Honesty and the Therapeutic Alliance

     I believe that I have written before on the subject of therapeutic relationship and its central nature in any therapeutic endeavor. Today, I am going to write about the crossover between therapeutic alliance and honesty.
     Honesty in therapy is, I think, a different topic. When I write about it, I am not necessarily writing about bluntness. Instead, I would rather discuss the use of honesty and its use/misuses right now. Honesty, I think, comes up very much when a clinician is asked questions. We are told/educated to be wary of questions. I don't disagree that some caution should be shown; I guess my main problem here is when you have an honest response, but it might be detrimental to therapy. Frequently, instead of answering the question, we choose to process it to hell and hope that the client forgets that he'she has a question. Heinz Kohut remarked at one point in his life that it is impolite not to answer a question.
     Not answering a question can inhibit a relationship because it can lead to an assumption of dishonesty, backfiring the processing response. Answering a question, even after some processing, can lead to a negative response, as well. A clinician does have to be careful, but to lie shows infidelity, to some degree, to the client. Processing out the reaction after the answer can very much strengthen the relationship.
     I guess one of the main things that I am trying to say here is that there is a direct relationship between honesty and the relationship. When one is strengthened (relationship), the other can grow. At the same time, the more one is honest, the stronger the relationship  may grow. There is a balancing act that takes place here . . . one that is very essential to future work. If one is too honest (or blunt, I guess) too soon, he risks, in a real way, the suffering of the relationship. I guess that this is the clinical implication of bluntness. This might happen when a therapist is burnt out or when their empathy, for whatever reason, is low during a session. The phrase that pops up in my own head some days is: "Well, let me tell you what is going on here." This is the language of interpretation. The difficulty with this is knowing when not to "give the truth." We must, obviously, be as intelligent as possible about when we us such means.
     As previously mentioned, a counselor must be honest with his or her client, especially when answering questions. Malingering must be remembered as things that take away from the amount of data processing space between the two members. If an honest answer leads to some problem, as mentioned, it is appropriate to process the disconnect. It is very important here to remember that apologizing should only be used when a real misdemeanor has been committed. It should not be the go-to response. What does frequent apologizing  do but attempt to push the relationship backwards in time with the unsaid understanding that that is bullshit. An apology, or a string of them, can only function as a weak "coping mechanism" for the relationship. Apologies aside, processing out the issue forward the meta-curriculum of honesty for the relationship. I have already been in situations where I have committed some unknown social slight, which led to a good lesson for me about cultural matters. Such a lesson could not have been learned without process willingness

Core Rules of Therapy

     I have been thinking about the topic of core rules for therapy for some time. Perhaps better said: I have been thinking about core rules for how I do therapy for some time. There are definitely some principles that I think are at the very center of how I practice. What I hope to do is start an on-going group of entries that will serve to illustrate this idea.

1. Silence. It is my understanding - both viewing my own experience and what I see from others - that clinicians always want to talk. For the beginning therapist, silence is scary, as it might show weakness or perhaps give the client and therapist a chance to think a problem through to an un-therapeutic end. Silence, when done correctly, can increase rapport between parties, because it allows the client to take charge of their own thoughts in an environment that might seem under the control of another party: the therapist. It also give the therapist, possibly, time to think. Some beginning therapists equate silence with incompetence; they end up saying something half thought-out than a thought of real worth. As we are in a profession that holds intent of action in the highest regard, does it not make sense to be able to think properly about a response that is appropriate, rather than electing to engage in a random jump of (il)logic?
2. Not everything is about you. This can be meant in a couple of ways: 1) We can mean that the actions of the client have much less to do with us than we might think and 2) we might mean that we are in service to others in a session - not ourselves. Being myself, both of these sub-topics took some time for me to really internalize (if I even have) and I still need to remind myself of these lessons regularly. Let us go into the meaning behind the words. I will attempt the first hurdle. It is simple to be overreactive and hyper-vigilant in the beginning of our careers. We are attempting, I hope, in this time, to build up a bedrock of skills and techniques that will allow us to forge ourselves into the therapists who we wish to become. This leaves us open and vulnerable to others. As therapists, there are almost no peoples more important in opinion to us as our clients. Were a client to say: "You are a bad therapist," it would crush us. Whether that is a wholly helpful reaction or not is not my goal here. This bedrock that we have created has been cracked, allowing more doubt to leak in that is normal. Am I doing my job well? Is this the correct line of work for me? These are logical questions that we ask ourselves in this situation (well . . . as logical as the reaction as a whole can be). We fall into a classic blunder that we ask our clients not to enter: mind-reading. We attempt to exorcise thoughts from our clients' heads through mind-voodoo - that is, without actually asking. Were we to ask, a good conversation might result about the match between client and therapist or the events that transpired that pushed our client to say such a thing. Allow me to get away from the previous example and posit another: A client and therapist have a good session (in the therapist's estimation). The client does not present at his/her next session. The therapist might go back over the mental notes that he wrote to point to a reason. He might find no reason. Either way, the clinician is allowing an unknown to control his behavior, possibly impeding him from acting in therapeutically advisable  manners to following clients. When the therapist asks the client over the phone about the situation, he learns that the client had a family emergency. A situation that, in reality had nothing to do with the clinician, had everything to do with him in his own mind. This shows real weakness or deficit or [insert non-offensive term here] that that clinician must analyze. The reason: Such a circumstance occurs frequently. The answer: address it, if possible, and if not, let it go. This, of course, comes from time and possibly outside therapy. This writer does want to mention that a pitfall occurs here for some people. I myself flirt with it from time to time, but not much (which will lead nicely into my second sub-topic in a moment). We must ensure that we do not trip into a lack of caring as an overreaction response to the too-much-caring that we previously felt. As previously mentioned in this work, moderation is normally the best option. It is of highest priority, when working with a client, to consider them. When I use the word "consider" here, I mean that we must consider all parts of them, including their words, body language, look that day . . . everything. To really consider someone requires one to see past themselves. I would like to say that I do not mean that the therapist should block himself off, but rather use his or her whole self as an antenna for the use of the client. 

Compartmentalization (cont'd) and "Value Armor"

     After thinking a little more about compartmentalization, I can see one real advantage to it: it might lead to long-term resilience against clinician-side traumatic shock. If we can seal part of ourselves away from view (from both the damage done to use by a client's story and our own ideas about it), we might be more able to heal after a particularly deep shock. I am somewhat unconvinced though . . . As I tell my clients, were we extremely comfortable with ourselves, most of these traumas would bounce off of our "value armor" - that is, the natural defense anyone has who knows who they are, what they believe in, and what makes them a person. It is extremely difficult to penetrate such armor, but not impossible; even the most comfortable-with-himself/-herself person still requires patches and upgrades to their armor. Life provides us with many experiences that test our armor and it is our job to continually ensure that it can stand up to most outside incursions. Many people perform such maintenance  on their own, while others require the help of a professional to repair their chinks. For these who can self-repair, only major dents need outside help in the form of a psychotherapist.

Compartmentalization

     In my continued attempt to question all things about therapy that I have learned (which is something that I think everyone in their chosen field really should do; such action brings innovation), I will now discuss the topic of compartmentalization - something all, if not most, therapists are told to engage in. The question for this entry is: Is engaging in compartmentalization beneficial to the relationship?
     Budding therapists are told that compartmentalization is key in therapy, as thoughts about one's own life might obstruct the work occurring in the session. Is this true? I'm not entirely convinced one way or the other. As with many such fundamental principles, we must take a look at why the "rule " was at first imposed. I see two ways of looking at this: 1) the Freudian method and 2) the everyman graduate school method. I must preface  this specific talk with the warning that I am not a Freudian analyst nor a ghost mind-reader. Therefore I have not the training or the "skill" to claim what I will do. Nevertheless, I will still engage in such palaver, as this is my work and I'd like to see if/how my thoughts change the future. I'm thinking that Freud thought that any interference from the therapist is/was bad (hence his arcs into counter-transference). He wanted the client to be able to open up in any way they see fit in order to get to their own solution, rather than a solution that the therapist thinks is appropriate. This led to the stereotype of analysts' taciturn natures in therapy. I do give Freud much credit here because he is still one of the main forces behind a clinician looking into his/her own countertransference to engage their deep-seeded motivations. Unfortunately, in our effort to ensure that no countertransference exists, many therapists still do engage in a fear-oriented therapy that is more about them in the end than the client. The other way to look at this problem might be to engage it from a more modern and educational approach: How are current therapists taught (or not) to compartmentalize? I will only speak for myself in this section and what was explained to me in my own Master's-level training. As far as I can remember, we, as aspiring clinicians, were taught that whatever didn't begin in therapy room was to stay outside that room. I'm thinking that this might have been so stressed to future clinicians in order to assure that our own issues do not impede the work being done in session. Otherwise stated: We, as beginners, need to assure that the session is for the client, not for the clinician. This is a good point, but I do wonder how far this mantra should be taken.
     Now that I have explained some of the origins of this idea as I see it, the next step is to figure out what the helpful and the harmful aspects of compartmentalization actually are. Furthermore, who does it help or hinder to engage in such action? As with most "fundamental" issues such as this one, there is some give and take either way. I think that the positives (or helpful factors) in  compartmentalization really do exist more for the young, or budding, therapist than for the elder, more experienced, one.
     It is, to some extent, a learned skill to block out personal issues in life. A therapist must be able to do this while in session - or a therapist must be able to disengage from therapy completely. This is where I think a critical argument one way or the other must be had. The former forces a therapist to cut off pieces of himself - not quite the "genuine person" that Rogers spoke of. On the other hand, to not cut some of it out might lead to the session being more about the clinician than the client. This can be useful if the meta-curriculum of that session is one where such a role reversal provides helpful insight to the client. This, alas, is a more senior technique and one that I'm not ready for yet. To be able to disengage from therapy completely is a luxury that many clinicians do not have, leading, possibly, to burnout or resentments of the job. There is much healing to be done in taking some time off to process such compartments created and figure out whether they are really needed anymore.
     As previously mentioned, I do laud Freud in his idea that researching one's own countertransference is very important. It can make a clinician better at his/her job. I do worry that compartmentalization takes us away from some of our more primal parts, leading to less data from which the therapist might work. I think that there is some merit to allowing some of the walls to drop and to permit the client's message to bounce around in some of the dark corners of the self. Sure, this might bring to the surface some very complex issues for the clinician and it is here that the clinician might start the compartmentalization process - understanding that they need to throw light upon that inner conflict at some other point. To an extent, leaving these compartments up might actually lead to stagnation in the self, in the client, and in the practice in general.
     As mentioned, if a client's pain resonates personally for the clinician, it is his/her job to undergo some kind of supervision or therapy to gain insight into that issue. This leads to personal growth, bringing things that were in the unconscious to the conscious to be played with and changed before allowing it to be re-submerged into the unconscious. We put that thought back in its place to change some of the other issues around it and to achieve wide-spread health. We also put that thought back into the unconscious because we can't hold it in the conscious for very long and doing so provides us with some measure of anxiety, as we add more to our plate than what we might be used to. Putting these barriers up might actually lead to a lack of means to more productive advancement.
     One main reason why a therapist exists is as a sounding board for the client's thoughts. I always visualize this in my mind as a literal board on which clients throw their concerns. It seems to me that compartmentalizing actually decreases the surface area of this board, allowing for more good material to pass a clinician by. As mentioned, we put ourselves out there to feel with the client. In order for this mutual feeling to occur, there must be much to fasten onto, whether that is the lighter or darker parts of ourselves. I think that it is sometimes the darker parts of ourselves that resonate the most with clients. If we don't allow ourselves to be open with clients, then there is really minimal space for the therapeutic relationship to thrive and heal. I can see how a teaching program might push compartmentalization in that, were they to teach the radical openness that I am quasi-advocating for, a fresh student might take the lesson too far and over-share or not temper their sharing with experience or reason (the former of which they have minimal or none).
     This brings me to talk a little about openness in therapy. It seems to me that there is a culture of lack of openness. It could have something to do with the ideas previously mentioned or more cultural/societal fears of liability and judgment that might come of self-disclosure. We must always temper such fears with the assessment of our clients' wellbeing.

Client Responsibilities

     A very good book idea might be one where I outline not the process of therapy, but rather the responsibilities and right of the therapee. Expectations of therapy would be vital. I would talk about stages of therapy, but constantly re-inform the reader  that they must ask their therapist questions. Asking questions to and of the therapist is a client's best tool. It allows a client to shield themselves from counter-transference; it allows a client to gain more understanding of themselves - something crucial in practice; it allows the client to increase their knowledge of the clinician in such a way to increase the bond between these two disparate points.
     I think that a client must be told that his/her self is the most powerful force in the therapeutic alliance. A clinician receives and reflects only; that is, a good clinician receives or reflects with very minimal else. The clinician and the client do work together; the clinician does not do work in spite of the client. This is called psychoeducation and is not true therapy.

Appropriate Emotional Investment

     It is important for a clinician to be emotionally interested, but not emotionally invested in his or her clients. There is an important distinction here that must be mentioned in order to further the point. A clinician who is emotionally invested in clients ties a string to clients' development, taking themselves along for a ride, which depends upon someone else's motivation. This, of course, brings up many issues regarding boundaries between clinician and client. A clinician does not want to be at the mercy of the client; this might cause ripples to be felt throughout that therapist's whole practice. The opposite end is where the emotionally cut-off clinician practices - a place that does not necessarily engender good therapy and creates (possible on purpose on some level) no emotional connection or attachment with the clinician. This, just like the opposite end, can lead to echoes into other therapy sessions. So what does the middle look like? And why am I so afraid of the extremes? And how have I seen myself going into either extreme?
     Betwixt these two extremes, a clinician finds the land of emotional interest without emotional investment or dependence. This is a space where the clinician is comfortable with being present and appropriately emotional/empathetic with the client without allowing his or her personal life to bleed through into the session (non-therapeutically). To some degree, I think that it takes time to find this balance.

Arguing Against Progress

     There are many things that I am afraid of - one of the more curricular ones is the quasi-inevitable heath-death of this field. Sarcasm and hyperbole aside, the lack of forward development in the field is of huge concern. What does a lack of change really mean? It means that the answers have been found and/or no one cares anymore. A good parallel is language: language develops until another is created from its ruin or something better or more efficient takes its place. I do worry about this because I don't see as many people asking the important questions in the field and engaging in deep introspection and supervision, in order to develop themselves. This baffles and hurts me. Without each member of our field asking questions that further themselves and the field as a whole, we will stagnate and possibly start to see what we have already accomplished as enough. This would surely be the death of the field. As our culture, society, and clientele change, so must we. One could say that culture, society, and clientele will always be changing, so the field will as well. The added component here must be pride. Man is full of pride (and laziness) in his work, wanting the effect to stop when homeostasis is reached. It is important to never feel lazy in this fight. To some degree, there should always be someone who is the nay-sayer or the devil's advocate; someone who is ready to push the envelope, point out the weaknesses, or instill doubt. One could almost say that we are not looking for a Unified Theory (as this would surely mean the end of the field), but rather the continued dialogue and struggle to find that within ourselves that helps another - and surely each of us can contribute something (a lesson, perhaps) that is wholly our own, wholly subjective.
     To argue is to seek continued survival; to find perfection is to encourage death. This is odd, in that one could think that I am purposefully undermining a perfect theory - but that is the exact problem: there is no perfect theory! We each must continually question how we practice in order to be better ourselves.