12. Doing Your Own Therapy - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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The therapist may be more important than the theory or the therapeutic orientation for effective therapy.  Good and great therapists with diverse theoretical foundations have often been found to have much more in common than differences.  Sprenkle and Blow (2007) presented that "the therapist/client encounter provides the best explanation for how a treatment works because it typically falls on the therapist to connect the dots regarding how change occurs within specific treatment models for specific clients, and with the specific presenting problem.  While in our previous work… emphasized the link between common factors and models by saying that common factors work through models (that is, that models activate or potentiate the common factors)… models work through therapists.  Models are mere words on paper.  They are no more 'effective' than the therapists who implement them.... common factors may be broadly and narrowly defined.  The broad sense includes all aspects of the therapeutic context that contribute to change.  In this sense, being a competent therapist is itself a major common factor in successful change.  In the narrow sense, common factors refer to the common mechanisms of change that are embedded in all models of effective therapy.  In this sense, the therapist activates these common factors" (page 110).

In an attempt to train high quality therapists to activate common factors of effective therapy, many psychotherapy graduate school programs require their students to have individual therapy.  One reason is for future therapists to experience being in the other chair as clients.  Perhaps the more important reason is that the personal emotional and psychological wellbeing of psychotherapists are critical to productive and safe work.  Psychotherapists offer themselves in intimate human reparative relationships to vulnerable clients.  Unstable, disturbed, or confused individuals, and perhaps the therapist in particular may do great harm to people in great need.  Trying to practice from an orientation that is uncomfortable or disconcerting would not lead to genuine practice or serve clients.  Finding a good fit between oneself and a theoretical orientation may be an essential step towards clinical excellence.  "…when the therapist becomes aware of her worldview and adopts a model that is congruent with this view, the therapist is able to reach her potential.  As a result, the therapy becomes a personalized vehicle for self expression and the model's intended change qualities are maximized because they are authentically practised.  This… creates a synergy between therapist and model, leading to the best possible treatment for the client (page 109).  While it makes intuitive sense that practising a model which is congruent with one's worldview might be necessary for effectiveness, it is hardly sufficient, since someone with this congruency can still be a poor therapist" (Sprenkle and Blow, 2007, page 111).

A rigid individual with control issues may gravitate to or choose a highly directive theoretical orientation that allows him or her to strictly control therapy and clients.  An emotionally insecure and needy therapist may resonate with humanistic therapies that give a lot of affirmations and nurturance to clients, and result in creating client dependence on the therapist.  The emotionally disconnected person may find refuge practicing from very cognitively oriented intellectual perspectives where one does not need to have empathy for clients.  From any theoretical orientation, running clients through some favored therapeutic mechanism without adapting to individual needs or responses is not good therapy.  Adaptation may be key to effective therapy.  "…compelling empirical evidence that therapists need to vary their approach in response to client qualities.  For example, clients who are more introspective, introverted and self-reflective are more likely to benefit from insight-oriented methods, whereas clients who are more aggressive and impulsive benefit more from skill building and symptom-focused procedures.  Furthermore, when client resistance is high, therapists should diminish their level of directiveness, and increase directiveness when client resistance is low. Again, if a therapist holds rigidly to a worldview, she may not be willing to make these adaptations.  We believe that therapists need to understand principles of change from several models well enough to adapt to a variety of clients and presenting problems" (page 112)

The capacity of the therapist to have the diagnostic skills, clinical insight, and array of intervention skills to be therapeutically agile is challenging.  A question arises for the therapist who cannot or refuse to become therapeutically adaptable.  Is he or she doing personal therapy or the client's therapy?  The therapist do not become a therapist by accident.  The term "wounded healer" describes the professional whose work and professional choices emanate from the wounds of personal lives.  Unfortunately, some therapists have not healed enough to be appropriately dispassionate, detached, and be clinically (from any number of orientations: cognitive, humanistic, psychodynamic, and so forth) present.  Some wounds may be cross-cultural wounds from the misfit between therapist's family culture and the emerging culture of society (including gender roles) or of therapy.  The therapist is human and may be vulnerable to the same issues that clients come to therapy for.  Guanipa and Woolley (2000) state that, "there has been increasing awareness and concern about the effect of therapist's conceptualizations of the presenting problems on the nature and direction of the counseling process… Research supports the idea that therapist biases in the definition of client problems may lead to the misunderstanding of the family and to misdiagnosis and ineffective interventions" (page 182).  Therapist biases may be subtle to highly intense.  

Guanipa and Woolley feel that marriage and family therapy training programs may need to require beginning therapists to "achieve a higher cognitive/contextual level of gender conceptualization, and may need to work on developing skills that include the formulation of alternative hypothesis and the understanding of gender as a socially constructed concept" (page 189).  The therapist may not be aware of personal biases.  They recommend fostering cultural sensitivity and self-awareness of one's cultural self and gender biases.  "Supervisors may need to encourage and model a more complete process of formulating the tentative gender and multicultural hypothesis that are required in clinical work, and then develop treatment plans based on a clear understanding of client gender and cultural roles."  Dienhart (2001) points out addressing gender may be complex than the therapist anticipates.  She points out that gender-sensitive family therapists actively try to engage men more fully, and to hold them mutually responsible with women, for problems and change in the family.  However, there were two apparently contradictory findings.  While it "was considered very important for family therapists to avoid placing upon women the primary responsibility for change in the family… almost all of the intervention identified focused on intervening with women, while few intervention ideas were directed at men" (page 21).  This may be from gender bias against men in therapy.  

The therapist with gender bias often sees "the man in the family as less competent than the woman in negotiating the therapeutic relationship.  The man's relative helplessness in this situation is often compensated for by the implicit yet powerful message of 'if I am not protected here, I'm not coming back'" (page 22).  As a result, the therapist may become manipulated to being over careful in interacting with a male client, partner, or family member.  Interventions may be less direct or powerful, muted, or even withheld.  On the other hand, difficulty in working with male clients may be handled with a male blaming stance, for example being critical of Carson and siding with Vee.  Instead of being intimidated or becoming rejecting, the therapist should address personal held stereotypes or inhibitions about male participation in therapy.  Then the therapist can more effectively address the reasons men in general and a particular man may be hesitant to participate in therapy.  For example, the therapist should considering if a man "torn between two powerful motivations- avoiding anything feminine and the desire to attach himself to a female."  If so, the male therapist may be a needed ally as a male client confronts "his own socialized limitations to his humanness."  At the same time, male clients tend to report greater satisfaction and be self-reflecting and self-revealing with female therapists (page 23-24).  Male clients may struggle balancing between having a female therapist that they anticipate will be more nurturing versus a male therapist who is more likely to understand his male cultural perspectives.  Some therapists will assert that they have no gender biases and furthermore, resist considering such information because they abhor stereotypes of any sort.  They insist they see each person as an individual without any consideration of potential influence on the person's emotional, intellectual, or intellectual process of ethnic, gender, class, or other group identification or experience.  As a result, they may not even consider these potentially significant experiences for clients.  Relevant resultant therapeutic concerns are ignored and such therapists may become unknowingly vulnerable to harmful counter-transference.

While gender issues relevant to therapy may not be addressed because of therapist's lack of awareness or unchallenged cultural assumptions, certain other issues such as child abuse, domestic violence, or infidelity may have sensational effects on the therapist.  Certain issues can be expected to trigger intense feelings in the therapist, especially if the therapist has similar personal, family, or group experiences.  Such reactions can become extremely harmful to effective or appropriate therapy.  For example, Daines (2006) warns therapists about their reactions to clients that have had an affair.  "A general guideline, though, is that if a feeling or thought emerges in relation to a particular individual or couple (for example feeling judgmental) that the practitioner would not normally expect to have in relation to the content of the consultation, then the possibility that something is being picked up from the patient needs to be considered.  When faced with infidelity, there are a wide range of reactions that can be experienced in the clinical situation (Table I).  These will not be constant or predictable as they will be influenced by the nature of the infidelity, its context, the developing understanding and values of the clinician, and current personal and professional issues for the clinician.  There will also be a variable awareness of reactions and feelings as some may be experienced as unwelcome or unacceptable.  Our aim is to be able to deal with our reactions so that we can concentrate on helping our patients with the sense of being troubled that they are bringing to us."

Scheinkman (2005, page 229) critiques prevailing assumptions in the field of family therapy that views contemporary marriage and monogamy as sacrosanct and sees affairs as a violation of this ideal.   She argues that perspective is the moral middle-class American way.  While others feel that fidelity is a matter of moral values and that affairs are always wrong and destructive, Scheinkman does not necessarily agree that in an affair, there is a villain and a victim and that trust and relationship is violated.  "…in American culture, affairs are viewed as a sign of moral corruption.  In other cultures, even though there is the recognition that affairs can be damaging and involve lies and betrayal, affairs are about something else.  They may be about loving more than one person, or about complementing marriage with romance, passion, sexuality, or autonomy" (page 238).  While the therapist may conceptually find some relevance with Scheinkman's views, he or she might still experience emotional reactivity to them and thus, find it difficult to practice holding her views.  The humanistic therapist could be at greatest risk in this or other sensational client situations.  It may be difficult to establish rapport with someone who has committed what the therapist might consider to be morally inexcusable.  Pretending not to be affected may be the most professionally irresponsible behavior.  The therapist with significant reactions to this or any other clinical situation or client circumstance should get consultation and may need to consider referring out.  Any emotional or psychological issue that the therapist may have can cause problems in relationships between or among people, including the professional relationship of therapy.  Individuals, couples, and families who come into therapy over issues sensitive to the therapist that may be a problem for that therapist.  "It is important that therapists resolve unfinished family of origin issues in order to heal and to prepare themselves to be therapeutically congruent. Just as clients carry negative impacts from the past, therapists also carry their own negative impacts from past events. Therapists who are emotionally healthy are more likely to have worked through their own personal issues. If therapists have not resolved these issues, there is a strong possibility that they will have a variety of reactions to clients' problems, for example, getting stuck, avoiding the issue, skewing the information, or losing focus. The use of self allows therapists to be fully present for their clients" (Lum, 2002, page 181-82).

Waldron et al, (1997) studied the effect of both client and therapist defensiveness on therapy.  Defensiveness is behavior that happens when a person perceives or anticipates threat.  Defensive communication becomes reciprocal as recipients respond with defensive listening and defensive communication in return.  It can be cyclical and tend to intensify to the degree that it can destroy relationships.  Defensive communication include blaming or evaluating, be judgmental or dogmatic, overtly controlling of another, or indifferent or that reflect superiority.  On the other hand, supportive communications may provide or seek information, are oriented to solving problems, or reflect empathic understanding or equality (page 237).  The therapist can become defensive in therapy, perhaps blaming the individual, one partner or one family member, judging clients, struggling with clients over control of sessions, or dealing with a narcissistic client causing harm to the outcome of therapy.  If clients sense therapist defensiveness they may form negative impressions, feel threatened, and lose trust in the therapist.  Therapeutic rapport is harmed as the defensive cycle is triggered.  Clients spend energy defending themselves in response.  

Waldron found that husband or wife defensiveness although correlated with each other did not predict poorer post therapy marital adjustment.  After taking into consideration other issues, there remained "the possibility that defensiveness may be a relatively stable attribute of the therapist… therapists need to be sensitive early in marital therapy to their defensive behavior and its impact" (page 242).  The therapist is insecure and become defensive when attempted interventions are poorly received may project negativity at clients for them "not being good clients!"  Lum (2002) reminds us that "Clients can be very sensitive to the therapeutic relationship and may sense if there are any biases, resistance, discomfort, unresponsiveness, or disrespect coming from therapists.  Thus it is necessary for therapists to become aware of their own internal processes and not to allow judgment or reaction to affect their ability to be fully present with the client…" (page 187-88).

When the therapist has issues that create problems in the relationship with the clients, the problems can fundamentally harm therapy and clients.  In the case of couple therapy, the marriage or relationship may be the client, or in family therapy, family continuity and functionality may be the client.  In the often intense and emotionally charged process of therapy, unaddressed counter-transference may be aroused.  The therapist may be challenged by decompensating or distraught individuals, fragmenting couples, and families in open warfare and find him or herself trying still to symbolically keep his or her parents from going into traumatic conflict.  Despite enmeshed in childhood with his or her own parent, the therapist may promote autonomy in the individual client.  The therapist may try to build the communication in the couple that he or she had never experienced but longed for in the therapist's own intimate relationships.  Closed or indirect disingenuous communication from the family-of-origin may drive the therapist to promote the client family to open honest communication.  And, then the therapist may get angry at clients that reminds him or her so much of previous problematic personal partners.  The therapist who is an abuse survivor may feel compelled to save the woman (or man) from the abuse the therapist suffered during childhood without intervention.  The therapist may lose the therapeutic roles and instead try to be the ally desired in childhood.  The patterns of communication and of roles, even of abuse may have been codified in the culture of therapist's family-of-origin.  Emotionally berating one's partner may have been acceptable or expected making similar client behavior highly triggering to the therapist.  Life experiences give a depth and passion to therapist's work, if they have been processed appropriately.  If inadequately processed or unprocessed, some life experiences may draw the therapist deep into emotional wells that contaminate the therapeutic process.  The therapist should not do his or her personal therapy on the client's time and dime!  Clients are not in therapy to help the therapist feel good about him or herself or to help the therapist process personal issues.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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