Category: Psychotherapy Blog Posts

Before specifying other aspects of a therapeutic frame, we have to consider what kind of individual therapy it is.

Ellis’s version of ABC to describe behavior was Activating Event, Belief, and Consequence. You open the fridge looking for OJ, find none (A), and feel crushed (C). Perhaps the belief that accounts for your feeling crushed was that your romantic partner doesn’t value you enough to leave you some juice. That might hurt, but would it crush you? Perhaps beneath that B is another B that nobody really loves you. That would be crushing. The hallmark of a useful speculation about a B is that if anyone believed it, they’d also feel crushed (or they’d do whatever C they are trying to explain). It’s only in cognitive-behavior therapy (CBT) that B’s are beliefs. Instead, B can just stand for “Between.” The idea of a Between honors the fact that we don’t all respond the same way to the same situations. Although ABCs unfold as such in life, in therapy the process usually goes C-A-B: some consequence is noted as interesting (an emotion, thought, or overt behavior); the therapist tracks down the activating event (if the C is something that happened in the session, the therapist has the advantage of direct access to the activating event); then the therapist works with the patient to understand the Between that connected the two.

The Between may be a thought or belief after all, but it may be self psychology’s organizing principle, system theory’s family pattern, behaviorism’s learning history, ego psychology’s unconscious conflict, and so on. I find verbal beliefs to be of limited use as Betweens; they are typically too generic (“I am unloved”) and convey too little information. Instead, a picture or a movie makes a better B. A picture might be the person’s image of himself as a pimply teen who just farted in class. This comes to him when he sees there’s no OJ, and he’s crushed. A movie might be a memory that plays in the background of his mom promising him a chocolate cake on his sixth birthday and then producing a box of cookies expecting him not to complain in front of his friends. The movie might be an old memory, a dream, a fantasy, or an event from the recent past. If you want to work with Betweens, you need a therapeutic frame that facilitates his disclosure of the image or the movie.

Not all therapies are about Betweens. There are also A therapies and C therapies. An A therapy solves the patient’s problem by changing the situation directly, such as removing temptation or avoiding “triggers.” A C therapy addresses unwanted consequences directly, rather than changing the person so they won’t occur as often. Drugs, meditation, and distraction are typical C therapies. When someone says that golf is her therapy, she means that it relaxes her, a C therapy, not that golf illuminates her old patterns and introduces her to alternatives. The great advantage of a C therapy is that you don’t have to understand what’s going on to treat a symptom. Someone with a fear of flying has to get on a plane for some reason; give him a beta blocker and let him go back to his A approach (if avoiding plane flights is not that great a burden). The great disadvantage of C therapies is that, unlike medicine where the symptom is always the bad guy, the problematic consequence of anxiety or depression may be the only thing motivating the person to improve herself or her situation. Remove the anxiety or depression with pills and you remove the motivation to make things better. I should add that there are some B therapies that don’t need understanding, such as exposure to planes. Each kind of therapy needs its own sort of frame.

Psychologically-minded therapy is about Betweens. In such a therapy, the idea is to change the person, not just the situation or the problematic outcomes. This is the kind of therapy that works best and longest, but not quickest. When I describe the implicit rules of therapy that foster disclosure and interpretation, I’m writing about psychologically-minded therapy.

Every relationship has implicit ground rules that serve the participants’ goals, that further their agendas about what kind of relationship they want or expect. For example, marriages vary in the extent to which the partners keep each other up to date about the daily vagaries of work. If you want to know what kind of marriage a couple has (or that you have) on this score, you can get a lot more information by probing the implicit rule about downloading work details than you can by asking them what kind of marriage they want to have. If you try the latter, two very different couples might both tell you that they want a marriage that’s a true partnership that’s playful and vital, and that they keep spouses up to date about work. Instead, you will learn more about the couple if you can determine whether they tell each other about major conflicts at work, about puzzling problems with colleagues, or about whether the coffee room ran out of skim milk. (This is an example of the more general directive in psychology to get examples.) A couple that describes itself as faithful can condone an enormous variety of sexual behavior with other people. You can learn more than the description by probing the rules about flirting—are full out affairs allowed? Internet or phone sex with strangers? Sexual validation by trolling for passes? The occasional sparkle in the eye? Revealing the face in public? Marital disputes that seem to be about “trust” and “respect” can often be focused, and resolved, by negotiating the rules. (But don’t forget power theory: the rules only at first foster the goals of the couple; eventually the rules become enshrined and need to be re-evaluated as goals change.)

Implicit and explicit rules define all sorts of relationships, including those between friends, colleagues, and even restaurant servers and diners. A list of rules shared in a geographic location is called a culture; a list of rules shared in a relationship is called a frame.

An important rule in any interaction concerns the amount of information you are supposed to consider in performing the role you are in. The classic example is not noticing a stutter, but old acquaintances also, for example, don’t bring up adolescent indiscretions when they find themselves working together. (They might, later, though, when rebuilding their friendship after work.) In this respect, the set of rules that govern a relationship are like the frame of a painting; the frame of a painting tells you the kind of thing it is and how much of it to consider.

A widespread rule is that you don’t tell people what you are really thinking, not about the seasoning on the meals they prepare, not about the wild sexual and aggressive thoughts that go through your head, and not about the ugly secrets from your past. This rule facilitates most social interactions (that is, it fosters the goals in almost all relationships), but it leaves people hungry for intimacy if they don’t have any friends, lovers, or family members who really get them. (One reason widowers have so much the harder time of it than widows in our culture is because when the wife in a straight marriage dies, the widower has often lost his only intimate relationship.) The inverse of the rule against intimate disclosure is that you are generally forbidden from commenting on the behavior of other adults if the comment identifies aspects of the self behind the social mask.

Many forms of individual therapy depend on access to thoughts, wishes, and memories normally kept behind the social mask. Good therapy also authorizes the therapist to comment on the patient’s behavior. The frame of therapy—its set of implicit rules—is designed solely to facilitate these two relational goals, disclosure and interpretation. Much is known about which rules lead to disclosure and interpretation and which inhibit them (which I will discuss in a subsequent post). The social rules against disclosure and interpretation are so pervasive that the frame of therapy must set it apart from all other types of social relating. The rules around professional relationships (as opposed to a therapeutic relationship)—learned in relation to doctors—push the therapist into an expert role that inhibits the interpersonal process. The therapist wants to be neither social nor professional, and yet the therapist and the patient are just two people trying to have a conversation (social) and the therapy is indeed a professional service. These are the Scylla and Charybdis of therapeutic relating, and the therapeutic frame requires an extraordinary effort. Of course, that’s like teaching an only child how to act like a sibling, and if the therapist has never experienced a therapeutic frame, it’s hard for her to believe that such a thing exists.

If you want to make a painting, you can buy a “paint by numbers” kit. A page or canvas has the design drawn on it in numbered irregular shapes that, once filled in with the appropriate colors, produces the work on the cover of the box.

It’s like art. You hang it on your wall. I don’t know whether you are expected to tell visitors that the drawing and plan were done by someone else, or whether you are expected to pass it off as entirely original.

When the recent exhibit, Becoming Van Gogh, went up at the Denver Art Museum, I was delighted to see what a bad painter Van Gogh was for the first few years. He began by copying drawings of the sort you might see in the back of a comic book—send in your rendition and ten bucks and we’ll tell you if you have talent. Then he copied existing paintings, and then he did some of his own. Without exception, he stank. But he knew he stank and he wanted to get better.

A paint by numbers kit allows you to produce something better right away. It also creates a cap on how good you’ll ever get. It’s the difference between defining self-esteem as the things we say to ourselves (or are said to us by others) and defining it (with B.F. Skinner) as the feeling you get when you have skills.

Would you rather snap your fingers and become instantly and magically expert at whatever your goal is or work hard for ten years to reach the same skill level? Aside from meaningfulness, the journey versus the destination, and ownership of ability, only those who choose the latter will keep getting better. Those who choose the former will spend their time snapping their fingers instead of reading, experimenting, and seeking feedback.

I went to hear a painter named John Roy talk about his work just after he had gotten his first computer. His pictures were pointilistic, a series of small squares colored in such a way that when you stepped back from them, you could see an image (usually a cow as I recall). John had programmed his computer to dictate the hue for each dot on the canvas (a more complicated business then; now your paint program can probably do this easily). After the lecture, I raised my hand and asked, “What do you do if the computer tells you to paint the square a color that doesn’t look right to you?” John said, “Oh, then I paint it the right color.”

That’s not just an artist talking. That’s also the way scientists, builders, and gardeners talk. That’s the difference between an expert and a technician, between psychotherapy and an empirically supported treatment.

Some clinical psychology trainees don’t know how to do some things that every psychologist ought to know, including diagnosing correctly, administering a mental status exam, writing SOAP notes, and safety planning for people thinking about suicide. I agree that every trainee should know these things, but my concern is that an emphasis on knowing them will turn these sorts of administrivia skills into the definition of competence. I have the same concern about the psychology licensing exam and the ethical code and the regulations governing casework in child welfare practice. I think every psychologist should know the difference between criterion validity and construct validity, and I think they should obey the ethical code. I think every caseworker should follow every rule and regulation governing casework. But my concern is that once a host of easily measured rules are obeyed, our field will forget that these are not the same as competence.

One way to look at the problem is that we want to know who is competent and who is not, but we are always tempted to measure what is easily measured, like the old joke about the guy who looks for his keys under the street lamp where the light is good rather than on his darkened porch where he dropped them. In fact, when Aaron Beck started redefining brief psychoanalytic therapy as a whole new approach called cognitive therapy, he predicted his approach would gain favor not (only) because he thought it was more effective, but because the approach conceptualizes change in a way that is easily measured (self-report: psychoanalysts are suspicious of self-report). The danger is that clinical training will turn into a checklist, and the only things that the checklist will not have are the only things that matter: critical thinking about emotional material, mastery of analogy, probing curiosity, empathy, humility, courage, and a welcoming attitude toward what is marginalized.

My view is that most diagnoses (some actually matter because they imply a treatment plan), SOAP notes, and so on are like punctuation. You really ought to punctuate perfectly; it’s not that difficult. But don’t confuse punctuation with writing ability or with the quality of the ideas of the writer.

I confess I’ve never written a SOAP note, diagnosed more than two axes, given a mental status exam, or done a safety plan. But I’m pretty sure I could figure out how to do it if I needed to.

These skills also seem to me to be like the skill of looking in the mirror before giving a lecture to make sure there’s no spinach in your teeth or anomalous discharges around various orifices. Learning to write a SOAP note is like checking your fly before greeting a patient. It doesn’t mean you’re a good therapist if your fly is always up or a bad therapist if you left it down once or twice, but you really ought to check it.