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Gift of therapyAn Open Letter to Beginning Therapists
By
Dr. Raja Roy Choudhury
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AN IDIOSYNCRATIC MÉLANGE OF IDEAS AND TECHNIQUES
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Remove the obstacle to growth
I do not have to do the whole job: Not to
inspirit the patient with desire to grow, with
curiosity, with zest for life, caring, loyalty or any
of the myriad of characteristics that make us fully
human.
No, what I have to do is to identify and
remove obstacles.
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Avoid diagnosis
A Diagnosis Limits vision: it diminishes ability to
relate to the other as a person.
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Therapist and patient as“fellow travelers”
We are all in this together and there is no therapist and no
person immune to the inherent tragedies of existence.
“Have Patience in everything unresolved and try to love the
questions themselves: Try to love the questioners as well”
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Engage the patient
Therapist: How are You and I doing today?
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Be supportive
Therapists have great power that stems from the
knowledge of their patient’s intimate life events.
Acceptance and Support from one who knows them
so intimately is enormously affirming.
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Empathy: looking out the patient’s window
We valued very different parts of the session: My elegant
and brilliant interpretations? She never even heard them.
Instead, she valued the small personal acts I barely noticed:
complimenting her clothes, awkward apologies for arriving
late, teasing her when we role- played.
-Therapist.
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Teach empathy
Help patients experience empathy with You, and
they will automatically make the necessary
explorations to other important figures in their lives.
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Let the patient matter to you
It is sad to think of being together with others for so
long and yet never to have let them matter enough to
be influenced and changed by them.
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Acknowledge your errors
The difference between a good and a bad therapist
is not the commission of errors but what you do with
them.
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Create a new therapy for each patient
Appreciation of the uniqueness of each patient’s
inner world and language, a uniqueness that
requires the therapist to invent a new therapy
language for each patient.
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The therapeutic act, not the therapeutic word
The patient’s view of helpful events in therapy are
generally relational, often involving some act of the
therapist that stretched outside the frame of therapy
or some graphic example of the therapist’s
consistency and presence.
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Engage in personal therapy
Q: What is the therapist’s most valuable
instrument?
A: The therapist’s own self.
A therapist should enter therapy at many different
stages of life.
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The therapist has many patients;the patient, one therapist
Do you ever think about me between sessions or do
I just drop out of your life for the rest of the week?
- Patient
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The Here-and-Now.
Immediate events of the therapeutic hour:
• What is happening here in the relationship-
Space between you and me.
• And now in the immediate hour.
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Why use the Here-and-Now
The interpersonal problems and Maladaptive
patterns will soon be displayed in living color in the
here-and now of the therapy hour.
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Using Here-and Now: Grow rabbit’s ears
Each individual has a different internal world and
the stimulus has a different meaning to each.
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Search for Here-and-Now equivalents
When there is a then-and-there Dysfunctional
interaction: The strategy is to find a here-and-now
equivalent of the Dysfunctional interaction.
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The Here-and-Now energizes therapy
Therapy is invariably energized when it focuses on
the relationship between therapist and patient.
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Use your own feelings as data
If in the session you feel bored or irritated,
confused, sexually aroused, or shut out by your
patient, then regard that as valuable information.
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Frame Here-and-Now comments carefully
Talk about how you feel, not about what the patient
is doing.
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What lies have you told me?
There is always some concealment,
some information withheld because of
shame, because of some particular way
they wish to be regarded.
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Blank screen? Forget it! Be real
Forget the Blank Screen: Therapist disclosure
begets client disclosure.
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Three kinds therapist self-disclosure
Therapist self-disclosure is not a single entity but a
cluster of behaviors: Some invariably facilitate
therapy and Some are problematic and potentially
counterproductive.
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The mechanism of therapy-be transparent
Suggest total disclosure about the mechanism of
therapy.
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Revealing Here-and-Now feelings-use discretion
All comments must pass one test: Is this disclosure
in the best interests of the patient?
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Revealing the therapist’s personal life- Use caution
The personal life of the therapist, there swirls the
controversy. But how can one have a genuine
encounter with another person while remaining so
opaque?
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Revealing your personal life-Caveats
Though patients have confidentiality, therapists do
not.
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Therapist transparency and universality
Disclosure of similar thoughts and feelings is
comforting and provides a “ welcome to the human
race”
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Patients will resist your disclosure
Those who desire magic, mystery and authority are
loath to look beneath the trappings of the therapist.
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Avoid the Crooked Cure
At times the therapist must provide “magic,
mystery and authority”. Keep it brief and help the
patient quickly make the transition into genuine
therapeutic relationship.
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On taking patients further than you have gone
Some cannot loosen their own chains yet can
nonetheless redeem their friends
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On being helped by your patient
Wounded healers are effective because they
empathize with the wounds of the patients; perhaps
because they participate more deeply and
personally in the healing process.
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Encourage patient self-disclosure
Anytime you feel like saying, “Dammit, all these
wasted hours, why didn’t you tell me this before”, is
just the time to bite your tongue and appreciate the
fact that the patient did finally develop trust to
reveal this information.
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Provide feedback effectively and gently
Here-and-Now feedback: Sticking to observations of
the behavior and what the behavior makes one feel.
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Increase receptiveness to feedback by using “parts”
“I understand that at times you feel like giving up,
that right now you even feel like taking your life. But
some part of you has bought the rest of you into my
office. Now, please, I want to talk to that part of you-
the part that wants to live”.
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Feedback: strike when the iron is cold
One principle that proves useful time and again is
to strike when the iron is cold- that is to give the
feedback when they are behaving differently.
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Talk about death
From the beginning of written thought humans have
realized that everything fades, that we fear fading,
and that we must find a way to live despite the fear
and the fading.
Learning to live well is to learn to die well.
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Death and life enhancement
Boundary experiences- Urgent experiences that jolt
us out of “everydayness” and rivet our attention
upon “being” itself. The most powerful boundary
experience is confrontation with one’s own death.
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How to talk about death
A calm, matter-of-fact dissection of the anxiety
about death is often reassuring.
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Talk about life meaning
What we must do is to plunge into one of many
possible meanings, particularly one with a self-
transcendent basis.
The question of meaning in life is not edifying. One
must immerse oneself into the river of life and let
the question drift away.
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Freedom
The chasm, the abyss of freedom. And with the
realization of the nothingness at the heart of being
comes deep anxiety.
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Helping patients assume responsibility
“Even if 99% of the bad things that happen to you is
someone else’s fault, I want to look at the 1% - the
part that is your responsibility. We have to look at
your role, even if it’s very limited, because that’s
where I can be of most help”
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Never (almost never) make decisions for the patient
Beware of leaping into make decisions for the
patient. It is always a bad idea. Not only do we lack
a crystal ball, but we work with unreliable data.
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Decisions: A via regia into existential bedrock
Decisions are a royal road into a rich existential
domain- the realm of freedom, responsibility, choice,
regret, wishing, and willing.
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Focus on resistance to decision.
Everything fades and alternatives exclude.
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Facilitating awareness by advice giving
Offering advice or prescribing certain behaviors not
as a way of usurping the patient’s decision, but in
order to shake up an entrenched thought or behavior
pattern.
More often than not it is the process of giving
advice that helps rather than the advice itself.
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Facilitating decisions-other devices
“I’m not going to change, Mother, till you treat me
differently when I was eight years old”
“The hardest thing for a man to give up is that
which he really doesn’t want”
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Conduct therapy as a continuous session
Psychotherapy – Cyclotherapy
We open up new themes, work on them for a while,
move to other issues, but regularly and repetitively
return to the same themes. Each time deepening the
inquiry.
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Take notes of each session
If therapists are historians of the therapy process-
to attend to the continuity of these sessions, they
must keep some chronicle of events.
If there is nothing significant to write then that in
itself is important piece of data as it signifies that
therapy is stagnating.
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Encourage self-monitoring
Any type of class reunion is generally a gold mine
of data, as are any opportunities to revisit old
relationships.
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When your patient weeps
“ If your tears had a voice, what would they be
saying?”
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Give yourself time between patients
Abraham Lincoln: “If I had 8 hours to cut down a
tree. I’d spend several hours to sharpen the axe”.
Don’t become the woodcutter who is too rushed to
sharpen the axe.
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Express your dilemmas openly
I believe you can almost never go wrong by
expressing your dilemma openly.
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Do home visits
“ I found his house to be filled with material
reminders of his wife, including , in the middle of the
living room , the old, shabby sofa upon which she
had died”.
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Don’t take explanations too seriously
“ There is no truth, there is only interpretation.
Even if we offer some elegantly packed insight of
extraordinary we must realize it is a construct, an
explanation not the explanation.”
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Therapy-accelerating devices
There are times to sit in silence, sometimes in silent
communion, sometimes simply while waiting for
patient’s thoughts to appear in a form that may be
expressed.
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Therapy as a dress rehearsal for life
Psychotherapy requires a close relationship, the
relationship is not an end- it is a means to an end.
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Use the initial complaint as leverage
The reasons for seeking therapy given in the first
session may serve in good stead during difficult
phases of therapy.
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Don’t be afraid of touching your patient
Me holding her hand was ballast preventing her
from drifting up and away into despair.
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Never be sexual with patients
They (therapists) will pay a high price not only from
external world in the form of civil censure,
punishment and wide spread disapprobation, but
internally in the form of pervasive and persistent
shame and guilt.
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Look for anniversary and life stage issues
Some individuals are affected by a birthday that
signifies outliving their parents. Dates of retirement,
wedding or divorce anniversaries, and many other
markers bring home the inexorable march of time
and the transience of life.
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never ignore “therapy anxiety”
Anxiety does not, like rain, descent upon one
capriciously but is explicable: it has causes that can
be discovered and therefore prevented and
controlled.
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Doctor, take away my anxiety
Therapist: “Tell me, what would be the perfect
thing to say? What exactly could I say that would
lead to your feeling better”
Patient: “ I want you to tell me I’m the most
beautiful, perfect baby in the world”
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On being love’s executioner
The good therapist fights darkness and seeks
illumination, while romantic love is sustained by
mystery and crumbles upon inspection. I hate to be
love’s executioner.
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A history of the patient’s daily schedule
Intense discussion of minute quotidian activities
rapidly increases the sense of therapist-patient
intimacy so necessary in the process of change.
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How is the patient’s life peopled?
With whom do they have regular contact? What
faces do they regularly see? With whom do
they have phone conversations or speak personally
during the week? With whom do they have
meals?
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Sharing the shade of the shadow
It wasn’t only that she ( therapist) reached out to
comfort me. No, it was something else: it was the
word we. Inference that she and I were alike, that
she, too, had her shadow side.
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Freud was not always wrong
Freud posits the fundamentals of psychotherapy:
Value of insight, deep self-exploration and
expression; existence of resistance, transference,
repressed trauma; use of dreams and fantasies, role
play, free association; and the absolute necessity of
a trusting therapeutic relationship.
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Dreams- use them, use them, use them
Dreams represent an incisive restating of the
patient’s deeper problem only in a different
language- a language of visual imagery.
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Full interpretation of a dream? Forget it!
Even if it were possible to interpret a dream fully, it
would not necessarily be a good use of the therapy
hour.
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Use dreams pragmatically:pillage and loot
Dreams, Pillage and Loot: Take out of it whatever
seems valuable, and don’t fret about the discarded
shell.
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Learn about the patient’s life from dreams
The dream is an extraordinarily rich tapestry
threaded through with poignant significant
memories of the past. Simply culling those
memories may often be a valuable endeavor.
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Pay attention to the first dream
The initial dream offers an exceptionally revealing
view of core problems because the dream-weaver
within the patient’s unconscious is still naïve and has
its guard down.
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Attend carefully to dreams about the therapist
My patient’s dreams have changed. Cobwebs fill
my hat. My office is dark and deserted. I am
nowhere to be found: My patients worry about my
health.
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Beware the occupational hazards
What a paradox it is that psychotherapists, who so
cherish their patient’s pursuits of intimacy, should
experience isolation as a major occupational hazard.
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Cherish the occupational privileges
We are cradlers of secret: Sometimes they scorch
me and I go home and hold my wife and count my
blessings. Others pulsate within and arouse my own
forgotten memories and impulses. Still others
sadden me as I witness how an entire life can be
consumed by shame and the inability to forgive
oneself.