Paul Wachtel on Therapeutic Communication

Paul Wachtel: I think what that refers to is that for many, many years now, it has felt to me that psychotherapists operate like battling ethnic groups. They stereotype each other. They’re overly attached to their own language and make fun of the language of the other. They gather in their tribe-like congregations and miss a lot of value in the other orientations. So my interest has been not only looking at what has been called the common factors--the processes of change that are common to many orientations--but looking also at the differences, and how we can put together what’s similar and what’s different and create a more comprehensive approach to theory and to therapy.

PW: What’s important is getting ourselves out of the ethnic battles and thinking instead about what’s really of value to people. I was originally trained psychoanalytically, and then became interested in behavior therapy and then cognitive-behavior therapy, and then also family systems and emotion-focused approaches. One of the things I learned from the behavioral and cognitive-behavioral end that has profoundly influenced every moment that I think I’m working psychoanalytically is the absolute importance and compatibility of the exposure paradigm. Much of what promotes change is the experience of repeatedly confronting and being exposed in a full, emotional way to the aspects of our lives that we have turned away from in fear or guilt or shame. Sometimes those can be external stimuli like a phobic object, but very often, they’re our own thoughts and feelings and experience of self. What I’ve learned from cognitive-behavior therapists, and I never forget it for a minute in my sessions, is that it’s not enough just to name it, interpret it, label it. You have to experience it. And that’s a place where the cognitive-behavioral and the psychodynamic can converge in powerfully important ways.

PW: I think job number one for a psychotherapist is to be able to understand how the world feels and looks to the people we work with. That’s another interesting point of convergence, by the way, in the larger realm of psychotherapy, that the ethnic waters are making less apparent than they should. In cognitive therapy, in particular, practitioners actually fall prey to the very errors that psychoanalysts fell prey to, which was thinking that if you just say the right words and label things and get people to think right, you’ll do the job. They will often treat the client’s thoughts as irrational and erroneous, and that’s very much the opposite of what you were just talking about.

But there has been a trend in CBT in recent years that’s often been described as a third wave, that includes dialectical behavior therapy (DBT)--Marsha Linehan and her colleagues--and acceptance and commitment therapy (ACT)--Steven Hayes and his colleagues. Central to both of those are two things that create potential convergence with psychodynamic and experiential therapies: an emphasis on acceptance of the person’s experience, and a respect for emotion that was largely excluded from CBT for a 20- or 25-year period.

When I first got interested in behavior therapy, I was interested in it not because it was behavioristic, but almost for the opposite reason—that it was actually very deeply experiential. Instead of just talking about what you were afraid of, you actually put yourself there. I listened to what clients were saying and what they were feeling as they were confronting it. That experiential element was very important. I learned a tremendous amount from the early behavior therapists, so I was stunned to see tapes of the very people I had learned so much from, when they started to fall under the sway of this rationalistic approach to cognitive therapy. Suddenly they were trying to talk people out of their feelings, trying to tell them, “If you think right, you don’t have to be sad. If you think right, you don’t have to be angry.”

What DBT and ACT do, instead of trying to talk people out of the feelings, is they go into the feelings. They validate them. They accept them. They bring them forth much the way a good experiential or psychoanalytic therapy does. And that’s combined with an interest in eventually promoting change. There’s a seeming paradox there, but I think Marsha Linehan’s term “dialectical” captures it well. It’s a term, by the way, that’s also used by Irwin Hoffman, a relational psychoanalyst. It is that tension between acceptance and change, between following the protocol and varying from the protocol. Hoffman calls it going according to the book and throwing away the book. That’s how we work most effectively.
 

PW: The importance of that was something I learned almost incidentally, though powerfully, taught unwittingly by my supervisors on the one hand and my students on the other.

My supervisors taught it to me by its absence. In other words, I became aware that asking questions like, “What should I say?” opened me up to charges of being superficial and literal. The message I often got was exactly what you’re saying: “If you understand it, you’ll know what to say.” So for a while, I was just feeling, “Well, maybe I’m stupid. But I think I understand the dynamics pretty well, and I seem to be understanding them much the way my supervisor agrees they are.” Yet sometimes I wasn’t sure what to say.

As I began to think about that more and talk about it more in my teaching, my students made me aware that they were getting something from me that they weren’t getting from any of their other teachers. They would say, “When we talk to you, you actually talk about what we should say. We’re not hearing that anywhere else.” That’s what first got me interested in writing about those details.

Then that got me really thinking, as I’ve continued to do over many years, about the ways we talk to people, and all the ways it can be problematic, the ways it can be helpful, and how it both shapes and is shaped by the ways we think about people.
 

PW: Hearing and understanding the tone of what we’re saying is one of the hardest things for people to do. It’s one of the most important, and I think people with good interpersonal skills do it naturally. I think it can be trained. But I do think it is hard.

One of the examples that I’m always struck by is if you’ve ever been in an unpleasant interaction with a sales clerk at an airport or something like that, often if you say something about what’s going on, they will say, “Why are you getting so upset? I haven’t said anything wrong.” And if you look at the manifest content of what they’ve said, that’s true. But if you listen to the tone of voice or you hear the way the sentence is constructed, you know you’re meeting with a hostile response. But the person who is being hostile or dismissive toward you often doesn’t understand that. That’s one of our real challenges.
 

PW: I think one of the things that we do, whether as teachers or as therapists--and here, I depart from the traditional psychoanalytic view’s emphasis on autonomy--

PW: I’m going to do it. Brace yourself.

PW: The idea of modeling is a very, very important one. We offer ourselves as models. Not that we’re model human beings, not that we’re any better as people or any more effective as people. But when we’re attending to the tone, to the effect, to the relationship, and when we do it well, our patients pick that up from us.

I’ve had patients say to me without our ever to having talked about it explicitly before, “You know, you always manage to say what I’ve just said in a way that feels like you hear it, you care about what I’m saying. It sounds better in your words than it sounded in my mind. But I’ve begun to learn to say that to myself now.” And it’s not that I’ve asked them to. That would be an authoritarian, mechanical way. But the modeling or identification that goes on is selective. The patient will take what works for him or her.

And it occurs mostly implicitly. The set of patients who have talked about this mention it after they had noticed that they’ve begun to do it. In other words, they don’t sit down and intend to do it, but they begin to notice it. Just the way they gradually notice the way I’ve been talking to them, they later gradually notice how they have begun to talk to themselves or to other people.
 

PW: Yeah. I’m often a critic of excessive explanations in terms of infancy because they contribute to the pejorative sometimes--described as pre-Oedipal and archaic and primitive and all that sort of stuff.

PW: Very much so. But if we think about the early attachment relationship, one of the things that’s interesting is that a parent’s interaction with an infant is almost completely about tone. It almost doesn’t matter what he or she says, because the infant doesn’t understand the words anyhow. But the infant does understand the tone, the feeling. So we develop very crucial skills in hearing the tone of others, which is part of what also is very central in good couples therapy, where the couple can have bad feelings keep reverberating between them. When you change the tone, good feelings start to reverberate.

PW: Some of the teaching is explicit. Clearly, we need to articulate and point out that theory does have value. But some of it occurs through identification. With my students, as they hear my way of speaking and thinking, those for whom it’s not alien and rejected begin to take it in and make it theirs. What comes out in some ways sounds like me, but, very importantly, it also sounds like them. It isn’t a copy of me. It’s the aspect of me that’s of value to them, and they know implicitly what’s the kernel and what’s the husk.

PW: I think you’re very accurately describing the direction of change in psychoanalysis. I, myself, identify very much with the relational point of view in psychoanalysis, and I’ve written from a relational point of view. And that point of view does embrace the very ideas that you were just mentioning. But when I wrote my book on relational theory and began to closely examine the relational thinkers whose ideas I felt fit well with mine, I also noticed that there were ways in which some of the older ideas continue to operate sub rosa, in a way that’s almost psychoanalytically validating in the sense that the early development of the field continues to influence it. The ways people talk about things explicitly is not necessarily the same as what is operating implicitly.

It seemed to me that, for example, relational analysts who are increasingly the emerging dominant perspective in psychoanalytic thought operate nominally and explicitly from a two-person point of view, a point a view that emphasizes mutuality, reciprocity, the way in which we are both in the room co-creating the subjective reality, and so on. Those are the conceptual terms, and they are certainly a really important part of relational practice.

But there are also ways in which relationalists continue to operate by the older one-person set of assumptions. They throw out terms like “pre-Oedipal” and “archaic” and “primitive” at almost the same rate that classical Freudians did.
 

PW: I think “emotionally dishonest” would be a harsher evaluation than I would make.

PW: All of us as fallible human beings are struggling toward ideals that we don’t always reach. But I think there’s value in the struggle, and I think we can move ahead. For example, there are very real ways contemporary relational analysts do practice very differently from traditional analysts of several decades ago.

But there’s still a way to go. And I’m sure, for example, in my own work, there’s still a way to go that I’m not recognizing. It’s inevitable. But I do think that the idea of something deep underneath that’s being hidden is a very seductive idea. To say that my relational colleagues might have some unconscious motivations for the particular positions they hold is not necessarily a criticism, because we all have unconscious motivations. It’s part of being human. You can’t not have them. That’s not the problem. The problem is when there are aspects of the way we’re thinking and feeling that don’t have a place to evolve and be looked at and experienced and integrated and modified.

If I have an experience that the patient is being emotionally dishonest--let’s say the patient is talking about his feelings about his wife, and I am hearing that there’s a lot more there than he’s willing to acknowledge--my role is not to point out to him his contradictions, his self-deceptions, his illusions. My role is to make room for the full range of his experiences so that he can examine them more fully. I would not be inclined, even in subtle ways--at least if I’m working as I hope to work--to point out his dishonesty. But I might say, “I’m hearing the ways in which you admire your wife’s achievements and feel that she’s misunderstanding you when she says that you’re being competitive with her. I hear that part of it. I’m wondering if there’s another part of the experience that you’re feeling isn’t acceptable, the almost unavoidable experience of also being envious or competitive with her.”
 

PW: Exactly. And that normalizing is not a denial--it’s an invitation. It’s not a way of shutting out the so-called unacceptable. It’s a way of inviting it in.

I think the other crucial word there is “also.” In workshops, I’ve sometimes jokingly said that your functioning as a therapist could improve 31.6% if you would just substitute one word for another. And I ask partipicants to guess what those words are. “Both, and” is one way, or “also” versus “really.” Often either saying or thinking, “What you’re really feeling is…” implies, “What you think you’re feeling is false.” I would suggest that if you think you’re feeling it, you almost inevitably, necessarily are feeling it. But you are likely also feeling some other things that are harder to acknowledge and harder to accept. So I switch from “really” to “also.”
 

PW: The ways that we actually talk to people and the feeling tone in the room often follows more from the tone we absorbed in our own personal therapy and supervision. And that that’s one of the reasons that older ways of practicing and thinking persist even after the official position has changed.

I also think, apropos what you were saying about what training used to be like and how it sometimes still can be, that for many years psychoanalysis was organized in a rather authoritarian way.
 

PW: Yeah. You had self-contained institutes with very little check on them. You had a hierarchical structure, you had training analysts, and you often had a kind of thought control: you would go into analysis, and until you got it right, which meant you got it the way you were supposed to think and feel, you wouldn’t even be approved to work with patients. That was a very problematic structure. It’s certainly been changing, but there’s still a long way to go.

PW: That is a big problem. I think the only thing that, by and large, brings tribes together is an external enemy. The fact that our whole culture is being increasingly dominated by nonpsychological thinking altogether, by corporate bottom-line thinking, will hopefully be a spur to seeing what our common interests are.

PW: I think all psychotherapists know that people don’t always see what’s reasonable. A lot of our work is trying to figure out how to get people to see what’s plain as the noses on their faces, but not evident to them. Often, whether it’s working individually with a patient or client, or trying to produce social change, it’s an uphill battle, and you have to be in it for the long haul. It’s one of the reasons that I also think the current corporate-promoted trend toward very short-term therapies, which translates into cheaper therapies, is often a mistake. Producing really meaningful change often takes a lot of effort, and it takes time.

PW: I have two different concerns about manualization. My strongest concern is that recently, when people have advocated criteria for demonstrating that psychotherapy is empirically supported, one criterion that’s often introduced is manualization. I think that that’s a very misleading and problematic criterion. It’s not that manualization can’t help in establishing what therapists are doing. But I’ve written in a number of places recently about some of the fallacies in requiring a manual as a criterion. One of the things it does is it creates a kind of caricature of science.

Science is supposed to be about finding creating ways to empirically investigate phenomena, but the criterion of manualization defines away any investigation of nonmanualized treatments. In other words, if your treatment isn’t manualized, then by the empirically supported treatments criteria that have been propagated in recent years, it can’t even be investigated. Therefore, it’s dismissed by definition rather than through research. And that’s very problematic.
 

PW: In the recently consensual (almost consensual, because I don’t consent and some other people don’t either) definition of what it means to be empirically supported, there are three things, each problematic, that are usually introduced. One is manualization. And the rationale for that is if we’re going to say that a treatment has been empirically supported, we have to know that was the treatment being administered. That much is reasonable, as far as it goes. But the problem is that manuals aren’t the only way to do that. You can, for example, have practitioners of a particular approach rate blindly a series of sessions, some of which are and some of which aren’t the kind of approach being investigated. And you can get high reliability, and that way you can investigate treatments that are not manualized and still establish whether that is the treatment being practiced. That’s one reason that manualization is a foolish criterion.

A second criterion derives from a kind of false precision. The idea is that we look only at patients defined by a particular diagnostic entity. So if you have a general pool of patients and they get better, that gets dismissed because the claim is that’s a nonspecific finding. The irony of that is by and large the vast majority of advocates of this empirically supported treatments paragon are cognitive-behavioral. And for many, many years, cognitive-behavioral therapists were condemning psychoanalysis for being supposedly a medical model. And now, here you have CBT people embracing the psychiatric DSM--a committee-wrought set of categories that have little to do with empirical science--as if it were the Bible. And there’s certainly a medical influence: requiring a specific diagnosis and slicing people up that way is aping physical medicine, in which you need to distinguish diabetes from rheumatoid arthritis because you treat them differently. But most of what we work with as psychotherapists is not usefully or validly understood as a series of discrete diseases. So to introduce that as a criterion is very problematic.
 

PW: Well, right now we can’t get past it because it’s politically useful for people who are advocating a particular point of view.

PW: I don’t know how my fraction compares with his, but I can get pretty angry about what is happening these days. Psychotherapy research is crucially important, but it’s got to be done honestly, and I think a lot of it these days, it’s not.

PW: And a part of that is this third illusory criterion, which is most seductive because there’s a lot that does make sense in it, but it’s, again, used politically rather than scientifically: the emphasis on randomized control trials (RCTs). That gets called the gold standard. Whenever I hear that, I like to think of the story King Midas, because turning everything into gold doesn’t always turn out well.

I think here it’s a gold standard only under certain circumstances. For example, in the studies of drugs and medications that most psychotherapy RCTs are modeled after, one of the crucial elements is that nobody takes seriously a drug study that isn’t double-blind. Otherwise, the placebo effects are completely undetermined. In psychotherapy, it’s never double-blind. You can’t have somebody say, “We’re going to give half of you psychoanalysis five days a week and we’re going to give half of you an exposure therapy three times once a week. But we won’t tell which we’re giving.” Obviously, that’s absurd. People know what they’re getting, and people know what they’re giving.

So there, already, the RCT is overblown and misses something. But, more than that, in order to maintain the RCT, two things happen. One, the studies have to be very short term, because otherwise, the more it goes on, the more you have uncontrolled variables, which excludes what you can do research on.

PW: Even in three sessions, they are an enormous number.

PW: Absolutely. And that’s, in fact, the other part of what’s problematic. Every psychotherapy offers us an opportunity to learn something. But if we are doing false homogenization and trying as hard as possible to give “the same thing” to each person in the group, we have very little opportunity to creatively learn from what we’re doing. And the crucial thing is that that’s not an anti-research view, at all.

PW: Social change is hard and slow, especially now that so many decisions are being made on an economic basis that secondarily justifies the psychological operation. So it’s hard to know what to tell them exactly. But the one thing I would say is that in making your case, understand really well the limits of the research that seems to support this truncated, limited, homogenized approach to things, because that research is very, very seriously flawed.

PW: That’s exactly the kind of thing that we need to emphasize. And this brings me back to why I was saying that I was not anti-research. I do think that because psychotherapy does create, almost instantly, a unique miniculture that evolves over time, it’s really hard for either party to understand or know fully what’s going on or to remember the sequences. You are recording this interview because if you try to reconstruct it a couple of hours after, it would be only a vague approximation of what’s actually going on between us. The same is true in psychotherapy.

So I’m very much in favor of research based on audio- and videotapes that give us a database. But those tapes can be examined in the naturalistic process of psychotherapy, rather than in a homogenized, manualized treatment for one kind of research paradigm. There are a whole range of process outcome studies that teach us things that the other kinds of studies can’t teach us.
 

PW: I think one of the problems in psychotherapy these days is that up until now, the people with the more narrowly mechanical ways of thinking have been more politically astute. And I think those of us who stand for serious research that addresses the true complexities of the phenomenon have got to do a better job of getting our point across.

PW: The name, Society for the Exploration of Psychotherapy Integration, is a mouthful, so we usually just refer to it as SEPI. It’s an international organization. It has members in 37 countries, and we meet all over the world. This May, we met in Evanston (Illinois). In 2013, we’re meeting in Barcelona.

Our members represent all of the major orientations. We all have our identities as psychoanalysts or cognitive-behavior therapists or systems therapists or experiential therapists, but we also are interested in learning from each other and integrating other people’s ideas.

I thought of SEPI when you were asking earlier, “What do we do about this tribalism, and how can we get people to listen to each other and learn from each other?” It is hard within organizations devoted to a single point of view, because in those organizations, often the other points of view are experienced as Other.

In SEPI, there is no Other. There is a sense of coming and listening to each other. It is a place where we try to heal that breech. I would be delighted if anybody reading this interview who was interested checked out the SEPI website, sepiweb.org. They can learn more about it from there.

PW: I think we clearly are embodied beings. We’re not just abstracted minds. Anything that affects our bodies affect our minds. So all of our experiences at every level, whether they be cultural or nutritional, are part of this set of mutually reciprocal interactive processes that shape and reshape our experience. For example, if we think about the relation between psychological processes and neuroscience, neuroscience is only as good as psychology and vice versa. Mutual bootstrapping is the only way that we learn about, and even know how to look at, the differences between parts of the brain and what it means when one part of the brain lights up in a fancy fMRI study. Those lights are only as good as the psychological criteria that are showing what the lights are about.

But that’s not psychological reductionism, because at the same time, the differences we see in parts of the brain lighting up can then re-attune us to notice differences in the psychological experience that we missed before, which in turn gives us still more refined tools for doing the next round of neuroscience studies. They keep going back and forth. It’s not just, “Neuroscience is the real thing and psychology is the surface.” They need to inform each other.
 

PW: Yeah, and the more we can create new knowns. We keep building on both, as long as we’re not afraid of the unknown and we have the courage to acknowledge the known, in the sense of not having a kind of false modesty, but having the courage to say, “I’ve learned something. I know something.” On the one hand, we need to be extremely modest as therapists. We need to be very careful about assuming we know, assuming an authoritarian position, assuming we understand. That’s crucially important. But we also need to be able to acknowledge that we know something. When we speak to the patient in certain ways with a voice of authority, that’s the authority that just comes with having immersed ourselves in many lives in depth, and having been changed by that experience. We’re not just some new random element in the person’s life--we enter with some expertise. And if we can hold both our ignorance and our knowledge in tension with each other, then I think we can be more effective, more genuine, and more able to move forward.