The complete title of this book is The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. I found it on Jacob Ham’s book recommendations; Ham is a clinical psychologist based in New York City. Ham has a big supporting role in Stephanie Foo’s, What My Bones Know, a personal memoire by an Asian American woman dealing with complex trauma. Perhaps I will write about that book in another post. I’m not going to go into complex trauma here, but I will in a future post. I’ll also go into Jacob Ham in a future post because he is a GOAT. (Aside: future posts are stacking up as I begin my first post for my brand spanking new mental health blog. I will also go into the development of the site in another post. So four future posts on the board.)
There are a lot of pearls in The Gift of Therapy. But the biggest, roundest, most luminous pearl is Dr Yalom’s therapeutic method he calls the “here-and-now.” The idea goes like this:
Most patients seek out therapy when their relationships are going badly. They come into the office with problems, past or present, with their spouse, partner, kids, boss, co-workers, neighbors, parents, classmates, etc. Rather than working to understand the behaviors present in those relationships, Yalom believes understanding the behaviors arising in the the relationship with the therapist while in session–behaviors that will necessarily and inevitably be the same ones of concern in those relationships outside the therapy office–offers the most fertile material for healing.
According to Yalom, the dusty idea of a patient talking endlessly about the past or even present relationships outside of the therapeutic space is not where therapy is most effective.
Take myself, for instance: I sought therapy in mid-life because I was having serious marital issues, my relationship with my kids was want of peace, and my parents were either estranged or painful to deal with. I was also fairly new to town living in a neighborhood with large lawns and no sidewalks. So I was lonely. All relational stuff.
By the time a patient makes that call and books an appointment with a therapist, she is past just blaming other people for her discontents. She correctly speculates about her role in her unhappiness. What’s going on with her? she wonders. Why does she alternate between feeling anxious and angry all the time? Why does she keep trying to fix her husband’s problems? Why does she repeat herself ad nauseum, doing her best impression of a shrew, and then hating herself for it? Why does she lose her shit and yell at her kids when she really doesn’t want to? She decides these questions might be worth answering.
So there she is with her new therapist. She’s about to begin an incredibly intimate relationship with this person, because she’s going to tell him (I’m going to use he/him here since I’m talking about myself in the second person with she/her pronouns) things she’s never told anyone. He’s that good at his job. According to Yalom, the therapist, in return, holds the patient in unconditional high regard. He likes his patient, enjoys their sessions, treats her as an equal in their therapeutic relationship, as partners in her treatment. (Aside, I will write a future post about how I found the right therapist for me.) He listens carefully to what she says and, more to the point, he observes her affect even more carefully.
Now, when the patient enters the therapeutic space, she brings with her a lifetime’s worth of behaviors she automatically deploys. In the case of a person struggling with complex trauma, most of these behaviors will be in service of helping her feel safe. She cannot help and has no control over it (yet) as a complex trauma survivor. The key word is “survivor”; these kinds of behaviors were learned as a child in order to survive her traumatizing childhood.
“Here-and-now” therapy begins the moment the patient walks into the room. Say you’re the therapist and you notice that the patient comes in and barely looks around, sits down without being asked where to sit, doesn’t take off her coat, and spends the first ten minutes avoiding eye contact–all fertile information for a good therapist. As the therapy progresses, the patient deploys one behavior after another from her big bag of behaviors (BBB). Some people call BBB “personality.” The therapist listens and watches how she expresses hurt, anger, pain, joy, pleasure, fear, boredom, etc., and gets to know her “personality.” When, not if, her behavior one day is incongruous to the emotion or situation unfolding in the room, he eagerly takes the opportunity to provide corrective responses and/or offers alternative interpretations/behaviors.
A therapist must be able to do 3 things simultaneously:
1) pay attention to the behavior, the affect and word choices, of the patient without judgement, at least not the judgmental kind.
2) be aware of their own behavior, their affect and words, simultaneously.
3) recognize where the incongruity/disharmony/conflict lies in the interaction of his behavior and the patient’s behavior, and address it with the proper intervention.
Most of us live our lives barely aware of what makes us tick. The amount of effort it takes to become more self aware is an enormous undertaking for the patient. The amount of education, training, intelligence, stamina, goodwill or love, and effort it takes to be self aware and aware of the other and aware of the dynamics between them and attempting to heal the broken dynamics as it arises in therapy, is the work of the therapist.
Allow me to illustrate the “here-and-now” method in practice.
Exhibit A: My maladaptive behavior of never wanting to appear stupid.
Instead of speaking and behaving authentically, I script dialogue in my head to impress others. This necessarily means I am not being honest, fully present, and experiencing the other person as is. I am interacting, not with the person in front of me, but with the person in my head, creating scripts for that person in my head. I am not even me. I am the me in my head talking to the other person in my head. I am disconnected from both myself and the other person. Full, honest, authentic engagement becomes impossible as a person who is always looking to look smart out of fear of looking stupid.
A good therapist would observe me waxing on about a book I read recently by this psychotherapist named Irvin Yalom. She would notice that I list several other books he has published, and provide a brief biography on the man. Then I launch into a summary of the highlights from my reading. The therapist notes that my voice drops to a lower frequency when I give my book report, adopting a pedantic tone. I look off to the corners rather than make eye contact, use a lot of multisyllabic words, always bringing my tone down at the end of a sentence to mark my period of expertise.
She, the therapist, interrupts my lecture when I mention how Yalom asks his patients near the end of a session how they feel about the session. She asks me how I feel the session went. I immediately recognize that she is doing precisely what Yalom preaches: find the issues arising for the patient in the “here-and-now”. After a pause, I tell her I feel like I need to impress her and not bore her, that I feel there is a power differential between her being an older white woman, with knowledge and experience, which I don’t have, giving her authority over me to reject me if she decides I’m boring and stupid. The way I deal with this intolerable state of vulnerability is to peacock my intelligence. I tell her it was the only thing that ever got me attention at home.
Then she does something she’s never done before–she discloses personal information. She tells me that she comes from a humble background, from people who would be called “white trash.” I almost guffaw, but manage to just widen my eyes. She happened to live amongst those who were much better off than she was. “Draw your own conclusions about what this might do to a child,” she says. She tells me she has undergone many hours of therapy herself. She also has dyslexia. So she doesn’t read much and prefers to get her training through video lectures. She says she’s quite certain that I know a lot more than she does about some things. I am clearly a big reader. Being older and white does not mean she is superior, it does not mean she is wiser, it does not mean she needs to be impressed.
And then she tells me that her sessions with me are the highlight of her work right now. She looks forward to our sessions together, finds me not at all boring, and my progress with her has been personally fulfilling. She believes that she has as much to learn from me as I do from her, and already has plans to help me in my career as a therapist. It’s part of her bigger purpose in life, guided by her faith, of passing it forward.
In the 47 years of being alive, I have never been seen this clearly while being accepted so completely at the same time. I burst into ugly, grateful tears.
I know from reading interdisciplinary material that this experience is being recorded in my brain and my body. A new pathway to being with another person has been mapped, faintly with only two sets of footprints, but mapped nonetheless. This is therapeutic progress. Through my relationship with my therapist, I experienced a new relational model in place of the trauma based relational model of people pleasing.
But old habits die hard. Being shown a new way of relating once or twice isn’t enough. I have to go out there, be vulnerable by being authentic with other people, and then live with the consequences, then do it again and again.
What happens in the therapist’s office is a microcosm, a laboratory of what needs to happen out in the world. I have to do the work outside of therapy to deepen and widen the new behavioral pathway that eschews trying to please people with my reading list. While that goes on, the old trail paced over a million times since childhood– because that was the way I could get some attention and respect from people, including my parents–gets less and less traffic, and eventually becomes overgrown with weeds and, at last, disappears. Also known as healed.
One trauma behavior down . . . .
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