Blogging on Good Therapy

by Noah Rubinstein, LMFT
Executive Director GoodTherapy.org

We named our organization GoodTherapy.org for a handful of reasons. One, good therapy is what most therapists, are striving to provide. Regardless of orientation, nearly all therapists can be included in the group of dedicated and caring folks who strive to “do no harm” in the healing process. Two, we want to express, in the title of our organization, the importance we place on quality in the psychotherapy process. Three, “good therapy” is catchy. The expression, “I (or he or she) could use some good therapy” has been around a long time. Fourth, GoodTherapy.org sounds better than www,JustOkayTherapy.org :)

But the phrase “good therapy” encourages a misconception: the idea that there is such a thing as pure good therapy, a process exempt of any problems or issues. In the same way that a perfect marriage is not one without problems, but rather one that works through problems – so is good therapy. No therapist is perfect and no therapy can be provided perfectly, no matter how ideal a therapy may be in theory. Even those of us who do the best we can to be conscious of our inner world and attuned to the therapeutic process have aspects we are unaware of, pieces of ourselves unhealed, and mistakes we make. (more…)

Written by Noah Rubinstein, LMFT, LMHC

Dear Friends,

GoodTherapy.org received an email today from a therapist concerned about one of the principles of good therapy: collaboration. I was surprised at first, but after reading her email I could see the validity of her concern and how she could be led to it by the way the definition was written. She was concerned that working collaboratively might retraumatize a person. I believe she was equating collaboration with total non-direction. I wrote her back to clarify. I thought I would copy my email here so others with similar concerns could be reassured, and so we could have a forum about it if people want to. Below is my email and better approximation to the spirit of collaboration. I hope you will add your wisdom to the discussion.

Hi Anonymous Therapist,
Your email is a gift to me… I can see how the idea of collaboration, as written on GT might mislead people into thinking collaboration is something it is not. I hope this email will begin to clarify to you what collaboration means for me and for others who work similarly. Although I have not had anyone else contact us with a similar concern, there may be others, and so perhaps I will update the definition on the website. Or actually, I may add another principle which I’ve been meaning to for a long time: Safety. Collaboration does not preclude safety…as you are concerned about… Anyhow, my thoughts are a bit scattered tonight as I’m tired from a long day… But I know if I don’t respond now other things will preoccupy me.

I hope this helps. I’m open to dialoging about this if you want. Also, I’m thinking I may add this to the blog as way to open a forum about it. I look forward to hearing from you and thanks again, Noah :)

Written by Julie Simons, LCSW

“So what do you do for a living?”

The inevitable question asked at any social gathering. Though typically an innocuous question, I find myself dreading it. This is probably due to the flash of fear I often see upon the word, “Psychotherapist.” Sometimes, people are even bold enough to ask, “So are you analyzing me right now?” Unfortunately, this is reflective of one of the many myths that continue to persist around this profession. So I’ve taken on the task of blasting some of those myths and hoping to provide a clearer understanding of what this therapy business is all about. (more…)

This Post is a promised follow up to a post from two weeks ago called “Do you believe “Personality Disorder” diagnoses are pathologizing?“  I was motivated to finish it this morning when I read a passionate comment posted by Jeana in response to the above mentioned article.  The comment can be found here, but for the sake of getting others into the spirit of which I finished this post, I will copy it here:

“I need to rant…I am so tired of therapists and doctors labeling clients PD then in essence giving up on them. I had a recent incident with a client that I have worked with for 6 months. She attempted to get more help by entering a day treatment program for her ED and was told by the MD, who had only read her chart that “with her PD and SI, [she was] too severe for the program.” Of course the client calls after 3 hours of Binging and Purging saying “What PD???” Uggg!! I talked to the MD who was cold, lacked compassion, and in my opinion was irritated by the client! Well, if you think she is PD (x3 BTW) then the last thing you should be is irritated. I can recall working in several inpt. tx centers as a mental health tech before I got my MA and hearing the staff talk poorly about the patients, esp. the BPD ones. If someone walked in with a BPD dx, you might as well hang a target around their neck! Where is the COMPASSION? If BPD is so difficult to manage as a therapist, imaging how hard it is for these people to live with! It is not a choice…neither is bulimia, binge eating or anorexia BTW. If you are burnt out, get out! I love my job!”

Although I don’t know a great deal about the history of psychiatry & psychology, and there are many others more qualified than I to answer this question, I’ll give you my armchair analysis.  I believe the “Personality Disorder” label evolved out of the common struggle experienced by early mental health care providers trying to help folks who were deeply wounded and defended.    It’s true that deeply wounded and defended people can be very difficult to work with, especially when we get our own defenses & wounds triggered.  And there is a lot to get triggered by.  People with “PD” constellations may self harm, attempt or feel suicidal, shift from idealizing their therapist to devaluing their therapist, get angry, become overwhelmed by parts of themselves which harbor great emotional needs, expect people to take care of them, quit therapy, and just as quickly beg their therapist to take ‘em back.  This is the short list. If we haven’t felt worthless, hopeless, and inadequate prior to working with such a person, it’s likely we will when we do.  This highlights the importance of doing our own work so that we can do our best to stay calm, curious, & compassionate in the face of nearly anything. 

But because the early history of mental health was occupied by many people who hadn’t trained in the art of self-soothing, staying calm and compassionate in the face of these kinds provocations was not the norm.  Rather, the first generations of mental health care providers probably felt dumbfounded, confused, at a loss of what to do, and, if some were already harboring burdens, probably they felt powerless and inadequate.  Others may have gripped tighter to their theories and pre-conceptions to avoid feeling powerless and inadequate.   I believe that it’s reasonable to believe that a portion of these early pioneers did feel powerlessness, worthlessness, and inadequate and protected themselves from falling into the abyss of these feelings, by leaning heavily on labeling, judging, and evaluating people, sometimes as hopelessly and fundamentally flawed.  Pathologizing, I believe, grew partly out of an attempt to place control over the uncontrollable and reduce feelings of inadequacy, fear, and hopelessness.   

Now that new generations of mental health providers have trained and developed in an environment and attitude dominated by the “pathological and deficient model,” the tendency to pathologize is practically unconscious.  Many don’t realize the impact of their words, labels, and attitudes, and many know of no alternative.    

Thank goodness for my heroes, those brave clinicians, who didn’t take it personally when their clients regressed, raged, rejected, blamed, or insulted them. Those that stayed curious and open eventually learned that even the most wounded, degraded, and abused individuals, have the capacity to access their own Self energy and can heal their exiled traumas without relying on years of advice giving, skill building, or high doses of medication. People have the resources needed to transfomr themselves within themselves and healthy therapy helps people to access these.  

Noah :)

Recently, someone asked GoodTherapy.org to include Personality Disorders within our list of Concerns Addressed (this is the list of concerns that people can select when searching for therapists and the list that all members select from when creating their listing). Our decision was a unanimous “no” and we thought it would be fair to explain why and to give our members the chance to make an argument for the use of the “Personality Disorder” diagnosis. I should say that we do support the inclusion of “personality disorder” symptoms in our list of concerns and we are currently working on translating these to fit into our list…. Please feel free to add your comments to this discussion below by clicking on the comments link directly below this post.

The following is our reasoning: We believe that by labeling a person as personality disordered or, in its more gentle form, stating that a person has a personality disorder, we are essentially claiming one’s personality, their personhood, their essence, is fundamentally flawed. What else are we, other than our personality? Such a diagnosis is very likely, if not absolutely, to produce more shame, worthlessness, and rejection in a person who probably has enough of it already. I don’t care how it is framed, normalized, or expressed: having a diagnosis called “Personality Disorder” says one thing: you are fundamentally flawed.

Please don’t get me wrong, I’m not saying I’ve never worked with people who’s inner systems fit the criteria for the DSM categories of Borderline, Narcissism, and others. The difference is that I don’t use the categorical and shaming word “Personality Disorder” to describe a person’s experience and I don’t view people as fundamentally flawed. Deeply wounded, yes, powerfully protected, yes, but fundamentally and irreparably flawed, no.

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I’ve received two requests to add Psychoanalysis to our list of therapies and I thought this would be a valuable discussion topic and one that would help me to make a decision about whether or not to include Psychoanalysis in our list of therapies.  Here’s my problem:  I know this may be biased an outdated, but the association I have (no pun intended) when I think of Psychoanalysis is of a withdrawn, unresponsive, and impersonal figure providing well timed interpretations about the transference of their “patient,” who lays with the analyst sitting behind and out of view.   I’m aware that this association is based on traditional Psychoanalysis and that the model has evolved beyond its original forms, into numerous approaches such as Object Relations and Self Psychology.  Neither do I underestimate the value of psychodynamic theory and its influence in my work.  I even took part in a year long object relations training about 10 years ago.  But Psychoanalysis presents more than a theory with useful concepts about the intra-psychic world, it’s the way Psychoanalysis encourages the analyst/therapist to “Be” with the client that concerns me.
So, I remain concerned that psychoanalysis does not fit our idea of what “good” therapy is and I’d like your opinion on it.  Here is more precisely what I’m questioning:

1) Do contemporary psychoanalytic approaches hold that that behind the layers of protection, no matter how self-destructive or hurtful to others one has been, there is a loveable and vulnerable Self at the very core?

2) Do contemporary psychoanalytic approaches hold an unwavering belief that people can grow, heal, and transform?

3) Do contemporary psychoanalytic approaches tend to view people as fundamentally and irreparably flawed on some level?

4) Do contemporary psychoanalytic approaches work collaboratively by helping a client to tap into their own intuitive wisdom or do these approaches instead rely more often on the analyst providing interpretation and insight to the client about his or her problems?

5) Do contemporary psychoanalytic approaches encourage the analyst/therapist to be free in their use of Self, open to purposeful self disclosure, and to hold a kind, caring, and compassionate state of being with their clients?  Or is it encouraged that the analyst/therapist be the detached evaluator who relies solely on the working through of transference as the primary method of healing?

Please feel free to post your comments and  thanks in advance for sharing your wisdom, 

Noah :)  P.S.,  thanks to everyone who’s responded.  I just posted a lengthy comment in response to all of yours.  Click on “comments” to read.

I received a message about nonpathological based therapy from an anonymous mental health professional.  He wrote the following commentary about me and my likeminded colleagues:

“Without saying so explicitly, you are implicitly judging psychopathology as an indicator of some pervasive ‘badness’ that is incompatible with the goodness of a human being. The trouble doesn’t lie with psychotherapists who recognize psychopathology, but with therapists who judge psychopathology as bad. It is no solution to blind yourself to 100 years of literature on psychopathology and it is no solution to blind yourself to the ‘whole’ human being, pathology included, who is sitting right before you. The solution is to face up to the covert declaration that you’ve made regarding psychopathology, namely, that allowing yourself to see patients’ pathology would make them bad in your eyes.”
 
I believe this well meaning and bright individual is jumping to conclusions about what it means to work nonpathologically.  I thought it would be useful to others who may jump to the same conclusions to share my response to him.  Here’s what I wrote:

“Dear Dr. Anonymous, Your first sentence which suggests that I and my community of “nonpathologizing” therapists are somehow judging psychopathology as some pervasive badness, couldn’t be farther from the truth.  Actually, it’s just the opposite.  S— happens in life and no one gets through life unscathed.  Protecting ourselves with depression, phobia, addiction or any other defense comes with the territory of being human.  We are all vulnerable, we all suffer, and we all develop strategies to survive.  What I am declaring is that “pathology” is adaptive and is possible to heal, change, and transform.

It is my experience that parts / strategies / ego states / defenses/ pathos are truly benign at the heart of it, not malignant.  A quick example of this is how the man with the high profile 100 hour a week job who endlessly strives to be the best, to be the most successful,  may really be attempting to cover and compensate for childhood feelings of worthlessness.  In my view the striving part of such a man is a “good” part in that it’s trying to help.  The man couldn’t have survived his worthless feelings without it.  Yes, the striving is destructive to him and his family, but it’s all he knew how to do….  This is one example of thousands.   So this is why I describe my approach as nonpathologizing, because it sees the good intention behind what you label as “pathology”.    Thus, it’s not that I’m blind to pathology… I may disagree with you about the origin of pathology and the potential for healing pathology, but I am not blind.
 
Furthermore, recognizing ”pathology” in another human being does not make one bad in my eyes, as you write.  In fact it’s just the opposite.  Seeing protective parts, defenses, and wounds within people opens my heart and evokes compassion.   The only hope people have of healing is developing understanding, compassion, and acceptance for their defenses and wounds.  If a therapist can’t open their heart to their client’s defenses and wounds it becomes less likely the client will be able to open their heart to themselves.”

Is there anything you would add in a response to the anonymous professional?  Please comment and let us know.

There are many models of therapy to choose from.  We believe there are a handful of common denominators present in all forms of “good therapy.”  These elements are described below:

Non-pathologizing

Viewing a person as greater than his or her problems is the hallmark of non-pathologizing therapy.  It does not mean problems do not exist, it means NOT viewing the problems as the whole person or the whole person as the problems.  Working nonpathologically does not negate pathology, it depathologizes it.  So for example, rather than labeling a person who’s angry as an angry person, non-pathologizing therapy views one’s anger as just an aspect of the person, but not all of who the person is. We do justice to a person’s true nature when we remember that behind the layers of protection, no matter how self-destructive or hurtful to others one has been, there is a loveable and vulnerable soul at the very core.

Empowering

Empowering therapists maintain the belief that people can grow, heal, and transform. This hope is held no matter how intense one’s defenses and wounds are. People can heal if they want to and if they can contribute to their own growth whatever is sufficient and necessary to that end. When a therapist views a person as fundamentally flawed or incapable of change, the person is more likely to feel and become flawed. Yet, one is more likely to discover one’s true nature when therapy sees beyond wounds and defenses. Some people may not heal in this lifetime, but let the therapist not be an additional barrier to whatever other obstacles may be presenting.  

Collaborative

Collaborative therapy can be established when a therapist encourages a client to become the co-therapist. Therapists who work collaboratively trust the client to know herself (or have the potential to know herself) better than anyone else, and trust the client to know what issues to address and what direction to go in therapy.  This orientation puts the client in the driver’s seat of therapy. The spirit of collaborative therapy is summarized in the words of Albert Schweitzer who once wrote, “Each patient carries his own doctor inside him…. We are at our best when we give the doctor who resides within each patient a chance to go to work.”

Self

Self is a state of being that a therapist can embody when with his or her clients.  It’s defined by Richard Schwartz and IFS therapy as a state of calm, curiosity, compassion, creativity, confidence, courage, connectedness, and clarity.  Self is considered a requisite of good therapy because it is this state that allows a therapist to work collaboratively without pushing, without pathologizing, and without retraumatizing.  For more information on Self please visit the Center for Self Leadership.

Relationship

Beyond technique and theory is the realm of the relationship: the ongoing human-to-human connection which provides the foundation for change. The relationship is the safe container which allows one to more fully and completely feel the presence of Self while in the presence of another. The therapeutic relationship benefits from a therapist who embodies Self and feels unconditional positive regard in the face of whatever the client may be experiencing. Without a therapeutic relationship there is no therapy.

Depth

Good therapy often times needs to go deep. There seems to be a split in the mental health field between approaches that emphasize cognitive solutions and those that emphasize emotional/ or body oriented healing. Both are important. However, our experience is that healing takes more than insight about a problem, cognitive countering, and surface behavior change. Rather than turning away from, countering, or compensating for our suffering, healing requires an exploration into the depth of the wounds that fuel extreme beliefs, feelings, and behaviors. To “counter and turn away from” is more of the same and only leads to more suffering. Also, healing requires feeling. As it is often said, “If we can feel it, we can heal it.” Many of our extreme beliefs, feelings, and behaviors are maintained because we have, in an effort to survive, avoided the wounds, pain, and burdens which lurk beneath. Good therapy helps one to process and complete whatever hidden and unhidden wounds one has harbored. Treatment without going deep can be like stitching up a wound without taking the bullet out; it’s more likely to remain sore and require ongoing attention. “Enlightenment consists not merely in the seeing of luminous shapes and visions, but in making the darkness visible. The latter procedure is more difficult and therefore, unpopular.” ~ Carl Jung

Sometimes We Can’t Help

We are limited.  We greet our clients with great hope.  We have spent countless hours studying or trade, doing our own inner work, mastering our technique, and learning to “Be” with our clients.  We have parts of ourselves that want to do good work.  We are compelled to help others release burdens and cope with suffering because we know how good it feels to do so.  Yet, there are times we can’t help.  We believe a good therapist never gives up hope that a person can heal in this lifetime, but also recognizes that he or she may not be the one to help, that the time may not be right, the client not ready, and that, for whatever reason, one may never do the work we envision them doing.  Good Therapy means letting go of expectations and outcomes for ourselves and for the people we work with, though, without giving up. 

If there is a principle of “good” therapy which you’d like to suggest, please feel free to share your ideas with us.  Click here to view the models of therapy list.

Welcome to my column on Collaboration and Nonpathology in Therapy. In this column I hope to share my occasional insights into collaborative and nonpathologizing psychotherapy which mostly present themselves during therapy sessions. I hope in particular to raise awareness and sensitivity to the inadvertent and subtle ways we can alienate the people we work with. My hope is to facilitate more human and authentic connections between therapists and the people they work with.

Noah