Tales from psychotherapy in practice
Tales from psychotherapy in practice.
On 2nd October 2015, David Taylor, Clinical Director at the Tavistock, was interviewed on the BBC Radio 4 Today programme about the recently announced outcome of a 10 year study into the efficacy of psychoanalytic psychotherapy compared with UK/NHS NICE recommended treatments.
Asked to sum up what this kind of therapy involves he replied “it is not passive … it is a joint endeavour by the patient and the therapist … and that is to do with understanding the experience of [the patient] and finding meaning in what is being experienced”. Put on the spot to say something succinct and understandable in a few seconds, I thought this was an inspired summary of what we do as psychotherapists.
The two books reviewed here, one by an existential psychotherapist the other by a psychoanalytic psychotherapist, are both about that search for understanding and meaning in our work with clients. Both talk about how often we are left with not knowing if or how we have helped and the nagging feeling we could have done better if only we knew what that was.
Creatures of a day by Irvin D. Yalom, Basic Civitas Books. Pub date: March 2014. 224 pages.
Now in his golden years (his description) Yalom has lost none of his touch as a writer, teacher and therapist. I enjoyed this book as much as any of his earlier case history compilations.
Over ten chapters consisting mainly of dialogue with occasional, minimal commentary about his private thoughts and concerns, he allows the stories to tell themselves. These all show clients grappling with existential issues that require from the therapist a humanistic, holistic approach and the flexibility to identify and adapt to the client’s needs.
There is only a glancing reference to theory in the Afterword where he says he hopes this book will be helpful to novice therapists in counteracting the prevailing trend toward therapies which consist of “highly specific techniques addressing discrete diagnostic categories” (pg 210). So definitely not a ‘one size fits all’ or ‘how to’ manual.
The book is potentially useful to any therapist as well as the lay reader. I certainly found it immediately helpful in suggesting ideas to keep in mind with some of my current clients. Best of all though for me was reading about where he breaks the rules and where he messes up – bare knuckle rides, pratfalls and all.
He illustrates repeatedly that we may never know how we have helped someone and that we must learn to live with the mystery. Being Yalom he also constantly reminds, through modeling in the dialogue sections, the value of using the ‘here and now’, checking in with the client about the state of their relationship.
Like me he enjoys and encourages a playful relationship with clients and I appreciated his examples showing how this can enliven therapy, making it more real and present, allowing the client to speak truth. For example, at a break in a heavy talk about us all being on the path to death, he asks the client how she’s doing and she replies “a few more healing sessions like this and I’ll need to go home by ambulance!” (pg 49).
Then there are incidents of rule breaking where I’m thinking “oh, no you didn’t really do that?!”. Such as pressuring a client named Alvin into agreeing to a home visit in order to discover what was preventing him from allowing people into his life. This was decades before reality TV shows about extreme horders and what Yalom found there shocked him. Alvin stopped therapy abruptly and Yalom was sure he had messed up badly. Then 30 years later they met (Alvin now happily married with a grown up family) at the funeral of a woman called Molly, a household organiser. Yalom had forgotten that after the final session he had phoned to suggest contacting Molly to sort out the mess. Now he was told, by a very grateful Alvin, that their sessions and Molly’s ministrations had turned his life around. Yalom was left with his mind swirling with thoughts “about the impossibility of ever learning how psychotherapy works” (pg 80). Yes, indeed!
The book title comes from The Meditations of Marcus Aurelius, a second century Roman emperor, who dictated daily his reflections on how to live a virtuous life. During a session Yalom quoted from this book and suggested the client might read it, while muttering to himself that he knows such suggestions are seldom helpful and often a bad idea. It did nearly backfire with this client who liked to retreat from the difficulty of the matters in hand by engaging in theoretical dialogue. But finally he did become inspired by The Meditations and resolved to make changes, saying “every morning he [Marcus Aurelius] took himself more seriously than I have ever done any morning in my entire life” (pg 204).
The Examined Life: How We Lose and Find Ourselves by Stephen Grosz, Vintage. Pub date: January 2014. 240 pages.
Grosz, an American who trained in London, has worked here as a psychoanalyst for 25 years. In the same number of pages as Yalom, he publishes 31 ‘episodes’ covering a wide range of issues including change, loss and alienation from self. His presentation style is the mirror of Yalom’s in that his ratio of dialogue to commentary is about 20/80, with much shorter but still satisfying case histories describing the understanding gained through the to and fro of client/therapist conversation.
Like Yalom he doesn’t refer explicitly to theory or diagnostic categories, rather each story illustrates individuals with unique histories and reasons for how they are now. He says he was gripped early in his career with the idea that we can become disconnected from ourselves, something he discovered initially about himself during training therapy and finds here with some of his patients.
Grosz also makes occasional references to a book or quotation prompted by something in the client’s story. One which caught my imagination being the short story of Bartleby by Herman Melville first published in 1853 (page 126). With the unwitting collusion of his over caring employer, Bartleby gradually stops working and gives up all effort and responsibility for himself. He increasingly responds to entreaties to action with ‘I would prefer not to’ while his employer becomes increasingly anxious for him. Eventually, he even prefers not to eat and dies of self starvation. For Grosz it’s a gripping illustration of how if someone else takes responsibility for our anxiety they risk taking away our motivation for change. This story also illustrates something we all experience when two competing inner voices say ‘let’s do it now’ and yet ‘I would prefer not to’. Such procrastination may be about something vitally important to explore, as happened with Grosz’s client in this episode.
I particularly appreciated Grosz’s penultimate episode where he challenges the notion of bereavement closure and “the tyranny of shoulds” (page 208) derived from the proliferation of self help books. This so often causes the bereaved person to suffer more because they’re stuck on the idea of closure, which mostly doesn’t happen. He points out that Kubler-Ross’s grief stages were originally about the process of dying, only later becoming the inspiration for the widespread notion that we can permanently end our sorrow while we continue to live. This idea has taken hold even though we know it seldom accords with our experience of bereavement. We have the possibility to suffer the pain of loss repeatedly until we die. It may return less frequently but can still be as raw (or more raw) when it returns, often unbidden like a thief in the night. And it can change, as for example when we are old and feel deeply sad in a different way for someone who died tragically when they were young. I find clients are hugely relieved when I suggest this alternative view of bereavement and encourage them to accept the loss into their life story – making it ‘mine’ – written deep inside for ever like Blackpool rock.
In his final episode Grosz talks about remembering long gone patients and yearning to reach out to them, to say one more thing, to get it right this time. I know that feeling!
In conclusion, I enjoyed both books and recommend them for anyone doing psychotherapy, whether psychodynamic or existential. They relate recognisable tales of the everyday situations we encounter with clients and our struggles to help them. Both writers discuss things they have found bothersome which is always interesting and instructive. Neither focuses on theoretical framework, they use simple everyday language which is a good model in itself. What came across for me was their passion and commitment to being as good a therapist as possible for each client, and their wisdom in acknowledging we never really know what that means.
Their presentation styles are different, such as their choice of dialogue/commentary splits. So that Yalom’s longer and dialogical chapters provide exemplars for therapeutic practice whereas Grosz’s brief episodes encapsulate and make memorable insights into a wide range of typical client dilemmas. Both approaches have their merits. Most importantly, these books worked for me in stimulating reflection on my way of working and development of my internal supervisor which I think is the main purpose of this genre.
 Details about this study are available on the internet : ‘Adult depression study (TADS) | Tavistock and Portman‘; and ‘Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: the Tavistock Adult Depression Study (TADS) – Fonagy – 2015 – World Psychiatry – Wiley Online Library‘.