Tuesday, March 23, 2010

...on being a therapist, part II...

In part I of this little series on being a therapist, I described many of the logistical and up-front considerations at work when a therapist first encounters a client.  Today I'd like to explore how therapy is an art form (even more than a science), and how the therapist is his or her own instrument in the execution of the art.

Many great psychiatrists contend that "it is the relationship that heals".  I would agree with that now.  I did not realize this at first.  You do the work of therapy, apply the concepts, make the interpretations, support the work of change - and as you do the relationship is what provides the healing. 

At the end of a course of therapy (if appropriate) I like to ask the client, "What, if anything, made the difference for you in the work we have done together?"  Rarely does anyone mention my 'amazingly insightful and astute interpretations', few mention any particular or timely interventions made, few seem consciously aware of a more adult point of view they now bring to their life ... 

Most will say something to the effect of:  "It was finally feeling understood."  "It was how I was able to reveal anything and not feel judged."  "It was how you accompanied me to hell and back."  "It was seeing in your eyes that I had worth and that I mattered."  Huh?, I would think.  All those years of study and training, all the effort at understanding their inner dynamics and it was because I listened, sat there, looked at the person ... that was it?!  Hmmmmm......  (I must admit that I had noticed that the less I said, the better I got!)

I used to be taken aback - after all the effort I had put into applying theories and concepts to their situation - after all the times I felt I had helped them develop more effective perspectives and behaviors to manage difficult situations - after all the times I had helped them come to terms with untenable situations - after all the support given while they effected change ...  and it seemed to be the quality of my presence that helped them most. 

Well, of course - Bonnie!!!  As a student of Eastern philosophies how could you not have seen that?
(Buddhism and Taoism - many Eastern philosophies, are, in fact, very psychologically sophisticated.)  So while you need to have acquired the concepts, the theories, the models, the protocols, the skills, the ability to understand, interpret and intervene ... what frequently matters most is the quality of presence you bring to the work.  Your ability to be mindfully in the moment with the client - providing a safe 'holding' environment for the client.  Simple attention and presence.  Ready, able and willing to accompany them wherever they may need to go in their interior landscape.

Master psychiatrist Mark Epstein, M.D. (a Buddhist as well as a doctor) has written a few books on psychotherapy.  His book, "Going On Being" is a little gem.  He weaves the book around the work of child psychiatrist, D.W. Winnicott whose years of research were often whittled down to pithy statements about the relationship between mother (caretaker) and child.  He encouraged caretakers of young children not to abandon and not to interfere.  (There is so much to learn from those few words - but for today I want to share how they apply to the psychotherapeutic relationship.)  "Don't abandon.  Don't interfere."  If the caretaker does either, according to Winnicott, it interferes with the child's "going on being" - the child's own private, precious process of learning, growing, developing, simply being.  The caretaker needs to offer a reliable, predictable presence to the child.  Presence.  Mirroring.  Accepting.  This allows the child's innate nature to develop at its own pace, to not be cautionned at every turn, to not be interfered with by too much praise or too much instruction, to simply be.

Epstein rightly applied Winnicott's suggestions to the therapeutic relationship.  Be there.  Be in the moment with the client.  Don't abandon.  Don't interfere.  Don't tell the client how to BE.  Accompany them while they develop their own pattern of "going on being".  In whatever field - when you get to the core principle - it is simple - it is pure - it is beautiful - and it works.  Facilitate the client's 'going on being'.

With Winnicott's words in mind,  I always try to be centered, grounded, in the moment, and mindful when I sit with a client.  I know the greatest and most healing of gifts I can offer is simple, human presence.  Not my particular presence, just mindful human presence.  Someone who wants to hear their story.  Someone who will not interrupt except for clarification.  Someone who will try to understand it from their point of view (even if they don't agree with all the rationalizations).  Carl Rogers called it "unconditional positive regard".  Someone who knows that the client's own private, precious process (being) is sacred.

So while some say it is the relationship of therapist with client that heals, readers of Winnicott and Epstein could assert that it is more precisely the quality of mindful presence that fosters the healing process or the ability to 'go on being' for a client.

You don't need to be a therapist to benefit from this insight.  We can ask ourselves, what quality of presence do I bring to my relationships with my loved ones?   One of the greatest acts of love is to simply pay attention.  Full attention.  Bringing our full, mindful presence to any exchange.  Simple.  Free.  Doable.  Loving.

Whether you talk to a painter, a photographer, a writer, an actor, a designer, a dancer - any kind of artist - they will all tell you that their work improves with the quality of attention and presence they bring not only to their art but to their life.  Many clients have taught me that this is also true for the art of psychotherapy.


  1. It's funny, Bonnie. All of this applies perfectly to teaching young children as well. I tell my student teachers above all else to develop positive RELATIONSHIP with the students. All teaching grows out of relationship.

    With positive student/teacher---really human/human---relationship, you're good to go. Learning will happen for both student and for teacher.

    Without positive relationship, a teacher might just as well go home and consult the employment classifieds to find new work.

  2. I think "don't abandon" is essential... but guidance away from unwanted behavior is important for children...I had a neighbor that both were therapist , they had two children that were allowed to do anything..( some really awful things) I spoke to them and they had that theory of allowing the child to come to thier own realization of bad behavior..with some comments of course from the parents as comments...the outcome after 6 years was very bad for both of these children....

  3. I think you've caught the essence of it beautifully. The rare quality of a good therapist is to be present instead of immediately jumping in to try and fix everything. At least that's what my wife (who is a therapist) tells me everytime I try to jump in an fix everything.

  4. This is quite a lot to think about, Bonnie. It made me try to determine if what you describe was the case with a therapist I went to some years back. I wanted to learn how to negotiate some very tricky relationships I had at that time, and to better understand the behaviour of others - and myself. To pick her brain, so to speak, and I did learn a lot. But now, reading what you have to say, I wonder how much of the fact that she simply paid attention to my story was responsible for the well-being that I felt after seeing her. Very, very interesting!

    A while back I came to the conclusion that my role with a number of people in my life is to simply listen to them. I gave up feeling like I had to help find answers for them and just...paid attention. Your post is a welcome validation of that, because at first I felt like not being 'helpful' meant a lack of something on my part.
    Oh Bonnie, Bonnie - you are SO interesting!!

  5. Hey Dan - the quality of our relationships is key. I was hoping to hear some comments from you on the Winnicott admonition to protect the 'going on being' of the child - and Epstein's application of it to therapy.

  6. Brian: Now that I think of it, I always find that quality of mindful presence in your poetry.

  7. Marlene: Yes, if you read all of Winnicott, you would see that he did not mean a parent should never, ever leave a child (don't abandon), nor did he mean that a parent should not instruct, guide, build values, ethics, morals, discipline in a child by saying 'don't interfere'. Of course, a good parent is going to offer guidance and loving discipline to young children who are trying to make your way in the world. Sounds to me like your therapist neighbors were distorting concepts to back up their lazy approach to parenting.

    Winnicott actually applied the concept of don't interfere to giving too much praise, too much help as a child tried a new skill, etc. He certainly would have seen it as appropriate to 'interfere' to help the child build social skills.

  8. Bagman and Butler (Mark): Yes, in a way it is quite presumptious to think we can 'fix' another human being. We can share insights, learnings and offer presence and support as they find their own solutions ... but fix - not so much.
    Thanks Mark.

  9. Hi Deborah: Many bristle at the term co-dependent - but if we can just for a minute realize that Western society holds many co-dependent values and expectations - we will realize why we often feel the need to help or fix.

    Having said that - sometimes people come to a therapist and do need specific help - and then, for me, it becomes more of a counselling session - problem-solving - teaching perhaps assertiveness skills or relational skills. Real therapy is about reflecting on patterns of thinking and behavior, the ways we have learned to protect ourselves that are now getting in the way of living fully, of resolving and healing what has been left unattended. Sounds like you received a nice combination of presence and concrete suggestions on how to manage relationships.

    There is no one perfect way to do therapy - as there is no one perfect way to parent, relate, live. That's why therapy is an art - it is always an improvisation - taking a variety of concepts and skills and juggling them in the way that fits for the individual.

  10. Just visiting your blog, these last several months, has given me, a quiet listener type, a deeper appreciation of myself, Bonnie.

  11. Hi Bonnie, (me again) I agree with Epstein and Winnicott, at least as you've presented them here (I haven't read either).

    I've come to see "teaching" to be something similar to witnessing. It's non-judgmental presence with the child, both one's own inner child and with the student you're with. Teaching asks more questions and provides fewer answers. Teaching is, yes, about being present without interfering. It's probably not teaching at all, really, but simply being there, close by, offering some support, and staying out of the way.

  12. I too work very hard at paying attention to my loved ones and myself!! Great series!

  13. Dan: For therapy too - asking more questions than providing answers. People are much more likely to effect change when they come up with their own answers. I know this also applies to learning.

  14. SueAnn (Slommler): The best gift you can give yourself and those you love.

  15. First I have to say thank you for sharing about your training yesterday... wow, Bonnie, extensive to say the least. "Going on Being" sounds like a must read. I am very intrigued. I purchased "Raising your spirited child" in an effort to understand my son who was so very different than anything I had experienced. Her tenet is the same, that we don't need to fix or change our children, or medicate them in most instances, but instead be present with them and guide and support them.

    I am learning so much and I value your experience and insight! I hope you will continue on in this series and share again soon :)

  16. Hi Vicky: If you are going to read anything to help your son - I would read Winnicott or applictations of D.W. Winnicott. His concepts around child rearing are exceptional. Epstein's "Going on Being" is more of an application of Winnicott and Buddhist principles to psychotherapy - a terrific read if that is what you are looking for ...

    A fabulous parenting book is "Everyday Blessings: The Winner Work of Mindful Parenting" by Myla and Jon Kabat-Zinn.

  17. Hi Vicky - TYPO - sorry! It is the INNER work of mindful parenting not the 'winner' work of mindful parenting. Trying to type too fast here.

  18. Dripping with insight and thoughtfulness, I will have to share this with my husband who is recently a clinical psychologist. He is extraordinarily good at what he does. I know this not because I have watched him at work, but I know the depth of his presence with people. He cares. It sounds like you do as well.

  19. Butternut: Thank you for dropping in and commenting. Your husband sounds like a lovely man - but you would never choose anything but ...

  20. Interestingly i have recently come to know & become friends with a lady who has said just that very thing about a counselor she is seeing... After many years (a lifetime) of being abused, used & not heard, she said those same words... She felt it was a spiritual experience, to be acknowledged in such a way and very healing <3

  21. so true bonnie...love this series! i am an RN & work with young adults. i am finding all the written goals & interventions really are not the healing forces. yesterday, a client i work with revealed her relapse & a suspected pregnancy.... she said she told me because she knew i would not "judge" her and she "trusted" me to help her. she said she felt bad keeping it from me cause she knew "you care about me". i don't have formal "clinical" education so i rely on the use of myself...just being there in a totally attentive, non judgmental, caring way & i'm honored to find this is what is helping this young girl! i have learned a few things from you.... keep it up please!

  22. patk860: Thanks for dropping by and commenting. Your presence and empathy with the patient is admirable.

    I would caution you however, to not go beyond the boundaries of your job description. I may have oversimplified the power of presence in my post. It certainly is key, but it must rest on the foundation of understanding developmental needs/process, ego strength, PTSD, the grief process, etc. etc. You could inadvertently be forming a dyad with the patient that cuts out the patient's therapist - having the patient confide in you instead of the therapist - to the patient's detriment.

    There are certain personality disorders where people who have them are masters at divide and conquer and at only being able to 'like' one person at a time. If that turns out to be you - everything will be invested in you and the psychological health professionals will be cut out of the loop.

    There's already a hint of you being manipulated (unconsciously by the patient) when she says: 'you care about me' ... She could be trying to get you to align with her in some way - even be making you a part of her fantasies.

    I would really be careful to not give any advice, as without a clinical background you could inadvertently set off a serious episode of self-harm.

    All that to say that while I was highlighting the vital function of presence - you also have to have the years of study and clinical experience to underpin the presence ... presence without understanding the person's psychological process, needs, vulnerabilities can be a dangerous thing.

    You are providing what sounds like great active listening and that will mean a lot to all of the patients with whom you come in contact.


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