Beginnings, Second Edition

The Art and Science of Planning Psychotherapy

Mary Jo Peebles

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136932298
• Edition: 2
• Topic: Psicología
• Subtopic: Psicoanálisis

Utilizing a decade's worth of clinical experience gained since its original publication, Mary Jo Peebles builds and expandsupon exquisitely demonstrated therapeutic approaches and strategies in this second edition of Beginnings. The essential question remains the same, however: How does a therapist begin psychotherapy? To address this delicate issue, she takes a thoughtful, step-by-step approach to the substance of those crucial first sessions, delineating both processes and potential pitfalls in such topics as establishing a therapeutic alliance, issues of trust, and history taking. Each chapter is revised and expanded to include the latest treatment research and modalities, liberally illustrated with rich case material, and espouse a commitment to thevalue of multiple theoretical perspectives. Frank and sophisticated, yet eminently accessible, this second edition will be aninvaluable resource for educators, students, and seasoned practitioners of any therapeutic persuasion.

Chapter 1

Beginnings

I am always a little nervous when I meet a patient for the first time.... If I’m not, I know I’m not fully present.

Richard Maxfield, from a class lecture in the Menninger

Postdoctoral Fellowship Program in Psychology (1980)

You open this book, and you are hopeful. Or perhaps skeptical. Or... how many dozens of other possibilities? Take a moment. Notice what you are expecting, seeking, wanting. Notice that you have anticipations. You are beginning with me, and before we have even “met” at any length through the pages of this book, you are already holding hopes, needs, protections against disappointment, and anticipations of what “working with me” might be like, might offer or bring. As you open into listening to yourself inside this internal space, you can begin to appreciate how much is actually held inside beginnings.

Beginnings hold a fullness of unripened possibilities—seeds planted long before two people meet, within the soils of their respective histories, carried by them to each new encounter. The first step in planning psychotherapy is to open up space for the beginning to be listened to. It holds valuable information about what the patient is seeking, what she¹ is expecting to find, what has gotten in the way of her being helped in the past, and how things might go differently in the present—in short, things important to us when planning psychotherapy.

The people we meet in our consulting rooms have tried many things already to help themselves. To expand their chances of reaching what they’ve been seeking, we want to open up space, for everything to be present—the hidden as well as the visible. Only then can we begin to begin, can we catch glimmers of missing, can new combinations emerge, and can possibility germinate, have room to breathe, and grow. We open up this space by slowing experience down, by listening, and by allowing the unknown.

Slowing Experience Down

Wisdom begins in silence.

Robert Lawrence Smith

A Quaker Book of Wisdom

In our speeded up age of text, Twitter, continuously scrolling CNN news tickers, flipper graphics refreshed every five seconds, pop-ups, and multi-screen feeds simultaneously viewed, we are losing the ability to slow down communication to an emotionally manageable level. People continue conversations with each other while simultaneously texting, iChatting, and scrolling through Facebook posts. We boast of being adept at multitasking. What we fail to grasp is that the mind’s capacity to hold the hundreds of resonances tripped by those tasks, and its ability to track and grasp the multiple swirls of feelings correspondingly stirred, lag light-years behind the speed of simply registering flat data bits. We can crunch incoming words and numbers faster than we can comprehend what we are feeling in response to what we just crunched. The emotional self gets left behind in the dust. We’re flooded. Only we don’t name it that—instead, we act irritable, feel edgy, and caffeinate ourselves to push through the inevitable fuzzy space that envelops.

Playwrights know the fullness that lies under words and inside spaces. Actors learn the depth of a pause, the magnitude of a silence for carrying huge weights of information. Particular words strike resonating chords—stirring cultural connotations or personal ones. The tone and inflection of the speaker tip and amplify meaning. The resulting cascade of emotions and thought balloons are too large to squeeze through the narrow neck of fast-paced banter. We may be agile at processing the top layer of text, but it’s the multiple currents flowing beneath that clog everything.

Our job as therapists is to open space adequate for hearing, appreciating, and soaking in all that is being said and taking place. We do this by slowing things down.

Slowing things down doesn’t mean holding up a stop sign. A slower pace is reached by quelling our impulse to jump in, to react, to too quickly assent, banter, or offer solutions. It values pausing, using the space to hear the resonances and remark on them. It appreciates when the patient has just put a huge quantity or particularly weighty piece out on the table and enjoins her to share that moment of appreciation with us. It takes seriously what is getting tossed off glibly, not by being heavy handed but by being thoughtful and reflective.

Slowing things down paradoxically expands time. It expresses interest—in what’s around the edges, what’s lying underneath, what’s held just inside the parcel of information the patient just offered us. Because we are interested and attentive (not pressing, suspicious, or vigilant), most patients feel us hearing and respond by saying more. We encourage them to hear with us what they just said. We model a surety that what is taking place is important. In these ways, we create the space for both of us to begin to listen, in a different kind of way than life outside the consulting room usually affords.

Listening

“Agent Lemieux, our job is to find the sense.”

“How?”

“We collect evidence, of course. That’s a big part of it.”

“But there’s more, isn’t there?” Lemieux knew that Gamache had a near perfect record. Somehow, while others were left baffled, he managed to figure out Now Lemieux stood very still himself. The big man was about to tell him how he did it.

“We listen.”

“That’s it?”

“We listen really hard. Does that help?” Gamache grinned. “We listen ‘til it hurts. No, Agent, the truth is, we just listen.”

Louise Penny

A Fatal Grace (2006, p. 90)

How many times do we hear what is being said? How many of those times are we listening as we hear?

Being Open

Listening is more than registering and recalling auditory information. It is a taking-in of everything that is there. It means opening, without arbitrary barriers, to being entered and to the content that enters.

To be open in this way, one needs clear boundaries. These boundaries arise from a steady sense of oneself and a steady way of tracking what is taking place inside—how one is feeling and responding in the moment, what is being stirred, where those stirrings come from. Healthy boundaries also are molded from a clarity about what is unsafe, and why, for our patient and for us—a clarity that comes from comprehension not just of factual knowledge but of one’s professional code of ethics. Boundaries provide the buoyancy that allows us to hold on, to ride the unexpected wave intact, to come back readily to the surface when we have momentarily been washed under. We may experience fear as we take the other in, but we can ride that fear as simply a wave that can wash over and pass through us. We may feel ambushed, but we know how to stabilize, how to let the uncentering occur and then how to return to center, in order to better see. Such abilities are not acquired lightly; one works at their development in one’s personal therapy, in supervision, and throughout one’s life.

We are all human; thus, we can understand the human experience of anxiety in the face of feared emergency. We can appreciate how sometimes each of us reactively erects emergency boundaries that are actually barriers, usually brittle and unhelpful (to us or to our patient). For example, we may find ourselves inadvertently trying to push comments back into our patient by prematurely taking issue with their accuracy or by misguidedly feeling called upon to justify or explain our “position” (e.g., Epstein, 1979). This usually occurs when the accuracy or emotion or penetration of what our patient is saying is unexpected or difficult to process, making it hard for us to tolerate and hold inside for a few minutes until meaning and context emerge more clearly. We may begin to speed up—talking faster, or too much, or bringing in too many ideas in one sound burst—when something has just made us anxious. We may catch ourselves diverting the conversation to a peripheral detail, because something inside the place central to where the patient is was somehow difficult for us to stay with. Or we may rue an abrupt shift in our tone toward edginess, critique, or tension; then realize we are trying to break something threatening into imaginarily conquerable bits. There are as many variations of these emergency boundaries as there are people. With attentiveness, over time, we learn to recognize our particular style of erecting them and to use their unexpected appearance as signals to ourselves that we must be momentarily disrupted or overwhelmed. Through doing so, with compassion toward our own vulnerabilities and toward the time it takes to learn, we can develop the ability to right ourselves and return to listening.

Being Porous: Growing the Ability to Listen to Ourselves

When we open, we are allowing ourselves to be porous. It is reassuring to understand that being porous does not mean losing definition or becoming diffuse. Nor does it mean passivity or allowing unrestricted vulnerability to unsafe exposure. We allow porousness; we admit passage of the outside in. These are judicious acts; by using awareness, we render them active choices. And, by so doing, we retain self-definition and clarity of presence, even while we are allowing things from the outside to come in.

An interesting phenomenon, and often-neglected realization, is that the porousness of openness occurs in more than one direction. Not only are we opening ourselves to experiencing what is in our patient, but in so doing, we also are opening ourselves to experiencing what is inside us. And what is inside us is also opened to being experienced by our patient. Awkwardly, what becomes visible to our patient along this other side of the two-way street is not always anticipated by us, nor does it always occur by our choice. Our patients see into us, much as we feel ourselves seeing into them. Our patients may not understand what they are seeing, much less know what to do with it, and many will not know how to articulate it, but they will react to what they pick up.

In addition, we will react to experiencing the inside of our patients, and more: We will react to experiencing the inside of ourselves—those personal feelings and memories held inside our interior spaces that (sometimes unexpectedly) get blown open, or simply stirred, by something our patient is saying.

We can’t avoid this way of communicating, if we are open. But we can keep things buoyant and resilient, effectively helping our patient, if we learn to know ourselves. It is important for each of us to understand, more or less, what has lain inside us, why we came to this work, what our suffering is, where lie the wounds—their size and shape, and how we have tried to heal (or hide) them. The fewer unknown spaces, the less fear. The less fear, the more we can allow the porousness necessary for listening.

Don’t get me wrong: There is always the unknown, always the unexpected. But the more we have navigated our own dark places, the easier it becomes to travel with our patients into theirs. And, the easier we find it to respond with less disruption and more humanity (and thus more helpfulness) when our patient unwittingly but accurately perceives something in us we hadn’t known was visible.

Allowing the Unknown

Into the woods,

Where nothing’s clear,

Where Witches, ghosts

And wolves appear.

Into the woods

And through the fear,

You have to take the journey...

Into the woods–––you have to grope,

But that’s the way you learn to cope.

Into the woods to find there’s hope

Of getting through the jouney.

Stephen Sondheim

Into the Woods (1987)

As Stephen Sondheim discerned within the fairy-tale narratives of centuries ago, our lives are journeys, usually quests—and sooner or later, our quests take us “into the woods.”

When our patient arrives at our door, she usually does so because she has landed in her woods, in one way or the other, and she is anxious to find a way out—quickly! She wants us to tell her which way to turn: Where is the path? Can she hope for the light to reappear? Is she hopelessly lost? She may be afraid to ask these things directly, but she is feeling them. To help her find her way, to piece together where she is and what her way might be, we must enter her woods with her, move through the dark alongside her without making her darkness our own, and bring our eyes, ears, experience, and knowledge to bear on the task of deciphering where she is, where it might help her to be instead, and what the clearest way of getting there would be. To do these things, we not only must slow things down and listen carefully but also we must be able to tolerate the dark. We must know how to allow the unknown.

First Tolerate...

It is scary to enter the unknown, “Where nothing’s clear / Where witches, ghosts / And wolves appear” (Sondheim, 1987). We will be afraid. We will be afraid of the darkness of nothing being clear. We can’t know immediately what is wrong with our patient; we can’t know if we will be able to help her. We can’t know exactly what she is saying or meaning. We will feel moments of confusion, if we are honest.

We also will be afraid of the monsters—the witches, ghosts, and wolves—that might be lurking around the corner. The primitive in people, the unexpected, the chaotic, the out of control: It is no accident that these things—and the suspense of wondering if and when they might strike—are the stuff of horror movies and terrifying thrillers. They are used in such movies because they reliably make us feel fear. When we let ourselves enter the woods of our patient with her, when we allow the unknown to unfold, we open space into which primitive, unexpected, and chaotic things might stir. We thus expose ourselves to the possibility of fear.

Our minds, reflexively, will try to not let us do this. Whatever stimulates fear is registered in our limbic brain as unsafe; therefore, from early on, we track the characteristics of encounters and people and amass a mental file drawer full of patterns. When encountering the new or unknown, we are programmed to speed-flip through these archived patterns, dimming any differential nuances or ambiguities as “noise” or artifact and thus clearing the way to leap, “successfully,” to rapid conclusions about what is in front of us, what is taking place, and how it will likely turn out. This kind of advance “certainty,” in the form of such reflexive conclusions, is how our brain strives to keep us safe. It is presumed so essential that we typically don’t realize the process is taking place. Blink! (Gladwell, 2005).

The problem with reflexive conclusions derived from the pattern-recognition of expectations, however, is that the data upon which the conclusions are based are compilations of past experiences. In short, we are concluding that what will happen is what has happened. In this mode of processing, there lies little room for new possibilities or new discoveries, since the objective is to limit the unknown. Therefore, in order to create space for fresh ways of appreciating the tangle of the patient’s woods, we must mindfully decline the unseen spin toward rapid...