ההקדמה בספרו של וואכטל "Therapeutic communication"

Therapeutic communication / Paul L. Wachtel

This is a book about therapeutic technique— about how to move from understanding the patient or client to putting that understanding into words. It aims to fill a gap in the literature and in many training programs, a gap that can leave the student therapist (and even the therapist with considerable experience) feeling, “I think I know what’s going on with the patient, but what should I actually say?” My aim in this book is to examine in great detail precisely what the therapist can say that can contribute to the process of healing and change. The goal is to put things in a way that is therapeutic, to confront difficult truths and feared inclinations without damaging the patient’s self-esteem or arousing needless distress and resistance. Although the book is a practical one, it is also an exploration of theory and the implications of contemporary research. It presents an integrative theory of psychological disorder and psychological change, a theory rooted in the psychodynamic tradition but drawing significantly upon developments in the cognitive-behavioral, systemic, and humanistic– experiential points of view. Throughout the book, the rationales for the clinical interventions recommended are described in detail, and the reader is shown why one way of saying things is preferred to another. My central focus is on the nuances of phrasing and meaning that I believe can make a crucial difference between comments to patients that are genuinely therapeutic and comments that unwittingly perpetuate the very problems the patient brings for treatment. But as important as this aspect of therapeutic practice is, it is obviously not all there is to skillful clinical work. Although the book gives unusual prominence to the crafting of comments, to the exact way in which interpretations and other messages to the patient are put into words, its concern is by no means limited to wording or phrasing alone. The theoretical chapters in Part I provide a comprehensive picture of the methods and processes that must be brought to bear in effective therapeutic work. And throughout the book, the therapist’s options for what to say in any particular clinical situation are examined and are considered in the context of the overall set of factors that create a thrust for change. A book about the implications of the language we use must be particularly concerned about the problems created by the long-standing tendency of our language to treat the human race as if it consisted of just one gender. The use of “he” and “his” to refer to generic human beings has been widely recognized as problematic. But I know of no effort to solve this linguistic challenge that is fully satisfactory. Sentences full of “he or she” and “his or her” are extremely awkward, and restricting oneself to plurals can lose the immediacy and vitality that comes with inviting the reader to imagine a concrete, singular human being. What I have chosen to do to address the problem is as follows: Whenever the generic human being referred to is the therapist, I will employ the pronouns “she” and “her”; when it is the patient, I will use “he” or “him.” This convention seems to me to have several advantages. To begin with, it obviates the need for littering the page with multiple pronouns or restricting oneself to plurals. But it also addresses more directly the most common prejudices and stereotypes that make our traditional language forms problematic. In our stereotypes, it is the professional, the “doctor,” who is male; the patient role, however, is one we often imagine occupied by women. The convention employed here reverses that stereotype. It calls attention to the fact that a large number of professionals in our field are women and reserves the more conventional use of the male pronoun for references to individuals in treatment or to people caught in one or another of the psychological dilemmas that I describe. Moreover, using male and female pronouns in different but systematically distinguished contexts affords greater clarity for the reader in those sections in which both therapist’s and patient’s responses or feelings are discussed. No solution to the vexing problem that our linguistic “foreparents” have bequeathed us is perfect. I hope, however, that the convention I have chosen serves reasonably well the (often competing) twin goals of, on the one hand, clarity and felicity of expression and, on the other, attention to the sensitivities of half the human race and to the need to challenge the preconceptions that have created obstacles to the full realization of the human potential of both women and men. On a different linguistic front, I have had to make a decision about the use of the words “patient” and “client.” Some therapists prefer the word “client” to “patient,” feeling it puts the person one works with on a more equal footing. In this book, however, I continue primarily to use the word “patient,” partly because I was brought up on it, and it simply feels more comfortable and natural to me, and partly because “client” connotes too great an emphasis on the business aspect of the relationship. Accountants have clients; for therapists to adopt the same word seems to me less than satisfactory. To be sure, “patient” too is problematic. (Indeed, all words are problematic for describing this most puzzling of human relationships.) But a participant at a workshop I held with my wife at Cape Cod a number of years ago made a point I found reassuring: Apparently, the Latin root of the word patient is “one who suffers,” whereas the root of the word client is “one who depends.” Thus, if the aim is to remove the putatively demeaning or condescending implications of “patient,” “client” is not a very good choice. Nor, in this context, is “patient” a bad choice to convey what it is that brings the person into therapy and that defines his relationship to the therapist. Finally, with regard to one more issue of language, it is my strong conviction that obscurity of presentation reflects not profundity but unclarity of thought. To the best of my ability, I have forsworn jargon and attempted to put into clear English my view of what goes on in the therapist’s office, why it works, and when it goes astray. There is something subtly authoritarian about prose that is intimidatingly dense. It attempts to ward off criticism with the implicit message “You are not smart enough to make a judgment.” It is my hope that the reader, whether she agrees or disagrees with what I am saying, will feel that I have been clear enough for her to feel smart enough. This book draws heavily on my own practice and on my experience in teaching, supervising, and giving workshops to students and practitioners at varying levels of experience. In drawing on the precise particulars of clinical interactions with patients— both my own and those of my students and supervisees— I have been concerned about ensuring their anonymity. Not only the names of patients but some of the identifying details of patient profiles have been changed to assure that the patients’ privacy is protected. The nature of this book’s focus requires it to be rich in clinical detail. Many of the arguments are built inductively around concrete illustrations from clinical practice, and throughout I aim to enable the reader to see precisely how the principles described are used in actual clinical interaction. Particularly in the last few chapters, I present extended excerpts of sessions to provide a sense of how the dialogue between patient and therapist is played out and how the process of working through proceeds. But, although it is certainly my intent to be persuasive, and the emphasis on concrete clinical detail is, in part, designed to further that end, when all is said and done, the material presented is clearly more properly understood as illustration than as evidence. Ultimately, it will take systematic research to establish with any degree of certainty how best to achieve the changes patients seek in coming to therapy. I have written elsewhere about what I view as the confusions and limitations that have frequently characterized judgments about what approaches to therapy are empirically supported or evidence based (Wachtel, 2010a), and I cite there a wide range of researchers who have generated studies and ideas that offer a broader and more supple foundation for holding ourselves responsible in the work we do. Prominent researchers from every orientation in our field have raised concerns about the degree to which the empirical investigation of our work as therapists has been overly focused on validating particular “brands” of therapy and manualized treatment “packages,” rather than addressing the underlying principles and the mediating and moderating variables that can enable us to understand better why particular therapeutic approaches work (Ablon, Levy, & Katzenstein, 2006; Allen, McHugh, & Barlow, 2008; Castonguay & Beutler, 2003, 2006; Ehrenreich, Buzzela, & Barlow, 2007; Goldfried & Eubanks-Carter, 2004; Kazdin, 2006, 2007, 2008; Rosen & Davison, 2003; Shapiro, 1995). Even more important, perhaps, is that this alternative view of the aims and methods of psychotherapy research is essential to understanding better why even when many of the standard “empirically supported” treatments do “work”— in the sense that they get better results than some control group— their results are often rather mediocre. In many of the studies cited as supporting their value, the gains associated with them are more accurately described as statistically significant than as clinically significant; that is, many of the “improved” patients still show considerable impairment (Kazdin, 2006, 2008; Westen, Novotny, & Thompson-Brenner, 2004). Moreover, follow-up in many of the studies is rather short term, and even when longer-term follow-up is done, the results often dissolve to a disappointing degree (Westen et al., 2004; Shedler, 2010). As Beutler (2004) points out, research that focuses on the underlying principles that account for therapeutic success can enable us to improve our effectiveness over time, whereas a focus on validating manualized treatment packages leads to a “pervasive tendency to pit one treatment model against another, or to pit treatment model against relationship, in a dogma-eat-dogma competition” (p. 229). It should be evident to the empirically minded reader that although this book is decidedly clinical in its orientation, there are manifold research implications in the formulations it presents if one expands the understanding of useful research beyond the evaluation of manualized packages. Many of the principles and assumptions presented here lend themselves quite clearly to empirical testing. One can readily imagine process studies in which the therapist’s comments are rated for the degree to which they embody or fail to embody one or another of the principles advocated here, and the immediate in-session consequences of utilizing or failing to utilize them are examined. Similarly, it is not difficult to envisage outcome studies in which samples from treatments are rated for the degree to which they embody one or another of these principles and the impact on therapeutic success or failure is assessed. Studies demonstrating the importance of conceptualizing psychological difficulties in terms of the kinds of circular patterns emphasized in both the theoretical and clinical sections of this book are more difficult to conduct. Studies of this sort require a greater degree of complexity and sophistication, especially if they are to show how the linear cause-and-effect formulations that presently predominate in our field are but part of a larger