Psychotherapy’s Greatest Debates

Assessing the State of the Art 2012

Magazine Issue
March/April 2012
Psychotherapy’s Greatest Debates

Last fall, for the first time, the Networker held a two-week virtual conference called “State of the Art.” The idea was to collect together the most provocative articles, inspiring Symposium addresses, and compelling online courses that had appeared in the various media platforms through which the Networker carries on its mission of furthering the exchange of ideas and information throughout our field—our magazine, annual conference, and year-round program of online courses and interviews. Through the miracle of modern digital technology, “State of the Art” allowed a worldwide audience of therapists from more than 15 countries not only to experience this material, but also engage in an ongoing conversation about it.

In addition to highlighting what we thought of as the Best of the Networker, “State of the Art” offered an entirely new program of sessions that accomplished something rare in our field—an opportunity for debate and dialogue among prominent figures exploring the important issues shaping current practice. What follows are excerpts from three of those dialogues, which proved to be the most-discussed events.

The Great Attachment Debate, Round 2

By Jerome Kagan and Dan Siegel

At the 2010 Networker Symposium, celebrated developmental psychologist Jerome Kagan expressed his view that Attachment Theory, a view of human development inspired by British psychiatrist John Bowlby that’s generated a huge research literature during the past 60 years, had failed to provide an empirical foundation for its premises and become irrelevant. In a heated confrontation at the conference, psychiatrist Dan Siegel, a pioneer in bringing an understanding of brain development into clinical practice and a strong proponent of Attachment Theory, interrupted a workshop to challenge Kagan’s assertion. Their exchange became the happening of the entire conference. As part of State of the Art, we invited Kagan and Siegel to have a follow-up discussion. What emerged once again became the dramatic highlight of the gathering for many, but this time, for their unexpected agreement, rather than their differences.

Q: Could each of you take some time to talk about what you consider the key factors in early development and the weight you give to each of those factors?

JEROME KAGAN: First of all, to talk about development broadly without endpoints gets us nowhere. So let’s take as criteria the problems that most therapists deal with each day: bouts of depression, anxiety, suicide attempts, drug addiction, problems with the law as young adults. How can we predict these symptoms from early and later life experiences?

My view is that each of these symptom profiles is multiply determined: there’s no single cause for any one of them. As I reflect on my research and all I’ve read—and I read a lot—one can make general statements about the order of importance of certain factors that lead to different symptom profiles.

I’d begin by looking at the temperamental biases that a person was born with. Then I’d look at the person’s social or economic class as a child. Were they born into poverty, a blue-collar family, the middle class, or an elite family? Next I’d look at their experiences with parents in the opening years of life.

Then I’d look at the patterns of identification at age 5 to 6. Was a grandfather arrested? Was a parent an alcoholic? These patterns of identification can have consequences that are very different from those created in the first year of life. A child could have had a loving mother in the first year and learn at age 6 that his or her grandfather was Hermann Goering, which could precipitate a depression, despite a secure attachment to parents at 1 year. The child’s ordinal position in the family makes a small contribution. Was the child an only child, first born, second born, or third born? Finally, the culture and historical era are influential.

No psychologist knows the varying influence of each factor for an individual. That’s for future scientists to determine. All we can say today is that these are the ingredients. The first four are the most important; the others are less important, but they have power.

DAN SIEGEL: I basically agree with the factors that Jerry has outlined. His work has certainly shown the importance of temperament, especially with people born at the extreme of a particular dimension of temperament, like behavioral inhibition. But while genetically transmitted factors like temperament are important, development is so much more complicated than anything that can be explained by genes alone. For example, we know from identical-twin studies that there’s only a 50-percent concordance when one child develops schizophrenia. So we really need to think rigorously about other developmental issues.

Because the baby is born so immature, and we have such a complex social system, the brain is being shaped by experiences of all sorts, especially with our earliest caretakers. Where Jerry and I seem to disagree is how much weight we give to some of these factors—in particular, how the history of children’s interactions with their early caretakers shapes the quality of their later attachment relationships (whether they become secure), and how these attachment relationships then become the foundation for later personality development.

As a clinician, probably the most direct influence on my work that’s come out of Attachment Theory is the Adult Attachment Interview (AAI), which I use with almost all my clients to get a picture of how they view their early-life experience. The AAI is basically a semistructured questionnaire with which you ask the adult about his or her recollections of childhood. The assessment isn’t based on what actually happened—because you have no idea what happened. It’s on something called the “coherence of the narrative,” which, in plain English, is how you’ve made sense of your life.

What the research about the AAI shows is that if you were abused as a child and make sense of how that terrible traumatic experience affected you, your children will be securely attached to you. But if you had that horrible experience, but haven’t been able to reflect on it and make sense of it—the research is very clear—your children will have more psychological challenges in life.

The important thing for therapists to remember isn’t that a person’s attachment history is their fate—it’s just the opposite: the research shows it’s how you’ve made sense of your attachment history that makes the difference. We can help our clients understand, “Hey, even though something painful happened to me, if I make sense of it, I can actually do something about it.” So what I’m saying is that Attachment Theory has led to the development of the AAI, a relational measure with incredible predictive power.

KAGAN: I have no doubt that if I interviewed 10,000 people for 90 minutes, I’d make the same predictions, but I wouldn’t call my interview an Adult Attachment Interview.

SIEGEL: What would you call it?

KAGAN: Just because you and others call it an attachment interview doesn’t mean it has anything to do with attachment.

SIEGEL: OK. But Jerry, it’s an interview where the topic is people’s recollections of their early-life experiences.

KAGAN: But the interview could be about anything. It could be about the economic crisis in Europe, and the result would be the same. The content is irrelevant.

SIEGEL: Really? But then, why is it that when you talk with a parent about how they dealt with a terrifying experience they had as a child, you can tell whether or not they have children who are securely attached.

KAGAN: Because the interview indicates whether the person is currently free of an anxious or depressed state that would interfere with their effectiveness as a parent. The interview provides no evidence as to what actually happened in the first two or three years of life, the intensity of any trauma, or the kind of attachment they had with their parents.

SIEGEL: So forget for the moment the word attachment. The important thing for therapists is to help clients make sense of their lives.

KAGAN: I agree. I only want to make the point that a focus on “secure attachment” doesn’t help us explain the experiences and states of most people. For example, after World War II, Anna Freud and Dorothy Burlingham studied 90 orphaned children who came from Auschwitz to a nursery near Hampstead, England. These were children who couldn’t have had a secure attachment. Many years later, Sarah Moskovitz, a psychologist from the University of California at Northridge, tracked them down and wrote a book called Love Despite Hate, which contained interviews with them. Most were living happy and productive lives. Many said, “I’ve made sense of my life. I understand what happened to me and I’ve gone on to have a good life.” But no one can explain why some had and some hadn’t developed a better adjustment. If we knew the answer to that question, we’d understand one of the great mysteries of life. Science isn’t there yet.

SIEGEL: Oh, I get it, Jerry. OK. So let me clarify something for me and you, and for everyone. Making sense of your life has nothing to do with what your parents offered you.

KAGAN: Correct. We still do not understand how or why the relationship to parents in the early years shapes the ability to make sense of one’s life. We’re far from having the full answer.

SIEGEL: For therapists, the important thing to remember is that even with people whose parents didn’t help them make sense of anything, there are still ways to develop relationships that can help them do that.

KAGAN: Of course.

SIEGEL: As we’re talking, I realize that you and I agree much more than you think. I don’t believe that if someone has a coherent life narrative on the AAI, it necessarily means they had a good relationship with their parents.

KAGAN: You shouldn’t call it an Adult Attachment Interview. It is more accurate to call it an Adult Coherence Interview? If you agree, then we have no quarrel.

SIEGEL: I love it! You know something—we’ve just achieved an unbelievable understanding.

KAGAN: Let me tell you something. This is the first time in my life that a conversation like this has arrived at an important insight.

SIEGEL: Give me a high five, Jerry. There you go!

KAGAN: All right!

Has Mindfulness Been Oversold?

By Ron Siegel and Michael Yapko

Today, mindfulness, once considered an occult Eastern spiritual practice irreconcilable with the secular, Western sensibility of the consulting room, hasn’t simply achieved respectability in our field: it’s everywhere.Sometimes it seems you can’t read a journal or go to a conference that doesn’t have “mindfulness” somewhere in the title. In fact, some believe that the mindfulness movement, if it can be called that, has achieved too much acceptance, too much applause—even acquired a kind of secular sanctity. So there’s something especially refreshing and provocative about the following conversation between a longtime meditator who sees mindfulness as rooted not so much in a spiritual tradition as in an attempt to correct some of the more unfortunate legacies of our evolutionary heritage and a hypnotherapist, skeptical of the gauziness of many explications of mindfulness, who sees it as simply a demonstration of some of the underappreciated healing mechanisms of hypnotic suggestion.

Q: Ron, whatever its spiritual benefits, you seem to think that mindfulness practice has such therapeutic value because it serves as a corrective to so many of our evolutionary survival mechanisms. Please explain what you mean by that.

RON SIEGEL: When we imagine what our ancestors had to deal with in the African savannah, it’s clear that they weren’t all that well-equipped for survival. Their teeth, their claws, their hides, their foot speed didn’t give them much of an evolutionary advantage. Basically, they had two things going for them: a prehensile thumb, with a richly endowed set of nerve endings in their fingers, and good muscles, so that their hands could easily pick up things; they also had their higher cortical processes and capacities for thinking. It was those two advantages that allowed them to survive in competition with the other wildlife.

Today there’s nothing wrong with our thumbs and fingers. They seem to serve us quite well throughout the lifespan, and contribute to our happiness and well-being. But that’s not the case with those higher cortical processes. We’ve evolved to be these creatures who are constantly thinking. What’s worse, we’ve evolved to mostly remember and think about the bad stuff, reviewing it endlessly and imagining how it might happen again. That may be because our happier, more carefree ancestors who tended to live in the moment and didn’t worry about the saber-toothed cats died before having kids. Our more vigilant ancestors were the ones who survived.

Today, across the clinical spectrum, we see people who are utterly tormented by living in the past, having fantasies of endless misery going forward. So mindfulness practice has evolved, in part, to try to gently train the mind to do what it doesn’t do instinctively: to come back to the present, to enjoy the moment, to appreciate the interconnectedness of things, and to not be so focused on survival.

There’s another obstacle to our experience of well-being: we evolved to be concerned with our rank in the troop. Look at any mammal group and you typically see there’s the dominant male with his harem, along with the other guys who want to topple him when they get a chance. That’s how the group is organized. Most of us still spend a remarkable amount of time worrying about how we compare to others, how others see us, and the like. This is another huge source of misery that mindfulness practices try to address by loosening our preoccupation with “me” and our place in the social pecking order. I think that’s why mindfulness practices are so broadly applicable with a lot of different kinds of psychopathology.

Q: At a practical level, how has mindfulness been applied in clinical practice so far?

SIEGEL: There are two broad ways. Effective therapy requires the therapist to be as fully present as possible, not being caught up in the distractions of the day or to-do lists, but being fully available to resonate empathically with the client—which mindfulness teaches. The other way that mindfulness has impacted clinical practice is a basic attitude shift. In many therapeutic traditions, particularly the behavioral traditions, the attitude has been, “Well, we have an unpleasant symptom here: let’s see how we can get rid of it.” But people who try to integrate mindfulness into their work tend to agree with the wisdom of Carl Rogers: “Acceptance is the precondition of change.”

A lot of forms of psychopathology are actually disorders of nonacceptance. When we try not to feel anxious, we become phobic and avoidant, perhaps even agoraphobic. When we try not to feel sad, we shut down and become depressed. When we try not to feel some other dysphoria, we start drinking and have substance problems, and on, and on. Acceptance is often a key factor in resolving most psychological disorders.

Q: More and more therapists seem to be agreeing with that viewpoint these days, but, Michael, you’ve voiced some cautions about the role of mindfulness in clinical practice. What’s not to like?

MICHAEL YAPKO: Well, my background is highly relevant here. I’ve been studying hypnosis and hypnotic phenomenon for the last 35 years. When therapists talk about mindfulness, they tend to offer a spiritual or philosophical explanation of how it works in the therapy room. They often talk as if they’re simply eliciting or awakening something in a person—as if they weren’t a part of that process. But there’s a world of difference between what people say they do versus what they communicate to their clients. When, for example, therapists go through a guided meditation with a client, they don’t realize that they’re being suggestive or are participating in a powerful relationship.

I want to go on record saying that I love mindfulness and experiential learning, which is much more potent than purely intellectual learning. The value of experiential learning over intellectual learning is beyond question. But in applying mindfulness in our work, I think we need to strip away the vague spiritual language in which we discuss it and look at what therapists actually say and do with their clients. When we do, it’s clear that mindfulness methods involve a lot of hypnotic suggestion and hypnotic methods, like age regression, age progression, catalepsy, and dissociation. And it’s the dissociative side of mindfulness, in particular, that impresses me.

Q: Is there something wrong with bringing spirituality into the consulting room?

YAPKO: There’s nothing wrong with it, but, as therapists, we can’t rely on global explanations of what we’re doing and how it works. Clients often know what they want, but they just don’t know how to get it. As clinicians, our job is to articulate the specifics of “Here’s how you get from here to there. Here’s how you move out of global thinking and take specific steps that’ll help you accomplish your goals.” We need to get clear about how what we’re doing can change the concrete realities of somebody’s life.

SIEGEL: I think much of what Michael is talking about is very useful. Basically, he seems to be saying we need to be mindful of what we’re applying when teaching mindfulness clinically. Of course, he’s right: we’re doing many different things. We’re involved in a therapeutic relationship, we’re prompting our clients to want to please us in all sorts of different ways, and we’re providing all sorts of suggestions. So when somebody is leading somebody through a mindfulness practice and says, “And the body will begin to settle,” that’s obviously a suggestion. So I think being conscious of that and all of the subtleties involved, as Michael is calling for, is vital.

That said, let me bring up a point about which he and I might debate. Is mindfulness just another interesting cognitive-behavioral technique—just something that therapists might add to their toolkit—or is it something more than that? As part of a broader conception of psychopathology, the alleviation of suffering, and, frankly, the purpose of living a life on this planet, I think both approaches to mindfulness can be of use.

One could make a pretty good argument that our purpose as psychotherapists is to alleviate suffering, and one approach to that is in the realm that some might call spiritual. Of course, spirituality has so many different meanings to different people. To most people, it implies a belief in a deity of some sort—a belief in the supernatural, a world outside of that which can be seen, tasted, touched, and felt. But there are other understandings of spirituality. In the Buddhist tradition, spirituality refers to a way of experiencing the interconnectedness of things. It involves understanding how the conceptual mind takes what biologists would call an ecological system and divides it up into this and that, me and you, the dog and the cat, rather than seeing all the interconnectedness, all the interdependencies. So, for some therapists, mindfulness is more than a set of methods: it’s a whole spiritual framework that offers its own insights.

YAPKO: I don’t have any difficulty with helping people develop an understanding of the interrelatedness of things. But I want to make sure that, as therapists, we’re clear about what exactly we do to create a context in which clients can discover their capacity to have these transformative experiences that seem magical and develop this ecological understanding.

That’s the starting point for any effective therapy, whether it’s CBT or psychodynamic therapy or any other approach: how do you set up a context for change? First of all, you start by establishing an expectation that you’re offering something that can help the client. I want people to have positive expectations for treatment and to be cognitively flexible enough and behaviorally flexible enough to be able to shift perspectives readily. I want this person to be willing to experiment, regardless of which therapeutic modality I’m operating in. So, rather than getting lost in the content of the teachings of Buddhism or any other approach or the spirituality of it, I’m interested in what the common denominators are that create hope and positive expectations for change, and prime people’s unconscious participation in a way that they can have nonvolitional, transformative experiences, whether they’re labeled “spiritual” or not.

SIEGEL: I think you’re calling on therapists to be more conscious of what we’re doing when we’re doing it. To be conscious of that, we have to be educated in a lot of different ways of noticing how people evoke responses and influence one another’s unconscious processes. That seems to me utterly essential and important. But I want to emphasize an important point here. Sometimes people ask me, “Where do I get trained to do mindfulness-based psychotherapy?” I say, “Don’t. Get trained to be a good psychotherapist. Get supervision from somebody who knows something about transference and countertransference, knows something about the effects of the therapy relationship, and knows something about a broad variety of psychopathology. And be sure to do your own meditation practice, so you become more aware of your present experience. Develop greater affect tolerance, loosen up in your attachment to your particular conceptual frame, so you can take things flexibly and lightly, and then let the two blend with each other later on.”

With most of the folks who come into my office for treatment, I don’t treat them with meditation. I never mention the B word—Buddhism. I say this because I want to disabuse listeners of the notion that if you’re incorporating mindfulness into psychotherapy, this means you’re teaching people to become a Buddhist or you’re trying to get people to go on a spiritual quest. Rather, mindfulness is primarily a means of guiding our own therapeutic understanding of what we see as human potential—where people might evolve.

Much has to do with the timing of this; the skill that we use in deciding for whom, what, when—the same kinds of decisions that I think a good hypnotherapist, or a good therapist from any tradition, is making all the time.

Q: Michael, what are the specific elements of hypnosis training that you think people interested in mindfulness should learn more about?

YAPKO: Much of what drives mindfulness is exactly what drives hypnosis—understanding how dissociation works. It’s vital to be able to detach yourself from experience in order to transform it. So that as soon as you say, “Watch your thoughts go by as if they’re clouds in the sky,” you’re making a strong, direct suggestion of dissociation. If you say to somebody, “Focus on your feelings” or “Focus on your breathing,” you’re suggesting that this person detach awareness from everything else in order to focus on breathing.

So now it opens up a whole slew of new questions. How, as a therapist, do you determine who is capable of that detachment, and how do you learn to work with people with varying capacities to do that? When we look at the difference between people who respond dramatically to mindfulness practice and those who respond minimally, it comes down to hypnotic responsiveness—something that’s been studied for the last half-century. There are a lot of different hypnotizability tests, through which we’ve gathered normative data, validity, and reliability on, literally, hundreds of thousands of people, assessing their capacity to respond to experiential processes, like mindfulness and hypnosis. Just telling people you need to practice more isn’t enough. We have to then ask the bigger questions. Is hypnotizability modifiable? Can anybody learn to have these kinds of experiences? If not, why not? And if so, why?

SIEGEL: You’re raising interesting questions—particularly, what’s the relationship of various states that happen during mindfulness practice and dissociation? I believe that mindfulness practices lead to a view of awareness as a steady unfolding of moment-to-moment shifting objects of attention. Further, that the felt coherence that we have—the sense of “I am me,” which is our conventional sense of self that most of us are embodying most of the time—is seen as something of a delusional overlay to the moment-to-moment experience within these processes.

YAPKO: When you say to somebody, “Focus on breathing,” you’re bringing into this person’s awareness the breath. You’re associating the person with their breathing. So as you associate them to their breathing, what are you dissociating them from?

SIEGEL: From identifying with the thought stream, such that they can begin to notice that it’s just a thought stream, rather than seeing that narrative as reality with a capital R.

YAPKO: Exactly. There’s what I’m talking about when I use the term dissociation. You’re saying to this person, in essence, “You’re more than your thoughts,” and that’s such a powerful message. To say to somebody with a history of trauma, “You’re more than your history.” To say to somebody who’s wrapped up in their feelings, “You’re more than your feelings.” But then we’re using suggestion as a vehicle for encouraging that separation, in order to say to the person, in essence, at a process level, “focus on this” or “defocus from that.”

SIEGEL: Most of us tend to think of dissociation as avoiding something. But within the mindfulness tradition, stepping out of the thought stream in order to be with the pain of sadness or the tension of anger is a felt experience that’s quite different from what’s conventionally thought of as dissociation. That’s usually viewed as a sense of detachment, rather than a sense of full participation in an experience without identification with it. I know this is a little bit of a subtle matter, but when one cries mindfully, it feels fully connected, alive, poignant, but there isn’t a lot of “me” there.

Q: I think the language of hypnosis, as opposed to mindfulness, is largely focused on the methods the hypnotist uses to transform the experience of the subject. But, Michael, you seem to be making the point that hypnosis brings about shifts in consciousness that are every bit as valuable as mindfulness traditions. What’s so important about those shifts?

YAPKO: First of all, the experience of acceptance is the vital cornerstone. Earlier, Ron cited Carl Rogers’s statement about acceptance from the ’60s. Erickson wrote a piece in the 1940s about how vitally important acceptance is as a precursor to utilization, and his work came to be known as “The Utilization Approach.” How do you acknowledge, accept, and utilize each part of the person in the most benevolent way possible?

The other thing that stands out for me is empowerment. If experiential avoidance is the antithesis of awareness, the question is why does somebody avoid? Somebody avoids when they feel helpless, hopeless, that there’s nothing they can do about their life. I want my clients to be able to know, at any given moment, what they need to respond to, and how to best respond to it to produce the best possible outcome. So, for me, it’s less a global sort of thing, and much more moment to moment. How do I make a wise choice now that’s going to serve me now, serve me later, help me, help the people around me? I think what’s positive about the growing attention to mindfulness is that it focuses on helping people develop an internal locus of control, which is central to empowerment. It teaches people that they can find resources inside themselves they didn’t know they had and change their self-definition as a result. You’re nobody’s victim when you start thinking in terms of your own internal resources.

Confrontation in Couples Therapy Who Needs it?

By Terry Real and Sue Johnson

The joke goes, “How can you tell a couples therapist’s office? Answer: By the skid marks left by the men being dragged there by their wives.” Critics have charged that the entire therapy enterprise isn’t particularly user-friendly for men, claiming that there’s a mismatch between the touchy-feely atmosphere of most therapy and the emotional taciturnity manifested by many male clients. Others have claimed that therapists too often aren’t tough enough to break through the resistance offered by reluctant male clients. The lively dialogue that follows between two developers of contrasting couples therapy approaches not only explores the fundamental question of whether men and women really want the same thing in marriage, but also gives the reader a ringside seat as two outspoken practitioners demonstrate exactly how they’d handle a variety of challenges in couples work.

Q: Back in the heyday of feminism in the 1980s and early ’90s, therapists talked much more about gender-based power inequities in marriage. What do each of you think a good couples therapist needs to understand about the different ways men and women approach intimate relationships?

TERRY REAL: The idea that both the man and the woman are going to come into therapy with equal dissatisfaction, equal motivation, equal articulation about their emotional lives is just a fairy tale from my standpoint. Women are socialized to think more about relationships, and to be more intimate and emotional than most men. It’s part of traditional masculine culture that the definition of manliness is invulnerability. So it’s women who want more in their relationships and, by and large, it’s women who pick up the phone and call a couples therapist. Therapy isn’t a gender-neutral endeavor; it’s much more of a feminine endeavor, and men know this. So the idea that we therapists should use an evenhanded approach in the face of this situation is another fairy tale.

SUE JOHNSON: I think it’s clear that the expectations of marriage have changed radically from, say, when my mother got married. She was just looking for a provider, and her main question of my father was, “Do you have a suit?” not, “Can you talk about your feelings?” So I think Terry’s right about that. But while you have to pay attention to how people are socialized, from an Attachment Theory point of view, men and women aren’t so different. They both have the same fundamental attachment needs, although they might express them differently. The tricky part for men is how much shame they feel about their feelings that they’ve been taught not to talk about. But we know that on a basic level, the map for human emotions isn’t that different for men and women, and the needs aren’t that different.

Q: Terry, you talk a good deal about something you call “leverage” in the consulting room. Why is leverage such an important concept to you?

REAL: To understand the importance of leverage, you have to understand grandiosity, especially male grandiosity. Therapy and self-help have mostly focused on helping people come up from a one-down position of shame. But we don’t really talk much about what it means to help people come down from the one-up position of grandiosity. This is really pivotal in terms of working with men, because they typically tend to lead from the one-up, grandiose position, while women present in the more one-down, victim position.

From the viewpoint of motivation to change, the problem is that grandiosity doesn’t feel bad. In fact, it feels pretty good. For some people, it feels good to make out with your secretary, or to haul off and scream at somebody. Why change?

The other issue with grandiosity is that it impairs judgment, especially regarding the impact that you’re having on others and the negative consequences of your own behavior. What I’m saying is that you often have a grandiose, singularly unmotivated person in couples therapy and, when you do, you have to ask yourself, Why should such a person change?

The answer is that, as a therapist, you better have something in your back pocket that they really want, and/or you better be willing to zero in on the negative consequences that they want to avoid. However, that’s not how we typically teach therapists to think. We essentially teach therapists to replicate the traditional female role: be understanding, supportive, and nurturing to a fault. We teach them to do everything except put their foot down. As a result, most therapists do everything they can to keep grandiose clients engaged, except really think about finding leverage. But the reality is that if the therapist doesn’t know where the leverage is, the grandiose person really has no reason to listen.

JOHNSON: I don’t see it quite the same way. Perhaps it’s because I’m female, but I’m not so focused on power. I think couples therapists who understand human attachment have the biggest leverage in the world, because they understand that attachment is the most basic human need, whether you’re male or female. We all need to know that we matter to somebody else, and that somebody else has got our back—that they care about us, and, if you call for them, they’ll come. Of course it can feel good to rant and yell, but you don’t have to do that if you really have a platform of safety under your feet, where you know who you are, and you know you’re connected with your partner. Grandiosity is a sign that you’re feeling an enormous amount of vulnerability and you don’t know what to do with it. So what we tend to do in EFT [Emotionally Focused Therapy], instead of looking for leverage, is create safety to help people explore that level of vulnerability.

Q: So let’s get a sense of how each of you might work with this kind of a client.

REAL: The other day I was working with a kind of classic MIT nerd. He had a bit of an Aspergers-ish quality, and his presenting problem was that he wasn’t getting enough sex with his wife. He had absolutely no friends, and his wife had built up an enormous resentment of him over the years. So this guy was sitting in my office, doing this kind of self-stimulation rocking thing, talking about how lonely he was. While he was doing that, he was popping a pimple on his nose, and little rivulets of blood were running down his face. I said to him something that probably would have gotten me into trouble with my supervisor back in my student days, “Henry. The thing you’re doing with your nose—it’s disgusting.” He looked at me, and went, “Huh? Oh, OK.” I believe that until I pointed that out to him, he’d had absolutely no idea how interpersonally repulsive what he was doing was.

One of the things that’s important to teach grandiose men is what I call remedial empathy. I had a narcissistic fellow—a type triple-A, super-successful guy. He had two severely developmentally disabled kids, who were openhearted and lovely, whom everybody loved except him. But when he was honest with me, his real feelings about his kids was that he hated them because their disability was a narcissistic affront to him. For quite a few sessions, I talked to him straightforwardly about his selfishness, teaching him about empathy and about how to get out of himself to recognize the needs of other people.

Then one day, he came in looking like a different person and said, “I got it.” He told me this story of taking one of his two boys to a Red Sox game, stuffing him, as we do, full of sausage and candy and the rest of it. As he was driving home, this little boy starts to throw up, but he’s trying to hold the vomit in because he’s so afraid of his father’s angry reaction. This man said he looked into the terrified eyes of his little boy, and for the first time ever, felt absolutely appalled that his own son was so frightened of him that he’d hold in his own vomit. He said, “I realized in that moment that it’s not about me. It’s not about my injury. It’s about him and what he needs.”

He said that was a turning point in his life, and I believe it was. First of all, I believe that that this man’s transformation wouldn’t have happened had I not been confronting him about his selfishness, although I prefer to think about how I work with people as “joining with the truth.” I also think that he needed to learn how to replace selfishness with an absolutely different orientation and different skills. He needed to learn how to be a more intimate human being.

JOHNSON: I’d come at this kind of situation differently than Terry. If you want somebody to explore their experience and grow, it seems to me that first you have to help them feel safe. Of course, sometimes people will tolerate confrontation whether they are safe or not, but lots of times, they won’t. They run from you, or they’ll defend and eventually leave. What strikes me about Terry’s story is that this man had a new, corrective, emotional experience. There’s a sense in which you can show people empathy, but in my experience, you can’t directly teach it. People have to feel it. You can’t teach somebody to be tender or to have sexual desire or to have compassion. It has to be a real felt sense.

So in EFT, we place a lot of emphasis on reflective processing. For example, imagine a man who, after many years of doing just the reverse, starts to express his feelings. When that happens, you hope that his wife is going to be accepting and loving. But what often happens instead is that the wife will say, “Well, what took you so long, buddy?” And then she clocks him by saying something nasty, right?

In that situation, what I’d do is confront by saying, “Could we just stop a minute, please?” Although, at one level, EFT is warm and cuddly, it can also be directive. I’d take the time to reflect the process, and say, “What just happened for you? Your husband turned to you and said, ‘You’re right, I do shut down and move away because I get so scared, and could you help me?’ You turned your body away, got an angry expression, and then turned back to him and said, ‘Oh, right! Now we’re all supposed to feel sorry for poor Larry.’” She looks at me, so I replay it. Then I say, “What happens for you when you hear him say this?” I give her the cue again, and I stay with her. You’re not blaming her for not hearing him; she’s going to get angry with you if you do that. You’re not blaming her. You’re saying, “Could you help me? There’s something about this that’s hard for you to hear. He’s opening up to you right now, but you can’t hear him. It’s hard for you to hear. Is that right?”

So she looks at me and says, “Yes, I can’t hear. I’m too angry.”

I say, “I understand.”

As I say understand, her eyes fill with tears. She turns to her husband and says, “Now . . . now you tell me your feelings, when I’ve hurt for so long? When you’ve shut me out for so long? Some part of me just wants you to . . . I don’t know what.”

I say, “You want him to hurt.”

She says, “Yes.”

I say, “OK, so can you tell him? ‘I’ve hurt for so long, part of me wants to hear you, but some part of me wants you to hurt, too.’” And she does this.

Well, that’s a shift. But it’s a shift that works with her feelings. It’s not a shift from my saying, “Now, do you see that slamming him doesn’t really work if you want your husband to become more open with you?” For me, that doesn’t work. It’s too top-down. She’s just going to fight me. I want her to look at how hard it is for her—even when her husband reaches for her now—to respond emotionally. That’s also confrontation, but a process-oriented, reflective confrontation, that’s done in a way that the person still feels that you’re with them.

REAL: I’m 100 percent with Sue on that last point. When you confront a client, you must do it in a way that leaves them feeling like you’re on their side. In what Sue just described, she addresses a part of this woman that wanted to hurt her husband. In the way I work, I talk about differentiating between the person and their dysfunctional behaviors, or their dysfunctional ways of thinking. One of the things I say at the end of many first sessions when I’m dealing with a grandiose person is something like this: “You’re warm, you’re funny, you take in what I have to say, and yet you’ve been having multiple affairs throughout this marriage. What’s sad about this is that I’m dealing with a decent person who’s been behaving indecently for the last 20 years. Let me help you extricate the decent person that you truly are from all of this crazy behavior.”

The way Sue would deal with a woman who clobbers her husband when he finally shares with her sounds effective, but I have a slightly different way of going about it. I might say, “Listen, what’s going on here is you’ve asked for his feelings, he gives you his feelings, and then you clobber him. Do you think that’s going to work?” And then it moves into where that comes from. I think my version—or the analog to Sue’s moving into feeling—is I’m moving into the family of origin. I’d speak to her about what I call the “marital wound.” I’d normalize it. I’d say, “I know you’ve been hoping to get this out of your husband for 20 years. You’ve been vulnerable over and over again, and been disappointed. Of course, you don’t want to be vulnerable now. I understand that. Yet, for this to work, you’re going to have to find the resources to do that.” So it’s more teacherly. It’s both more telling the truth to the person about what they’re doing that’s blowing their own foot off and, beyond that, investigating where that behavior comes from in their history. I also want to be sure to suggest new moves they might try.

Unlike Sue, I don’t believe that the people who come to us always have the solution inside themselves and what we need to do is just help them find it. I believe that the people who come to us have what I call “relational deformities” that they learn in their family of origin. The son of a rager is a rager, and the reason why he’s a rager is because he grew up with a rager, and he thinks raging at things is OK. So I talk about how that behavior is getting in the person’s way and where it comes from. I try to move that person from being comfortable with his own behavior to feeling bad about it—in a healthy way—if it’s dysfunctional or destructive. I talk about bringing someone out of shamelessness into healthy shame. It’s at that point that you teach them what being more vulnerable in a situation might look like. I do what Sue called top-down. You can shoot me, but I think it works.

JOHNSON: The tricky part about shame is deciding whether it’s healthy or not. But the trouble with shame is that the actual tendency behind shame, if you look at the structure of the emotion, is to hide and withdraw. So it’s a pretty tricky to decide when to shame somebody. If you’re saying to somebody, “Do you understand the impact you have on your partner?” I don’t think that has to be shaming. I mean, I agree with Terry that most of us learn these basic ways of being in our family of origin. The man who constantly shuts down and stays very still as his wife gets upset with him probably grew up in a violent family in which the only way not to be abused was to basically disappear into the wallpaper. You can say that it’s a choice, but it’s a default option that was laid down in his brain at a early age, and when he’s panicked—and I’m using the word literally, because all the neuroscience on attachment says that’s exactly how you feel when you can’t connect with your partner—he goes into withdrawal and is no longer cognitively available to see the impact on his partner. As Terry says, he can’t comprehend how he’s shooting himself in the foot. You’re going to have to give him an experience in the session of talking about his terrified withdrawal or putting into the words the feeling that “There’s something fundamentally wrong with me: I’m completely flawed.” Anything that adds more shame on top of that is going to make it that much harder to reach this guy.

But when this kind of man finally starts to be able to tell his wife about his deep fear that nobody could possibly love him, you can see him, literally, grow in the session, because he starts to understand that his emotions are workable—that he can actually talk about them. You can ask him, “Can you feel this right now?” And he says, “Yes, I feel it right now. I can’t look in her face because I’m afraid I’m going to see this terrible disapproval.” Then I encourage him. I ask him to look at my face, and then to look at his wife’s face, and then he sees that she’s full of love and caring for him. Then he says, “I’m so scared to really show you who I am.” She then leans across and she puts her hand on his knee.

That man’s just had a corrective emotional experience of a part of himself that was filled with shame, and he’s now able to be out in the world with his wife and feel her tenderness. That’s how people grow together in a good marriage. The wonderful thing about marriage is that it’s a second chance to really be in a new dance with a new person, deal with those childhood emotions differently, and get much more positive feedback. So we go there, rather than using shame in the way Terry is talking about.

REAL: One of the things we say in RLT [Relational Life Therapy] is that if you change the affect, you’ll change the stance. So we’re right in line on that. One of the differences, though, is that we’d actually teach somebody how to do it. For example, when we’re teaching somebody how to give feedback to somebody, we coach them to skip over their first feeling—their most accustomed feeling—and see if they can move to an unaccustomed feeling. So if you’re used to leading with small, vulnerable, helpless, desperate feelings, we want you to get in touch with your power and anger. If you’re used to being big and angry, we want you to get in touch with your hurt and vulnerability. But I also think you can lead with a cognitive shift, and it can have a lot of emotion with it. The other thing I want to say is the therapy isn’t shaming. The goal is to help somebody move from being shameless to healthy or appropriate shame. We don’t shame our patients: we teach them how to be better. I had a case in which the woman was a rager who screamed at her husband in front of her kids.

In one session, I said to her, “You have to stop doing this.” She said, as most ragers do, “It comes upon me too quickly. I can’t.”

Then I made a strategic move. I said, “OK, here’s what I want you to do. Do you have pictures of your kids?” Yes, they were beautiful kids. “OK, you have my permission to rage at your husband in front of your kids. But before you do that, I want you to look at some family photos of your kids and look into their eyes and say, ‘I know what I’m about to do is going to cause you deep and permanent harm, but right now, my anger is more important to me than you are, so screw you.’” I put my arm around her shoulder, and said, “Let’s practice that, shall we? Hold up the pictures, and ‘I know . . .’”

She burst into tears and said, “I can’t say that to my children.”

I said, “No, my dear, but you are saying that to your children. You’re saying that every time you scream at their father in front of them. All I want you to do is say it out loud and own it.”

Then she said, “I’ll never rage at my husband again for the rest of my life.”

I’m here to tell you—that was 17 years ago, and from that moment forward, she stopped that behavior. That’s what I talk about as bringing somebody from shamelessness into healthy shame. This woman had grown up with a lot of rage, and it simply didn’t occur to her that if you get pissed off at somebody, you don’t get to rip their head off. That thought wasn’t in her repertoire until she came into therapy. I think it’s a disservice to take somebody like that and not actively give them the tools they need to move beyond it.

JOHNSON: I agree that you have to help clients contain certain negative behaviors, but we might do it in a different way. In this case, an EFT therapist would stop and then reflect the process. “You’re caught in that rage, right? And that rage pushes your husband away from you and leaves you all alone. But you’re caught in that rage. Let’s listen to the rage.”

If you listen, and you press the elevator and go beneath the rage, what you hear is desperation. What you hear is helplessness. What you hear usually, when someone is raging at their partner is, “I’ll make you listen to me. You must listen to me. If I can’t impact you, there’s no relationship. I don’t matter to anybody.” That puts people into a complete funk.

So yeah, you’d show her. You’d unpack that rage in the session, because it’s what we’d call a secondary emotion. You’d go down to the primary emotion, which is “If I don’t yell, you’ll never listen to me. If I don’t yell, I’m all by myself.” We’d also validate this woman. “When you were a child, the only thing you ever saw was yelling, so that’s what you do. But right here, right now, it’s pushing your husband away.”

Q: As I hear the two of you describe your approaches, I’m struck by how much, in addition to your theories, your actual work is shaped by your personalities and your gender. What do each of you see as your primary role in the process of change?

JOHNSON: EFT is based on Attachment Theory and the science of bonding relationships. Guided by that, much of what I do as a therapist is based on my belief that my role is to be a surrogate attachment figure who doesn’t allow their kid to act out in front of them, but directs them gently, and helps them explore and move and grow. Part of that may have to do with my personality, but I think it’s more than that. It’s a particular way of seeing problems, and a particular way of being with people.

Q: Are we coming down to a classic distinction between the different ways that men and women look at relationship? Terry, are you a surrogate attachment figure or, in the time-honored male tradition, a bit more of a coach?

REAL: Well, if I’m an attachment figure, it’s a paternal rather than a maternal one. But I think my job is to coach the two partners to have a corrective emotional experience with each other. I’m much more like a 12-Step counselor, or, if you prefer, a coach.

Illustration © James Yang

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