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In This Chapter:

The Four Seasons of Therapy

The Participant Observer Dance

Discovery and Behavior Change

Chapter 6: Following the Flow

 

This chapter will examine four ways to follow the flow of sessions. Each schema will be useful at times.

 

1. The Seasons of Psychotherapy

Each session has its seasons. In an earlier chapter, the Three Step Dance provided a method for following the flow of the session and reacting according to the state of resistance. Using the seasons as a metaphor will help to identify different "seasons" and the changing role of the therapist. In the springtime, when knowledge was flowing easily, it was time to stay quiet. When fall came and the flow was bogged down, it was time for intervention, and when the patient entered a wintery freeze, it was time to be conciliatory.This works for cycles within the session, but also describes phases covering weeks, months or even years.

Spring

When the patient is bringing new data and what you hear has the delicate quality of fresh, crystal clear material, it is important to think to yourself, "Oh, this is Spring, and it is time for a very light touch." The patient is feeling safe, and as a result is taking extraordinary risks. Paradoxically you may experience impulses to say or do something that will stop the flow. Now is the time to listen intently with a very open mind. Spontaneous thoughts that come to you will provide an interesting stream of associations, but this is a time to observe, and probably not the time to be too intellectual or to draw conclusions.

Summer

After a while, the flow may slow and move into a more thoughtful mode where understanding is consolidated. The material is not so fresh. Patterns are being identified. The patient notices that his or her current reaction is similar to one you had already noticed. It is time to put things together, to draw conclusions. You can both be active in organizing, comparing and making sense of what you have learned. Traditionally this might be called a "working through" phase. The work is positive and productive, but no longer bears the delicate, fresh quality of new material.

Fall

This is when you notice a slowing in your progress. Your understanding is no longer expanding, nor do you feel so clearly what the patient is experiencing. In short, you have begun to encounter resistance. At first, you take note of what you experience and ask yourself what is interfering with the flow and why that might be. Perhaps the patient has become abstract, so you no longer can catch the feelings. Perhaps the material is repetitive and does not give you anything new. Or it may be that the patient seems to be focused on something irrelevant. Before you conclude that the latter represents resistance, open your mind to the possibility that what seems irrelevant really isn't. Is the material fresh but different than what you expected? When you are clear that the process is bogged down, then it is fall.

Again, it is time for a gentle "nudge" to see if that gets the patient back on track. If not, it is time to share your observation that something is impeding the flow. Now your metacommunication will have started you both on the exploration of resistance. The subject is new, and you may move right back into springtime, but you may also experience a prolonged struggle to resolve a more entrenched resistance.

Winter

I often think of a patient who for at least a year felt that I was a very poor therapist. She thought that my responses were drab and textbook-like, that I wasn't up to the job and didn't really care anyway. Being fairly sensitive to the way I am perceived, I was not at my best. We struggled along. I used metacommunication. I tried to put into words the way she felt about me. She would usually deny her critical thoughts, but her manner expressed her attitude very clearly. Little progress seemed to be made, but she continued to come to sessions.

It was a classic negative transference, I became the recipient of her rage at her mother. She had never been able to express this rage, because her mother was too fragile to handle it. She saw me as too weak as well, and held back her feelings on the assumption that I wouldn't be strong enough. Her rage gradually leaked out anyway. Two things made this long winter successful. First, I regularly interpreted her feelings towards me, making for tiny increments of cathartic healing of the rage. Second, my persistence showed a kind of strength that ultimately made it clear that her rage was not actually destroying me.

One day, Spring came. Without much discussion, she decided I was not so bad and accepted me as I was. She began to listen to what I had to say, and to be more open, herself. A few months later, she was ready to leave therapy and has continued to do well since.

 

2. The Participant Observer Dance

Patients are always tugging at their therapist. Without realizing it, they have their own understanding of how you can help, and it is usually as a human being, not a therapist. When the patient's agenda clashes with the agenda of the therapy, we have a different kind of resistance. It is one that doesn't always have the autumnal feel described above. Freud first noticed that patients seemed to prefer acting out their neuroses, rather than remembering or understanding them. Similarly, the there may have a transference plan in which the patient has a secret alternative for feeling better, where the therapist is the designated agent of change. With no conscious idea of the unconscious roots of his or her plan, the patient sets out to recruit the therapist. Often this involves influencing the therapist to be different. In the example above, my patient wanted me to be stronger than she thought I was.

Freud called this new form of resistance, "transference resistance." He found that resolving it was fully as helpful to the patient as any other kind of healing. In fact, the essence of psychoanalysis came to be identified with the development and resolution of transference resistances.

Harry Stack Sullivan gave one of the best conceptualizations of how this actually feels and plays out. He described the therapist as a Participant-Observer. The patient tugs on you to participate in his or her hidden agenda. At first, you only have a vague sense that the patient wants you to behave somehow differently. Perhaps the patient comes up with a personal question or request that seems minor and insignificant. Neither of you is aware that this is the first step in carrying out a plan. Whether you do what the patient wants or resist, you have become a participant in the patient's struggle. You are forced to be an ally or an antagonist.

As long as the action remains underground, unspoken, not recognized, then you are a participant. Once you are involved, the intensity of the struggle will increase until it becomes apparent to one or both of you. When you realize that you have been drawn into a transference resistance, you have the special prerogative of returning to the observer position. All you have to do is employ metacommunication, otherwise known as interpretation. This is exactly the same metacommunication that worked for other kinds of resistance! When you begin to speak about the tension between yourself and the patient, you are no longer a participant. You have returned to your role as an observer.

During the therapy, you will go through cycles of being drawn into the participant position untill you realize what is happening and return to the observer role. With each cycle, you will both learn a little more.

It has been noted that therapists who try too hard to remain "neutral" and disengage from the therapy will prevent the transference from developing. The recommendation is to loosen up a little and allow yourself to be somewhat engaged. A more accurate way of looking at it is that aloofness is another form of being a participant. You are saying that whatever the patient wants from you, you will refuse to give. In the face of this active antagonism the patient will either quit treatment or take his or her plans deep underground where neither of you will see them. On the other hand, your active engagement as an advocate and helper in the treatment process does energize both the conscious work and unconscious agendas. More on the therapist's stance later.

 

3. Periods of Discovery and Periods of Behavior Change

At the beginning of treatment the emphasis may be more on gaining understanding of the entrenched dysfunctional patterns that afflict the patient. As you gain some understanding and have a strong working hypothesis, you may find a prolonged phase in which the action takes place mostly outside the sessions as the patient works on incorporating new behaviors.

One of the clearest examples is in work with trauma survivors and those who have had severely disadvantaged early lives. Learning to treat themselves as valuable is a long, hard job. The action consists of adopting more positive behaviors, resisting the tug of internalized negative attitudes, and in doing so, laying down new, more positive attitudes. At each stage of this process, feelings are generated that are subject to cathartic healing as the patient shares his or her struggle.

Working with patients during phases of behavior change feels more like coaching than traditional therapy. Without the motivation, education, and encouragement, progress would be slower, or the patient might lose heart. Persistence is key. The frequency and even duration of sessions may be reduced during this phase, but being too eager to do so may result in backsliding.

Assuming you are successful, then as the patient is more successful in life and the stress level is down, if you are alert to it, you will begin to see five-year-old agendas appearing. As survival is more sure, the patient will begin to seek to fulfill desires that have been held in secrecy. Even at the end of what seems to be a successful therapy, there may be a new phase of discovery and resolution of early wishes and plans.

 

4. The "Grow Graph," Predicting Problems During Rapid Change

This paradigm pertains most to periods of behavior change. The model is often accurate in predicting reactions to stress that happen when things are going well and patient and therapist least expect trouble. It was originally developed to describe early recovery from addictions, but is true about change processes in general. The grey curve describes current functioning. Starting at the "comfort zone" at the bottom of the curve, the patient's stress is at a minimum. Changes in behavior towards more healthy behavior or regression to less healthy behavior are equally likely to lead to increased stress. Pushing too hard into healthy behavior will cause the recovering addict to relapse. Encouraging frequent forays into the "grow zone" where moderately healthier behaviors are practiced, results in lasting change through internalization of new values and attitudes.

When patients retrogress in functioning, they experience stress. They typically become angry, irritable, and agitated. It is very helpful to be able to identify this phenomenon and its cause. This is the typical picture of the "dry drunk." Below is a discussion of how successful treatment results in movement of the curve to the position shown in red.

The effect of long term growth is that the curve shifts down and to the right. This means that the patient's "comfort zone" is even more comfortable than before, and is associated with a higher level of healthy functioning. The same challenges remain but at a different level. What underlies the graph is the fact that our sameness is held in place by internalizations, and these always require hard work to modify.

Backlash: An important use of the Grow Graph is to educate patients to the dangers that accompany positive change. These reactions can be manifested in many different ways. They may be in the form of anxiety or depression but, in our action oriented culture, they often show up in the form of impulses to do something destructive and "good ideas" that turn out to be self-defeating.

Control: Additionally, the Grow Graph helps patients to understand that they can control the degree of stress they experience in therapy. Slowing the adoption of new, healthy behaviors is useful when stress is too intense. I have sometimes used "miles per hour" as a measure of the rate of change. The feeling of going 90 miles per hour is a good metaphor for how therapy feels when it is going dangerously fast.

Rest and Regroup: Finally, the Grow Graph is a way to illustrate the fact that continuous change is not possible or desirable. Humans function best when periods of growth are interspersed with time to rest and regroup in the comfort zone. Different people self-sooth differently, and may find comfort in different circumstances. With the active therapist encouraging risk taking, growth and change, it is very reassuring for that same task master to acknowledge the patient's need to rest.

 

Conclusion

By recognizing and following the ever changing seasons and phases in the therapy, you will be alerted to your appropriate role at any given moment. You will develop a repertoire of responses and habits so that eventually your awareness of the season will fade into the background. It is always important to recognize what season you are in, and whether you are acting as a participant or an observer.