3. The Third C- Control - RonaldMah
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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3. The Third C- Control
Therapist Resources > Therapy Books > Therapy Interruptus
Therapy Interruptus and Clinical Practice,
Building Client Investment from First Contact through the First Session
Chapter 3: THE THIRD C- CONTROL
by Ronald Mah
• The client (especially a couple or family) often needs the therapist to take control of the process.• Cross-cultural insight and awareness may indicate taking a more assertive controlling role with certain individuals, couples, and families.• The therapist may need to redefine the core problem rather than accept the client's definition.• Clients who lack confidence in themselves and the process of therapy often depend on the therapist's confidence, especially in early therapy.• Articulating the therapeutic or change/growth or healing process gives confidence to clients and credibility to therapists.• Therapy can be defined as the search and development of a new process to replace an identified ineffective life process.
The therapist must establish control in therapy, and especially in couples or family therapy. The individual, couple, or family is contemplating or in therapy largely because it is out of control. The intrapersonal and/or interpersonal mechanisms and dynamics are out of control, dysfunctional, and hurtful. Anxiety, depression, and stress response may be overwhelming individual emotional-cognitive functioning. Behavior choices may be highly problematic for the individual. The therapist has a range of approaches that may be appropriate with an individual. However, non-directive styles that may be very appropriate for individual work (self-actualizing, introspective exploratory, or individuation work for example) may be counter-indicated for couples and families. They may feed into the continuing of the out of control cycle between the partners. "Even in the first session, therapists may need to set a context for discussion that is different from what occurs in the home for their clients who have a partner" (Thomas et al, page 31). In individual therapy, the therapist has only to manage the relationship between the client and him or herself. Individual therapy is a new relationship (individual with therapist) without prior history, grievances, or emotional shadows with the therapist. In couple therapy, the therapist has to manage several relationships. There is a potentially loaded relationship with each of the partners that one or both may perceive as an authority figure recruitment or alliance from negative prior experiences. And, of course there is the relationship between the partners that is out of control. Neither of the partners is in control, so in many ways they are looking for someone to be in control or someone to help them find control. That would be the therapist! The therapist taking control as a transitional role may be essential to the couple's process.
A passive, less therapist directed process might allow what is out of control to get further out of control. An individual may require concrete direction and structure from the therapist. This may be more critical for a couple or family that is already emotionally and behaviorally chaotic. "…if a therapist were to allow the free exchange of negativity within a session… the credibility of the therapist may be undermined and the induction/motivation phase inhibited" (Thomas et al, page 21). Couple or family therapy, especially with volatile partners or family members may challenge a therapist who prefers a more client centered or directed process or has a more evocative style of therapy. The client may not have the patience for three or four sessions of assessment. Telling the story or their stories may be acceptable, but clients may want something almost immediately from the therapist. The client, especially a couple or family is often eager to give control to the therapist who demonstrates that he or she merits it, while simultaneously trying to maintain control through perpetuating ongoing problematic dynamics. The therapist may need to quickly get into the couple or family's system and stop the bleeding, interrupt the abuse, or break negative cycles. In that sense, couple or family therapy is a transitional tool, hopefully to allow clients to move from dysfunction to health. An individual who spirals negativity through shame, anger, anxiety, fear, or other intense emotions may need a strong immediate therapist approach. People who respond to authoritative (if not authoritarian) direction when things are out of control may especially need the therapist to take control. Clients who find familiarity with a directive approach may include non-European-American, lower economic classes of people, and people from totalitarian societies.
An older Russian couple that had recently immigrated had been referred for couple therapy over the parenting issues around their 10-year-old son. The son was doing poorly in school, refusing to bathe, throwing tantrums, and demanding expensive presents. The father who had been a professor at a prestigious university lost his job in the changes triggered by the new Russian society. Here in the United States, he was unable to find work because of his limited English skills. His sense of power and control in the family and in life was decimated. In Russia, the mother had been a full-time housewife. Here, she was able to use her music skills to teach piano; she became the only wage earner. The son was the only one with English proficiency. A humanistic and communication oriented, but passive therapist assigned to them in the agency had conducted unproductive therapy that made them feel even more out-of-control. A new therapist was enlisted. The new therapist worked from the assumption that as former citizens of Russia (actually, the Soviet Union-a totalitarian country), that they would be responsive to a directive and authoritative voice- not a nice American therapist! The first intervention was to have a Russian translator. Using the son as the translator would have perpetuated the inappropriate power and control that he had established in the family.
The therapist used a very directive approach -- virtually scolding the parent's for getting out-of-control. When the son tried to interrupt, the therapist told him to be quiet… that the adults were talking and making decisions, not him. The son had previously usurped power and control within the family and was now attempting to continue to maintain control in the session. There would be other times for him to be heard, but not now when the family was out of control. Allowing the focus of therapy to be re-directed to him and getting engaged with him, was too similar to the parents' dysfunctional response to him. The therapist kept control of the session, cutting off the parents' complaining about their son, each other, and being in America. Allowing them to continue would have been both them keeping control of the family dynamic by perpetuating the complaining, and keeping everything stay out of control. Joining them in their complaints about the son would not have been a productive therapeutic response. The therapist admonished them to establish control and structure and consequences for their child's behavior using very authoritative tones and gestures. The therapist made it clear that as the therapist, no excuses would be tolerated. The therapist expected positive results immediately that would be reported in the next session. The therapist finished the session by telling the son that he could go back to being a kid because his parents were ready to act like parents again. Later that week, the mother's individual therapist at the agency came to the therapist and said, "What did you say to them? They think you're great!"
The family therapist inferred the probable cultural familiarity of the Russian couple to an authoritative voice. The therapist had previously conducted extensive study in multi-cultural and cross-cultural therapy, plus had personal experiences of being a son of immigrant parents. Along with his siblings, he had been used as a social and cultural translator beyond being the English language translator for his parents. The developmentally inappropriate responsibility had caused the therapist as a child a certain amount of anxiety. However unlike the Russian son, the therapist had not acted out with misbehavior. The therapist's Chinese parents had also come from a traditional authoritarian society (pre-Communist China) where professional authority figures were held in high regard. While familiar with modern American professional and client relationships, specifically humanistic-oriented psychotherapist-client relationships, the therapist knew such a relationship would be a cultural misfit with the Russian couple. As a cross-culturally conscious therapist, he knew he could use his authoritative position to "demand" structural family change with the Russian couple.
Taking control of the session was critical to therapeutic success. Sharpley & Heyne (1993, page 591) addresses control issues in therapy. "…relationships are mutually defined by participants' messages to each other. By avoiding certain topics or sorts of messages and including others each participant indicates 'This is the sort of relationship we have with each other'… These interactions indicate which of the participants is in control of the relationship. More fully, allowing or not allowing the other participant's message to stand respectively indicates acceptance or rejection of that participant's definition of the relationship. Thus, control of the behaviour of the other participant is attempted by the manoeuvre of acceptance or rejection of the messages of the other participant." With the Russian family, the therapist rejected two problematic client messages or behaviors: the first by the son to draw attention to himself, and second by the parents inviting the therapist to join in identifying the son as the problem in the family. Accepting either message or client behavior would have misdirected the therapy with the couple's and family towards an oppositional defiant disorder diagnosis of the son or some other mistaken assessment. The family definition of their relationship would have colluded with the couple's abdication of parental authority. The first session and the ensuing therapy would have remained in the son's, couple's, or family's dysfunctional control versus in the hands of the therapist.
"With specific reference to counselling relationships… verbal interactions are also the medium for achieving control within the interaction between counsellor and client… the issue of who is to set the rules (and thereby control the definition of the counselling relationship) is important from the beginning of the counselling interview. In this way, the counsellor or the client decides what are to be the topics of discussion within the counselling relationship. Therefore, because the counsellor must be in control if the interview is not to reach an impasse… as the situation wherein the counsellor accepts the client's definition of the relationship), such verbal control was hypothesized… to be central to effective counselling. Unless the counsellor defines the relationship, clients' difficulties will be perpetuated because the client will lead the counsellor to discuss only what is symptomatic. The counsellor would thus not be in a position to influence the client's emotions and somatic sensations, and would be ineffective in terms of assisting the client to achieve insight or modify behaviour… almost all theories of psychotherapy will acknowledge some therapist control in terms of influencing or facilitating client growth." The son's behavior was not the key issue, but was symptomatic of the core problem- the parents' loss of authority and control. Therapy would have gotten stuck in an impasse replicating the same family dynamics except with an additional ineffectual adult or parent figure of the therapist. Rather than accepting this role, the therapist used strong language to take the more authoritative- virtually authoritarian role with the family from the outset. The couple was eager to give up control to the therapist since they were so ineffective in maintaining control. The son calmed down immediately in the first session as adults took adult roles and he was freed of his role in the family dysfunction. After the couple and family was stabilized in the first session, the subsequent sessions went very well. As the therapy proceeded as couple therapy (there was no need to continue as family therapy), the couple was supported and guided to take more and more appropriate control of their son and family. The son's behavior improved the more the couple found confidence in their process. The therapist happily modulated my authoritative or dominating role in the couple therapy as the couple became more empowered and self-sufficient. By the final sessions, the therapist could completely abdicate control as the couple fully owned their own process.
Therapy starts any number of ways that require affirmative action by the therapist. In the midst of therapy, intense emotions can erupt and chaos can ensue. Hurtful, damaging, and even abusive communication and behavior from the home is duplicated in therapy. This can happen within an individual as embedded shame and guilt manifest. Or it may occur among family members. No matter how self-righteous a member of the couple may feel, he or she also knows that the interaction is dysfunctional. Often family member have sufficient maturity to recognize personal behavior as dysfunctional but insufficient maturity or growth to curtail such behavior. One or both or more family members may want to but cannot control their processes from further damaging the relationship. From physical threats, screaming accusations, malicious judgment, overt and covert put downs, eye rolling, deep sighs, and silence, the couple or family often cannot control itself in front of the therapist. The individual may not be able to control him or herself in front of the therapist. Or, they control themselves in therapy but speak of being out-of-control at home or in other situations. If the therapist cannot assert control and at least, stop the typical discourse from replicating over and over in the session, the client loses confidence in the therapist and in therapy. Client confidence in the viability of their relationship may already be tenuous and may not withstand it if the therapist- an educated, trained, experienced, and credentialed/licensed professional cannot stop the toxic process. Clients can become better able to tolerate the same negative dynamics at home after starting therapy, from having tolerated it happening in the therapy room with the therapist's assistance. Outside of the therapy room, it is on clients whether they can integrate aspects from the therapeutic process. They already know they are not good at it so it's no surprise if there is not quick change. In the therapy room with the therapist to do… something different, they expect that at least they won't just repeat the same old battles. In the therapy room, it is on the therapist to not let them repeat the same old battles or swirl in the same emotional and cognitive morasses.
CONFIDENCE
A prospective client seeking therapy often is insecure not only about the viability of his or her life and/or relationships but also whether therapy can be effective. It may be appropriate to inform the client that the therapist is aware that there may be doubt that therapy will work or from one or more members of the couple or family regarding staying together and if couple or family therapy can work. The therapist should not for example, reassure the client that couple therapy would keep the couple together or solve their problems. However, the therapist can convey confidence that he or she is believes in his or her own skills, knowledge, and experience to conduct the therapy. Goldstein & Shipman (1961, page 133) found that the "degree of favorableness of the psychotherapist's attitudes toward psychiatry and psychotherapy is positively and linearly related to the degree of patient symptom reduction." The therapist can speak with enthusiasm and confidence, perhaps saying,
"I know what I am doing. I cannot control how you will use or respond to what we do, but I know I have my experience and skills to respond to whatever you do or present. You can use my confidence until you experience enough to have your own confidence."
At times when a client, couple, or family lack self-confidence or confidence in the process (including whether to invest in a process), they may need to the therapist to express his or her confidence with more specific information. For example, the client will often ask the therapist, "How does therapy work? How long does therapy take?" The therapist may be tempted to respond, "I don't know yet. I don't know how messed up you are… or, how much the two of you have messed it up. And for how long it'll take, I don't even know yet how long it took to really mess it up!" Playful sarcasm may fit a therapist's personality. That is a stylistic or personality issue relevant to individual therapists that not all therapists should attempt. Sarcasm is but one method to acknowledge the challenge of the issues and the uncertainty of the therapeutic outcome. Sarcasm or another response suited to the specific therapist need to demonstrate therapist confidence. The client often has a need to understand the process of couple therapy and to gain some semblance of confidence and control both in therapy and as a client. The sarcastic answer is relatively honest, although not recommended unless the therapist senses that the client is receptive to a humorous response. Such communications are versions of "It depends!" The therapist cannot honestly predict how therapy will work, only what he or she may try to do or has experienced previously as working. No therapist can predict how long therapy will take since there is such variation in client investment, degree of emotional injury, prior distress, family of origin legacies, communication skills, and so forth.
Yet, such client questions reflect the client's need for reassurance for a sense of what one will have to go through. And, they are a test of the therapist's connection, credibility, and control. If the therapist ignores the needs underlying the questions, he or she misses connecting to the client's anxiety about the process. The therapist that responds coherently and logically so that the client or couple understands and is reassured gains credibility. If the therapist responds with ambiguity, saying for example, "I don't know. We'll have to see," without further qualification, the client may experience the therapist as being out-of-control. The individual or the couple often initiates therapy because as an individual or as partners, they have no effective process or a highly harmful process to deal with the individual's, couple's, and family's needs. One or both partners may have a cultural pattern or process of interaction that does not fit the new demands of their new context. The new context may be being a couple or marriage itself, residence in a new community, immigration, a change in economic status, a new job, and so forth. The individual, couple, or couple knows the new context is being handled poorly. The client looks for the therapist to communicate that, "I got it." The questions are an opportunity for the therapist to educate the client about how therapy works, while enhancing his or her connection and credibility with the individual, couple, or family and keeping and being given control of therapy.
NO PROCESS TO OWNERSHIP OF PROCESS
The following is a way to answer the questions: "How does therapy work?" and "How long does therapy take?" The client's or couple's anxiety underlying the questions is also addressed with theoretical and therapeutic integrity.
1. "How does therapy work? First, you (or the two of you) don't (or the family doesn't) have an effective process to handle your needs. You have a lousy process causing so much harm that it has brought you to therapy. We need to identify the lousy process. It might be a culturally mismatched process for your current needs. The mismatch can be from your (or respective) family-of-origin models and/or ethnic models. It would probably be a good idea to identify where the models come from."
This initial response draws upon principles of psychodynamic, family systems, and cross-cultural theories. This honors each person's psychology as having come from logical experiences that make the behavior or choices make sense, but not functional in the new circumstance of the couple. No one is crazy. No one is arbitrarily choosing illogically. In fact, the individual responds in some logical pattern from early experiences, training, and models. Partners often were drawn to each other because it was "logical" given their backgrounds. Children respond with predictable survival mechanisms to the demands of the family based on developmental principles, temperament, and family dynamics. Therapy is characterized as an exploratory process.
2. "After figuring out why you has your process (or each of you have your processes); and why and how your personal (or joint) process developed; and why it doesn't work very well, then therapy becomes about learning a new process with the help of the therapist and other resources. It's like learning a new culture for functioning in a new community because the old cultures don't fit well for success. In learning a new process, problems will arise that make following through consistently difficult. Every problem is potentially merely something to be readily problem-solved, or it may reveal deeper issues that may fundamentally challenge developing a healthy process. We won't know how many relevant issues will arise or how long it'll take to resolve them until we uncover them and work on them. Therapy continues as long as there are any substantial obstacles to resolve that interfere with learning your functional couple’s process. "
This part of the response asserts that answers and learning a healthy process for relating can be relatively simple if there are not any substantial underlying issues. However, if there are important underlying issues, secrets, or forgotten or denied traumas and distresses, then therapy can become more complex and take longer. Theories or therapeutic principles offer perspectives for examining and understanding client dynamics and behaviors, but the therapist asserts that he or she cannot entirely predict what issues will be found in the exploratory process. Therapy cannot be a prescriptive process but must instead be investigative and reactive as the therapeutic circumstances demand. However, therapy will address anything relevant that is discovered. The first two steps are the major work of the therapy. Clients will often want to skip to the last step of problem solving or elimination immediately or prematurely. If clients can actually do that successfully, then therapy is easy. However, that would probably mean they didn't need to use therapy in the first place!
3. "As you develop a reasonable and reasonably effective process, you will continue to have some hopefully minor problems. You will continue to practice and get better at the process, while using therapy to get coaching and problem-solving assistance from the therapist. You may find that any new or different processes will require breaking old habits or revealing secret rules of your old processes. Sometimes continuing to examine the cultural or family origins of the old processes will be necessary because unarticulated inhibitions can sabotage and prevent developing a healthy process. Ideally, you'll go from bringing problems from home to work out in therapy, to reporting how you worked out problems together on your own."
The core reasons for the client's dysfunction are uncovered in the first two steps. However, despite insight, catharsis, awareness, and other potentially transformative therapeutic experiences, old instincts, habits, and impulsive reaction to triggers will persist. Understanding or otherwise, "getting it" does not often readily mean individuals and especially, a couple or family can integrate therapeutic gains into daily interactions. In dysfunctional patterns of behavior, there is a mixture of negative and positive actions with too great a preponderance or intensity of negative actions. In client's newer hopefully more functional patterns of behavior, there is still a mixture of negative and positive actions with a lesser frequency and severity of negative actions. The client cannot tell in the short-term if a negative action is a part of the old dysfunctional patterns or part of newer more functional patterns. Therapy in this stage serves to minimize the negative patterns from becoming too frequent, too intense, and preventing them from igniting greater negativity.
4. "The more you have ownership of your psychic self or your relationship… the more you have ownership of a healthy process, the less you will need therapy. You might spread therapy appointments farther apart to every other week or once a month for a while. Eventually, when you have a reasonably successful process and can own and manage the process on your own, then therapy has worked and can terminate. This would mean you have evolved from your previous dysfunctional process that had caused such pain, and created a new process. It is a cross-cultural transition to what works for you in the here and now. Then, we can talk about keeping problems from occurring again, and figuring out how and when to use therapy again if needed."
The final part of therapy would be to anticipate problems that might arise later or how the relationship may erode again. The therapist and the client then discusses plans to prevent relapse. The following example is of a couple that learned how therapy worked, went through therapy successfully, felt comfortable that they could manage their relationship process without therapy, and incorporated possible future therapy into their couples process.
The couple came for therapy because of conflict over Mike feeling shut out from Marissa because of dynamics from her side of family. He feels unable to express his needs clearly to her in a way that is not demeaning to him. He dealt with his upset by pulling away and sulking. Marissa feels that he has made his choice and doesn't want to chase after him or challenge him. From her cultural background, it would be inappropriate for a wife to challenge her husband openly. Mike experienced her backing off from him as more invalidation, which made him sulk more. As the youngest son, which in his family as it can be in some cultures, Mike was relegated to minimal status. His needs and his person were always discounted among the siblings. The older kids never included him in their plans. He always had to beg to be included, "Can I go too? How about me too? Me too, me too." Mike's nickname became "Me 2 Me 2," a sarcastic combination of his pleas and the Star Wars droid named "R2D2." Mike was still sensitive to being ignored or excluded. In Marissa's family dynamic, no one was allowed to challenge her father. Right or wrong, everyone had to let it be or his wrath would come crashing on down. Marissa instincts kept her from challenging or connecting to Mike when he was upset… even when her family does things to him that she recognizes as unfair.
They said they had never been in therapy and asked, "How does therapy work? And, how long does it take?" The therapist described the "no process to ownership of process" model of therapy to them. It gave them confidence that therapy could work and the therapist could help them. Early therapy, which focused on the first step revealed their process and the family-of-origin and cultural beginnings of Mike's and Marissa's individual processes. They both calmed considerably when they realized how their processes came from identifiable but mismatched family dynamics. The therapy moved forward to the second step to negotiating a way for Mike to express his unhappiness out loud that she would be ok with. They decided on a timeframe where sulking would be tolerated. Mike gave permission for Marissa to challenge his sulking after the timeframe had expired. Marissa learned to express her anxiety out loud… and so forth. The therapist coached them through the third step in problem solving issues in developing a process/culture that worked for them. After three months of therapy, they reduced from once a week to every other week to once a month as described in the fourth step. By six months, they felt confident enough about their process that they wanted to continue without couple therapy. About a year and a half later, the husband called and cheerfully proclaimed, "We need to come back for our 5000 mile tune-up!" He and his wife had started to veer off their healthy process. They had learned through the original couple therapy what healthy felt like and recognized that they had gotten off kilter. They remembered the lesson about their creating their process and including the plan to return to therapy as a part of that process. The couple returned for a "tune-up" of three or four sessions that put them back in tune. About three more years later, Mike called again, "Time for our 10000 mile tune-up!" Once again, it took only a few sessions for them to find their true north. The therapist can adapt a personal professional version of this "How does therapy work" or "Process of Therapy" explanation that reflects his or her theoretical orientation or therapeutic practice. A psychodynamic therapist would have a different emphasis than a narrative therapist; a therapist who draws upon non-violent communication would frame it somewhat differently than one who uses strategic principles, and so forth. Each therapist, however, should be able to articulate an approach that promotes client connection, professional credibility, and control to create a sound context for therapy.
