Open Book

Tales of the Consulting Room

Stories are how we learn to be therapists

Magazine Issue
July/August 2003
Tales of the Consulting Room

The Mummy at the Dining Room Table: Eminent Therapists Reveal Their Most Unusual Cases

By Jeffrey A. Kottler and Jon Carlson

Jossey-Bass. 320 pp. ISBN 0-7879-6541-3

Let’s face it, to be a therapist is, among other things, to be a voyeur. We spend our days in our front-row seat on the intimate parade of human foibles, and we couldn’t do our jobs with any enthusiasm if we didn’t enjoy watching the parade. But while we may be voyeurs, we’re not passive voyeurs. Therapy is a deeply engaging process, in which the boundary between observer and actor shifts frequently. To be effective, we must also get involved, becoming players and shaping the drama we’re watching.

One of the ways we manage this balancing act, making sense of the endless details of people’s lives to which we are privy every day while maintaining our boundaries, is by telling stories, both to ourselves and others. That’s what we focus on with our clients, and that’s how we pass along what we know to each other. Stories about cases are central to how we learn how to be therapists and maintain our sanity once we do. Telling them allows us to step back from them, learn from them, and release some of the burden of carrying them. And so in our field we have a vast literature of cases, which tend to come in three major types, well-represented by the books that are the subject of this review.

The first type of case is about the clients and the poignant, amusing, or mind-boggling ways they manage or mismanage their lives. A second type of story is more didactic, focused on the process of treatment and how therapy works in a particular case. Then there’s a third type, less about the content of clients’ lives and treatment and more about the therapist’s inner experience. These can be either self-glorifying stories–look how smart I am, look what important and intriguing people come to me–or, more thoughtfully, stories of the therapist’s own growth and transformation through his or her interaction with the case.

The Mummy at the Dining Room Table: Eminent Therapists Reveal Their Most Unusual Cases is a gallery of sometimes amusing, often bizarre, cases of the kind most of us might see once or twice in our lifetimes. The title case, for example, involves a family that, literally, kept their embalmed aunt propped up in various poses for seven years. The authors, psychologists Jeff Kottler and Jon Carlson, traveled around the country interviewing “eminent” therapists (mostly originators of theories or methods) about the most memorable and unusual cases they’d ever had. The result ranges from the truly outrageous to the merely unusual. The outrageous cases, like Albert Ellis’s “Oedipal Dilemma,” in which a father has an extended affair with his daughter, or Susan Johnson’s “The Woman Who Hanged Herself to Check Her Husband’s Response Time” are fascinating but don’t teach us much because they focus on the freak show aspect of therapy. In those cases, there’s not much technique or instruction involved beyond the spectacle of the therapist holding on for the ride. In contrast, the less extreme cases are often quite helpful and instructive because they include more about clinical decision-making. Frank Pittman, for example, offers a nice riff on how we use the lessons from some clients to benefit others: “They [clients] are misinformed about how to live a life. It’s my job to learn from all of my other patients how you can screw up, and how you can recover, and then make whoever I’m seeing more aware of what the possibilities are.”

Where Mummy deals with the lessons from clients in a more instructive way, it’s useful and informative. Where it seems more interested in titillating than educating, the focus shifts from”How I dealt with this difficult case” to “Can you top this?” The authors occasionally even seem to egg on the clinicians they’re interviewing toward the sensational–which is disturbing, but also seductive. Even when I didn’t like the tone, I could feel myself wanting to tell my own most amazing cases, in a kind of competitive, “I’ve been there, too” way. Not my best reflex, nor ours as a field. Mummy ends up with the feel of a late-night, all-therapist bull session: some good learning, some laughs, and some unusually candid acknowledgment of how little we sometimes know about what to do next.


Clinical Epiphanies in Marital and Family Therapy: A Practitioner’s Casebook of Therapeutic Insights, Perceptions, and Breakthroughs

Edited by David A. Baptiste

Haworth Press. 429 pp. ISBN 0-7890-0105-5

A totally different kind of casebook comes from editor David A. Baptiste, Jr., in Clinical Epiphanies in Marital and Family Therapy. Like Kottler and Carlson, Baptiste has solicited cases from a wide variety of therapists. These cases are presented in a “critical incident” format: each builds to a carefully delineated key intervention or event that’s identified by the therapist as central to the outcome of the case. Sometimes the interventions are unusual, like the instruction to a suicidal client to go to a funeral parlor to see if she still wants to commit suicide, or an extended discussion of penis size. Others are as simple as asking a question in such a way that a client really hears it for the first time, or reframing the issue effectively. No matter what the “critical” intervention is, it’s usually interesting to see what the therapist felt made the difference.

The cases in Baptiste’s book are as carefully and academically presented as those in Kottler and Carlson’s are spontaneous and sketchy. No bull-session format here! The chapters follow a formal outline which produces a number of excellent, richly textured case studies filled with useful detail. Most of the authors, presumably at Baptiste’s urging, dwell at considerable length on theoretical issues and dilemmas. The critical incidents themselves are reported in detail–which results in an unusual look into the guts of a case. For instance, one therapist faces his client’s ultimate ability to commit suicide, acknowledges his fear and his impotence to stop her, gives her “a long hug,” and says, “Go in peace.” (She doesn’t kill herself.) The book also reminds us that the critical intervention is seldom a well-planned strategem, but a spontaneous, often slightly aberrant or risky statement or action by the therapist.

While the cases are generally believable and vivid, Baptiste unfortunately buries each one under two lengthy and often tedious commentaries, which also follow a precise outline. The commentators wrestle with subtle theoretical differences, debate various scenarios of “What I would have done differently,” and push their own agendas–gender, ethics, timing quibbles–that sometimes make the cases too long. But where Kottler and Carlson’s cases all teeter on the edge of the bizarre, Baptiste’s are solidly centered on the process and the lessons to be drawn from it more than on the drama of people’s lives.


Epiphanies: A Psychotherapist’s Tales of Spontaneous Emotional Healing

By Ann Jauregui

Prima Publishing. 224 pp. ISBN 0-7615-6376-8

Ann Jauregui’s Epiphanies is as different from Clinical Epiphanies and Mummy as possible. It’s a highly personal wander through the author’s creative and intriguing mind. More about her personal development than about cases, it really isn’t a casebook at all. The few, almost dreamlike, cases are illustrations of her very different take on therapy, filled with silences and what she calls a sense of “mystical longing.” Deeply interested in meditation and the role of stillness and unconditional presence, Jauregui examines a nonlinear, often nonlocal source of therapeutic power, derived from her ability to sit quietly and make room for the deep stirrings of her clients. For example, “‘Light is streaming into me!’ [the client] exclaims, surprising us both, and we are transported out to the place beyond personal weather where the universe makes itself known to us.” Jauregui joins her clients in their epiphanies in isolated moments of transformation. The cases, a page or two long, have little storyline, and include nothing about technique. They describe a recurrent crescendo to an intensely personal breakthrough, culminating in some variation of “I’m going to be all right.”

The reader is drawn in by Jauregui’s comfort with this personal and nonscientific view. She writes, for example, “Meanwhile the most riveting moments in psychotherapy are those moments of surprise and discovery that seem like magic, or alchemy, or something we don’t know how to theorize about. These moments arrive like a dawning. Or a pop. There may be a rush of tears, an exclamation, a slow grin. However they come, there’s no doubt about their reality.”

The book is an amalgam of a lot of Jauregui’s early history, snatches of poetry, philosophical musings, notes from conferences she attended, and random quotes and ideas. For example, “‘I was wrong.’–Ram Dass,” appears as an epigram in the middle of a chapter, with no explanation. It’s just there. She follows a highly personal train of thought throughout, and the reader craving clarity about either the people or the process may be frustrated and confused.

Yet the book is delightful. Jauregui’s near-total faith in “our innate all-right-ness” and the “moments in which we feel most intensely alive and aware that nothing needs fixing” (italics hers) is persuasive and engaging, inchoate and murky though it be. Where Mummy says, “It’s a crazy world,” and Clinical Epiphanies says, “Here’s how to fix it,” Epiphanies says, “Relax and make room for people the way they are, craziness and all. Be with them as fully as you possibly can, and see if something wonderful doesn’t happen.”

Epiphanies isn’t a good road map for people who want to learn how to create epiphanies. Jauregui would say you can’t make them happen: you can merely encourage them by being fully present. Her book has a sense of wholeness and respect for the individual at its heart–a stance that’s engaging and quieting. This crazy business we’re in is, in the end, not about technique or theory or even stories, but about quiet moments of seeing the world differently with the help of another, more seasoned soul.

For me, each of these books fits a different phase of my professional life. When I was consumed with technique and turning points, I would have devoured Clinical Epiphanies. When exciting, startling cases used to stimulate the voyeur and the raconteur in me, Mummy at the Dining Room Table would have been an irresistible read. But these days, those stories don’t have the same pull for me that they used to. In my therapeutic dotage, I find myself most drawn to moments of mystery and profound (if sometimes fuzzy) understanding, whether or not they can be deconstructed and made edifying. As a result, Jauregui’s cases have the most resonance for me. However, there will always be a plethora of stories and storytellers to choose from, and it behooves each of us to find his or her own resonance.

In the end, all three books are about how stories help us stay grounded in the fundamental reality of the clinical situation. In an age of cynicism about clinical efficacy, quantification of results, and tough-minded research, stories bring us back to the humanity of the individual people and the lives they really lead. Stories help us, voyeurs that we are, continue to see clearly and compassionately the people who are bringing us the next story.

David Waters

David Waters, PhD, is a psychologist in private practice in Charlottesville, Virginia. He was a professor of family medicine and psychiatry at the University of Virginia Medical School for 37 years. He retired in 2008.