Learning Objectives

This is an intermediate-level course. Upon completion of the course, mental health professionals will be able to:

• Explain the difference between a therapeutic stance which embodies an ethic of compassionate detachment, of dispassionate detachment, and of disciplined compassion.
• List three clinical reasons for engaging in therapist self-disclosure.
• Discuss four ways therapists demonstrate authentic care with clients.
• Describe three ways in which the sensitive use of humor can strengthen the therapeutic alliance.
• Explain how multi-cultural competence includes examining personal biases of the therapist based on their own ethnic/racial identity.

This course incorporates a contemporary mixture of evidence-based practice, practice-based evidence, and theoretical information pertaining to ways psychotherapists can use their selfhood to strengthen the therapeutic alliance and optimize treatment outcome. Although the knowledge, case studies and clinical vignettes provided may improve participants’ ability to manifest qualities such as greater empathy, genuineness, and effective use of humor and self-disclosure in their work with clients, these are therapeutic skills that require ongoing development beyond that any single course can impart.

This course is based on two chapters from Dr. Gnaulati’s book, Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care (Beacon Press, 2018). The book unpacks the problematic incentives in the health-care system and academic psychology that explain the declining availability of quality talk therapy. A persuasive case is made for preserving in-depth, personally transformative psychotherapy.

Outline

• Introduction
• Practicing With Personality
  • Away with Therapeutic Detachedness and Professional Aloofness
• Authentic Care
• The Therapist’s Authoritative Voice
• Self-Disclosure
  • Normalizing perceptions the client is convinced are aberrant
  • Catalyzing deeper client revelations
  • Tactfully expressing social feedback
  • Advice giving
  • Admitting one’s core biases
• Humor in Therapy: Cultivating an Appreciation for the Absurd
• Professionalism Reconsidered
• The Healing Relationship
• Empathic Immersion
• Sensitively Confirming and Confronting Clients
• Feeling With, and Feeling For, the Client
• Instilling Psychological Mindedness
• Bolstering a Sense of Personal Agency
• References

Introduction

This course will outline and elaborate upon “disciplined compassion” as a therapeutic stance that can be adopted by psychotherapists to enliven and optimize their work with clients. There's a performing – not just informing – dimension to putting clients in touch with underlying feelings. The therapist's care and compassion manifests itself as skill at knowing how and when to amplify versus dampening a response, prolong or foreshorten an emotional reaction, use sparse versus ample wordage, react animatedly or sedately, make a point loudly or quietly, and make eye contact or avert it. All these decisions must be coordinated as authentic expressions while the therapist rapidly processes verbal and nonverbal interactional information in the consulting room.

Disciplined compassion, as embodied by the therapist in these ways, provides the sort of receptivity and sensitivity clients need to effectively access, articulate, and acquire expressive mastery of their own unformulated emotions. To take a reserved approach out of the belief that the therapist's expressiveness could contaminate the client's access to presumed fully formed, self-contained, pure emotions can limit the range and intensity of emotions clients can access and articulate. Clients also need to know we not only can encounter them, but can also counter them. Not only face them, but also face off with them. Too neutral a stance can deprive clients of valuable direct feedback from the therapist who supposedly knows them intimately and is well positioned to offer it.

This course will address these topics in highly practical ways, as well as notions of authentic care; the use of humor and self-disclosure in therapy; and, how therapists who aim to be transparent and personable can still be eminently professional. As we shall see, it is quite possible to be both personable in your clinical role and highly professional – one doesn’t cancel out the other. Case vignettes will be utilized throughout the course to heighten the practicality and usability of the ideas covered.

Practicing With Personality

All too often, the training and education of psychotherapists sets them up to be excessively directive or non-directive – too hands-on or too hands-off – in their approach to clients. The directive therapist employs techniques and clinical agendas which can get in the way of freeing clients up to articulate what really troubles them. The non-directive therapist strives to get out of the way of clients to free them up to articulate what really troubles them. In both approaches there is scant attention paid to how the therapist can use his or her personality, or subjective experiences in the room, to allow clients to get with the way they are troubled and express this more resolutely. Therapists need to be actively attuned, authentic, and authoritative if this is to occur. These are human qualities with human applications in psychotherapy. It entails the therapist becoming acquainted with and knowing how to enact time-honored virtues such as sincerity, forbearance, forthrightness, tact, discretion, and mirth.

Away with Therapeutic Detachedness and Professional Aloofness

Sophie Freud, the granddaughter of Sigmund Freud and a long-standing faculty member at Simmons College School of Social Work in Boston, was once asked for advice about how to best conduct psychotherapy. Her answer was plainspoken:

“Be yourself, I tell them. Act as if this relationship were a friendship, without the usual reciprocity of attending to each other’s needs one expects of friendship. Reciprocity lies instead in the privilege of making a difference to another person.”¹

We assume that Sophie’s grandfather would roll over in his grave at such a proposition. After all, the iconic psychoanalytic stance is that of a “blank screen,” in which the therapist is sphinx-like, or stalwart in controlling his or her emotions so as to train all powers of concentration on the client’s disguised feelings and dark inner motives. However, we know from the historical record that Freud was an ambivalent adherent to his own method. We get a window into a more nuanced view of how Freud conceptualized the role of the psychoanalyst as early as 1895 in Studies in Hysteria:

One operates, as best one can, as an enlightener, as a teacher, as the representative of a freer or superior philosophy of life, as a confessor, who by his continuing compassion and respect for the confessions that are made, as it were grants absolution. One tries to do something for the patient in human terms, as far as is allowed by the capacity of one’s own personality and the degree of sympathy that one can find for the case in question.²

Freud was fond of issuing scientific-sounding exhortations about the need for psychoanalysts to be “abstinent,” muting their own subjectivity in the pursuit of purer objective interpretations about the client’s real wishes, feelings, and intentions. Nonetheless, in the dark recesses of his own psyche, we know that Freud was apt to perceive the therapist as a sort of tribal elder who was equal parts confidant, confessor, and life coach – a careful listener and purveyor of wise counsel. Despite this more humanistic rendering of the therapist’s role, variations of the “blank screen” model still shape the method many therapists are trained to utilize. By “blank screen,” I mean a stance where therapists are encouraged to neutralize their personality in the room with clients in order to optimally perform a method, technique, or intervention.

In the world of cognitive behavior therapy, it is the intervention, not the interventionist that matters. Like the good scientist, the good cognitive behavioral therapist embodies an ethic of dispassionate detachment to best do his or her job. Subjective experiences in the room with clients are not crucial sources of therapeutic data, at least not when evidence-based practice is followed. What matters is standardized application of technique: doing therapy exclusively in the format for which it was scientifically validated. In this model, therapists should really be interchangeable if there is strict adherence to treatments protocols.

For those who practice a more conservative version of psychoanalytic psychotherapy, an ethic of dispassionate detachment also prevails. Back in the mid-1990s, as a graduate student in New York City, the bastion of psychoanalytic psychotherapy, I remember being chastised by a supervisor for sitting face-to-face with a client. The supervisor was adamant that this reflected my “countertransferential” need to be liked by my clients, an insecurity on my part. He counseled me to sit adjacent to the client, facing away from him, and to be relatively stone-faced.

This was necessary for the “transference” to emerge, or for the client to come at me with expectations and disappointments that were rooted in past painful relationships with caregivers. If I showed too much of myself, I would contaminate the process. If the client got mad at me, or began acting seductively, my actions in the room would be the cause, not his unconscious distorted perceptions of me. This supervisor seemed to construe every attempt on my part to affirm clients’ feelings and perceptions as rooted in my personal insecurities. In reassuringly nodding my head with clients, or paraphrasing for them what I sensed was of emotional significance, I was committing the sin of countertransference. I was infantilizing my clients by keeping them dependent on my approval. My supervisor spoke about these matters with utter conviction.

I eventually parted ways with this supervisor due to what I experienced as his icy disregard for the effects of his supercilious behavior. He seemed oblivious to how the dispassionate detachment he counseled me to assume (and which he himself embodied in his supervisory role with me) covertly incorporated attitudes and behaviors that were far from neutral. Being a blank screen with clients was tantamount to being unselfconsciously aloof. In most human contexts, aloofness begets distance, guardedness, and irritation – hardly an atmosphere conducive to therapeutic acceptance and openness.

In contrast to the ethic of dispassionate detachment that imbues the practice of cognitive behavioral therapy and traditional psychoanalytic work, Carl Rogers championed an ethic of compassionate detachment in his client-centered approach. In A Way of Being, Rogers highlights a Lao-tse quote that best encapsulates standards he believes therapists should strive for:

If I keep from meddling with people, they take care of themselves;

If I keep from commanding people, they behave themselves;

If I keep from preaching at people, they improve themselves;

If I keep from imposing on people, they become themselves.³

Although Rogers was a champion of therapists being authentic as a means to actualize similar tendencies in clients, he advanced a non-directive therapeutic style – one wherein therapists subdue and bracket their own subjectivity. In Rogers’ model, therapists self-detach in the act of empathically tuning into clients. The therapist becomes a sort of human mirror, being present to and fleshing out what are believed to be the client’s separate feelings, existing inside their separate self. One can think of it as a sensitive way of being objective, or correctly and accurately perceiving the client for who they really are. But the caricature of the Rogerian practitioner selflessly reflecting back a client’s feelings is a real trap into which inexperienced therapists can fall. Empathy that is not thoroughly grounded in the therapist’s own subjective experience can come across as artificial. It’s postured empathy. True empathy involves deep emotional engagement and identification with clients’ life problems. It’s an experiential blend of finding oneself in the other while simultaneously discovering the other in oneself.

The therapist is emotionally moved by the client from within their own emotional center. There is a meeting of two subjects. To use an awkward metaphor, the therapist bleeds along with the client. However, there is a distinction between empathically engaging clients, and sympathetically over-identifying with them. The therapist still strives for what is called “differentiated relatedness,” or an ability to find himself in the client’s experiences without making oneself the focus.

The corollary ethic for the type of therapeutic stance I am proposing is one coined by James Bugental, the American existential psychotherapist – disciplined compassion.⁴ This ethic gives genuine care and concern its rightful central place in the therapeutic process. It suggests that, at bottom, what makes psychotherapy auspicious is the therapist’s abiding devotion to the client’s emotional welfare. In the words of Jerome Frank, in his landmark book Persuasion and Healing, it is a “determination to persist in trying to help, no matter how desperate patients’ conditions or how outrageous their behavior.” ⁵

As we shall see, a sincere and eager desire to help on the part of the therapist has more in common with how people comport themselves and interact in everyday relationships than with a specialized scientific or medical practice.

Authentic Care

Among humanistically oriented psychotherapists it is axiomatic that therapist authenticity begets client authenticity. For instance, Lewis Aron, in A Meeting of Minds, proposes:

“Emotional honesty, accessibility, directness, openness, spontaneity, disclosure of the person of the analyst – these create in the patient heightened naturalness, forthrightness, access to the repressed, recognition of and sensitivity to the other, increased self-esteem, and greater realism about, and hence depth, in relationship.”⁶

Likewise, David Elkins, former president of the Humanistic Psychology Division of the American Psychological Association, asserts: “In the presence of an authentic therapist, the client’s being, no matter how repressed, will resonate and respond.” ⁷

The vast majority of psychotherapists probably uphold a belief in the importance of authenticity in dealings with clients. Embodying authenticity in one’s dealings with clients is a whole different matter. I’ve yet to hear of any graduate course offered on “authenticity training.” Yet the work of being authentic is arduous. It involves being in the moment with clients without the safety of a script or a rigid role. Self-discipline, tact, and sensitivity are involved in saying the right thing, in the right way, at the right time, whereby the client feels understood and responded to as a unique person. These are true authentic relational moments that boost the quality of therapy offered.⁸ Without high degrees of self-discipline, tact, and sensitivity, there’s the risk that the therapist will say the wrong thing, in the wrong way, at the wrong time, harming the client and potentially ending the therapy. By comparison, being emotionally present with a client so as to say the right thing, in the right way, at the right time, can be psychologically invaluable and make therapy critically important as a venue to make him or her feel understood.⁹

Therapists are left to draw from their own humanity to learn how to be authentic with clients. A prerequisite is the general integration of the therapist’s personality. Adequate familiarity with and acceptance of one’s primal emotional states is a must – pride, shame, grief, rage, envy, lust, and greed, for instance. To practice more authentically as a therapist you first have to be sufficiently “congruent” as a person; generally speaking, one’s outward behavior has to align with one’s inner intentions. There is an acquired capacity to say what you mean, and mean what you say. Coming across as a credible person is foundational for establishing oneself as a credible psychotherapist. These personal-psychological achievements then get finessed and tailored to the clinical situation. Correspondingly, acting naturally, valuing transparency over mystification, directness over indirectness, spontaneity over stiltedness, tact over tactics, a more egalitarian therapist-client arrangement, and common speech over clinical jargon, now all become relevant.

A key way therapists can manifest authenticity with clients is through using ordinary language or common speech, rather than clinical jargon, in their therapeutic communications. Addressing clients in this way makes the therapy more personal than impersonal. Spontaneously generated word choices that are idiomatically in sync with the client’s verbal disclosures not only make the client feel special, but emotionally enliven the therapy.⁹

Use of everyday speech also avails clients with modular verbal expressions they might use in the world when trying to make themselves understood. Not that the therapist is in the business of prescribing language. In therapy, as in real-life interactions, we all organically and tacitly pick up words and phrases that have poignancy for us. Insofar as the therapist’s utterances are littered with common words, rather than clinical jargon, the client has covert and overt access to verbal communications that, if adopted, are generalizable to everyday life. People don’t tend to use words or phrases like “projection,” “cognitive distortion,” or “identification with the aggressor,” in ordinary contexts. Verbalizations like: “I think it’s really you who is sad, not me;” “maybe that’s an exaggeration;” and “I think you are slipping into being overbearing like your dad without thinking about how this might hurt your daughter,” are more utilizable. Some clinical examples will drive home my points.

Keith, a thirty-one-year-old Asian-American man, saw me due to depression. He’s been passed over for promotions at work and was unable to end a dissatisfying long-term relationship with his girlfriend. Keith’s father had had a strong hand in making all his major life decisions for him. He had picked out which college Keith had attended, the profession he had entered, and the neighborhood he lived in. Not surprisingly, Keith was overly compromising in his romantic and professional life. I interpreted: “I can tell it’s incredibly difficult to stand your ground having grown up with a father who didn’t give much ground.” The theme, as well as the phraseology, of “standing one’s ground” and “giving ground,” subsequently became important in my therapy with Keith.

Monica, a forty-one-year-old mother of three young children, often berated herself in my office for not being an attentive enough mother. Juggling career and family demands kept her in a constant state of exasperation, being unable to do either well, at least in her mind. Monica’s perfectionistic tendencies and predisposition to compulsive action interfered with her being fully engaged with her children. Days before Halloween, Monica’s six-year-old daughter Lucy announced from the backseat of the minivan that after school she wanted Monica to go shopping for materials to make costumes. She had loved making costumes with her last year, she told her.

Monica cried as she related this story to me. I softly replied: “I think you should stop and be thankful you’ve done something right as a mother with a daughter wanting to relive a special moment. It’s like Lucy is your conscience reminding you to slow down, hit the pause button, just be.”

One of the most underrecognized forms of inauthenticity masquerading as good clinical practice pertains to the therapist’s need to be clever. Not infrequently, our need to be clever arises from the disquieting effects of the client’s repetitiousness and stuck-ness. Many clients tell and retell painful life events in therapy, and repeat troubling and troublesome behavior, despite their best intentions to change. We therapists are often haunted by the feeling that change should happen faster, galvanized by a more sophisticated interpretation or skillful application of technique. Countertransferential cleverness becomes a risk. We impatiently leap in and offer explanations for the underlying causes of clients’ behavior and propose solutions, when perhaps all they need in these moments is their agony witnessed, once again.

Taking clients at their word, truly entering and residing in the manifest content of their narratives, the warp and woof of their everyday lives, of what they feel actually matters, requires that we therapists give ourselves over to the ordinary. I am both amused and intrigued by the seeming banality of the topics many clients bring to therapy: sleeping in separate beds because a husband snores; standoffs over which restaurant to dine at; home remodels that threaten to lead to divorce; friction over contrasting disciplinary styles with children; personality conflicts with co-workers. We can delegitimize what for clients are legitimate concerns when we are too eager to read into the deeper meanings behind their attitudes and actions.

Sometimes our need to be clever is rooted in our unwillingness or inability to give ourselves over to the ordinary. Our interpretations and interventions become disguised ways of coaxing the client to talk about what should actually matter to justify the potency of our education and training, or to simply stave off boredom. Which is not to say that clients do not need, yet resist, deeper meaningful linkages. It is not always clear, when a client is irked by his wife’s perceived stonewalling, whether a head nod acknowledging his frustration is in order or a deep interpretation: “Antonio, I think your wife’s stonewalling gets to you because it is reminiscent of how your mother treated your father.”

Many therapists intellectualize the therapy to stay mentally stimulated in the face of hour-in, hour-out client disclosures of everyday struggles and conflicts. Seeing ourselves as “master decoders of meaning,” can give us a sense of higher purpose about the profession, at least in an intellectualized way. Thinking up a clever interpretation, musing on linkages in the content of the client’s disclosures, assuming more of an observational than participatory stance, can speak to our own difficulties in being emotionally present, tracking and matching the client’s transitory feelings and gestures. There is intimacy to this. There is also the professional hazard of de-personalization, as well as emotional and mental exhaustion. Intellectualizing the therapy can be a means to cope with these hazards.

The exquisite receptivity and sensitivity required in practicing with authentic care is nothing short of a labor of love. It’s also the labor therapists get paid for. Knowing why, when, and how to do or say something truly therapeutic involves ample mental acuity and interpersonal sophistication. Most salutatory interactions in psychotherapy occur at a subliminal or implicit level. Moment-to-moment, the well-attuned therapist is naturally modulating their nonverbal behavior to enhance client engagement and understanding. Facial expressivity, eye contact, speech prosody, voice cadence, and level of gestural animatedness are subliminally coordinated against what the client seems to need and can tolerate. The therapist has to have one eye trained on whether his or her expressiveness is too little or too much for the client to assimilate, and recalibrate accordingly. A smile, a sincere frown, raised eyebrows, eye rolling, or a calm demeanor – any of these physical embodiments of thought and emotion, deployed in the right way, at the right time, can have therapeutic benefits, even though they mostly occur outside of both the therapist’s and client’s conscious awareness. Rapid decisions have to be smoothly executed about which words to use, in what tone, backed by which gestures, in ways a particular client can ingest. Practicing psychotherapy well is akin to manifesting sublime levels of discretion, which the British philosopher A.C. Grayling defines as: “… knowing when to speak, what not to say, when to stop, and how to deflect a conversation when a doubtful turn has been taken.” ¹⁰ There is love in this kind of work, and work in this kind of love.

Finally, a feature of authentic client care is being able to remember the memorable in the client’s life. I’m often surprised when clients are surprised by my ability to bring up relevant historical information or noteworthy life events they formerly disclosed. I find that when I truly care about clients and become completely engrossed in their life stories, the memorable events in their life become etched in my memory banks.

The Therapist’s Authoritative Voice

As a real person, striving to be oneself, albeit a more muted, professional, other-directed version of oneself, the therapist strives for clarity and candidness of expression that sets the tone for therapy. One way this is achieved is through linguistic authorship, or wording interpretations and clinical comments reflecting how – nothing more and nothing less – they are the renderings of the therapist’s own mind. They are their formulations, predicated on whatever human and clinical wisdom they possess.

Therapists are often uneasy about personalized use of language – the use of the first-person pronoun “I” – resorting more frequently to the second-person pronoun, or delivering more impersonal “you-statements.” Third-person pronouns are commonly selected to give an air of professionalism (e.g., “It’s hard to get a husband to listen who seems so caught up in himself”). It’s as if “I-statements” put the therapist and client in a sort of friendship zone, and are thereby anathema to the need to provide a medical or scientifically backed service. To project expertise, many therapists make interpretations like: “You seem stuck reacting to your wife in the very ways your father reacted to your mother;” “You say your husband is the angry one in the marriage, but this might be partly a projection as you yourself struggle managing your anger;” or, “You seem to be holding back from saying what you really feel.” Personalized versions of these are more prone to be underutilized: “It looks to me like sometimes you get caught reacting to your wife in the very ways your father reacted to your mother;” “One thought I find myself having is that it seems easier to see your husband as struggling to manage his anger than to see yourself struggling to manage your own anger;” or, “I can see you are having some feelings that are hard to express.”

The assumption may be that it is more clinical- or scientific-sounding to avoid “I” statements. Still, no matter how much we linguistically dress up our therapeutic utterances to make them seem objective, rooted in sound theory or science, we are the author of our own remarks. They bear the signature of our subjective filters, or what we consciously and unconsciously deem experientially and clinically relevant and important.

Prefacing our interpretations and clinical comments with the first-person pronoun, or so-called “I” statements, allows us to be authoritative, without being authoritarian. In other words, we can take a stand on clients’ struggles, and say something plausible, something that derives simply from one person’s perspective (who happens to be the therapist), something that can be considered by both client and therapist and legitimately denied if found wanting. Not something that should be swallowed whole because of its supposed veracity, and if denied, taken as an indication of defensiveness.

Linguistically putting yourself into the therapy can also make it more emotionally evocative, enlivening it, leaving clients feeling you are personally invested in them.¹¹ A sampling of my standard ways of prefacing clinical comments go as follows:

One thought I have is … ;

As I see it … ;

This may say more about my biases here, and if so let me know, but … ;

Of course, where my mind goes when you tell me this is … ;

I would be careful doing that … ;

Hold on a minute, I’m confused...;

It occurs to me that … ; and,

Something tells me that you...

There are even occasions where I speak for clients, or offer modular expressions that are refined versions of what they vaguely communicate, or hint at. The emotional texture of the interaction is usually synchronous such that, in a manner, the client and I are speaking in one voice. I am speaking for the client while speaking with them. Some case snippets will clarify.

Two years into therapy, forty-seven-year-old Magdalena recalled a disturbing exchange with her father dating back to when she was an impressionable young woman. He drove across town to her apartment to reassure her that he still loved Magdalena’s mother, despite the fact that he had conducted numerous affairs during the marriage. Unselfconsciously macho, he announced to Magdalena:

“I remember the animals I have killed while hunting more than the women I have fucked.” Magdalena replied, “Wow, that’s deep, dad.”

Alarmed, I piped in:

“Deep? Any other words come to mind? How about: “Dad that’s so callous and cruel. Could you be any more cold-hearted!” As if he was oblivious to the fact that his flesh-and-blood young daughter was sitting next to him and would be harmed, not reassured, by such a comment!

Magdalena wept as I fleshed out with words and affect what was in her preconscious experience. She had recalled this disturbing exchange after having shared a conversation with her movie-star husband about the importance of monogamy. He flippantly remarked that monogamy was a false ideal for powerful men exposed to sexual opportunities. He cited evolutionary reasons for this. While on location, he had multiple opportunities for casual sex, which he acted on, trying to convince Magdalena that these weren’t a threat to the marriage. The conversation with her husband about monogamy was Magdalena’s indirect way of trying to obtain reassurance about his love for and fidelity to her. I commented: “He didn’t pick up on your need for reassurance, eh. I’m not wanting to have an intellectual conversation about the pros and cons of monogamy. I’m telling you this because I want you to accept that I’m the one you love, and you want to be with me and only me.”

Magdalena chimed in:

“I do want that, yes, that’s what I really wanted to tell him.”

We assume that if clients are to progress, they need to be accountable to their own “ego ideal,” their own better self, to act on acquired insights and realizations. I would say that it’s the rare client who is self-motivated in this way. Most of us muddle through life vexingly reenacting the same old bad habits, even when we have insight into our behavior. When emboldened, we can act auspiciously on our own behalf. But often we do right by our higher aspirations because people whom we know and trust nudge us in the right direction at the right time. We are more dependent on others to create tipping points for change than we want to believe, or that the American cultural ideal of rugged individualism permits.

Potent psychotherapy sometimes involves the therapist using his or her authoritativeness to call clients out and push them beyond themselves; to keep them from repeatedly making the same bad decisions, even though they have a measure of insight into why they do it; and, to shake them out of their emotional slumber, their propensity to sleepwalk through life, or counteract what Freud meant by the “death instinct” – the expectable inertia we all encounter against actively existing.

By authoritativeness, I mean the therapist feeling a reasonable degree of human responsibility for the client’s well-being and betterment: the therapist extrapolates from his or her intimate knowledge of the client, acquired clinical knowledge, and life philosophy, to wholeheartedly say something to the client that is a stimulus for action. What we are talking about here is the therapist being so moved by the client that he or she takes a stand, hears the call from the client’s better self, and speaks up in its defense. At key moments, the therapist is the steward of the client’s better self and needs to be judiciously active in its defense.

Along these lines, Maurice Friedman, whose 1977 book The Healing Dialogue in Psychotherapy presaged many issues raised by contemporary relationship-oriented psychotherapists, asserted: “The therapist may have to wrestle with the patient, for the patient, and against the patient.”¹² Yet in these declarative moments, we therapists still have to be sensitively assertive. Irwin Hoffman, the distinguished psychoanalyst, aptly captures this:

“ … whether we like it or not, we are inevitably involved in some measure as mentors to our patients … we also have to try to act wisely even while recognizing that whatever wisdom we have is always highly personal and subjective.” ¹³

For example, George, a forty-six-year-old lawyer prone to be overly dutiful and perfectionistic in his work habits, mentioned to me that if his supervisor refused to give him Thanksgiving week off, he would unilaterally decide to go out on sick leave. With good humor, I replied:

“Maybe this is your way of saying that because you work so hard you deserve time off on your terms! But hold on! This seems to me to be one of those occasions when you risk morphing into your mother – stepping on toes, putting your foot in your mouth, and possibly getting yourself in hot water at work. You don’t need to come out swinging like your mother, just be persistently assertive, stand your ground about needing Thanksgiving week off, persist, insist … use your good lawyer skills!”

Francesca, a forty-year-old home-maker with three children who caught her husband having an affair, felt impelled to immediately file for divorce. Francesca tended to be impulsive and action-oriented, and when hurt, to go on the offensive. She was no stranger to betrayal and infidelity in her life. Her brother was addicted to drugs, and his denial, lies, stealing, and failed promises were excused by her parents. Her father took off suddenly, but briefly, with another woman when Francesca was a teenager. Several key boyfriends had also been unfaithful. I softly, if not solemnly, proposed:

“Francesca, I think it’s premature to file for divorce. I know Alan betrayed you and this is especially devastating because he knows your history. But this has to be bringing up old hurts and injuries, and you and I need to take all the time necessary to sort this out emotionally before you make any life-altering decisions. From what you have told me, Alan typically is trustworthy and you have had a solid marriage up to this point. Filing for a divorce may make you feel powerful, refusing to put up with lies and betrayal, and having an out, like you didn’t have as a kid. But, I think it’s premature.”

Brian, a thirty-nine-year-old gay client of mine, was tired of arguing with his fiancee over the travel and after-work dinners that were an integral part of his job. They were not, he repeatedly had to reassure him, a concerted attempt to avoid and reject him. Reportedly, his fiancee’s mother had died when he was eleven years old, and his father had left him with relatives to immigrate to and start a new life in America. Brian’s fiancee seemed unaware of how his history set him up to expect rejection and sudden abandonment. Brian often felt attacked by his fiancee for not being devoted or attentive enough, for not making him his one and only life priority. During a session where Brian seemed dejected and defeated, he announced to me that after the marriage he was going to quit his job and travel with his husband for a month in Europe. With a concerned look on my face I pushed back:

“Right now I’m feeling protective of you. Quitting your job and touring Europe might solve some short-term problems – end your job dissatisfaction and prove to your fiancee that you are committed to him with a capital “C.” But you have very little money in savings, no job options to replace the one you have, and you guys are determined to adopt kids after the wedding. I’m starting to think that this decision reflects how defeated you feel standing up to your fiancee about the importance of your career and the need to travel. I’m thinking that it is probably high time your fiancee gets therapy to take a close look at how his abandonment history places unfair demands on you to be the uber-devoted, “all-good parent” he did not seem to have.”

Sometimes a straightforward, kindly worded, affectionately expressed admonition can simultaneously convey deep understanding of a client’s core struggle and support a positive change of attitude and behavior. George, a forty-two-year-old pediatrician, in keeping with his upbringing as a devout Catholic, experienced a vague, omnipresent sense of guilt that leapt out in situations where his personal enjoyment and satisfaction warranted attention. It was far easier for George to identify and pursue activities based on a sense of duty and obligation than on desire. At the start of a session, George apologized for having to rearrange the cushion on his therapy chair to make himself comfortable. I quickly commented: “There’s no need to say you are sorry for wanting to be comfortable.” We both smiled knowingly.

All too often, our therapy models and manner of practicing presume that clients should be their own source of motivation, communicativeness, and behavior change. To rely on the therapist for motivational energy, communicative finesse, and input about advantageous changes is viewed as a form of unhealthy dependence. This harkens back to the Freudian notion that inside us all, at an unconscious level, is a greedy infant, holding out to have our needs met by others so we can avoid growing up and taking initiative regarding our needs and wants. This falsely pathologizes any adult need for outside reassurance and validation. It belies how even self-reliant clients with a strong inner compass still need their therapist to say a hearty “good,” or “I like the sound of that,” to reaffirm something well said or done.

Self-Disclosure

The rules for being neutral and abstinent, or displaying simple empathy, are clearer and easier to follow than those for being human in the room with clients. When urged by clients to self-disclose about attitudes toward childrearing, relationship advice, or the likes, many therapists deflect. Remaining neutral, interpreting the underlying motive, or reflecting back underlying feelings are the typical fallback responses many therapists are trained to generate when clients put direct questions to them. The anxiety of being put on the spot leads many therapists to routinely side-step direct questions and recoil from uttering anything resembling a personal or professional opinion. On the other hand, there are risks of overstepping one’s role in a chummy, talkative way. The client’s need for feedback gets eclipsed by the therapist’s need to share. There are no uniform rules pertaining to when, how, and why to self-disclose to clients. But there are some general rationales.

Normalizing perceptions the client is convinced are aberrant

Perhaps the clearest indication for therapist self-disclosure is to resoundingly normalize experiences and perceptions clients unselfconsciously think are aberrant. This is especially beneficial for clients raised in homes where so-called mystification has occurred. The controversial Scottish existential psychologist R. D. Laing wrote voluminously about the damaging effects of mystification in families. The Self and Others and Sanity, Madness and the Family are books in this domain that stand the test of time. Periodically I encounter clients whose perceptiveness and deftness at seeing through pretense was undermined and disconfirmed early on by caregivers. Their need for confirmatory feedback from me, as a trusted therapist, to verify the accuracy of their perceptions is paramount if their hardened self-doubting tendencies are to be undone. This might involve me animatedly reframing what the client believes is a liability as a personal asset.

Gertrude was one such client. Growing up, she cherished solitude which her mother judgmentally misconstrued as evidence of her being a social misfit, a loner, and depressed. During a session where Gertrude was maligning herself for being an “oddball,” in agreement with her mother, I retorted:

I don’t think your mother gets you, Gertrude. I see you as a complex person who is an introvert by temperament. Someone who would rather be alone with her own thoughts than around people who jabber for the sake of jabbering. I know because I’m like that myself. Your mother seems to have maligned your need for solitude instead of seeing it as a wholesome thing, a personality trait that speaks to your depth as a person.

Catalyzing deeper client revelations

Spontaneous therapist self-disclosures can also catalyze more penetrating client revelations. We can issue the usual reminders to clients to refrain from holding back, to be candid and upfront with their communications. Yet sometimes it takes risky displays of honesty and frankness on the therapist’s part to give clients license to shoot from the hip.

In a recent session, I had the following exchange with Barry, a thirty-five-year-old music industry executive in turmoil over large-scale changes taking place in his profession and considering his next move:

Barry: What do you think I should be doing right now to set myself up for a better future?

Dr. Gnaulati: Right off the top of my head? Full disclosure based on how I see you and what I know about you?

Barry: YES!

Dr. Gnaulati: I see you as an intellectual who has made compromise after compromise in your career to mold yourself into a businessman, which you are ambivalent about being, at best. When I stop and fantasize what life could be like, I imagine you getting a master’s degree in English and teaching at a reputable private school, using your executive skills to work your way up into a high-level administrative position over time.

Barry: You are so right on. But, if my colleagues and friends heard I was going back to school to get a degree in the humanities, they would see it as a go-nowhere degree. (With pronounced frustration) I REALLY NEED TO FIGURE OUT WHAT TO DO!

Dr. Gnaulati: OK. Now it’s your turn. No holds barred, total fantasy. What Would you love to pursue?

Barry: Full disclosure?

Dr. Gnaulati: YES!

Barry: A job with the Washington Redskins.

From there Barry spoke free-flowingly and intoxicatingly about his love of this football team and his determination to look into a marketing job with them.

Tactfully expressing social feedback

Social living requires a generous amount of pretense, nicety, and politeness that at its outer edges becomes socially acceptable falsity. I suspect we all secretively crave honest feedback, to see ourselves as others see us, so long as it is provided by a credible source. Opportunities for candid, fairly objective, tactfully communicated social feedback we can learn from are rare. Clients often invite and welcome this. The average therapist is neither trained to provide it, nor armed with a clinical rationale that it is beneficial. Regardless, as therapists we are uniquely suited to provide tailored feedback to clients given our intimate knowledge of their personal histories and psychological vulnerabilities.

During a couples therapy session with spouses who were separating and wanted my help executing this plan with the least amount of emotional fallout, the husband, Frank, seemed hard-edged in his interactions with his wife, Mary. I leaned in:

Dr. Gnaulati: Frank, what you just said and the way you just said it sounded bossy to me. It’s interesting. It seems stylistic, like a typical masculine way of communicating, where you are just imparting information. You get confused when Mary is irritated with you. To me it seems you really don’t mean to be brash, that’s the word that comes to mind. But, whether or not you intend any harm, that’s the effect it seems to have on Mary.

Frank: I’m not disputing that. I am finally starting to see how hard it is for me to show empathy.

Frank happened to be one of those clients whose logical and officious communicative style did not reflect defensiveness so much as a traditional masculine way of relating. He took direction well about how to listen better, though not because he was passive or pathologically dependent. Pragmatically speaking, he accepted the need to be more understanding with his soon-to-be ex-wife and since he did not have the skill set, and valued my expertise, he welcomed the opportunity to acquire it.

Advice giving

In the Freudian and humanistic traditions, advice giving is largely thought to promote inappropriate client passivity and dependence. There are those clients for whom a childlike form of dependence is reinforced by asking for and receiving advice from therapists. The rule of thumb, more often than not, is to put it back on the client to articulate what they identify as preferences, goals, and solutions, and thus to promote a sense of healthy personal agency. However, in my experience, I make exceptions when it comes to childrearing advice. We live in an age where parental investment in optimal childrearing is at an all-time high. There is really no fundamental psychological preparation for the transition to parenthood. The lifestyle and mindset changes associated with new parenthood happen rapidly and mostly subliminally, and the average parent is caught perpetually playing emotional catch-up between the life that was and the life that is. Knowledge about childrearing from therapists who keep up on it and happen to be conscientious parents themselves is valuable beyond belief to clients.

Jennifer and Jamal visited me to figure out how to understand and deal with their 13-year-old son’s sudden refusal to be home alone with Jamal. Lukas, the son, was legally adopted by Jamal when he was about five years old. Lukas’s biological father had died from an aggressive form of melanoma before he was born. There were no indications that Jamal was being abusive, intrusive, or overbearing with Lukas in any acutely problematic way. If Jamal was guilty of anything, it was occasionally letting his anger spike because his high-pressured job and Jennifer’s health problems were all too much. By temperament Lukas was shy and reserved, unacquainted with angry feelings. Jamal’s rare angry outbursts seemed to throw Lukas off kilter, even though they were not directed at him. Lukas subsequently developed an “all-bad” perception of Jamal, cancelling out all the good he had instilled in his life over the years – the hours of Lego play together, being read to as a child, the fun family vacations. Lukas simply wanted to avoid being around Jamal at all costs. As best as I could understand, I construed the issue as Lukas unconsciously grappling with his biological father’s death, his aversion to anger, and a re-awakened desire to have his mother all to himself like he did for the first five years of his life before Jamal came along. Jennifer and Jamal were well educated, so the Oedipal reference was a source of amusement. I advised the parents thusly:

“Until we know more about what is driving all this, I would respect Lukas’ need to be apart from you, Jamal, as much as can be allowed given the exigencies of family life. That said, I don’t think either of you should play into Lukas’ all-bad perceptions of you, Jamal. When Lukas shuns you, Jamal, I’d show him in reasonable ways how hurt and confused you are, while giving him space. In these moments, Jennifer, it is probably good for you to gently come to Jamal’s defense whereby you are aligning with him, and not playing into the whole Oedipal dynamic, to not let Lukas divide and conquer, so to speak. There has to be a way where you, Jennifer, can be Lukas’ loyal advocate, while being Jamal’s also.”

Admitting one’s core biases

Therapists’ core biases have a way of manifesting themselves, whether overtly or covertly. It’s better to be transparent about them for those clients who will readily perceive them anyway, so long as it doesn’t alter their experience of the therapist or therapy in any adverse way. It can have mystifying effects if a client has a diffuse sense of your bias, a felt sense of where you stand on an issue, yet you deny him or her sure knowledge. Under the best of circumstances, if a client tacitly knows where a therapist stands on an issue of personal importance, and the therapist concurs, it can free the client up to speak more openly about it, leading to greater therapeutic rapport, a sense of fellow-feeling and kinship that can enrich the therapy experience. If the client does not share your bias, there can be an agreement to disagree. For many clients this can be a psychological achievement. They can go on feeling positive about the therapist and therapy, despite differences in opinions, lifestyles, and beliefs. That said, there can be occasions in therapy where a client demands that the therapist be in concrete agreement with him or her to preserve beliefs and values that are essential to going on living. This can be a Faustian bargain, where to dance around answering in the affirmative, or to openly acknowledge disagreement, means the therapy is over. Or, to lie and go along with the client to assuage their pain means the therapist’s personal integrity is compromised.

Over a decade ago, Francesca, a long-term client of mine, was admitted to a local hospital to deliver a baby daughter. She was overjoyed at the prospect of being a mother and supplying her extended family with its first grandchild. Her marriage was rocky, but the pregnancy had brought her closer to her husband. Tragically, Francesca’s baby was stillborn. We scheduled an emergency session to process this horrendously tragic event. Francesca was understandably distraught. She wept bitterly and pleaded with me to agree that she would see her daughter in heaven:

Francesca: Tell me that I’ll see my baby daughter in heaven.

Dr. Gnaulati: Francesca, it must be devastating to think that your baby girl is gone forever and you might not ever see her again. I can’t even begin to imagine how painful this must be.

Francesca: (getting more and more distraught) I need to know that you think I’ll see my baby daughter in heaven.

Dr. Gnaulati: I know how badly you wanted to be a mom. There was every indication you would give birth to a healthy baby girl. It is all so very, very tragic what happened.

Francesca: So you’re telling me I’ll never see my baby daughter again. I can’t deal with that. (sobbing bitterly)

Dr. Gnaulati: I guess I am saying she’s gone and this is awful beyond belief. The grief and loss may be too much.

It should not surprise the reader to discover that Francesca did not return to therapy. I gave her a referral to a Christian counselor, per her request. In her distressed state of mind, a shared concrete belief in an afterlife was crucial to prevent her from hemorrhaging with grief. Since I do not believe in an afterlife I could not, in good conscience, give her the concrete reassurance she desperately needed. I focused on standard therapeutic ways of helping Francesca face her unbearable loss. This was not enough. To this day, no matter how I rationally substantiate the professionalism and therapeutic sensitivity I showed during that session, I still feel traces of Francesca’s devastation

Let me offer some final thoughts about therapist self-disclosure. There is always the specter of self-aggrandizement and self-gratification when therapists choose to self-disclose. Questions need to be asked of ourselves: Are we looking for attention or focused on the client’s betterment? Are we reassuring and affirming client experiences, or stealing the focus? Are we enlivening the therapy experience for the client more or are we staving off our boredom?

During moments of self-disclosure, therapists need to be pithy, concise, and on point. Clients should be well aware that the therapist is self-disclosing for poignancy reasons, to emphasize information that is mutually considered to be of value to the client.¹⁴ Quick return to what is on the forefront of clients’ minds is important.

Humor in Therapy: Cultivating an Appreciation for the Absurd

Many disorders and psychological afflictions are characterized by an underdeveloped sense of humor, especially a dearth of appreciation for the absurd. In the Myth of Sisyphus, existentialist philosopher Albert Camus writes: “What is absurd is the confrontation between the sense of the irrational and the overwhelming desire for clarity which resounds in the depths of man.”¹⁵

Anxious and depressive mindsets can be perpetuated by an unrelenting propensity for clarity, rationality, order, efficiency, or obedience in the face of life events, relationships, and work commitments, which are messy, cumbersome, have ambiguous outcomes, and defy logic. Being on edge, bitter, resentful, or envious can be the emotional consequences of not surrendering to the absurdity of it all, accepting life as it is rather than life as it should be.

Many clients who embody schizoid tendencies, who are overly concrete in how they understand themselves and others, intellectualize, or have a compulsive need for order and efficiency – so called Type-A personalities, and those with obsessive compulsive or autism traits, for example – recurringly get ensnared trying to make an irrational world conform to their rational expectations. These can be seen as “taking oneself too seriously conditions,” the goal of therapy being, to borrow a quote from French philosopher Jean Paul Sartre, to “overcome the spirit of seriousness.” Or, to piggy back off Camus, to “relinquish our appetite for the absolute” and “our nostalgia for unity.”

To some degree we all are afflicted with a spirit of seriousness, or prone to totalize, dogmatize, and personalize. Existentialists like Albert Camus would have us believe that a sense of the absurd is necessary to live with less pretense and deception, and more humility, in the post-modern world where there is an absence of any super-ordinate universal logic, any all-encompassing meaning system, any ultimate solution supplying us with scripts for living, any cosmic plan, any prime mover or divine presence quarterbacking life for us.

At times, depression is really apathy resulting from having sacrificed one’s autonomy, passively living a scripted existence, unsuccessfully trying to ignore the dawning awareness that the social or religious conventions which ought to instill meaning in actuality have lost all meaning, all relevance.

As the evolutionary story goes, humans were not designed to live to be octogenarians. Antibiotics, cancer-busting drugs, high-tech life-saving medical devices and the like have greatly extended the human life span. As recently as 1800, few countries in the world had life expectancy rates above 40.¹⁶ Currently, the life expectancy in industrialized nations worldwide hovers around 80.¹⁷ Marriages and work lives that once averaged 20 or so years, now average 50 and up.¹⁸ Coping with boredom, monotony, and the same-old, same-old is unavoidable. Depression can indicate existential boredom, or being in a career, job, marital, or family situation that is perceived to be inescapable, that has become staid, monotonous, and overly predictable. Taking flight and reinventing oneself are quintessential ways Americans typically respond to existential boredom. But individuals bent on acting responsibly refrain from rashly abdicating family, parental, marital, and professional obligations. Having it in our repertoire to somehow find a way to adapt to and accept the monotonous, banal aspects of life is an existential imperative. An appreciation for the absurd involves a lightness of being, rendering seemingly inescapable life situations we find unfair, irrational, inefficient, monotonous, or banal, somehow more livable. An appreciation for the absurd helps us laugh at and laugh off these unavoidable and unpleasant aspects of life.

Humor and a keen sense of the absurd also enable us to be more boldfaced in accepting the precariousness and arbitrariness inherent in human existence. A core dimension of our benign human denial system involves blinding ourselves to the role randomness and arbitrariness play in the unfolding of life events. Yet, all too often, chance and luck govern life outcomes. The French probably lost the Battle of Waterloo because Napoleon happened to have a fierce case of hemorrhoids that morning and could not mount his horse to command his troops.¹⁹ The Titanic might not have sunk had the crew member in charge of the crow’s nest, or lookout post, had not forgotten to drop off the key to open it the morning of the maiden voyage, and so to access the binoculars used to lookout for dangers.²⁰ It is humbling to contemplate how much being in the right place, at the right time, with the right person has dictated the ups and downs in our professional and love lives. Mirthful humility about this can stave off anxious and depressed feelings.

I recently finished up a ten-year course of therapy with a middle-aged woman who credited my use of absurdist humor as instrumental in helping her overcome depression. Mary was a fifty-five-year-old public defender who had dedicated her professional life to representing poor and marginalized clients. She prided herself on being rational, reliable, dutiful, and efficient in her work life, and maneuvering every day in the byzantine bureaucracy of the criminal justice system was torturous. Mary was disenchanted with the young public defenders; they were apolitical and had no sense of mission, preferring to jabber on about Walking Dead episodes than adequately service their clients. She railed at the support staff who seemed incapable of putting files in the right places. She frowned upon the hubris of the translators she relied on with her Spanish and Mandarin-speaking clients. She was paralyzed going up against judges who followed the letter of the law in bizarre ways that dehumanized client after client.

This work environment filled Mary with a sense of futility, demoralization, and entrapment. It was inconceivable that she exit the practice of law in the public sector for political (in college, Mary became acquainted with leftist politics) or personal reasons. Having grown up in poverty, raised by a mother who had burned through six marriages (with all the attendant instability), she needed bedrock security in all areas of her life.

Mary lived with her mother and supported her financially. This also left her feeling trapped and demoralized because her mother was insufferably talkative. Mary was a self-avowed introvert; she had even seriously flirted with the idea of becoming a nun. Her ideal job was being a librarian at a nunnery. Therefore one can only imagine the psychological effects of living with a mother who talked non-stop, collected rescue Labradors and tchotchkes, and whose abrasive tendencies emptied out her social life, leaving Mary to be daughter, friend, companion, caregiver, and provider all in one.

Years of grieving and expressed frustration in therapy gave way to acceptance and an awareness of the unavoidably absurd aspects of both her home and work life. We increasingly engaged in humorous word play that was mutually satisfying and promoted lighthearted acceptance, a counterpoint to Mary’s usual melancholic resignation. One day, Mary divulged her irritation at the courtroom support staff who misplaced files. I commented: “I guess they would rather file their nails than nail filing the folders.” We both laughed, with Mary eventually softly chuckling: “Well what do ya do, what do ya do.” I added: “If the choice is between murdering them and putting up with them, I guess you’ll have to put up with them.” Mary laughed again, then conceded: “I guess I’d go out of my mind if I was filing files all day long for years on end … . I should cut them some slack.”

Another time I noted: “The thing you can count on with your mother is you can’t count on your mother.” It was true, and it was funny, and a little sad, and over time, the humor and the perspective helped Mary react less seriously to her mother. This type of comment enabled Mary to build anticipatory disappointment, to refrain from expecting the impossible.

Off and on during treatment we revisited an exchange between Mary and her sister that was vexing. Mary’s sister was a devout Catholic who nonetheless had done very little financially or otherwise to help Mary out in taking care of their mother. One day Mary told me that her sister had condescendingly said to her: “There’s a place for you in heaven.” I shot back: “No wonder Sartre said Hell is other people. Hell is other people telling you there’s a place in heaven for you as a way to rationalize their own unwillingness to take responsibility.” I had tapped into and amplified Mary’s muted feelings pertaining to her sister’s hypocritical statement. My feeling, the word play, the philosophical reference, all made her feel understood – both in terms of her value system and how she defined herself as a person (her intellectual sophistication, her ethicality), in addition to tapping the truly difficult circumstances of her life.

On another occasion, Mary brought up the “There’s a place for you in heaven” comment and added: “I don’t know what the Lord’s going to say when he discusses how she hasn’t sent a birthday card to Mom in over thirty years.” I quickly chimed in: “I do. He’s gonna say something like, whoops, it’s a few years in Limbo for you dear lady!” We both laughed uproariously. There was spontaneity, intimacy, resonance, and deep confirmation in the interaction. Mary’s laughter tacitly revealed that she had made peace with her sister’s hypocritical religiosity. And Mary witnessed me enjoying my work, me enjoying her, me grasping her life struggles more resolutely.

A humorous comment can be a cut-to-the-chase experience, entailing an instantaneous rapid preconscious processing of interpersonal events eventuating in a joke or quip which leaves the client feeling sturdily understood. At an implicit level, when we joke with clients it is indisputable evidence that we enjoy them. Laughter is an intelligent way of accepting the unchangeable, and when it happens in common, it makes us feel good together. We therapists need to remind ourselves that humorous interactions with clients can cement a tacit connection, and add a quotient of compatibility that benefits the working alliance in psychotherapy.²¹

Professionalism Reconsidered

The personal development of mental health professionals has a bearing on the effectiveness of the services they offer in a way that rarely applies in other careers. If our dentist or accountant seems even-tempered and discerning as a person, it’s a bonus. We hire them for their technical knowledge, not their human know-how. It’s an entirely different matter in the mental health field. The effective psychotherapist somehow must have the presence of mind to immerse him or herself in an array of client problems without undue doubt or insecurity. Clients need to steadily and confidently expect that the upsetting stories they tell and retell will not emotionally rattle the therapist in fundamental ways. Most of the time, tolerably suffering what clients feel is insufferable, is a must. We carry clients’ unborn grief, sadness, elation, rage, envy, pride, and shame. This requires great depth and dimensionality of personhood.

Psychotherapists have a professional duty to psychologically work on themselves.

Our therapeutic instrument is our personhood and how we use this clinically in the room with clients. Emotionally speaking, we can only take clients as far as we have gone ourselves. If we disavow aspects of our humanity, it will be hard to help clients avow these same qualities in themselves. Blind spots for our own thwarted grief necessarily impede our ability to prompt clients to see and dwell in their own grief. The same applies to other emotional states.

These days, the professional duty to continuously psychologically work on ourselves has been eclipsed by a barrage of other priorities. In the frenzy to get established in the field, many new psychotherapists seem compelled to distinguish themselves as specialists of one sort or another. Typically, they tout these specialties as evidenced-based. Not a week goes by where I don’t receive an email from my local professional organization looking for a referral for a practitioner who has a specialty with clients or clinical entities such as: transgendered youth; eating disorders; parent alienation syndrome; divorce; victims of domestic violence; children with poor executive functioning; teen suicide; borderline personality disorder; depression in mid-life homemakers. Of course, it’s important to keep up on the literature in these areas, have a working familiarity with a range of diagnoses, and acquire discreet skills over time. However, we forget how there are overarching psychological dynamics and human frailties common to most clinical entities. It would be refreshing to receive an email from my local professional organization requesting a practitioner who specializes in tolerating and working with such phenomena as despair, contempt, healthy pride, obsessive jealousy, dysfunctional vanity, or out-of-control greed. For therapists to become familiar with these core human concerns, it is essential that they personally struggle with traces of them existing in themselves.

Multi-cultural competence, or an acquired knowledgebase to treat clients across a variety of racial and ethnic groups, is receiving renewed attention in psychiatry, psychology, and social work graduate schools and training sites across the United States. This is highly understandable. It is estimated that by 2050, the percentage of racial minorities in the country will increase to about fifty percent of the population.²² In the next decade, in some urban settings, upwards of eighty percent of therapist-client pairings will comprise cross-racial/ethnic dyads.²³ It is important, but insufficient, for mental health professionals to merely have a knowledgebase of what is common and normative across racial and ethnic groups. For instance, to read up on the role of “filial piety”²⁴ in the Asian-American community – the deep cultural obligation to respect and be loyal to one’s parents and elderly family members – and learn that second-generation young adult Asian-Americans frequently live a “dual life,” being more Westernized in public, and deferential at home. Awareness of this different norm keeps therapists from pathologizing such behavior.

It’s also not enough that therapists strive to avoid “color-blind racial attitudes” in which the harm clients face because of covert or overt forms of racial privilege and institutional discrimination is glossed over; for instance, pathologizing the justifiable anger and suspicion of racism at work on the part of an African-American client passed over for a promotion at work.

The all-important step to acquiring multi-cultural competence in clinical work involves the therapist exploring and examining their own racial/ethnic identity. A red flag for therapists to watch out for is when they either overvalue or devalue cultural attitudes and behaviors with which they have been raised. For instance, a White therapist might idealize the need for adolescents to individuate from parents. He or she may minimize a Latina mother’s complaint that her son is being unacceptably disobedient. Or, the reverse, a Latina therapist might idealize an adolescent’s need to be compliant with parents and minimize a White mother’s complaint that her son is being overly submissive.

Therapists also need to watch being too culturally insular in their personal lives in ways that subtly reinforce values and attitudes they think are normal for all people. More so than in other professions, we have an obligation to build cultural competency through putting ourselves in contact with members of various racial and ethnic groups on a regular basis. When we see clients from racial and ethnic groups other than our own, we not only have to feel comfortable in our own skin, but comfortable in their skin. We need to look at them looking at us and be accepting of and at ease with their otherness, with simultaneous confidence that we can understand their concerns because of our shared humanity. Along these lines, Adrian Van Kaam, the founder of the Institute of Formative Spirituality at Duquesne University in Pittsburg, aptly claims: “True therapeutic concern is, at the least, an implicit awareness of the inalienableness of my client’s life.” ²⁵

Finally, now more than ever, there’s pressure for therapists to conform to bureaucratic protocol which, if not actively resisted, can result in substandard client care. Ironically, there are many procedures therapists are instructed to follow that are considered commensurate with being an ethical professional which, if over-prioritized, can lead to unethical behavior with clients, in the human sense. During our initial visits with clients we are supposed to go over our office policies and procedures and set the formal rubric for therapy. To talk about fees; cancellation policies; mandated reporting requirements; diagnoses to go on insurance forms; and, treatment goals and objectives. Therapists feel the top-down pressure to be formal during the initial psychotherapy visits, while clients are longing for us to be informal, and to just listen. I often wonder if the current fifty percent drop-out rate²⁶ after the first few psychotherapy visits is abnormally high because too many therapists inappropriately yield to top-down bureaucratic requirements, and thereby lose the client.

Typically, when clients enter therapy they are in a state of real need. Any stigma they have about pursuing therapy can easily win out. If anything, the burden of proof is on the therapist to represent therapy as a worthwhile venture. Our full presence of mind and breadth of authentic care needs to be engaged during these initial visits. To enter therapy is to cross the threshold into a healing relationship, one where the therapist uses human virtues – sincerity, forbearance, forthrightness, tact, discretion, and mirth – for clinical purposes, so that whatever emotional breakdown the client experiences, in time, will achieve the psychological status of an emotional breakthrough.

The Healing Relationship

Let me begin with a sample of my clinical work that illustrates how effective psychotherapy pivots on the therapist’s know-how, or wisdom in action. Using this wisdom, the therapist works to communicate ideas to clients with the right words and the right degree of emotion as a catalyst for real client change. This is closer to a form of human expertise – exquisite sensitivity and communicative finesse – than technical expertise, or some employment of a learned code of clinical behavior. We know from the research literature that when therapists bring more of their whole self to the clinical encounter, clients benefit.^27-29

On occasion, my sixty-one-year-old retired police officer client Jordan amicably refers to me as his “bartender without the alcohol.” The fact that I chuckle rather than stiffen up and make any number of standard therapeutic interpretations (e.g., “I think this reflects how uncomfortable you are being in therapy with a trained professional and really opening up”) indirectly conveys to him that I accept him for who he is and see the logic in his comment. An exchange with a bartender happens to be Jordan’s blue-color, cultural reference point for a relationship where license is given to peel back the facade and speak more candidly about life’s troubles.

Jordan is not, as therapists are wont to say, an “insight-oriented client.” He is not particularly psychologically minded. There’s no painful confusion lessened by the search for a deeper understanding of why his life has turned out the way it has. There’s scarce exploration of how his early life experiences have created problematic relationship expectations in the present. Jordan is mostly indifferent to acquiring a richer understanding of why his two previous marriages ended in divorce, why he has no male friends, or why he has no “bucket list” of cherished life pursuits he hopes to bring to fruition in retirement. Which is not to say that Jordan is immune to and capable of learning from psychological linkages I make when the issue at hand is fathomable to him, and I plead my case with the right words, communicated with the right degree of emotional expressivity. Or, that our therapy relationship is not a productive one. Far from it. Let me explain.

One presenting problem Jordan had on entering therapy was that his daughter Marianne rarely spoke with or visited him. This was a constant open emotional wound for Jordan – trying to somehow cope with the psychological equivalent of having a dead child. Jordan had been a devoted father to Marianne in the years leading up to his contentious divorce from her mother, when she was about seven. But during her preteen years, Marianne lived almost exclusively with her mother and maintained sporadic visits with Jordan. These visits dropped off drastically once she became a full-fledged teenager. After Jordan’s ex-wife remarried a successful physician, Marianne was enrolled in an elite private school where she became an accomplished show jumper. Even though Jordan was highly articulate and educated, he had been forced to pull out of a doctoral program in Sociology in his late twenties, just shy of completing his dissertation, to work full-time to provide for his wife and children from his first marriage.

He now wore a shaggy beard and identified as working class. This seemed to widen the divide between him and Marianne, who was primed by her mother’s high-society lifestyle to view Jordan as a person of lower status and the middle-class neighborhood where he lived as a ghetto. Her attitude dampened any motivation to maintain visits with her father. I deduced from Jordan’s disclosures that his ex-wife might tend to demonize those she felt injured by and might strongly need others to share her absolutist negative attributions. In Jordan’s mind, his former wife’s psychology was one of “if you’re not for me, you’re against me.” If there was any truth to this, it would be extremely difficult for Marianne to have a positive image of Jordan, particularly if her mother harbored a mostly negative one of him.

Despite the forces stacked against him, Jordan somehow believed that “family was family,” assuming Marianne should simply override her mother’s malignant image of him, disentangle herself from her privileged lifestyle, set aside her adolescent self-involvement and commit to visits with him. His typical approach on the phone with Marianne was to launch into a lecture on the need to value family, do the right thing, and spend time with her father. The more Jordan felt shut out by Marianne, the more he demanded that she share information with him about her everyday life. This demand, however, hardened her perception of him as overbearing. It was as if Jordan believed his only recourse was to guilt Marianne into maintaining visits. In my mind, this attitude simply consolidated Marianne’s image of Jordan as stodgy and unpleasant to be around, even though he genuinely loved her and was desperate to spend time together.

Noticing that a dysfunctional dynamic in his relationship with his mother was recurring with Marianne, I got worked up during one session and uttered:

“Jordan, sometimes I think you turn into your mother, lecturing Marianne on how she needs to value family and visit more often. I remember this is exactly what you told me your mother would do. There would be the weekly calls where you would hold the phone away from your ear as she launched into a monologue about how neglected she felt as a mother, entitled to, but denied, more contact from her children. Her approach might have worked for you and guilted you into keeping in touch with her. But, it is an approach that is not working with Marianne.”

Jordan sat back and absorbed what I had to say.

This insight paved the way for Jordan to realize that while he certainly deserved more contact with Marianne, he needed a different approach. It was not an insight that, once achieved, fundamentally altered Jordan’s habit of guiltily lecturing Marianne. Mostly, he needed kind-hearted reminders from me: “There you go again Jordan, sounding like your mother and getting irate when Marianne inevitably wants the phone conversation over in a hurry!” Over time, in his conversations with Marianne he was better able to catch himself midstream and take a different tone with her. He was less apt to demand she commit to visits. He invited her to reach out to him when she was so inspired and when her busy school schedule permitted. Despite his best efforts, Marianne largely shunned any contact with Jordan.

In the early phase of therapy, Jordan railed at the unfairness of it all. He clung to an image of how his relationship with his daughter should be – regular visits actively encouraged by her mother; invites to show-jumping events; friendly phone conversations. This unrealistic picture fueled his bitterness. Gradually, Jordan accepted the emotional truth that he was essentially powerless to turn the tides in his relationship with Marianne for now, because of the seemingly impossible psychological and family dynamics at play. For Jordan, a former college football player and law enforcement officer, to acknowledge feeling powerless was no easy feat. At opportune moments, I pressed to see if behind the anger there was grief over missing out on seeing his daughter grow up, the same daughter he had held in his arms as an infant. Tears welled up in his eyes, and mine also.

Anger monopolized Jordan’s emotional life less regarding the situation with Marianne. In time, his mindset was one best characterized as a mixture of sad resignation and hope for a future where Marianne might decouple herself from her mother in the transition to college and show an interest in resuming a relationship with him. Jordan became less obsessed with exerting time and energy trying to correct his relationship with Marianne to no avail, or, as I put it, “Giving up the futile pursuit of trying to draw water from a dry well.” Jordan, who could be quite lyrical, had his versions of this realization: “Yeah Doc, like shoveling sand against the tide, or making a perfect swan dive into an empty pool.” Instead, Jordan turned his time and attention to his adult children from his first marriage, and their grandchildren, who were responsive to his overtures and enjoyed his visits.

Another presenting problem Jordan brought to therapy was the complicated nature of his marriage to his current wife, Betty. He was adamant that he had agreed to the marriage for convenience reasons – to pool their financial resources. There was every indication that Jordan was ambivalent about the marriage. He joked that, even though they lived under the same roof, they didn’t live together. (He lived above Betty in a duplex). They both seemed to prize solitude and were overly attached to their personal routines. Jordan complained that he desired more companionship with Betty, more conversations, more travel, more physical intimacy. Yet rarely did he initiate and persist in the actualization of activities, intimate get-togethers, and travel plans. Instead, he secretly kept relationships going with several female friends he met on-line, rationalizing that, really speaking, he was not married and needed more companionship than Betty was willing to offer. Invariably, Betty would catch on to Jordan’s outside female friendships (he claimed they were non-sexual) and understandably withdrew in self-protection. The outcome left Jordan feeling emotionally neglected by Betty, justifying his need for other women friends.

In my work with Jordan, I waited for openings to call attention to how the demise of his first two marriages may have soured him on the whole idea of marriage. As emotionally constricted as Jordan was – which probably limited the quality of intimacy he was able to offer his wives – he nonetheless prided himself on being a loyal, self-sacrificing husband and father. That his former wives just fell out of love with him and angled for their own financial interests and child-custody conveniences during and after the divorces not only hurt him emotionally but fractured his value system. By staying ambivalently married to Betty, Jordan was safeguarding himself against re-experiencing the rejection and demoralization he had previously experienced with his former wives.

For all his difficulties with Betty, the one virtue she indisputably wore was loyalty. I confirmed this quality for Jordan in the concrete details of his disclosures to me: her willingness to accompany him to his medical appointments and care for him after his multiple surgeries; her eagerness to include him in her family events; her conscientious and fair handling of their finances. Once, drawing from Jordan’s and my shared reality as lapsed Catholics, I asked: “Is it fair to hold Betty responsible for the sins committed by your exes – their disloyalty, their self-interest – when Betty really seems to have your back?” Jordan’s perception of Betty as a loyal partner was strengthened by my confirmatory feedback. Healthy guilt emerged whereby he did not want to hurt Betty anymore by keeping outside lady friends. He cut off all ties with them, and if any resurfaced, he vowed to tell them he was married and include Betty in on the details of any interactions. I could even discern that Jordan was less likely to hold back letting Betty know he appreciated having her in his life.

Thornier therapy issues remained in our therapy. Jordan can be passive, and his lack of initiative and persistence were Betty’s main complaints about their relationship. Give Jordan a list, a scheduled event, or a family obligation, and chances are he will follow through. Ask him what dreams he has moving forward in his life with Betty, how he can spice up his life more by adding travel and entertainment events, or what he can do to jump start his sex life with Betty, and Jordan is speechless. Some of this silence is explainable in terms of Jordan’s preference to live a simple, unencumbered, relatively solitary life in retirement, as a welcome countermeasure to his overly social, overcommitted career in law enforcement. However, we laugh that he is forever the Catholic altar boy, wired to live a life of duty and obligation, as if there’s sin in pursuing personal enjoyment and satisfaction. As a former altar boy and Catholic seminarian myself – both of which I told Jordan early on in treatment – I could profoundly relate to his struggle. A dimension to my ongoing work with Jordan remains niggling and nudging him about identifying and persisting with what he really desires, what might make his life fuller, more fulfilling.

As of this writing, Jordan has been in weekly psychotherapy with me for almost four years. Our therapy relationship could easily have failed before it even started. In the beginning, Jordan was a reluctant client, brought in under mandate by Betty who was exasperated by his lack of real commitment to her. He had never been in therapy before. He carefully guarded his privacy because of his undercover work in law enforcement. He was used to doing the inquiring, the investigating, the detective work. He was a burly man; a pull-yourself-up-by-the-bootstraps type, not given to shows of emotion, other than angry rants. What made the relationship viable, then therapeutically productive? Obviously, the answers are myriad.

Jordan clearly needed an egalitarian arrangement, not a hierarchical one. He needed to sense that we both basically encountered the same existential predicaments, muddling through life facing problems common to all humans. I asked Jordan once what he would do if, rather than join in with him briefly in discussing British soccer, sharing my views on religion with him as requested, or answering whether I could relate to his challenges as a father, I would have responded like a typical therapist: “Jordan this is your time to talk about you, not to avoid that and get me to talk.” Jordan remarked that such a comment would have ended the therapy right then and there.

Session in and session out, Jordan incrementally learned he could count on me to be earnestly interested in and emotionally captivated by whatever was on his mind. He learned to expect that I would be applying whatever wisdom I could muster to zero in on something of emotional relevance, said as best I could, in a way he might truly hear. These conditions fostered greater emotional vulnerability and prompted Jordan to talk less self-consciously about his troubles. The more credibility I gained in his eyes because of my style of relating to him and genuine regard and affection for him, the more I could lean in and confront him when necessary.

My relationship with Jordan shows how the healing properties of the therapy relationship reside in the client experiencing and re-experiencing the confident expectation of empathy and confirmation; confrontation rooted in loving concern; usable psychological insights; and, affirmation of the need to live life more actively, desirously, and deliberately.

Empathic Immersion

Empathy’s rise to prominence as a basic therapeutic stance is a testament to clients who implore their therapists to just stick to the task of listening to and accurately understanding their personal experiences. Both Heinz Kohut and Carl Rogers – the two theorists credited with according central importance to therapeutic empathy – have their humbling stories to tell about how they finally learned to value the act of tuning into clients’ subjective experiences more carefully and caringly, eventually systematizing their own schools of therapy.

Treating a middle-aged professional man harmed by religiously based parental intolerance, Kohut, rather candidly, spells out his epiphany:

The patient, as I finally grasped, insisted – and had a right to insist – that I learn to see things exclusively in his way and not at all in my way. And, as we finally came to see – or rather as I finally came to see, since the patient had seen it all along – the content of all my various interpretations had been cognitively correct but incomplete in a decisive direction.³⁰

Rogers is almost apologetic in his epiphany:

Very early in my work as a therapist, I discovered that simply listening to my client, very attentively, was an important way of being helpful. So when I was in doubt as to what I should do in some active way, I listened. It seemed surprising to me that such a passive kind of interaction could be so useful … the most effective approach was to listen to the feelings, the emotions, whose patterns could be discerned through the client’s words … [then] ‘reflect’ these feelings back to the client – “reflect” becoming in time a word that made me cringe. But at that time, it improved my work as a therapist, and I was grateful.³¹

It was the misuse of Rogers’ method of reflecting back clients’ moment-to-moment feelings and concerns that made him uneasy – the therapists who simply mouthed back clients’ words in a rote fashion:

Client: I’m irritated with my wife because she mistakenly took my car keys in her purse this morning and I had to take the bus to work.

Therapist: So you are irritated with your wife because she mistakenly took your car keys.

Nevertheless, both Rogers’ person-centered and Kohut’s self-psychology therapy approaches underscore how psychologically restorative it is for clients to have their shifting feelings and ideas tracked and re-iterated with genuine care and attentiveness. For Rogers, ready access to consistent empathic recognition helps clients avow, express, and integrate feelings, thereby making them more “congruent” as people; or, less emotionally split off and phony.

Kohut believed that meeting clients’ “mirroring needs” was critical to their attainment of a viable and vital sense of self. Therapy rich in mirroring experiences allowed clients a second chance at development. Clients visiting him complained of feeling depleted, void of ambition, or prone to drastic downturns in their self-esteem when falling short of their goals and aspirations. Kohut surmised these vulnerabilities were the outgrowth of insufficient and inadequate mirroring of their basic emotions during their tender years. In particular, the consistent absence of the “gleam” in a caregiver’s eye in response to a child’s outward display of talents and abilities; and, a caregiver’s unavailability to help process grief, shame, and rage reactions during the inevitable let-downs all kids face.

In the self-psychology model, the therapist’s sustained and predictable focus on sensitively handling clients’ moments of elation, chagrin, sadness, fear, or even rage at being misunderstood has profound remedial effects. Mirroring affirmation of clients’ proud moments remedies thwarted self-esteem formation. Repeatedly seen as worthy, they more resolutely see themselves as worthy. Over time, reliable access to sensitive attunement when there are upsurges of intense emotion lessens the potential for clients to get emotionally flooded by such experiences. Emotions such as anger, sadness, and elation, are avoided less and become acceptable aspects of clients’ self-experience, which makes clients feel more alive and energized.

Many beginning psychotherapists – especially in the current “quick-fix,” therapy zeitgeist – shy away from upholding an empathic stance with clients. They often believe they are not being productive enough if their primary mode of relating to clients centers on “reflecting” or “mirroring” clients’ subjective experiences. They assume that mirroring lacks sophistication and devalues their vast education and training. I often remind my trainees of the implications of Rogers’ and Kohut’s ideas. I reassure them of the therapeutic value to settling in and becoming absorbed in the subjective experiential lives of their clients; of yielding to and following along with clients’ moment-by-moment disclosures; of accepting the free-flowing, non-linear nature of the endeavor; of starting sessions without any conscious agenda, trusting that something emotionally relevant always presents itself. The ideal state of mind to inhabit is cleverly captured by the New England psychoanalyst, Sheldon Roth:

What we are always striving for is to be at the edge of the patient’s most immediate experience and awareness. When our patient walks through the door we have no real idea of what this might be. We want to behave as if excessive movement puts all of living nature into hiding, as it does at a woodland pool.³²

Much that is wholesome about therapy involves the clinician’s covert automatic imitation of clients’ verbal and non-verbal behavior.³³ Empathically immersed therapists give themselves over to the organically unfolding interaction, unconsciously and preconsciously adapting their behavior to that of the client’s. Synchronized, well-timed nods, frowns, grimaces, leg folds, and chin rubs lubricate and embolden client disclosures. There is abundant, barely conscious, facial dialoguing in good therapy of the sort that leaves clients feeling attended to and understood.

Sometimes, empathic responses encompass short phrases that the therapist uses to convey that he or she is tracking what’s on the client’s mind, or to pithily sum up what the client feels. The brevity of the expression reflects a respect for the tempo of the client’s communications, a desire to not markedly interrupt him or her “mid-stream.”

Adam, an emotionally constricted pharmacist, arrived flustered for his therapy session. We had the following exchange:

Adam: (with frustration in his voice) There was a road crew blocking traffic with cones in both directions in my neighborhood this morning. I was stuck in my own driveway! There are no shortage of fools out on the road.

Dr. Gnaulati: The circus is in town!

Adam: And the clowns are out!

Mary Anne, a busy executive and mother of three daughters, bemoaned the fact that she had no time to herself:

Mary Anne: I’m clocking about a fifty-hour work week right now, on top of all that’s expected of me at home. I’m not eating right, nor exercising. Everywhere I turn, I have to put out and put out; just keep on giving. You can only imagine how I feel … .

Dr. Gnaulati: Depleted?

Mary Anne: Exactly. I’m so unbelievably worn out and exhausted.

Empathy can have evocative effects for clients. It can act like an emotional stimulant, freeing clients up to access and more fully articulate dimly felt emotions.

Because Janet’s aunt had no children of her own, she felt compelled to step in and help out while her aunt was dying in hospice care. Janet had earlier confessed to me that she was repulsed by her aunt due to her being an alcoholic who watched soap operas all day.

Janet: Who am I to judge? Maybe my aunt was content with her life.

Dr. Gnaulati: You sound to me that in retrospect you feel guilty for not having had more compassion for her while she was dying.

Janet: I suppose so. I feel bad. I could have made her final days a little easier.

Dr. Gnaulati: How?

Janet: Sneak her cigarettes, buy her better booze. I don’t know.

Dr. Gnaulati: I can tell you have some regrets …

Janet: Yeah. I guess I just feel bad about the life she had and wished I had not been so put off by her.

Sticking with and teasing out the implications of clients’ word choices and metaphors in ways that draw out underlying feelings is another form of empathy. My client Liam made every effort to reach out to neighbors and friends to make his home a desirable place for their kids to gather, so his kids had companions. All too often, however, his invitations were ignored or turned down. He frequently felt adult family members and friends failed to match his zeal to spend time together. Growing up, Liam’s home had been a veritable neighborhood hot spot where kids and their parents convened. This all changed suddenly during his pre-teen years when his mother died.

Liam: I feel like I’m losing at the game of life. I’m not sure what I’m doing wrong, or if I’m doing anything wrong. Friends are getting together and not including me. My son is definitely not part of the in-group at school. It is very different from how I remember my life as a kid. It’s all overwhelming, like there’s a big hole in the plane and I’m trying to cover it up.

Dr. Gnaulati: Planes usually crash when there’s a big hole in them.

Liam: I’m going to cry, but I can’t. I want to get back to the point I was making … .

Dr. Gnaulati: (with a soft voice) … Maybe the point is there’s a lot of sadness and loneliness that’s hard to just go with …

Liam: (sobbing uncontrollably) … Before my mother died, our home was the hub. Family and friends came to us.

Therapists also use their empathic understanding to turn an implicit impression nested in the client’s narrative into more of an explicit realization.

Lydia, who elected to home-school her children, was demoralized because her husband Marlon frequently underappreciated all it took to both raise and educate their children.

Lydia: When I tell Marlon I’m essentially working two full-time jobs – running a household and educating our kids – he claims I’m exaggerating and making excuses for myself. He calls me lazy and disorganized. Then when I push back and tell him he’s being mean, he accuses me of being too sensitive.

Dr. Gnaulati: So Marlon doesn’t see himself as too critical, he sees you as too sensitive. It looks to me like you think Marlon has a blind spot for how critical he can be.

Lydia: He really does. It’s getting to the point where I feel I need to swallow my feelings when he starts up and just say something to appease him.

As should be evident from the above clinical examples, empathy only truly validates client experiences inasmuch as the therapist feels moved by, not removed from, the client.³⁴ Real empathy is far from sterile affirmation. It’s not an applied technique, or a function the therapist provides. It involves genuine emotional engagement from the therapist. When therapists empathically give from their humanity, the client feels not only heard but confirmed. His or her pain and suffering, hopes and aspirations, fears and anxieties, attributes and foibles, are not just observed, but authenticated.

As we learned above, confirmatory feedback plays an important role in normalizing the feelings, attitudes, and self-perceptions that clients abnormalize. Of course, sensitive confrontation in therapy also has its place. The conscientious therapist has the client’s better self and greater well-being in mind. There are always those moments in the office when the therapist is prepared to hold clients themselves accountable for the betterment of their social and emotional well-being.

Sensitively Confirming and Confronting Clients

Several lines from Walt Whitman’s widely acclaimed poem, Song of Myself, capture, quite lyrically, the quality of personal involvement that distinguishes confirmatory therapeutic gestures: “I do not ask the wounded person how he feels, I myself become the wounded person … It is you talking as much as myself … I act as the tongue of you.” ³⁵

In clinical terminology, Dr. Martha Stark, Clinical Instructor in Psychiatry at the Harvard Medical School, claims the appropriate state of mind is one where the therapist remains “centered within her own experience, allowing the patient’s experience to enter into her, and taking on the patient’s experience as her own.”³⁶ Being fully and wholly present to clients in this way is especially important to normalize needs and desires clients are wont to abnormalize.

Coming out of a long-term relationship with an abusive, possessive boyfriend, twenty-eight-year-old Sara went through a period in her life where she welcomed casual romantic relationships with men. She restored some confidence in her ability to live life independently. As the novelty of rediscovering her freedom wore off, she secretly longed for a close, monogamous relationship with a man. Not the type of monogamy marked by the enmeshment and possessiveness that existed with her abusive ex-boyfriend; rather, one where both partners give each other space, or show mutual regard for each other’s independence. Sara found herself wanting more than several of a string of boyfriends had to offer. On the face of it, her wants were perfectly legitimate: texts and phone calls returned in a timely manner; romantic dates planned and followed through with; initiation shown to give her gifts and suggest travel locations she might enjoy. In short, Sara wanted clear signs that she held a special place in the heart of whatever boyfriend happened to be in her life.

Sara delegitimized her legitimate romantic needs. She berated herself for “weirding out” due to becoming hurt and irritated with a given boyfriend when it took him days to respond to her texts. She saw herself as a needy person for wanting a man to initiate and execute a date. It was “psycho” of her to be jealous when she discovered that a new, reportedly committed, boyfriend refrained from putting pictures of the two of them on his Facebook page, even though pictures of his ex-girlfriend remained there. It was in this context that we had the following exchange:

Dr. Gnaulati: It seems hard for you to gauge what’s OK to expect from a man!

Sara: I just need to be more chill and focus on me and my own life. The last thing I want is to be the jealous, weirdo, girlfriend.

Dr. Gnaulati: Maybe you’re jealous, hurt and irritated for good reason! As I see it, it’s a baseline requirement for any serious romantic relationship to want a man treat you special, make dates and follow through with them. Don’t you agree?

Sara: I guess so.

Dr. Gnaulati: I wish you would know so! You lost good years in that horrible relationship with your ex-boyfriend and a big part of me thinks you deserve so much better than you’re getting with men.

Sara: (with sadness in her eyes) You’re right.

Clients need to know we not only can encounter them, but can also counter them. Not only face them, but also face off with them. Client-centered therapists (like child-centered parents) lose credibility if their expressions of sympathy and positivity are staid and overly predictable. More often than not, the issue is not whether to confront clients when they get stuck behaving egregiously or selling themselves short, but when and how. This decision involves therapeutic tact, described by Yale University psychologist, Jesse Geller, as follows: “the capacity to tell clients something they don’t want to hear in a manner in which they can hear it.”³⁷ The struggle entails benignly standing against the client, prepared to stand one’s ground and withstand any ire this creates; or, as the prolific British psychoanalytic essayist, Adam Phillips puts it, “ … the analyst has to be tenacious without being authoritarian.”³⁸

Generally speaking, when clients act out (e.g., engage in unselfconscious impulsive, reckless, and blameworthy behavior), the therapist’s job is – in a good-natured way – to engender in them an awareness of the negative consequences of their actions. They take too little responsibility for their actions. As counterintuitive as it sounds to the average caring therapist, healthy guilt needs to be aroused; but in a way that circumvents the potential for clients to feel all bad. The focus is on the bad deed, not the badness of the doer of the deed. The following clinical vignette will illustrate:

In the early years of their marriage, before children came along, Bob and Joanne were in mutual agreement that they had more love for one another. Bob wrote sweet notes to Joanne recognizing her cleverness, sincerity, and quick wit. Joanne made picture books of memorable times they shared together. In couples therapy with them I had a palpable sense of the love and respect they had for each other despite the testiness and brittleness in their interactions.

Bob was prone to being boorish, making crass and critical comments that stunned Joanne. In turn, she would withdraw and respond coldly to Bob’s subsequent make-up overtures.

Two months into treatment, we had a session in which Joanne described to me the picture book she had compiled early on in the marriage photo-documenting the paths her and Bob’s lives had taken, culminating in them meeting and falling in love. I suddenly found myself tearing up and cobbled together a response:

Dr. Gnaulati: That’s so sweet and tender … there’s love that you have for each other that has gotten baked over by ways you get caught injuring each other. Bob, too much of the time I think you can be unselfconsciously critical and harsh like your mother. This then aggravates a tendency you picked up from your father, Joanne, to withdraw and appear indifferent when Bob excitedly shares his work day with you … .you injure each other and risk eroding a love that has always been there.

Bob and Joanne appeared caught off guard by my tears, as was I. They were riveted by my comments and demurely nodded their heads in agreement. The following week they reported that the session had been a “mini breakthrough” and that Bob was kinder, asking Joanne if she needed more help around the house. Bob thought Joanne was more lighthearted and engaged with him.

Some clients are poised to disavow positive things that are calling out to be said. They are overly invested in their distorted negative self-perceptions and attributions. Tenacious verification of what they obviously have going for them is required to challenge their hardened self-deprecatory image.

Alan, a twenty-eight-year-old graphic artist with disabling social anxiety who dropped out of college and was living with his parents, often blithely launched into a litany of his failings with me:

Alan: Let’s face it, I’m incompetent. There are the competent ones who do well in college and make something of their lives. Then there’s people like me with nothing going for them who sponge off their parents.

Dr. Gnaulati: What are you talking about Alan! Granted, you may not have a college degree, you may be going through a transitional time in your life, having to live with your parents and struggling to conceive of some form of gainful employment; but I find you to be incredibly bright and articulate, an autodidact who is interested in literature and philosophy for its own sake, and someone who has a knack for seeing through pretense. That’s not incompetence!

The examples I have provided should clarify that real empathic confirmation draws form the therapist’s humanity. It involves emotionally diving into and divining clients’ painful life stories. Professional aloofness and detachment cannot be the therapist’s routine fallback position to keep from getting mixed up in and with clients’ psychological afflictions. We do well to heed the advice of the existentialist psychologist Emmy van Deurzen:

As therapists and counselors we need to be capable of letting our lives be touched by those of our clients. It is no use occupying the higher moral ground from which we can look down with mere empathy, interpretation, or judgment: we have to struggle with our clients’ problems.³⁹

Feeling With, and Feeling For, the Client

There’s a long-held belief in the field that disturbing emotions are like psychic forces lodged in clients’ unconscious minds awaiting excavation through correct identification by the therapist. Emphasis is placed on the therapist mostly subduing his or her emotionality, reflecting back what the client feels: “I can see that being passed over for the promotion at work makes you mad.” Once correctly labeled and accurately mirrored by the therapist – then vented by the client – disturbing emotions somehow no longer disturb.

However, this more intra-personal view of emotional experience is increasingly being replaced with an inter-personal one.⁴⁰ A convergence of knowledge from fields as diverse as relational psychoanalysis, infant research, attachment theory, and affect regulation theory is beginning to change our thinking about emotional experience. The so-called “intersubjective” model, which I subscribe to, underscores how the content, intensity, duration, and outward expression of client emotions are inextricably linked to how they are responded to by the therapist. How quickly a client’s feeling states emerge and are recovered from; how long they last; how faintly or intensely they are experienced; and how adept a client will become at finessing their outward expression – are all contingent upon on the therapist’s verbal and non-verbal expressions of mutually generated feelings in the room.

Because emotions are relationally contagious, therapists need to allow themselves to feel these contagious effects. An unfortunate carryover of the rule of abstinence, or neutrality, as a therapeutic stance, is that clients are deprived of the potentiating effects of therapists’ expressiveness. If clients are to be put more in touch with their underlying feelings surrounding a painful disclosure, it sometimes takes a therapist to amplify his or her own mutually generated reactions to clients’ disclosures. To take a reserved approach out of some belief that this contaminates the client’s access to fully formed, self-contained, “pure” emotions, is misguided.

There’s a performative – not just informing – dimension to putting clients in touch with underlying feelings. The therapist’s skill at knowing how and when to amplify versus dampen a response, prolong or foreshorten an emotional reaction, embody a gesturally animated versus sedate expression, use a loud or quiet voice to make a point, draw out eye contact or avert it – all as coordinated authentic expressions while rapidly processing verbal and nonverbal interactional information in the room – is the sort of receptivity and sensitivity clients need in order to effectively access, articulate and elaborate their own unformulated emotions.

Along these lines, Dr. Allan Schore, a national expert in affective neuroscience at UCLA, writes:

For a working alliance to be created, the therapist must be experienced at being in a state of vitalizing attunement to the patient; that is, the crescendos and decrescendos of the therapist’s affective state must be in resonance with similar states of crescendos and decrescendos of the patient.⁴¹

Dr. Schore has published voluminously on the importance of therapists standing in as “psychobiological regulators” for clients, using their more expanded emotional repertoires to arouse and de-arouse clients’ feelings along therapeutic lines. This is more of a naturally occurring process arising out of therapists’ acute attunement to and sensitive handling of clients’ shifting emotional states, rather than some established technique.

Sometimes a therapist and client are so in synch in the joint venture of fleshing out all the underlying thoughts and feelings a client experiences surrounding a troubling life event, that the therapist can flit back and forth from feeling along with the client, to feeling for the client – even switching into actually speaking for the client in more elaborate ways that enlarge the client’s emotional potential. Some examples are warranted.

Twenty-six-year-old George told me of an interaction he had while out at a fancy restaurant with his high-powered attorney parents and their wealthy friends. The discussion turned to an app one of the friends was designing aimed at luring people into gambling at younger ages. George, a very perceptive, interpersonally astute though debilitatingly self-conscious man with a knack for seeing through pretense, responded: “Do you have to make money at other people’s expense?” The family friend sneered at George’s presumed naivete, claiming that in capitalist society exploitation and moral ambiguity was inherent in the whole enterprise of accumulating wealth. George confided in me that the family friend designing the app was brash and self-centered. He was cruel to his wife, who once confessed to George’s mother that she only stayed married to preserve the opulent lifestyle her husband’s career afforded her.

My anger mounted as George narrated his story. Noticing him shutting down, I felt a pull to defend and emotionally invigorate him. I leaned forward in my chair and raised my voice:

Dr. Gnaulati: You didn’t feel like pushing back when he called you naive like saying, “I might be naive but you are about as self-centered as they come, with a wife who is unhappily married who only stays with you for the money, a wife who is wearing golden handcuffs. The two of you pursue wealth and status, life feeling emptier by the day, yet falsely believing you are happy. What the heck!”

George: (laughing, seeming to feel protected and understood, half shocked, yet half emboldened). I’d never say that!

Dr. Gnaulati: I get it, I’m being over the top. But don’t you believe it and at some level wish you could say some version of that?

George: (blushing, yet using a firm voice) Of course I believe it and wish I could have been honest with that pompous ass.

In the words of the prolific York University psychotherapy researcher, Dr. Leslie Greenberg, this was my way of “changing emotion with emotion; or, emotionally addressing the withdrawal tendencies in fear and shame … by the thrusting forward tendency in newly accessed anger at violation.”⁴²

Another example will help. A middle-aged college professor named Gustavo came to see me after an incident where his wife accused him of being unfeeling and callous in his reactions to a non-life-threatening medical procedure she needed. He had arranged for her to see a local expert in the field; escorted her to various preparatory appointments; talked to the doctor on her behalf because her anxiety interfered with her cogently representing herself; and ensured that she have a dose of valium on the morning of the surgery to de-escalate her anxiety. All the same, Gustavo was in agreement with his wife’s sense that he was oddly detached and lacking compassion for her. Why was he not more loving toward his wife in her hour of need? Maybe his wife was right that he was a “cold fish,” a “vain man” who valued professional accolades over family attachments.

As we explored their marital relationship, it came out that Gustavo had worked hard to put his wife’s children from a first marriage through private school and college, despite the fact that their father was well off and refused even to pay child support. The first husband was highly manipulative in his custody dealings. All the same, Gustavo’s wife insisted that this difficult man be included at all holiday events and family functions involving the children. Nonetheless, his wife frequently chastised Gustavo for being unsupportive and overcommitted to his academic research. Curiously, Gustavo was convinced his wife was spot-on in seeing him as unforgivably cold-hearted. In the context of one of these exchanges, I showed my irritation:

Dr. Gnaulati: Gustavo, you seem to represent your wife’s point of view very well, and under-represent your own point of view, or any feelings you might have about being accused as unsupportive. (gently pounding my fist on the chair). I’m noticing that I’m more angry at your wife than you are right now! There’s not a voice inside your head that wants to say: “Honey, I know I can let you down by not being more emotionally involved; I know you need more from me emotionally; but, working hard to put the kids through school and college is the main way I’ve shown my support. So too is putting up with your unbearable ex-husband for the sake of the kids. It’s downright hurtful to me that you not only don’t appreciate that, but see it as me escaping from the family!!!”

Gustavo: (Laughing loudly, segueing into obvious irritation) When I stop and look at it, that’s actually how I feel. I need to get better at not letting my wife get into my head and seeing me as being selfish for working hard at my career. I did it mainly to put her kids, whom I adore, through school and give us all a good life!

Obviously, being gesturally animated and emitting somewhat leading comments like these can be risky (although, strictly speaking, we are talking about emotionally leading comments the therapist is led to by the client). I’m not endorsing wild, anything-goes therapy. Ruptures in the therapeutic relationship can ensue if the client perceives the therapist has fixed biases about what and how the client should feel. I’m proposing that therapists strive to embody disciplined spontaneity; that is, use their intimate knowledge of any particular client to make rapid intuitive judgments as to what might be communicated to the client of a therapeutic nature, and how, in order to draw them out emotionally. Working with disciplined spontaneity is effective, I think, when the client chimes in, picking up on saying more about the underlying emotional reactions the therapist channels for the client. Or, at face value, it is effective because the accuracy of the therapist’s emotional channeling of the client’s unconscious affects is consensually validated by the client.

Instilling Psychological Mindedness

Emotionally enlivening clients and leaving them feeling understood is only one component of the therapy relationship. Another is facilitating their acquisition of greater self-understanding, or psychological mindedness. The latter term can be traced back to an obscure paper penned in 1973 by the now-deceased Menninger Foundation psychoanalyst, Sheldon Appelbaum.⁴³ In a nutshell, it pertains to peoples’ capacity and willingness to seek insight into links between their current troublesome and troubling behavior and unresolved events in their past, as well as to decipher their own and others’ motives and intentions. Use of the mindedness term among mental health professionals, as well as in popular culture, has dwindled. This is largely because of the “analysis paralysis” Freudian bias associated with it; or, the presumption that Freudian insights are arcane and don’t actually lead people to change their over-reactivity, irrational habits, and self-defeating tendencies. There’s truth to this, but it’s not all true. Some personal reflections of the benefits of Freudian insights in my own life will clarify.

My teenage son’s bedroom is a disaster. Going back a year or so, each time I saw the wet towels on the floor and dirty dishes on his desk it took every ounce of energy for me to avoid becoming apoplectic. My silent anger completely disabled me from saying or doing anything constructive to inspire him to keep his room clean. If anything, my anger inspired him to keep his room dirty because – in his normal adolescent way – he had found my Achilles heel; a ripe issue he could defy and oppose me on to express his autonomy.

Why did this particular issue emotionally undo me? My own adolescence was far from normal. From about age thirteen to seventeen, I lived away from home in a Catholic seminary in rural Aberdeen, Scotland, studying to be a priest. I had my own cubicle with sparse room for a bed and a chest to keep my clothes in. I kept it immaculate. I had to. I was a prefect in charge of checking the cubicles of other seminarians to ensure they were clean. Leaving my own room unclean was unthinkable.

So one reason for my anger was my tacit sense that that my son should adhere to my authority just as the other seminarians whose cubicles I checked had done. What’s more, I had essentially by-passed my own adolescence, conforming to what the adults in my life expected of me, deluded into thinking that any normal acts of adolescent rebellion were signs of intolerable disobedience. The lingering effects of this were intolerance of one of my son’s favorite ways of rebelling – keeping a dirty room.

In time, realizing that I had an unusual adolescence that set me up to malign my son’s rebellious dirty-room behavior gave me some flexibility in thinking about and responding to it. It lessened the intensity of my anger, but certainly did not make it go away. It made me ignore the mess sometimes to keep the peace. At other times I came on strong, imploring him to respect the need to be more cleanly and organized in his life. It made me step back and wonder if my son’s room was his regression-zone, his place to let it all go in reaction to his demanding private school, where he had to compete academically and keep it all together.

My point is that helping clients hit upon historical explanations or covert motives for their undesirable behavior doesn’t make it vanish. Instead, they now have a context for understanding their behavior and a newfound flexibility in responding.

There are other therapeutically useful Freudian notions besides that of history repeating itself if we don’t recollect it and come to terms with it (repetition compulsion). Over the years, I have found that calling attention to clients’ reliance on prototypical Freudian defense mechanisms has personal and interpersonal benefits. For example, take the case of projection, shedding light on a client’s unawareness that he or she shares the same unlikable qualities found objectionable in another. True insight into acts of projection can have humbling effects and leave the client more annoyed with him or herself, than with a significant other.

My client Maria attended a nontraditional high school, eager to graduate as quickly as possible by taking a high school equivalency test. Her stepbrother, Wally, had recently graduated from high school, but lived at home without any regular job or realizable life plan. Maria frequently complained to me that Wally was disorganized, lazy, and uninspired.

Maria: I’m so disappointed in Wally. He spends most of his day in his his room on his computer. I feel like barging in and telling him, “Dude, go get a life.”

Dr. Gnaulati: I know you are disappointed in Wally because he’s not doing more with his life. Maybe you’re worried that Wally’s life is in YOUR future and are disappointed in yourself for not doing more with your life?

Maria: It bothers me that I don’t have more motivation at school and just want to be done with it all.

Psychoanalysis is not the only school of thought offering therapeutically meaningful insights. In the humanistic tradition, clients’ behavior can be demystified in light of struggles with the unavoidable existential givens of the human condition: death, loneliness, freedom, nothingness. I find myself gravitating toward existentially oriented interpretations and quips that are rooted in common concerns that clients bring to me, such as:

Maybe you allow yourself to get caught up in compulsive action as a way to keep your mind off looking at the big changes you would need to make in your life to be happier. It’s easier for most people to follow a script, than write a script.

When you are on your death bed, I doubt you are going to regret not having racked up more billable hours at the law firm! You’re probably going to wish you had more quality time with the ones you love.

You seem to feel like your priorities are all off. What are your REAL priorities? I wonder if what keeps you in this unsatisfying relationship with your girlfriend/boyfriend is the fear of being alone?

I can tell you’d rather be alone than around conventional people living conventional lives.

You sound like there should be some absolute purpose to your life outside of yourself that you need to discover, as if you don’t have to define that and act on it for yourself.

In fairness, cognitive behavior therapy (CBT) has its own brand of psychological mindedness that it tries to instill in clients. At its core, CBT helps clients step back and think more clearly about how they think (versus why they think the thoughts they have). Cognitive distortions – such as polarized thinking (inappropriate all-or-nothing/black-and-white explanations for events); personalization (assuming too much responsibility for negative outcomes); overgeneralization (coming to a false general conclusion based on a single piece of evidence); and, catastrophizing (exaggerated negative expectations) – when pointed out to clients, can be self-utilizable as stop-gap measures to alleviate their anxiety. In humanistically oriented psychotherapy, pointing out clients’ thinking errors doesn’t occur in a didactic or systematic way, as is the case in traditional CBT. The process of raising clients’ consciousness about the cognitive distortions they automatically employ occurs more naturally, as they sporadically occur in the flow of a therapy session. The therapist is not using an intervention so much as offering tidbits of reflective personal feedback based on questionable assumptions nested in the client’s verbalizations. For example:

Forty-nine-year-old Cameron, a devout Catholic, entered therapy to address depression that set in after his divorce.

Cameron: I feel so alone. It’s at its worst on the weekend when I don’t have my kids with me. I failed the marriage.

Dr. Gnaulati: I failed, or IT failed? You seem to be taking exclusive responsibility for the marriage not working out.

Brandon, a young adult client of mine, took a gap year from college. He did not anticipate how lonely he’d be apart from his girlfriend and male buddies who all went to college straight out of high school.

Brandon: I’m starting to think that when I eventually go on to college I’ll be lonely and have no friends.

Dr. Gnaulati: I think you’re overgeneralizing based on how isolated and lonely you are right now! If you remember, it was not that long ago your weekends were packed with social gatherings!

Bolstering a Sense of Personal Agency

In 1933, Freud issued his famous quote regarding the aim of psychoanalysis: “Where id was, there ego shall be.” In Freud and Man’s Soul, Bruno Bettleheim clarified that the correct English translation from the original German encompassed less jargon: “where the experience of it-ness was, there shall be an experience of I-ness.”⁴⁴ In broad terms, what Freud meant by this is that a sense of personal agency – of feeling in control of and having control in one’s life – requires us to familiarize ourselves with and appropriate our emotions; especially our “primitive” ones. Time and time again in therapy, accessing, articulating, and having a therapist confirm our propensity for anger, lust, grief, envy, pride, and so forth, helps us feel like we are the subject of our emotions, not simply subjected to them.

This is not to say that any of us can achieve supreme control in our emotional lives. As the respected Boston psychiatrist, Dr. Arnold Modell once claimed: “We cannot control what we feel any more than we can control our heartbeat. Our feelings simply happen to us. What we can control, at least potentially, is our interpretation of those feelings.” ⁴⁵ We can try to understand why we feel the way we do more penetratingly, which, as I earlier indicated, can give us more flexibility in the way we respond. We can also work at modulating and finessing our outward expression of emotion: gauging the right amount of intensity to make a point; using less accusatory language; walking away rather than grinding away; transitioning faster out of negative emotional states; and, responding to, rather than perpetually reacting to, others’ emotions. This is part of the “emotion work” clients commit to in therapy, and in life.

Continual acceptance that life needs to be lived more actively than passively also bolsters our sense of personal agency. This often makes the difference between living a life that makes us happy, not just content. Along these lines, Daniel Russell states in Happiness for Humans: “Living a happy life means actively living, engaging the world, finding things to live for and then living for them.” ⁴⁶ At work, and with their families, clients raised to accommodate to the needs of others and to comply with adults’ demands can passively default to over-prioritizing what they should do and under-prioritizing what they might enjoy doing. Such clients can benefit from reminders to prioritize and actively pursue sources of personal enjoyment:

I know you need doses of solitude to function best. You don’t seem to be making that enough of a priority in your life right now.

Is that really what you want to be doing with your time?

I can tell that you are struggling to use your free time wisely; but it’s a struggle that probably needs to be owned more.

With all you have going at work and home, it must seem like there’s no time for you. I worry if you don’t MAKE time for you, doing what replenishes you, your depression will worsen.

Personal agency not only involves living life actively, but purposefully. Russell adds: “There are ends we act for, then there are ends we live for: ends that give our existence direction and purpose, that make the difference between a shapeless existence and a complete life.”⁴⁷ In When Nietzsche Wept, America’s leading voice on existential psychotherapy, Irvin Yalom, puts it more bluntly: “Not to take possession of your life plan is to let your existence be an accident.”⁴⁸

Therapy can be a domain for clients to clarify, assess, and commit to pursuing life commitments that are in line with their own true talents, preferences, values, and ideals. This is a decidedly subjective process. What applies for one person doesn’t necessary apply for another. Clients sometimes wish there were “objective” standards for living that they could adopt wholesale. They reference other people in their lives who have it all together – if they could only be just like them. In those moments, refocusing their attention on who they are, what they are genuinely good at, and what gives their life meaning and purpose, is indicated.

In the transition to parenthood in his early forties, Marco, an accomplished physics professor, put his career on hold to be more available at home as an involved dad. Now that his son was in preschool, Marco felt freed up to invest more time and energy into his academic life.

Marco was a brilliant divergent thinker who could perceive the pros and cons of many ideas. This is what made him an accomplished scientist. But it also could disable him from making career choices in line with his overriding academic interests.

Marco: I’m really not sure what I should be emphasizing in my career. Should I pursue my own start-up company, using some of the commercial applications of my research like several of my colleagues? (laughing) I could buy a yacht. Should I put additional time into mentoring my post-doctoral fellows? I have my hand in so many research projects right now I don’t know if I’m coming or going.

Dr. Gnaulati: Not a pleasant state of mind to be in …

Marco: Javier, my colleague in South America, flies all over to conferences, is laser focused in the lab, and still has time to play trumpet in a band. I wish I was more organized and productive like that! Maybe I should take up the trumpet!

Dr. Gnaulati: He is he and you are you. I remember you told me that his wife is a stay-at-home mom, who places few family demands on him. He may have free time that you don’t. Now that you are reprioritizing your career, what’s really of value to you?

Marco: Good question. I don’t have the foggiest.

Dr. Gnaulati: You don’t have any idea?

Marco: Well I do wish I had more time to just hang out with my post-docs and dialogue about new ideas in physics.

Dr. Gnaulati: Maybe taking you back to your own graduate school years when there was the intellectual fervor you had for physics?

Marco: YES. I feel too much like a bureaucrat and a manager running the lab. At heart, I’m a people person who gets the most out of engaging in organic social interactions with like-minded thinkers in physics. I need more of that in my life.

Clients afflicted with debilitating emotional problems and unfavorable life circumstances often feel they have no choice but to passively resign themselves to their fate. There are times in therapy with such clients when caring and careful processing of despair and grief takes on significance. Then there are times when their defeatism needs to be challenged. Existentialist philosophers and writers often underscore the fact that we are thrown into a world not of our own choosing, but somehow have to carve out a life as best we can. Camus’ The Myth of Sisyphus is an allegory of how life can be lived with “the certainty of a crushing fate, without the resignation that ought to accompany it.”⁴⁹ Sartre once said: “Freedom is what we do with what is done to us.”⁵⁰ A specific quote by the Irish playwright, Samuel Beckett, is worth bearing in mind when digging in with clients mired in resignation: “Ever tried. Ever failed. Try again. Fail again. Fail better” ⁵¹ (tattooed on the forearm of my favorite professional tennis player, the Swiss, Stan Wawrinka!).

Clarissa’s mix of social anxiety, obsessional, and autism spectrum symptoms were of a magnitude such that she needed to attend a non-traditional high school. Upon graduation, under vehement protest, Clarissa lived in an assisted-living boarding school to enable her to take college courses and learn skills of daily living. She exposed herself to everyday tasks, like taking the bus across town and preparing meals with peers, under great duress. Mostly, she was content cloistering herself in her room, reading and expanding her prodigious knowledge of history, politics, and philosophy through internet searches. Moments like these were common in my work with Clarissa:

Clarissa: I should just be left alone to stay in my room. I don’t see the point in having to make meals and hang out with people I have nothing in common with.

Dr. Gnaulati: I know you prefer to be left alone in your room Clarissa, but how is that going to help prepare you for life up ahead when you will need to live on your own? I suppose every little step you take being social adds up.

Clarissa: (crying) That’s pathetic. Like taking the bus and cooking meals are successes. Successes are getting straight A’s in college, like my sister.

Dr. Gnaulati: I know you wish you had her life, but you don’t. You have your life and it’s filled with overwhelming hurdles. With your social anxiety, taking the bus across town IS a success, and if you poo-poo that, it’s going to be very hard for you to have a belief in yourself.

We find, in therapy, that many clients have rarely, if ever, been in relationships marked by sustained empathy, concern that is genuine and abiding, and persistent encouragement to live life actively and purposefully. Thus, the therapy relationship can be new, emotionally invigorating, and personally meaningful in and of itself. Confident expectation that they will be listened to and sensitively responded to largely on their own terms, can awaken long-since foreclosed memories, desires, grievances, and aspirations. For clients who have lived lives of self-effacement and conformity, leaving them susceptible to feeling demoralized and depersonalized, the therapist, and the therapy, can even be a veritable emotional life-support system to make a true-self viable. We should not be surprised if such clients become acutely attached to their therapist and immensely invested in therapy. That’s because it represents an “ontological endeavor” for them – an invaluable experience toward becoming an authentic person, more connected to the emotional wellsprings of their life, and sources of meaning and purpose that ultimately make life worth living.

References

(Note: To return to the course after having clicked a footnote, click the Back button in your browser.)

1. Quoted in Joseph J. Shay and Joan Wheelis (Eds.), Odysseys in Psychotherapy (New York: Ardent Media Inc., 2000), 115.

2. Sigmund Freud and Joseph Breuer, Studies in Hysteria (New York: Penguin Books, 2004), 284.

3. Carl R. Rogers, A Way of Being (Boston: Houghton Mifflin Company, 1980), 42.

4. James F. T. Bugental, The Art of the Psychotherapist (New York: Norton, 1987).

5. Jerome Frank, Persuasion and Healing (Baltimore, MA: John Hopkins University Press, 1991), 40.

6. Lewis Aron, A Meeting of Minds (Hillsdale, NJ: The Analytic Press, 1996), 170.

7. David N. Elikins, Beyond Religion (Wheaton, ILL: Quest Books, 1998), 185.

8. Vera Bekes and Leon Hoffman, “The ‘something more’ than working alliance: Authentic Relational Moments,” Journal of the American Psychoanalytic Association 86, no. 6 (2020): 1051-1064.

9. Ida Stange Bernhardt, Helene Nissen-Lie, and Marit Rabu, “The Embodied Listener: A Dyadic Case Study of How Therapist and Patient Reflect on the Significance of Therapist’s Personal Presence for the Therapeutic Change Process,” Psychotherapy Research 31, no. 5 (2021): 682-694.

10. A. C. Grayling, The Heart of Things (London: Orion Books, 2005), 134.

11. Rachel Schaper et. Al., “Language Style Matching and Treatment Outcome in Anorexia Nervosa,” European Eating Disorders Review. Advance online publication (2022). https://doi.org/10.1002/erv.2943

12. Maurice Friedman, The Healing Dialogue in Psychotherapy (New York: Jason Aronson, 1985), 137.

13. Irwin Z. Hoffman, Ritual and Spontaneity in the Psychoanalytic Process (Hillsdale, NJ: The Analytic Press, 2001), 74.

14. Tal Alfi-Yogev et al., “Client-Therapist Temporal Congruence in Perceiving Immediate Therapist Self-Disclosure and It’s Association With Treatment Outcome,” Psychotherapy Research. Advance Online Publication (2022). https://doi.org/10.1080/10503307.2022.2151947

15. Albert Camus, The Myth of Sisyphus (New York: Alfred A. Knopf, 1955), 73.

16. See http://ourworldindata.org/data/population-growth-vital-statistics/life-expectancy/

17. Ibid.

18. Ibid.

19. Phil Mason, Napoleon’s Hemorrhoids and Other Small Events that Changed History (New York: Skyhorse Publishing, 2010).

20. Ibid.

21. Adrian B. J. Brooks et al., “Banter in Psychotherapy: Relationship to Treatment Type, Therapeutic Alliance, and Therapy Outcome,” Journal of Clinical Psychology. Advance Online Publication (2023). https://doi.org/10.1002/jclp.23482

22. See http://www.apa.org/pubs/info/reports/dual-pathways-report.pdf.

23. Ibid.

24. See Kwong-Liem Karl Kwan, “Counseling Chinese Peoples: Perspectives of Filial Piety,” Asian Journal of Counseling 7 no.1(2000): 23-41.

25. Adrian Van Kaam, The Art of Existential Counseling (Denville, NJ: Dimension Books, 1966), 29.

26. See Marna S. Barrett, et. al., “Early Withdrawal from Mental Health Treatment: Implications for Psychotherapy Practice,” Psychotherapy: Theory, Research, Practice, Training 45, no.2 (2008): 247-267.

27. Shari M. Geller and Leslie S. Greenberg, Therapeutic Presence: A Mindful Approach to Effective Therapeutic Relationships (Washington DC, American Psychological Association, 2023).

28. Enrico Gnaulati, “Relational Healing in Psychotherapy: Reaching Beyond the Research,” Psychoanalytic Inquiry 41, no.8 (2021): 593-602.

29. Shannon McIntyre and Lisa Wallner Samtag, “Promoting and Empathic Dialectic for Therapeutic Change: An Integrative Review,” Journal of Contemporary Psychotherapy: On the Cutting Edge of Modern Developments in Psychotherapy 52, no. 2 (2022): 127-136.

30. Heinz Kohut, How Does Analysis Cure (Chicago: University of Chicago Press, 1984), 182.

31. Carl R. Rogers, A Way of Being (Boston: Houghton Mifflin Company, 1980), 137-138.

32. Sheldon Roth, Psychotherapy: The Art of Wooing Nature (Northvale, NJ: Jason Aronson, 1987), 229.

33. Harold Chui, Xu Li, and Sarah Luk, “Therapist Emotion and Emotional Change with Clients: Effects of Perceived Empathy and Session Quality,” Psychotherapy 59, no.4 (2022): 594-605.

34. Rakesh Kumar Maurya, Amanda C. DeDiego, and Michael M. Morgan, “Counsellors’ Lived Experience of Empathy and Compassion: An Interpretive Phenomenological Inquiry,” Counselling and Psychotherapy Research 22, no. 4 (2022): 1077-1086.

35. Walt Whitman, Leaves of Grass (1855; New York: Book-of-the-Month Club, 1992), 155.

36. Martha Stark, Modes of Therapeutic Action (Northvale, NJ: Jason Aronson, 1999), 155.

37. Jesse D. Geller, “Style and its Contribution to a Patient-Specific Model of Therapeutic Technique,” Psychotherapy: Theory, Research, Practice, Training 42, no.4 (2005): 479.

38. Quoted in Anthony Molino (Ed.), Freely Associated (London: Free Association Books, 1997), 138.

39. Emmy van Deurzen, Paradox and Passion in Psychotherapy (New York: John Wiley & Sons, 2001), 108.

40. Gerben A. van Kleef and Stephane Cote, “The Social Effects of Emotions,” Annual Review of Psychology 73, (2022): 629-658.

41. Allan N. Schore, Affect Regulation and the Repair of the Self (New York: Norton, 2003), 48.

42. Leslie S. Greenberg, “Emotions, the Great Captains of our Lives: Their Role in the Process of Change in Psychotherapy,” American Psychologist 67, no.8 (2012): 700.

43. Sheldon A. Appelbaum, Psychological-Mindedness: Word, Concept and Essence,” The International Journal of Psychoanalysis 54, no.1 (1973): 35-46.

44. Bruno Bettelheim, Freud and Man’s Soul (New York: Vintage Books, 1984).

45. Quoted in Roger Frie (Ed.), Psychological Agency: Theory, Practice, and Culture (Cambridge, MA: The MIT Press, 2008), 41.

46. Daniel C. Russell, Happiness for Humans (Oxford, United Kingdom: Oxford University Press, 2012), 5.

47. Ibid, 19.

48. Irvin Yalom, When Nietzsche Wept (New York: Harper Perennial, 2011), 272.

49. Albert Camus, The Myth of Sisyphus (New York: Alfred A. Knopf, 1955), 54.

50. Quoted in Robin Wright, Dreams and Shadows (New York: Penguin Books, 2009).

51. See https://en.wikiquote.org/wiki/SamuelBeckett#WorstwardHo.281983.29

 

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