There are three different kinds of client, according to Steve De Sheza:
• Visitors are highly ambivalent about the whole exercise—very often they are there grudgingly, at the behest of a partner, boss, educational establishment, medical professional or court of law.
• Complainers love to catalogue all their problems, how much they suffer and are mistreated by others, but they refuse to see any role that they might play in either the cause or the cure. They are greatly attached to their troubles and have no intention of actually doing anything to relinquish them (they will defend them, wrote Freud, like a lioness defends her young).
• Customers—the best clients—are present, open, engaged and highly motivated. They want things to change. They’ve had it with the status quo, with feeling bad all the time, with aspects of their life that have become worn out or problematic. They’re tired of being stuck. They have faith that better days lie ahead.
“Customers” have a sense of some kind of direction or goal for their therapy. A partial list:
--to feel less anxious, depressed, afraid, panicked, unsafe or stuck;
--to improve relationships;
--to express and manage emotions in a better way;
--to change specific unhelpful repetitive behaviours, habits or patterns;
--to come to terms with some kind of loss;
--to process difficult events or trauma of the past;
--to explore and “find” oneself;
--to be supported in coping with a great, transformative challenge such as leaving home, bereavement, redundancy, divorce, illness and disease;
--to make sense of the story so far;
--to live life more fully;
--to find some meaning, purpose or spirituality;
--to prepare for death.
Can therapy meet these goals? Sometimes, to some extent, for some people. But change is not always so easily steered. Unhindered, it happens naturally: we’re born, we grow, we blossom into a gorgeous ripening. We can't help but grow—it's what we do. We are fluid, like a river, as Heraclitus argued two and a half thousand years ago. Nothing will ever again be quite the same as it is right now. But sometimes our growth can be stunted, stuck or skewed. We don’t get the optimum psychological light, water, nutrients and nurturing that we need. Life’s troubles, stormy weather and other obstacles get placed in our way. We get shackled; as Rousseau wrote we are “everywhere in chains.”
What prospects for growth, for change, in these circumstances? Carl Jung wrote: “We cannot change anything unless we accept it. Condemnation does not liberate; it oppresses.” This paradoxical theory of change, echoed by Carl Rogers, Arnold Beisser and others, says: We can only become more like the person we want to be by first fully cherishing the person we are. I believe this acceptance arises from two factors: self-knowledge, and, for want of a better word, love.
We are troubled by our symptoms, defences, age-old problematic patterns, unconscious desires or other less pleasing, disowned or denied parts of ourselves. But when we have a thorough grasp of these things and where they came from, coupled with an acceptance of them by both Self and Other, they cease to bind us so tightly and in some cases simply melt away. We come to realize that we do not need our crutches any longer, that the world will embrace us without them, that it is safe to lay them down. By contrast, when we don’t understand them, don’t have compassion for them, cannot accept them, we are subjecting ourselves to oppressive condemnation. We try to command our stifling troubles away but discover that they only cling to us ever tighter. We have limited success with our diets, our New Year’s resolutions. Our CBT assignments may offer respite from our symptoms, but the relief seems superficial and short-lived. We quickly develop negative thoughts about our doomed attempts to “think positive.”
For lasting change to occur, both ingredients are necessary: an integration of knowledge and love, head and heart, the intrapsychic and the interpersonal, “Logos” and “Eros,” yin and yang.
• Knowledge can emerge through reflection and self-help, but is more effectively gleaned in therapy, via collaborative exploration, enquiry, interpretation and analysis. Our unconscious processes, evident in the “transference”—our habitual emotional responses that get activated in the consulting room—are made conscious. The experience of therapy can deepen emotional and physical knowledge, as well as the purely cognitive kind. We come to understand and make meaning out of how we have learned to be in the world—we did what we had to do to survive our childhoods or later challenges. We shine some light on the shadows. We gain insight, and some control. We become more integrated. The river flows freely again.
• Love is clearly a highly-charged word. It's a hopelessly simplistic shorthand for a kind of human energy that comes in many flavors. In this context I mean it as a quality of the therapeutic bond between client and therapist, nurtured by Rogers’ “core conditions” of empathy, congruence and “unconditional positive regard,” and greenhoused in a non-judgmental, safe, boundaried space. According to Jackie Gerrard: “Unless and until there can be felt moments of love for the patient by the therapist, the patient is not able to develop fully.” But love is not just some positive affirmation that the therapist directs towards the client; what is beneficial is to be able to love as well as feel love; to experience a certain sort of intimacy, to explore vulnerability in the presence of another, a sense of what Karen Maroda goes so far as to call “mutual seduction” and “emotional surrender.” This kind of love is what keeps you both in the room when things get bumpy. It allows the client to trust that it’s OK to reveal the more unpalatable, unspeakable parts of their experience. Love allows you to admit to hate, for instance, and work with it, which can be highly therapeutic. In a letter to Jung, Freud wrote: “Psychoanalysis is in essence a cure through love." The love gets internalised; self-rebuke and condemnation are replaced by self-compassion and acceptance.
Outcome research shows that there is little difference in effectiveness of one kind of therapy over another—the so-called “dodo bird verdict.” However, research also shows huge variation between individual therapists within the same orientation. So what makes the best therapists so special? Different authors and researchers have emphasized the importance of different common factors. Miller et al argue, for example, that “supershrinks”—the best of the best therapists—demonstrate “deliberate practice”: they think, act and reflect with the client’s goals and tasks always in mind. For O’Brien and Houston, therapists “need to have the ability to engage the client in a co-operative participation with regard to the goals and tasks of therapy, to provide an opportunity for the client to express emotion and to create a healing therapeutic bond.” Perhaps it is simply the capacity for client and therapist to form a relationship which transports them to a place of knowledge and some kind of love that is most helpful in facilitating change. All a therapist has to offer is their subjectivity—the flawed, imperfect sum total of their personality, training, years of therapy, life experience and history.
There are, of course, some things that can’t be changed. I don’t believe the idea that you can have anything if you just want it enough and work hard enough to achieve it—this is often a piece of self-aggrandisement offered by privileged people who have been the lucky recipients of a fortunate environment. I don’t believe in “conversion therapy”—I want to live in a world where people are free from oppression, the subtle kind and the not-so-subtle kind, for their natural, human, unimpeachable sexual orientation. I don’t believe people have much opportunity to bring about change in the levels of inequality, social immobility, and government and corporate power that weigh on them—the so-called “complainers,” it turns out, have much to complain about. Life is more of a Greek tragedy, less of a Richard Curtis movie. Circumstances conspire against us; we don't get anywhere near to reaching our potential. I agree with David Smail that psychotherapy’s tendency to suggest all a client’s problems exist within the client—to “blame the victim”—is disrespectful, unethical and oppressive. Smail takes the argument to an extreme, as if we have no personal agency at all. “There is no such thing as an autonomous individual,” he writes. But even from that vantage point, he sees a modest role for therapy—to provide clarity, encouragement and solidarity.
Ultimately, change is not an event but an ongoing process. Therapy is perhaps less about achieving a specific, tightly-defined goal, and more part of an ongoing attempt to foster greater self-knowledge, and an enhanced capacity for love. Armed with these, the client (not to mention the therapist) is in a good position to heed the call of the “serenity prayer”: We walk out of the consulting room and back into real life with heightened reserves of courage to tackle what can be tackled, of serenity to accept what can’t be tackled, and of wisdom to know the difference between the two.