you, attack you or deprecate you. Many times, erotic transference is not about sex but early longing (usually a longing for a parent-child connection), so (i) do not take it personal, (ii) don’t criticize the client, (iii) don’t join her, (iv) allow the feelings to persist, without gratifying them.
31.
Watch your own feelings & fantasies
Be attentive and own the feelings and fantasies the client elicits in you (fear, anxiety, sympathy, sexual desire, anger, hate, desire to rescue or to parent him, furor sanandi, etc), do not try to ignore, suppress or brush them away, they are telling you something. Keep in mind that the client will try to do to you what he does to others (and push you to do to him what he is used –or expects– to receive from others). One way to discover the client’s transference is to ask “what is he trying to make me do?” Does he want the therapist to like him? Is he asking to be kicked out or abused by the therapist? Is he trying to seduce you? Does he want you to take care of him (or vice versa)? Is he fighting to submit you? Likewise, you will project your own old patterns and repetitions/ selfobject needs/ organizing principles onto the client. It is almost like waltzing back and forward, letting the client guide us (transference) while being very careful not to step on her toes (countertransference). 35 36 37
Carl Jung Thich Nhat Hanh Carl Rogers © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Trust yourself. You know more than you think you do. 38
Trust your own feelings and intuition. Where does this “x” feeling comes from? Does it come from your own past/needs/stuff? Or is the client’s transference or projective identifications? Be willing to share them (if they are for the client’s best interest). Be attentive to what is going on inside you. How are you feeling? Are you confused? Bored? Angry? Happy?
32.
Work in yourself. If I had six hours to chop down a tree, I'd spend the first four hours sharpening the axe. 39 The key to warriorship and the first principle of Shambhala vision is not being afraid of who you are. 40
The nature of therapy requires the therapist’s commitment to his own growth, which makes him a perpetual patient, thus avoiding becoming a therapeutic technician (kind of keeping a beginner’s mind). You have blind spots that your clients will trigger or at the very least detect; be open to hear about them and explore them. The fact is that we all are like snails; wherever we go, we carry on our back a shell full of our psychological stuff (our unresolved issues), which will not go away until we deal with it. No matter where you go, “you” will be there with you. Gnothi Sauton 41 .
33.
Your job is not to teach, save or rescue you clients. If we can abandon our missionary zeal we have less chance of being eaten by cannibals. 42 Therefore, one should act without being attached to the fruits of activities, for by working without attachment man attains the supreme goal of life. 43
The setting, the client and even your previous conditioning may be pulling you to become the client’s messiah, guru or prophet. In such model, everything seems to depend in the wisdom/knowledge/cleverness of the therapist. Do not fall in the “enlightened therapist” trap. There is an enormous temptation and pressure for the therapist to produce something, to intervene in some way, to use a technique, to ask the right question, to make the right interpretation that would produce the Eureka feeling in the client, which would help her make sense out of things and live happily ever after. Bear in mind Freud’s admonitions against the educative and therapeutic ambitions (furor sanandi) the craving to help, the self-
38 39 40 41 42 43
Dr. Spock Abraham Lincoln Shambhala tradition Know Thyself Carl Whitaker The Bhagavad Gita (3,19). © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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indulgent hunger “breakthroughs”.
for
cure 44 .
Don’t
try
to
produce
great
Embrace the therapeutic experience not getting attached to results (the fruits of action), allowing the process to unfold and the transference to form, neither trying to make things happen nor developing a specific agenda. Understand that client may apparently “get worse” before showing any therapeutic gains. Also make friends with the idea that many times you will not know whether a client is progressing or whether you are being helpful in her growth process. Learn to function in ambiguity, with now knowing, begin comfortable in a place of not-knowing, focused on Being rather than Doing. Observe yourself, especially when you sense a disagreement/struggle with the client (even if very mild or subtle, even if the client does not seem to notice it). It may be a salient indicator that you are trying to guide the client to see things “your way”. Give up your missionary seal.
34.
Don’t try to fix, cheer up or fine-tune your clients.
Your job is not to “fix” your clients, make them feel better or help them “fit” in society. Wholeness, not perfection is the purpose of therapy; this has been stated many times in many different ways. Jung used to say that he’d rather be whole than good. To accept the good and the bad of life 45 . Human beings with the ability to honor life’s darkness as well as its light. The ‘cured’ client would no longer seek for a happilyever-after ending, or trying to meet society’s expectations but be her own true self. Kohut talks about the therapist as a helper who supports the patient until she “emerges from it [therapy] a more solid and authentic adult that the one who entered treatment”. It is not a question of what to do, but how to feel differently, how to be different.
35.
Don’t try to know it all. If you ask me a question I don't know, I'm not going to answer. 46
Watch out for the myth of psychotherapy: In the therapy room there is one distressed person with problems and one professional who has it all together 47 . In reality, you do not know all the answers and you are not supposed to (even when you think you have “the” answer, you would not give it to the client, right?). How could you know what is best for the client? Don’t worry when you don’t know what you’re doing; worry when you think you do. 44 Whenever a psychotherapist has too great a need to cure his patients—in order to prove his own worth, for instance, rather than out of concern for what the patient needs—he will tend to become easily frustrated and intolerant of patients who don’t get better quickly. Until they learn to recognize and come to terms with this rage to cure, therapists generally have trouble distinguishing their own needs from their patients’ needs. 45 Klein’s “Depressive position” 46 Yogi Berra 47 Michael Kahn
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36.
Neither better, nor worse.
You are neither better, nor worse that you client (and you are not supposed to be) Together you are just “fellow travelers” in the path of life 48 . The therapist has to clear his own path (as much as possible) and then invite others to walk a similar one together; as someone who, while may have already visited this specific “country” is nonetheless a wanderer, still learning and discovering new things. At one level, we are all each other’s manifestations of Avalokiteshvara the bodhisattva of compassion, illuminating each other through our mutual interactions.
37.
Personal Modeling. One must live the way one thinks or end up thinking the way one has lived. 49
You have a responsibility to your clients. Whether you like it or not, they’ll observe you (just like children would) to see if you follow your own preach, if you walk your talk. Even if you do not think that your clients see you that way, your behavior in the therapy room should be your most accomplished example of what a healthy human being should/could be. This includes taking care of yourself and your own needs.
38.
You’ll make mistakes Knowledge rests not upon truth alone, but upon error also. 50
Face the fact that you’ll make mistakes. Console yourself in the additional fact that, in an almost paradoxical way, not the therapist’s skills, but his blunders (including but not limited to the empathic failures) are what promote significant therapeutic change. According to Winnicott, clients will certainly use your mistakes in their process; therefore, you would do well in learning to use them yourself (even if it means a study of your own unconscious countertransference).
39.
Be honest, transparent and candid. Be yourself. Especially do not fake affection. Neither be cynical about love. 51
Never pretend to be what you are not, or to feel what you do not feel. You can decide whether you want to share your thoughts and/or feelings with the client, but in any case, never lie to the client. Be genuine, strive to be transparent, not wearing any “therapist mask” and do not pretend to be someone you are not.
40.
You are a human being.
48
Irvin D. Yalom Paul Bourget 50 Carl Jung 51 Max Ehrmann, Desiderata. 49
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Some cannot loosen their own chains yet can nonetheless redeem their friends. 52
Holy men may be in niches, but they are certainly alone. Keep yourself human, real and accept your limitations and struggles. The client will affect you. Be attentive to your own process, your own countertransference (cotransference) and your own selfobject needs. Be spontaneous. Whenever you think that it would be in the client’s best interest, do not hesitate to share what is going on within you. Therapists (just as clients) have needs but keep in mind that therapy is for the client’s benefit. Ideally, as long as you are aware of your needs, you will be able to discriminate if any given desire or pull to share comes from you or from the client, and whether it would be beneficial for him. All know the way, few actually walk it. 53
Be willing to walk the path that your client is walking. If the client walks faster than you or goes beyond where you are, be willing to learn from him and be encouraged by his example. By helping in such occasions, you are not being hypocrite, you are doing your job supporting the client.
41.
Be yourself. Do not attempt to be the Buddha. 54
It is not about theories but persons. It is not about techniques but being honest and fully present. What is happening between the two people takes precedent over the method one is using. Find your own voice and counseling style.
42.
Humor. More errors are made solemnly than in fun. 55
Therapy is important but it need not be deadly serious. Humor can be useful, not only to break a grim mood, but also helps to keep the therapist sane. Relax, it is only therapy. It is serious business but not life itself. You should be able to enjoy this work. Take this guide with a grain of salt, go out and try it. In twenty years come back read this guide again and see how you are doing.
52
Friedrich Nietzsche Bodhidharma 54 Dōgen 55 Don Herold 53
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Bibliography Basch, M. F., (1980) Doing psychotherapy, New York : Basic Books Bruch, H. (1974) Learning psychotherapy: rationale and ground rules, Cambridge: Harvard University Press. Corey, G. (1991) Theory and practice of counseling and psychotherapy, Pacific Grove, Calif.: Brooks/Cole Pub. Co. Grolnick S. (1993): How to do Winnicottian Therapy. In one's bones: the clinical genius of Winnicott. Northvale, N.J. : Aronson Ivey, A (1994) Intentional Interviewing and Counseling. Pacific Grove: Books-Cole Kahn, M., (1997) Between therapist and client: the new relationship, New York : W.H. Freeman and Co., Kottler, J. A. (1985) Introduction to therapeutic counseling, Monterey, Calif.: Brooks/Cole Pub. Co. Neill, J. R. and Kniskern, D. P., (1982) From psyche to system, the evolving therapy of Carl Whitaker. New York : Guilford Press Strupp, H. & Binder, J. (1983) A Guide to Time Limited Dynamic Psychology, New York: Basic books. Sullivan, B.S. (1990) Psychotherapy grounded in the feminine principle. Archetypal foundation of the therapeutic process, Wilmette, Illinois: Chiron Publications. Yalom, I.D. (2002) The gift of therapy: an open letter to a new generation of therapists and their patients, New York: HarperCollins.
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Sergio Rodriguez-Castillo California Institute of Integral Studies August 2009 In order to use the mutual experience, one must have in one’s bones a theory of the emotional development of the child and the relationship of the child to the environmental factors D.W. Winnicott
One should always start out on the wrong foot. Carl Whitaker
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
Contents Foreword:............................................................................................................................................. 3 I. The Client ......................................................................................................................................... 4 1. It is all about the client..................................................................................................... 4 2. Learn about the client....................................................................................................... 4 3. Clients want to heal........................................................................................................... 4 4. Follow the client.................................................................................................................. 4 5. Clients already know the answer.................................................................................. 5 II. The Therapy ................................................................................................................................... 5 6. Therapy as a Relationship and a Holding Environment. ...................................... 5 7. Listen....................................................................................................................................... 5 8. Let the affects flow. ........................................................................................................... 6 9. Don’t push the river........................................................................................................... 6 10. No right, wrong or simple answers.......................................................................... 7 11. Encourage responsibility............................................................................................. 7 12. Don’t decide for the client.......................................................................................... 8 13. Validate the client’s feelings. .................................................................................... 8 14. Be empathic..................................................................................................................... 8 15. Be nondefensive............................................................................................................. 9 16. Do not judge your clients............................................................................................ 9 17. Symptoms are metaphors. ....................................................................................... 10 18. Objectionable clients. ................................................................................................. 10 19. Beware of labels ........................................................................................................... 11 20. All is present in the session. .................................................................................... 11 21. Therapy is a process................................................................................................... 11 22. Cut back on interpretations...................................................................................... 12 23. Appreciate silence. ...................................................................................................... 12 24. Be totally present but don’t turn into a full-time therapist. ......................... 12 25. Acknowledge the anxiety in the room.................................................................. 13 26. Believe your clients’ stories, but with a grain of salt. .................................... 13 27. Notes-taking................................................................................................................... 13 28. Be grateful...................................................................................................................... 13 29. Intersubjectivity............................................................................................................ 13 The Therapist.................................................................................................................................... 14 30. Do not confuse your role with you......................................................................... 14 31. Watch your own feelings & fantasies ................................................................... 14 32. Work in yourself............................................................................................................ 15 33. Your job is not to teach, save or rescue you clients. ...................................... 15 34. Don’t try to fix, cheer up or fine-tune your clients.......................................... 16 35. Don’t try to know it all. .............................................................................................. 16 36. Neither better, nor worse.......................................................................................... 17 37. Personal Modeling........................................................................................................ 17 38. You’ll make mistakes.................................................................................................. 17 39. Be honest, transparent and candid....................................................................... 17 40. You are a human being.............................................................................................. 17 41. Be yourself...................................................................................................................... 18 42. Humor............................................................................................................................... 18 Bibliography...................................................................................................................................... 19
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Foreword: I wrote this paper originally as par of my preparation to begin my psychotherapy practicum on fall 2006. Although some my view and understanding of psychotherapy have evolved as I gain experience both as a professor and a clinician, I am happy to see how most of what I wrote back then still holds true to me as the bedrock of my therapeutic practice. Almost needles to say that what follows are highly personal lessons; they deal with my issues and with those aspects of therapy that concern me the most (my own “issues” as we therapist like to say). I have tried to be as comprehensive as I can, but again, the focus is in what I need to keep in mind; therefore, many of these suggestions may not make much sense to other practitioners. Likewise, what follows reflect both my understanding of psychotherapy and they approach it is taught in CIIS’ Integral Counseling Psychology program. I am not claiming in any way that these principles are “the” way psychotherapy works, only and humbly the way I understand it. Although I would not want to get into a debate about the general validity of my conclusions, I’d love to know your thoughts and reactions about it. You can contact me through the www.ciis.edu website. Finally, it is worth mentioning that, although I have included a bibliography at the end of this guide, I am afraid that it only represents a very small piece of the material consulted for this work. I have incorporated ideas from many readings, classes, conversations, etc. The concepts, ideas and “tips” about how to “survive” as a beginning therapist, how to deal with the clients and what to do and what not to do come from many of my teachers and mentors. As a result, it would be impossible to list and give credit to all of them. All I have done is to put them together to create this survival guide. Paraphrasing Anthony De Mello, my task has been that of a weaver and the dyer, so I take no credit at all for the cotton and the thread. My hope is that these principles maybe as helpful to others as they have been for me. Love, Sergio
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A SURVIVAL GUIDE TO PSYCHOTHERAPY I. The Client 1. It is all about the client. Everything, even the client’s opinion has about you, has very little to do with you. The client improvement (or worsening) is more his/her doing than yours. Avoid feeling that you are instrumental in assisting the client to enjoy life more fully (the need to be needed) or giving yourself credit for the client’s growth. You are not that important. Psychotherapy is not so much about what the therapist does or says, but how the clients experiences (the Selfobject experience) what is being (or not being) said or done.
2. Learn about the client. Learn about her 1 life, hobbies, family, interests, world, idiosyncrasy, habits, the way she relates to others, what “pushes her buttons”, expectations for therapy, how does she feels about herself, about significant others, about therapy, etc. Encourage the client to talk about her feelings, thoughts and fantasies, including those about you and your feelings thoughts and fantasies. Learn to develop, from the first meeting, a sincere interest and appreciation for the client.
3. Clients want to heal. When the eye is unobstructed, the result is seeing; when the ear is unobstructed, the result is hearing; ... When the mind is unobstructed, the result is wisdom; When the heart is unobstructed, the result is love. If you could get rid of illusion, you would be happy. 2
Clients want to get better, to solve their problems, to be happy; they just do not know how. Acknowledge their courage in trying, be empathetic and supportive to their efforts and patient with their (some times seemly unending) wandering away of the “real” issues. Hold them in their process. Help them by pointing the way they stand in their way and how to remove obstacles for growth. We are witnesses, not guides. Relax; you are only a facilitator, not the protagonist of the story.
4. Follow the client. Let your communication be, Yea, yea; Nay, nay: for whatsoever is more than 3 these cometh of evil.
Start with what you have. Ask “what is going on?” “Where is the distress?” Clients know what they want to talk about and deal with. 1
In order to make the writing and reading easier (and since I am the one writing), I will write using the masculine for the therapist, while alternating the gender of the client. 2 Anthony De Mello 3 Mt 5:37
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
The therapist never writes the agenda for change, clients do. Beware, in as much as possible, of your unconscious agenda and ask where is it coming from? Whatever happens is good; fear is good, anger is good, resistance is good, openness is good. All is well. There is no plan.
5. Clients already know the answer. ...the maximum help you can give patients is to foster reliance on their own resources rather than yours. 4
Even if they do not know it. Help them discover those answers within. Your main responsibility as a helper is to assist others in finding their own answers. Align with the client’s healing powers (their unconscious plan to get better).
II. The Therapy 6. Therapy as a Relationship and a Holding Environment. See therapy as a reliable and understanding relationship where two people work together towards free spontaneous growth. It is not about clever interpretations, but the therapist’s ability to develop a safe environment for the client, encouraging her to try her own solutions, walking together in the therapeutic relation, where two persons meet, relate, and by means of it, healing occurs. Think of the therapy room as a setting, a potential space 5 and a sacred holding environment, where client and therapist assemble to grow and (in Winnicott’s terms) to play.
7. Listen. We have two ears and one mouth so that we can listen twice as much as we speak. 6 The greatest compliment that was ever paid me was when one asked me what I thought, and attended to my answer. 7
Listen well, listen carefully, listen with your whole self, listen to what is being said (discrepancies included), to what is not being said, to how is being said, why is being said and when is being said. Everything counts, from the way the clients greets you, how and where he seat, how he begins the session, the topic he chooses to talk about, the questions he asks, to the way he says goodbye. When the client asks a question, ask yourself, what is he really asking? What is the question behind the question? When focused in listening we are less prone to 4 5 6 7
Strupp & Binder D.W. Winnicottn Epictetus Henry David Thoreau. © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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react, to jump into conclusion. Is a bit like meditation, if we are able to remain in the present moment (not reacting, not making inferences or drawing conclusions), we will be able to see and hear what is really going on. We might be able to realize even what the client really is telling us, behind all his words and affects.
Listening is an art not easily come by, but in it, there is beauty and great understanding. 8 Listening means immersing oneself in the world of another human being; allowing oneself to resonate to the spoken and unspoken message.
So when you are listening to somebody, completely, attentively, then you are listening not only to the words, but also to the feeling of what is being conveyed, to the whole of it, not part of it... You can only listen when the mind is quiet, when the mind doesn't react immediately, when there is an interval between your reaction and what is being said. Then in that interval there is a quietness, there is a silence in which alone there is a comprehension which is not intellectual understanding. Listening has importance only when one is not projecting one's own desires through which one listens. Can one put aside all these screens through which we listen, and really listen? 9
8. Let the affects flow. To urge the patient to suppress, renounce or sublimate her... transference would be, not an analytic way of dealing with them, but a senseless one. It would be just as thought, after summoning up a spirit from the underworld by cunning spells, one were to send him down again without having asked him a single question. 10
Do not try to placate anger or console a cry. Help your clients to go deeper in the direction they are going (but do not push them; intensity does not necessarily equal progress).
9. Don’t push the river. Psychotherapy must proceed at its own pace and any effort to speed it or slow it because of the character of the therapist can only be destructive. 11
Avoid the “this hurts me more than it hurts you” critical attitude: Clients are whiney, clinging, depending children and need to mature. Life is tough and every man is for himself. The sooner they learn this, the better. Should not we force them to grow up? Keep shattering their vain hopes, stepping onto their clinging fingers for them to see reality. Of course, it will hurt us more than it will hurt them, but it is for their own good; right? Wrong. At times, it seems hard not to be critical to clients. Of course it is easy 8
J. Krishnamurti J. Krishnamurti, Book of Life 10 Sigmund Freud 11 Carl Whitaker 9
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to get the impression that clients make their lives harder than necessary, they should know better. They are full of resistances and defenses, they behave childlike and illogically. We should point this to them, right? Wrong. Clients are just blind not to realize that whatever is going on in therapy is not about us, it is about their parent, mother, brother, sister, whatever. They are not sophisticated enough to see this, but luckily for them we are. Should not we point it to them every time they do it? Wouldn’t we do well in explaining them that they are kidding themselves, that they would be better of facing the facts? Wrong. Being critical as above, we become the latest version of the clients’ parents, teachers and preachers, telling them how inept they are. Pointing out what they do wrong would not help and instead will reinforce the precise assumptions underneath the behavior (the pathogenic beliefs) that they are trying to eradicate. Respect the client’s views and struggles. Whenever you thin that you know better what she should be doing; seriously consider the possibility that it is her who knows best and work hard to try to discover the ways in which she is right. Whatever words we utter should be chosen with care for people will hear them and be influenced by them for good or ill. 12
Be thoughtful, considerate and gentle. Respect the client’s pace. You will not be doing her any favor by pushing or forcing her to realize something (even if it has been clear for you since day one). Don’t push the river.
10.
No right, wrong or simple answers. The truth is rarely pure and never simple. 13
In psychotherapy (and maybe in everything in this world) there is no absolute truth, right or wrong. Things are useful and useless (in Patañjali’s Yoga klista and aklistah); and even these are relative to each client’s specific situation and moment in life. What may be seen as an undesired resistance in one client may be a healthy selfpreservation mechanism for another that has kept him “together”. Keep in mind that defense mechanisms are unconscious means of selfprotection. There are no simple answers or solutions to any of the client’s problems. The client is –at the very least– as a complicated human being as you are.
11. 12 13
Encourage responsibility.
The Buddha Oscar Wilde © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Most people do not really want freedom, because freedom involves responsibility, and most people are frightened of responsibility. 14
Be realistic when establishing goals. Don’t do for the client what she can do for herself. Don’t make promises of solving problems or create false expectations (don’t seduce the client). If you take onto yourself the responsibility your clients need to learn to direct their lives, you’ll be blocking rather than fostering their growth. Allocate the responsibility where it belongs, with the client. Our job is to gently assist them to learn to make choices independently and have the courage to accept the consequences of those choices. The therapist is engaged in the art of making subtle suggestions, many of them more by our deeds that by our words. Point to the client whenever she does in the therapeutic relationship the behavior she is working on. When making observations, use “parts” instead of general statements.
12.
Don’t decide for the client.
Never make decisions for the clients or guide them to the conclusion you think is best (even if you think you are right). Instead help them to own their actions, their feelings and face reality (but don’t push them). Resist the temptation to give advice. Your task is to help clients discover their own solutions and recognize their own freedom in action, not to deprive them of the opportunity to act freely.
13.
Validate the client’s feelings. Approaching a person with the intention of really being honest often reminds me of taking a cold shower. The anticipation is frightening, the initial impact shocking, and the outcome, refreshing, cleansing, and invigorating. 15
Remember that the client may feel inadequate, deficient; even by the fact of coming to a therapist. Communicate to him (by deeds more than words) that he is Ok, that you are not judging him and that you unconditionally accept him.
14.
Be empathic. The patient, as I finally grasped, insisted –and had a right to insist- that I learn to see things exclusively in his way and not at all in my way. 16
Empathy is not a technique but an attitude. Put yourself in your client’s place. You’ll learn more about your client by allowing yourself to feel what she is feeling than by trying to figure her out. Empathy does not necessarily imply love, affection or compassion; it can be 14 15 16
Sigmund Freud Schutz, William; Elements of Encounter, p. 100, Joy. Heinz Kohut © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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expressed in disagreement or in accord, and that it does not imply a fusion with the client. Alternatively, it can be achieved by actively arousing, or letting oneself be pervaded by an absorbing human interest in the person one wills to understand. It implies approaching the client with understanding, respect and wonder, 17 to establish a relationship. Whenever you don’t understand, ask the client for help, when you think you understand, check with her.
15.
Be nondefensive. Better curious than furious.
Whatever feelings clients express about you, be interested, encouraging and without judgment. Acknowledge the client’s reactions and assume that they are accurate. Always be willing to ask yourself what you did to provoke any particular response, and be willing to encourage the client to talk about it. Whatever the stimulus, do not preen when praised and do not punish when attacked 18 . Don’t attempt to justify yourself or to dismiss the client’s reasoning with an interpretation.
16.
Do not judge your clients. Don't judge a man until you walk a mile in his moccasins 19 .
Remember that the freedom to express feelings depends on the assurance that they are value-fee, that they will draw neither blame nor praise. How could you judge a client? Remember that most probably you would be doing the exact same things had you growth in his family and had his life. “Empathy is vicarious introspection, a method for inquiring into the subjective experience of another...” 20 Get interested not judgmental. Kohut teaches that it is hard to change and grow until someone has really seen (and I would add understand) where we are now. Look down at me and you see a fool; look up at me and you see a god; look straight at me and you see yourself. 21
In as much as you are able to keep in mind constantly that you are just like the client (perhaps maybe luckier), you ought to be able to stop from judging and instead unconditionally accept him. Again, a religious simile might help to clarify this point. It has been suggested that the most remarkable feature of Jesus was the fact that he knew that, as a human being, he was not better than the rest of us. Highly evolved people everywhere share such feature. If they do not judge, 17 18 19 20 21
In an I-Thou fashion. Michael Kahn Native American adage Heinz Kohut. Charles Manson © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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how could you? The concept can be taken even beyond, to the spiritual realm of “oneness”. If you keep in mind that neither the client nor you are your “personae”, but parts of the whole (just like two drops of water in the sea), what is there to be judged? If you can see through the illusion of separateness and acknowledge that we are all one, there is nothing to like or dislike about the client. Being all one, who is the one judging and who is being judged?
17.
Symptoms are metaphors. Neurosis is the inability to tolerate ambiguity. 22
Symptoms are artistic creations of the psyche, a magical attempt to alter an unbearable reality. There is always a good reason for whatever the client does. Reframe symptoms as efforts to grow. Every symptom has a reason, a meaning, there is wisdom in them. A symptom is a solution; ask yourself a solution to what? What is its purpose or function? Symptoms are symbols pointing at something; but in as much as possible, think of horses, not zebras 23 . Honor the symptom, since it is doing something for the client. What is the client getting out of it? Try to focus in the roots, not in the leaves, but do not ignore the leaves either (which is what is visible anyway).
18.
Objectionable clients. I am human and let nothing human be alien to me. 24 . Everything that irritates us about others can lead us to an understanding of ourselves. 25
What to do with a client that you just find unacceptable? (whether because you dislike her, because her presenting problem overwhelms you, etc). There is really not such thing as an unacceptable client/problem (within the limits of your own physical integrity). If you find it hard to accept someone with unlovely qualities, think of the person as being up against those qualities inside. One can accept the person while disapproving the action. Just as with children, even when they do “wrong” we keep in mind that they are only children and as such, they are not evil, just do not know better. In other words, the fact that one censures the behavior; does not mean that one condemns the child. Think about what the client’s being through. Find the scare child within her. Connect to her humanness. If there is something you particularly dislike about the client or you would like to change in her, first take a good look within and find out if 22
Sigmund Freud Galloping footsteps should evoke suspicion of horses before zebras. More obvious hunches should be entertained before rarer ones. 24 Terence 25 Carl Jung 23
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it not something that could better be changed in you.
19.
Beware of labels
As well as diagnosis, syndromes, disorders, acronyms and the like. Although it might be useful to develop some preliminary hypothesis, do not get attached to them. Every person, every situation, every problem is unique. Accordingly, there is not such thing as a text-book neurotic, teenager, mid-life crisis, divorce, depression, etc. The moment you label somebody as a “bipolar”, “ADHD”, “depressive”, etc. you’ll stop looking at the person and only see the label, you will loose the unique individual before you and only see psychopathological symptoms. In that very moment, you’ll stop seeing the person and start disregarding anything that does not fit with the diagnosis. This is a well-known fact, applied to our profession. Krishnamurti 26 used to say that the day we teach a kid that a fluffy, colorful moving object is called “a sparrow”; he/she has lost something 27 . From that day on, every time he/she sees a new (and unique) similar fluffy thing, he/she will say, “Oh, another sparrow, I know sparrows”.
20.
All is present in the session. Life isn’t mind over matter, it is present over past, and present over future. 28
The client will bring into the session whatever he is dealing with outside. Focusing in the relationship (while keeping in mind the client’s history, background and context) will help you both to elucidate what is really going on. “So, how are you and I doing today?” At the moment of the encounter between therapist and client, the client’s whole world is present; all the significant relationships, basic hopes and fears; all are present and focused on the therapist. Make and effort to check into the “here and now” each session.
21.
Therapy is a process. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer. 29
Psychotherapy is a walking together, a constant unfolding, a process that accelerates the development of a person, a series of experienced events that catalyze the natural growth of the psyche. Enjoy the ride with the client as she unfolds. ...let go and submit to the therapeutic process rather than trying to run it. …recognize our helplessness and focus not on how to do the work but on how to let the work happen, how to restrain our impulses to block the process… accept a far humbler (and more difficult) role than that for which our academic training prepared us. We must witness rather than guide, enter into the patient’s pain rather that cure it. … We must be willing to be confused and 26 27 28 29
As quoted by Anthony De Mello That is the awe for its uniqueness. Carl Whitaker Rainer Maria Rilke © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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lost if we are to accompany someone into chaotic, uncharted areas of [the patient’s] soul”. 30
It is the search that matters, the asking of the questions. Therapy, as life, is a journey, not a destination. The process itself is healing, even if certain goals are not achieved. 31 Life is an unanswered question but
let's believe in the dignity and importance of the question. 32
22.
Cut back on interpretations Psychotherapy is not making clever and apt interpretations; by and large it is a long-term giving the patient back what the patient brings…[I]f I do this well enough the patient will find his or her own self and will be able to exist and to feel real. 33
Our role is not to make clever interpretations, but to let the client explore, play and be creative with whatever he is bringing to therapy. Kohut explains how interpretations are irrelevant, since it is the client’s experience of the relationship (being understood and seen) what has a real impact. Must probably client are not even interested in listening to “brilliant” interpretations.
23.
Appreciate silence. See how nature - trees, flowers, grass - grows in silence; see the stars, the moon and the sun, how they move in silence...we need silence to be able to touch souls. 34
Befriend silence; become comfortable in it, inside and outside the therapy room. If during the session, what does it tell you? Who provoked? Observe the process and how it fills (or not) the room. Doing nothing is doing something. Sometimes is good and even necessary to leave the patient alone, and not insist that every little thing means something (even if deep down you know it does).
24.
Be totally present but don’t turn into a full-time therapist.
Your clients deserve (and are paying for) your full undivided attention during the session, but do not carry them on your shoulders once the hour is over. Avoid losing yourself in your clients, learn to “let clients go” and do not carry around their problems until you see them again. You will certainly think (and even worry) about them during the day, but do not be their therapist 24x7. Trust that they have the capacity to live their lives and make their own decisions outside the session. Likewise, don’t “therapize” your partner, family and/or friends. Be the best therapist you can be for your clients, but leave that “persona” in 30 31
Sullivan, B.S. Especially when the number of sessions is limited. 32
33 34
Tennessee Williams
D.W. Winnicott Mother Teresa of Calcutta © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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the therapy room.
25.
Acknowledge the anxiety in the room A journey of a thousand miles begins in the first meeting.
Anxiety prevents the person’s internal communication system from functioning appropriately. The client most likely feels anxious and you should be too (especially in the first session). Normalize the situation without belittling the client’s feelings. Acknowledge his courage in being there, and provide some assurance that it was the “right move”, that she is not crazy and that there is hope.
26.
Believe your clients’ stories, but with a grain of salt.
Remember that people (you included) don’t always tell the truth. Even if they are being as honest as they can possibly be (and many times they will not be that honest), you are only listening to your client’s side of the story. Keep looking at clients in an I-Thou way, honoring their self-exploration efforts, while acknowledging that there are many things going on during the session. Many times, even if we want to, we cannot tell the truth because we ignore our real motives, which have been repressed long ago, buried in the darkest cave or our mind (our shadow). Our unconscious is always there, like a puppet-master, pulling strings of which we are not even aware. How can our clients be fully honest with us when we cannot even be honest with ourselves? And since we all do it, nobody should be condemned for it. All the same, always remember that, in the session, reality is not as important as the client’s perceptions.
27.
Notes-taking.
Do not take notes during the session but do not rely on your memory either. At the end of each session, write about the main issues discussed, your feelings and unfinished business. Use a few minutes before the session to review such notes.
28.
Be grateful.
The privilege of entering into another’s life is among the highest a person can ever get. Be thankful of the honor of being a witness of the client’s struggle and story and a confidant to her. Our clients trust us with what is most valuable for them, their life stories, their fears, their feelings and desires. It is a privilege and a responsibility to be the recipient of such treasures. Honor and respect that and vow to do your best to assist them to find their own answers.
29.
Intersubjectivity. The meeting of two personalities is like the contact of two chemical
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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substances: if there is any reaction, both are transformed. 35 You are me, and I am you. Isn't it obvious that we “inter-are”? 36
In the therapy room, as the client begins to go deeper into himself, so too does the therapist into his own self in a series of reciprocal transactions. The therapist is not an objective viewer, removed of what is going on in the session; as such, he cannot be the arbiter of reality. The truth we believe about ourselves, the world and the client, is no more (though no less) ‘real’ than that of the client. All we can ‘know’ is our own psychic reality. The client is affecting you (and you would do well in welcoming this) at least as much as you are affecting him.
The Therapist 30.
Do not confuse your role with you. By acceptance I mean a warm regard for him as person... ...no matter what his condition, his behavior, or his feelings. 37
Transference is powerful. It is about you, but do not take it personal. Remember that the client hate, admiration, sexual desire, etc., may have less to do with you than with her past and ways of organizing experience. Don’t let yourself be destroyed or demoralized by the patient, even when she ignores you, attack you or deprecate you. Many times, erotic transference is not about sex but early longing (usually a longing for a parent-child connection), so (i) do not take it personal, (ii) don’t criticize the client, (iii) don’t join her, (iv) allow the feelings to persist, without gratifying them.
31.
Watch your own feelings & fantasies
Be attentive and own the feelings and fantasies the client elicits in you (fear, anxiety, sympathy, sexual desire, anger, hate, desire to rescue or to parent him, furor sanandi, etc), do not try to ignore, suppress or brush them away, they are telling you something. Keep in mind that the client will try to do to you what he does to others (and push you to do to him what he is used –or expects– to receive from others). One way to discover the client’s transference is to ask “what is he trying to make me do?” Does he want the therapist to like him? Is he asking to be kicked out or abused by the therapist? Is he trying to seduce you? Does he want you to take care of him (or vice versa)? Is he fighting to submit you? Likewise, you will project your own old patterns and repetitions/ selfobject needs/ organizing principles onto the client. It is almost like waltzing back and forward, letting the client guide us (transference) while being very careful not to step on her toes (countertransference). 35 36 37
Carl Jung Thich Nhat Hanh Carl Rogers © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Trust yourself. You know more than you think you do. 38
Trust your own feelings and intuition. Where does this “x” feeling comes from? Does it come from your own past/needs/stuff? Or is the client’s transference or projective identifications? Be willing to share them (if they are for the client’s best interest). Be attentive to what is going on inside you. How are you feeling? Are you confused? Bored? Angry? Happy?
32.
Work in yourself. If I had six hours to chop down a tree, I'd spend the first four hours sharpening the axe. 39 The key to warriorship and the first principle of Shambhala vision is not being afraid of who you are. 40
The nature of therapy requires the therapist’s commitment to his own growth, which makes him a perpetual patient, thus avoiding becoming a therapeutic technician (kind of keeping a beginner’s mind). You have blind spots that your clients will trigger or at the very least detect; be open to hear about them and explore them. The fact is that we all are like snails; wherever we go, we carry on our back a shell full of our psychological stuff (our unresolved issues), which will not go away until we deal with it. No matter where you go, “you” will be there with you. Gnothi Sauton 41 .
33.
Your job is not to teach, save or rescue you clients. If we can abandon our missionary zeal we have less chance of being eaten by cannibals. 42 Therefore, one should act without being attached to the fruits of activities, for by working without attachment man attains the supreme goal of life. 43
The setting, the client and even your previous conditioning may be pulling you to become the client’s messiah, guru or prophet. In such model, everything seems to depend in the wisdom/knowledge/cleverness of the therapist. Do not fall in the “enlightened therapist” trap. There is an enormous temptation and pressure for the therapist to produce something, to intervene in some way, to use a technique, to ask the right question, to make the right interpretation that would produce the Eureka feeling in the client, which would help her make sense out of things and live happily ever after. Bear in mind Freud’s admonitions against the educative and therapeutic ambitions (furor sanandi) the craving to help, the self-
38 39 40 41 42 43
Dr. Spock Abraham Lincoln Shambhala tradition Know Thyself Carl Whitaker The Bhagavad Gita (3,19). © Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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indulgent hunger “breakthroughs”.
for
cure 44 .
Don’t
try
to
produce
great
Embrace the therapeutic experience not getting attached to results (the fruits of action), allowing the process to unfold and the transference to form, neither trying to make things happen nor developing a specific agenda. Understand that client may apparently “get worse” before showing any therapeutic gains. Also make friends with the idea that many times you will not know whether a client is progressing or whether you are being helpful in her growth process. Learn to function in ambiguity, with now knowing, begin comfortable in a place of not-knowing, focused on Being rather than Doing. Observe yourself, especially when you sense a disagreement/struggle with the client (even if very mild or subtle, even if the client does not seem to notice it). It may be a salient indicator that you are trying to guide the client to see things “your way”. Give up your missionary seal.
34.
Don’t try to fix, cheer up or fine-tune your clients.
Your job is not to “fix” your clients, make them feel better or help them “fit” in society. Wholeness, not perfection is the purpose of therapy; this has been stated many times in many different ways. Jung used to say that he’d rather be whole than good. To accept the good and the bad of life 45 . Human beings with the ability to honor life’s darkness as well as its light. The ‘cured’ client would no longer seek for a happilyever-after ending, or trying to meet society’s expectations but be her own true self. Kohut talks about the therapist as a helper who supports the patient until she “emerges from it [therapy] a more solid and authentic adult that the one who entered treatment”. It is not a question of what to do, but how to feel differently, how to be different.
35.
Don’t try to know it all. If you ask me a question I don't know, I'm not going to answer. 46
Watch out for the myth of psychotherapy: In the therapy room there is one distressed person with problems and one professional who has it all together 47 . In reality, you do not know all the answers and you are not supposed to (even when you think you have “the” answer, you would not give it to the client, right?). How could you know what is best for the client? Don’t worry when you don’t know what you’re doing; worry when you think you do. 44 Whenever a psychotherapist has too great a need to cure his patients—in order to prove his own worth, for instance, rather than out of concern for what the patient needs—he will tend to become easily frustrated and intolerant of patients who don’t get better quickly. Until they learn to recognize and come to terms with this rage to cure, therapists generally have trouble distinguishing their own needs from their patients’ needs. 45 Klein’s “Depressive position” 46 Yogi Berra 47 Michael Kahn
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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36.
Neither better, nor worse.
You are neither better, nor worse that you client (and you are not supposed to be) Together you are just “fellow travelers” in the path of life 48 . The therapist has to clear his own path (as much as possible) and then invite others to walk a similar one together; as someone who, while may have already visited this specific “country” is nonetheless a wanderer, still learning and discovering new things. At one level, we are all each other’s manifestations of Avalokiteshvara the bodhisattva of compassion, illuminating each other through our mutual interactions.
37.
Personal Modeling. One must live the way one thinks or end up thinking the way one has lived. 49
You have a responsibility to your clients. Whether you like it or not, they’ll observe you (just like children would) to see if you follow your own preach, if you walk your talk. Even if you do not think that your clients see you that way, your behavior in the therapy room should be your most accomplished example of what a healthy human being should/could be. This includes taking care of yourself and your own needs.
38.
You’ll make mistakes Knowledge rests not upon truth alone, but upon error also. 50
Face the fact that you’ll make mistakes. Console yourself in the additional fact that, in an almost paradoxical way, not the therapist’s skills, but his blunders (including but not limited to the empathic failures) are what promote significant therapeutic change. According to Winnicott, clients will certainly use your mistakes in their process; therefore, you would do well in learning to use them yourself (even if it means a study of your own unconscious countertransference).
39.
Be honest, transparent and candid. Be yourself. Especially do not fake affection. Neither be cynical about love. 51
Never pretend to be what you are not, or to feel what you do not feel. You can decide whether you want to share your thoughts and/or feelings with the client, but in any case, never lie to the client. Be genuine, strive to be transparent, not wearing any “therapist mask” and do not pretend to be someone you are not.
40.
You are a human being.
48
Irvin D. Yalom Paul Bourget 50 Carl Jung 51 Max Ehrmann, Desiderata. 49
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Some cannot loosen their own chains yet can nonetheless redeem their friends. 52
Holy men may be in niches, but they are certainly alone. Keep yourself human, real and accept your limitations and struggles. The client will affect you. Be attentive to your own process, your own countertransference (cotransference) and your own selfobject needs. Be spontaneous. Whenever you think that it would be in the client’s best interest, do not hesitate to share what is going on within you. Therapists (just as clients) have needs but keep in mind that therapy is for the client’s benefit. Ideally, as long as you are aware of your needs, you will be able to discriminate if any given desire or pull to share comes from you or from the client, and whether it would be beneficial for him. All know the way, few actually walk it. 53
Be willing to walk the path that your client is walking. If the client walks faster than you or goes beyond where you are, be willing to learn from him and be encouraged by his example. By helping in such occasions, you are not being hypocrite, you are doing your job supporting the client.
41.
Be yourself. Do not attempt to be the Buddha. 54
It is not about theories but persons. It is not about techniques but being honest and fully present. What is happening between the two people takes precedent over the method one is using. Find your own voice and counseling style.
42.
Humor. More errors are made solemnly than in fun. 55
Therapy is important but it need not be deadly serious. Humor can be useful, not only to break a grim mood, but also helps to keep the therapist sane. Relax, it is only therapy. It is serious business but not life itself. You should be able to enjoy this work. Take this guide with a grain of salt, go out and try it. In twenty years come back read this guide again and see how you are doing.
52
Friedrich Nietzsche Bodhidharma 54 Dōgen 55 Don Herold 53
© Sergio Rodriguez-Castillo, San Francisco, Ca. 2009
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Bibliography Basch, M. F., (1980) Doing psychotherapy, New York : Basic Books Bruch, H. (1974) Learning psychotherapy: rationale and ground rules, Cambridge: Harvard University Press. Corey, G. (1991) Theory and practice of counseling and psychotherapy, Pacific Grove, Calif.: Brooks/Cole Pub. Co. Grolnick S. (1993): How to do Winnicottian Therapy. In one's bones: the clinical genius of Winnicott. Northvale, N.J. : Aronson Ivey, A (1994) Intentional Interviewing and Counseling. Pacific Grove: Books-Cole Kahn, M., (1997) Between therapist and client: the new relationship, New York : W.H. Freeman and Co., Kottler, J. A. (1985) Introduction to therapeutic counseling, Monterey, Calif.: Brooks/Cole Pub. Co. Neill, J. R. and Kniskern, D. P., (1982) From psyche to system, the evolving therapy of Carl Whitaker. New York : Guilford Press Strupp, H. & Binder, J. (1983) A Guide to Time Limited Dynamic Psychology, New York: Basic books. Sullivan, B.S. (1990) Psychotherapy grounded in the feminine principle. Archetypal foundation of the therapeutic process, Wilmette, Illinois: Chiron Publications. Yalom, I.D. (2002) The gift of therapy: an open letter to a new generation of therapists and their patients, New York: HarperCollins.
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