"Knowledge, Know-how and Being in Psychotherapy"
This article was first presented at the 1997 Annual Conference of the Quebec Society of P rofessional P sychotherapists, it was a response to the question: What a re the attitudes, skills and talents of an experienced therapist? I wondered how to speak without saying what’s already been said, how to talk without pretention or vanity. I fell back on the only thing I knew, what I do. I sought to trim my thoughts to the bare essentials. I was forced to confront my own limitations, reject any comparison with other approaches, avoid the temptation of grandiose theory and take the risk of exposing myself before my peers. I wrote the text in one swoop, then re-read it to assure myself that the words resonated within me. I wondered how my colleagues would receive it: as a jumble of mundane precepts or the profound simplicity I was searching for. Moved, my colleagues encouraged me to share it with others.
I am a Gestalt therapist. I can only speak for myself. I work with a set of assumptions.
Knowledge dictates know-how and the quality of the latter depends upon our being.
For myself, the only meaning in the universe is that which each individual gives.
Life is a series of processes with distinct rhythms and cycles.
All heathy organisms tend to satisfy their needs in the search for a new equilibrium.
We exist in relationships with others whether we are aware of this or not.
We are who we are for better and for worse.
We are responsible for what we think, do, say or feel.
We are limited by our genetic codes, the boundaries of our skin, our training, the inevitability of our death.
What is, is. What was, was and will never be again. What counts is what is in front of us, here and now.
Things happen; no one’s to blame.
Only in accepting what is, including our worst qualities, without judgment or reserve, can an opening occur to permit the new to emerge.
Commitment is the only worthwhile response I’ve found to existential anxiety.
Clients come to therapy because they can’t support themselves in their environment; they feel they can’t be faithful to themselves in relationships with others; they feel bad and they want to feel better.
I credit the client with intelligence, that they know in their heart of hearts what is best for them. They have avoided it, rejected it, buried it or forgotten it.
The client is fundamentally healthy, their decision to enter therapy is a sane response to his felt need.
Each client has their own unique experience, values, path and rhythm of change.
They have every right to be wary, hesitate, take a step backward, remain mute or leave therapy if they want.
I focus on the obvious and the emerging.
In the first telephone call, I’m all ears as the client reaches out to me for help, and I open myself to how they do this.
In the first session, I listen to their story, what brings them to therapy, the emotion behind the words what is important to them, the meaning and labels they apply to their experience, the reasons they offer for their illness, the degree of responsibility they assume, and also for everything they have done to alleviate their suffering, because it hasn’t worked.
I establish a therapeutic contract in order to give them responsibility immediately. I’ve learned to ask what they want, how they imagine themself being well, the potential impact on their relationships, the time they think it will take and how they conceive their role. If I consider their vision unrealistic, I say so.
I also establish a secure frame for our work as a symbol of our mutual commitment: the time and frequency of our sessions, the fee, and the appropriate notice for cancellation. When I take a vacation, I give notice well in advance, so the client can take my absence into account.
In session, I listen to what they say, for what’s missing and the dominant theme. I’m interested in their tone of voice, their posture, gestures, how they walk, sit, stand, hold their head, how much effort they make, whether they flee or hold on to me at the end. I’m interested in their capacity to feel their body, perceive the environment, identify their needs, mobilize their resources and fulfil their goals, and everything they do to interrupt this natural process. I work to help them admit what they feel, to realize what they do, to speak from the heart, move in harmony, think with feeling, and here I’m interested in what I may be doing to obstruct it.
I enjoy working on the pre-verbal level to offer a respite from the analytical, logical narrative which I don’t consider contactful: dream-work, supporting excitement, asking clients what
sensations they feel when they label an
emotion, to mime in a gesture or posture a feeling they can’t identify as theirs.
I support honest and genuine expression and confront the phony and the self-defeating. Here I listen for the deep needs often expressed in a twisted fashion. I work with polarities to re-establish equilibrium and natural functioning.
If they invoke an error of their past expecting punishment or absolution, I’ll ask what they’ve learned. When they interpret, I bring them back to the facts. If they propose an action in violation of their values, I ask them how they’ll live with it. When they blame someone, I may ask them to put themself in the other’s shoes. When they talk of being rejected, I ask how they rejects others or themself. I can ask them to exaggerate a gesture, an attitude, a twisted posture, or just to make a little less effort.
When they ask me to interpret their dreams, I invite them to describe, in the present tense and in the first person, the dominant objects, person or atmosphere. Sometimes, for emphasis, I suggest they add the phrase: “and
this is my existence”.
When I judge a reaction excessive, I’ll question what situation it reminds them of; the same thing when there’s transference. If they ask me a question, I’ll ask them to state what they’re
thinking. And when I choose to
respond, I do so honestly without a sugar-coating.
If they find their grief unbearable, I may share my own and let my own sorrow show.
If they’re incapable of identifying an emotion, I can whisper a word or suggest they paint their feelings.
When a client weeps for a dying loved one, I ask when they’ll cry for themself.
When a client expresses guilt, I’ll check if they feel resentment.
When they forget something they’ve said in a previous session, I may recall what they once shared. I indicate when they’re back in the past, or anticipating the future. When they seek to control everything, I remind them of the forces beyond us.
If I’m touched or bored I’ll say so. If I’m feeling angry, powerless or incompetent, I can choose to tell them how I feel. I share the messages I hear from them. If an image crosses my mind, I’ll evoke it. And at an opportune moment, I can ask a probing question.
Although trained in Gestalt games, I use them sparingly. I may employ the “empty chair” to initiate dialogue between clients and rejected traits of their personality or in situations of interpersonal conflict so they realize how they project their disowned parts onto others.
Often, I ask my clients if they will simply accept the existence of a feeling or a fact. Often, they aren’t able to. Then I ask if they’ll accept the fact that they don’t. Usually they do, and it’s the beginning of change.
But mainly, it’s in the silence between us that the client turns inward and feels what’s going on.
My role as a therapist is to help my clients relieve their suffering, this implies both personal discipline and professional ethics on my part.
Clients with psychosomatic symptoms must have a medical exam; the same goes for the clinically depressed, in order to eliminate organic causes.
If I find myself repeatedly stuck with a client, I’ll go for supervision. If I don’t feel I can help a client, I’ll refer. I take care of myself in the session. I’m attentive to my own physical sensations, I’ll get up and go for a glass of water if I’m thirsty. I take at least a half-hour between clients to make notes and disengage in order to be ready for full contact again. I question my need to be a therapist. And I work at increasing acceptance of my own personal discomfort.
Empathic listening, yes, but not at the expense of my own mental health. Compassion surely, but tailored to the needs of the moment.
We are who we are for better and for worse. Human beings aren’t perfect. Therapists neither, nor need they be. The capacity to commit oneself is sufficient. When we are deeply involved with our clients, our presence is refined, our errors seen clearly, and any need for reading, supervision, additional training or personal therapy emerges on its own.
When I try to be a good therapist, it never works. It’s stilted, the session goes nowhere. And the client ends up feeling shitty, believing it was their fault.
When I accept my nervousness before each session, I tremble with cold and have the impression that I’m opening to what is possible in the hour to come.
I work in a therapeutic frame: a fixed period of time, limited by my experience, my training, my personal shortcomings, with fragmentary information. Yet, I’m there for a purpose.
Faced with a client, commitment is the only response I have: to invest my energy and feelings, and risk my being with them. Doing so I confront my own values and therapeutic assumptions. In sharing, I call upon the client to do likewise: to say out loud what they think within, to share their hopes and fears, and bear the unbearable. Somewhere we are partners in the same quest.
Insofar as I accept the course of my life, my own rhythm of change, my worst qualities and my own difficulties in living, there is a possibility that my client will come out of hiding to meet me, heart to heart, in that space between regret and fear, that is called therapy.
“To take to heart”, demonstrated Heidegger, is “to take things as they are, there in front of us, here and now, the presence in the present.”
This paper was printed in »Cognica«, the journal of the »Canadian Guidance and Counselling Association« (November 1997), in »Guide Ressources« (Oktober 1997) and in »Psychothérapie Québec« (January 1998).