Michael Hoyt on Brief and Narrative Therapy

I wrote a different book, in 1995, called Brief Therapy and Managed Care. At that time, I expressed the view that there are ways of working with managed care. And I still think there are ways of working with some managed care, but more and more I've heard too many horror stories that have impressed me with how much difficulty managed care—especially in the for-profit sector—has been thus far in the world of psychotherapy. Managed care has not yet produced the promise we were hoping for, of being more efficient and distributing services to more people.

She sent me a Christmas card last year—her condition has even worsened—in which she said—if I could think of the exact words it would be better—I'm so choked up thinking about it that I'm blocking on it. It will come back to me.

And sometimes it's very hard. And it's getting harder for therapists. Most of us, I think, went into this crazy business—this wonderful, strange business—for very good reasons. We want to make the world a better place, we care about people. And oftentimes we get suspected: "You're doing this out of some neurotic need," "Aren't you co-dependent?" or "You're on a power trip" or something like that. The term "countertransference" has gotten to the point now where therapists are sometimes concerned about themselves too much. (See references for Hoyt, 2001a, 2001b, 2001c 2002.) I think it's very important for us to keep remembering the positive reasons we're in this field. Otherwise, I think it's a sure burnout.

Hey, now I remember what the card said: "Memory is what God gave us that we might have roses in December."

Often times I think we've had the idea that we somehow have superior knowledge. And even if in some ways we know a lot, I think by following the client closely, rather than leading the client, in the long run, the person will become more empowered and more of a person.

For example, you might say to a depressed client: "What you call depression, what else might you call it? Some people would call that sadness. Or some people would call that oppression rather than depression. Is something putting you down or holding you back?"

There's also a conflating or confusion between the idea of length of treatment and depth of treatment. There are some patients that I have seen once or twice or three times and it was "deep" or "heart" work or whatever one would call it. And other patients I've seen for long periods, it never really had much soul or passion in it. So I don't think that length of treatment is always the indicator of what is better.

What I have tried to do is a number of things. I'm fascinated with people, and I'm almost an anthropologist at times. I'm curious how people got to be who they are, what makes them tick, what their hopes are.

This long pre-dated the managed-care issues. Imagine if a patient came into a private practitioner's office with a long list of issues and problems that obviously required long-term intensive treatment. And imagine he or she says "But I don't really have any money—I can only pay you $300 total." Many well-intentioned practitioners would say something to the effect of, "Well, I can see you two or three or four times." They might do sliding scale, and maybe pro bono for awhile. But sooner or later they would also say, "If you can't pay, I'm not going to be able to give you professional services on an ongoing basis." So sometimes I've wound up in a situation discussing with patients—whether it's in an HMO or in a private setting—"How do you propose to pay for this? This is a professional service. For consideration of a certain amount of money you'll get a certain amount of service." It becomes a very complicated thing, because you don't want to just cut people off—but you also need to make a living

I think another word of wisdom is that it's important to be multi-theoretical, to have different lenses you can look through. The other word is "eclectic," but I don't like that word because it sounds like "chaotic" and "electric" in the same breath, like when you throw techniques at someone and you don't know why. But I think it's important to be "multi-theoretical."

We're in this wonderful, strange business: we go into small rooms with unhappy people and we try to talk them out of it, so to speak. We're here at the Evolution of Psychotherapy conference. The first speaker was brilliant and right on. And the second speaker was brilliant and right on, and completely contradicted the first. And the third said something really brilliant and right on and had a very different perspective—and each of them and their proponents have helped thousands of clients. Not everything is equal, but there are different ways to go, and nothing works all the time.

I think when you're stuck — and we all get stuck every day — we don't quite know what to do or the therapy isn't going anywhere—the first thing I'd do is consult my client. "How is this working for you? What am I missing? I don't think we're looking at this the right way. What are your thoughts and ideas?"

I would also suggest talking to people who have a different theoretical orientation than oneself. If you're psychodynamic, go talk to a cognitive behaviorist. If you're a cognitive behaviorist, go talk to a Jungian. If you're a Jungian, go talk to someone who does biological psychiatry, and so forth. Because the way you're looking at it, your lens, your frame, your conception, may not allow you to see the client and to see solutions in a way that's going to be helpful for this person. We often want to go talk with someone we really trust, someone we went to school with, because we had the same professors and the same books are on our shelves. Sometimes it's like talking to a mirror. You almost know what they're going to say; they're going to confirm your pre-existing beliefs, because they have the same frame. It's OK to do that, because sometimes you get ideas. But if you're not getting the ideas that are going to move the therapy forward, it's time to talk to someone from a different orientation. How you look influences what you see, and what you see influences what you do. And if you're not seeing something helpful, get some new glasses. Some stories are better than others.