Abstract
This is an introspective essay based exclusively on my experience as a psychotherapist through a half century of practice. No remedies to the issues that are raised or offered. The purpose of this writing is exclusively to stimulate awareness and discussion.
After over 50 years of practice, I am chronically aware and surprised by what I do not know. I have spent a great deal of time over the years seeking a universal and durable truth to guide me in my work.
What I have learned is that these truths are ever changing. They are changing I have finally realized as I am changing as a person; as a work in progress.
I have become certain that regardless of training, treatment modality, clinical experience and wisdom the fundamental ingredient that drives therapy is who I am as a genuine person in that authentic relationship with a person who is the focus of the therapy process.
Keywords: Introspection; Clinical Experience; Internal Conflict; Transparency
Statement of Purpose
My goal in developing this essay is to address the inner conflict experienced by me as the therapist when my personally held beliefs or core values are challenged by the material presented in the course of the therapy process.
As a therapist, a participant in the therapeutic relationship, I am reactive to behavior, situations, stated thoughts and expressed emotions by those with whom I hope to assist.
I am aware that my reactions whether expressed or consciously acknowledged cause a change in the dynamics of the work that is taking place and to a greater or lesser degree of the therapy outcome.
My reactions no matter how therapeutic I wish them to be are always filtered and processed through the idiosyncratic triggers that I have accumulated over the span of my life.
Underlying Premise
As a therapist I have the obvious limit of being just a person no matter how well I carry out our professional role. We as therapists do not enter the therapeutic process with a blank slate. We come with many pages of personal history, life experience, firmly held beliefs, and with well-developed personalities with all the positive attributes and flaws that make up who we are.
Every therapeutic relationship presents an unavoidable ethical dilemma; how much of who I am and what I believe can Iframe in a positive therapeutic direction while not compromising who I am as a genuine and honest person.
Without exception we all have expectations as to how we perform our life and professional role. When I was in training in the late 1960s and 70s the stated expectation was “that at all times the social worker must be warm, accepting and non-judgemental”. It is difficult to believe that any of us can achieve these feeling-based behaviors at all times with all people in all situations.
Many of my early years in practice were marred by a sense of failure that I had been unable to at all times be “warm, accepting, and non-judgemental” in my heart and thoughts. I certainly never discussed this flaw which I believe was a major contradiction to professional standards. In retrospect what I was most disappointed in myself was my inability to re-invent myself to achieve a purist achievement of professional goals.
I am acutely aware that my therapeutic interventions are always impregnated by my personality, my intrenched beliefs and my spontaneous reactions. I know that camouflaging my reaction is always inferior to attempting to identify the genesis of them and actively attempting to process these feelings behind the reactions. Knowing what is best to do has not led to an easy or straight forward process. What I have found is that accurate insight into reaction that may emanate from any page in my personal history is a daunting task that often leads to blind alley or incorrect conclusions. An even more labor intensive task is using these insights to promote a working resolution that prevents the reaction from contaminating the genuine therapy process.
In the interest of an honest therapeutic relationship not surprising some of my internal conflicts have been best resolved and removed as roadblocks in the therapy through open, transparent, direct and honest dialogue. I have found that this approach is a slippery slope and one filled with dangers. The problem is that when I tell what I believe to be the truth so I can unburden myself I may be in danger of sabotaging the therapy. What has been a persistent troubling issue for me is determining if telling the whole truth as I perceive it is of greater benefit to me as a person or to the person with whom I am working.
I know that without exception telling the truth is an essential ingredient of a therapeutic relationship; a two way reciprocal telling of truth.
The problem with telling the truth is the truth I can offer is not a magnificent ordained error-free truth but instead is a limited one confined to my perception and conclusion as to what I believe to be the truth.
What is often difficult for me is making a well thought out and rational distinction between telling the truth and telling the whole truth. I am not an advocate of the false information but ponder when telling the whole truth is helpful and when it is harmful. Perhaps this can best be framed as a conflict between the individual’s right to know, to receive full disclosure and the individual’s right in treatment to not be harmed.
Dilemmas
Personal
I am always disappointed in myself that I do not like everyone; a naïve and unrealistic expectation.
In my unspoken and unchallenged self image I believe myself to be free of bias as well as consistently fair and wise. In my self-inventory I see myself as always eager and well prepared to be of help to others.
Unfortunately my self evaluation is plagued with overstatement and subjective inaccuracies. I have long ago abandoned the practice of constructing a similar self-inventory of my many flaws and deficiencies.
In my everyday life not liking a person or just not enjoying their company does not create a conflict for me. I have guilt free freedom to engage with or avoid a person at will.
As an ethical therapist I do not have this unrestricted freedom to allow my personal preferences to guide my behavior.
It has always been relatively easy for me to deal with people who have directly or indirectly earned my dislike through their negative conduct. When my dislike for a person is supported by data that is offensive to me then my conflict is reduced. If I can say to myself that I do not like the person for a specific reason I feel justified in my negative attitude based on the evidence against the person.
Much more troubling for me is that when I do not like a person who has done nothing to earn my negative response. At these times I can often not identify the etiology of my feelings toward the person. Often no event, personality trait or behavior stands out to me for my negative reaction to the person who I cannot convince myself to like.
When my reaction is of a large part egocentric and subjective I am left with a sense of diminished control. It is in this situation that the course of action that would change the equation is most allusive for me.
I sometimes create post hoc reasons for my reaction aimed at soothing myself, but I am rarely convinced by my explanation.
Political
Growing up in Memphis I was told in no uncertain terms that three topics should never be discussed outside our home. Not surprising these tabu topics were money, religion, and politics.
Over my years as a therapist I have abandoned the prohibition against discussing money and religion as they impact the individual, their family, work and friendship.
I am then left with the third tabu against discussing politics intact and excluded as a factor in the work of therapy.
As all of us who are not living in isolation in a cave near the Arctic Circle are aware we live in a time of great diversity of political beliefs. We also live in a time of great and passionately fueled political polarization.
I certainly have not been immune to developing strong personal pollical beliefs. I claim no particular expertise in evaluating the right or wrong course of political direction in this country, but this has not prevented me from my adopting tenacious political beliefs and dogma.
The extreme views expressed by individuals with whom I work in therapy regarding the good and evil of those who are not on the same “team” has presented new difficulties for me even in determining what is clinically pathological and what is in the non-pathological range of beliefs that one might entertain.
Belief systems that at one time would be indicative of a delusional state or a psychotic process now are frequently presented to me in the form of multiple complex conspiracy theories presented by non-psychotic individuals as a central tenet of their belief repertoire.
Further complicating the flow of therapy is projection by the person with whom I am working as to what they believe my personal political philosophy to be. My silence on topics political is often interpreted as agreement and support of the ideas being presenting. My observation has been that it is reassuring in therapy to believe that I am a member of the “us team” rather than the “them team”.
I have found that it is with great difficulty that I refrain from challenging pollical positions that seem to me to defy even common sense which may appear to be obvious truths to the person with whom I am working.
For me the issue of allowing freedom of expression without interjecting my personal political belief is the most slippery of slopes.
Disappointment
One of the “truths” of conducting therapy that I was taught early on in my training is that should I want the achievement of a goal in therapy more than the person with whom I am working wants to achieve them than the therapy outcome will be unsuccessful.
I have learned that lesson well and have forgotten it often.
In this flawed equation the process of goal setting is contaminated by inserting my preference of goals superior to those of the person with whom I am working to assist.
It seems easy for me to forget in the course of conducting therapeutic interventions that the person with whom I am working is the sole owner of both the issues that brought them to therapy and the therapy itself.
In the therapeutic process it is often difficult for me to remember that I am only the facilitator of change not the person who will ultimately decide which changes occur, the pace of change, and indeed if positive change occurs at all.
I surely hold cards in my hands but not the powerful trump card or even a full house.
While being aware of my delicately limited power to provoke change it is a paradox that I am deeply disappointment when the therapy has not produced a positive outcome.
Adopting a grandiose view of my influence to cause change I soul search as to what I should have done that would have been more successful in achieving the task at hand.
Emotion
For the past 30 years, the primary focus of my therapy practice has been working with individuals and families who have had their lives disrupted by demyelinating disorders and life altering burns.
These populations while difficult appeal to me as I wish to be useful in some way and to feel that I am using my life in a manner that has meaning for me.
I frequently make home visits as a primary venue in which to offer therapy.
Many of those with whom I work require specialized travel services which makes travel to my office painful, stressful and expensive.
Students often accompany me in making these visits. I am accustom to the panorama of loss and suffering that exists in the homes; the students are not. While working in the homes of individuals with catastrophic impairment I frequently am guilty of ignoring the needs of the students who are at times horrified, overwhelmed and to a degree traumatized by what they see.
At the end of each day I hold a debriefing with the student to discuss and clarify the reaction to what they have seen, heard and sometimes smelled during the visits. Generally I find these meetings to be unremarkable and with few surprises.
During one of these meetings I was shaken and horrified by a student’s spontaneous and uncensored remark.
What she said was that someday in her practice she hoped to be like me and “have no feelings at all”. What a terrible goal.
What she had seen with her fresh eyes was a flawed role model. What she saw she believed was an appropriate and desirable goal for her to achieve in practice.
In her shared observation she had uncovered a role behavior that I had carelessly assumed as a self protection over many years of practice.
Her remark evoked a crisis for me and an urgent need to reexamine how I approach suffering and loss as I continue to practice.
I made a commitment to myself to reclaim and examine my authentic feelings and to re-discover an appropriate and genuine affective presentation in the therapy setting.
I know that it is essential that my emotional expression must always be subordinate to the emotional display expressed by the person with whom I am working. I attempt to remember that it is always their show and that I am only a supportive actor with a subordinate role.
Should my emotions take center stage I believe I am stealing from the person who is relying on me for dedicated care.
Regulating my emotion and emotionally driven behavior has always been a challenge for me when immersed for days, weeks and years in the suffering of others.
My relationship with many of the people with whom I work spans years and at times decades.
With my practice focus being for the most part on people with catastrophic life disruption I often see a person early in a disease process. As a general rule we continue to work together over a large span of years while the quality of life and physical status of the individual declines.
As we work together to maximize a life under attack, I cannot help but be aware that our journey together will end with a more extensive disability, loss of independence and finally death.
My experience with sadness is magnified by my knowledge of how the progression of the lives of the people with whom I work and know will be played out and concluded.
I do not ever work with children. The exclusion of children from my therapy practice is not that I doubt the efficacy of therapy for children. It is that working with suffering children is a burden too painful for me to bear. Maintaining a balance between expression of empathy and honoring therapeutic boundaries has required a great vigilance for me. I critique my success and/or lack of success in this area of practice as an ongoing process.
Working with individuals who have lost much of the attribution of a positive quality of life has generated unspoken internal conflict for me.
I definitely do not want the person that I am working with to die. I also do not want them to continue to endure the multitude of losses they are experiencing in their last stages of the disease process.
While this conflict is unspoken by me it has been an internal conflict that haunts me and has escaped any resolution that might free me from the internalized conflict.
In the beginning of practice I was naïve as to the emotional impact that being a therapist for the extremely impaired would daily visit on me.
Much in violation to what I was taught I attend many funerals.
At times over the years I sit in my car well away from the individual and their loved ones’ view and cry.
Silence
I have always had a love-hate relationship with silence.
I am acutely aware that silence is a rare and priceless commodity. Silence is a force filled with anxiety and great power.
At one time in my life I was passionate to become a lay analyst.
I enrolled in a rigorous five year training program which included my personal analysis.
During the first year except for the month of August I was a participant in my own analysis with a training analyst for fifty minutes on three mornings a week. My personal analysis was a major tenet of the process. I believed that I was doing well as a participant in the program.
At the time of my first year formal evaluation I was bewildered, embarrassed, and devastated to be told that I would not be retained in the program for a second year. No appeal process was offered.
What I learned was that it was the unanimous opinion of the committee that I was “far to chatty” to be an analyst.
In retrospect, I realize that they were entirely correct.
I have been trained as both as a Cognitive Behavioral Therapist and as an Interactive Family Therapist. My therapy approach is an integration of Beck’s Cognitive Therapy and Minuchin’s Structured Family Therapy.
Neither the model nor the hybrid I have created utilizes silence as a therapeutic tool.
One major vehicle that I employ in my work is the use of metaphor delivered in the form of storytelling.
I am always consciences in labeling stories to be factual and verifiable, hearsay or apocryphal.
In practice I am extremely interactive as the model demands. I am always in danger of becoming so enamored with the sound of my own voice that I overlook or ignore the power of therapeutic silence.
As is often the case I believe is true for most people I learn and change most in the face of crisis. In a profound crisis in which I played a minor role in helping members of the Amish community to address the tragedy that took place on the 2nd of October 2006 in Nickel Mines, Pennsylvania.
The non-Amish driver of the milk truck had collected the milk from the Amish farmers barricaded himself in the one room school house and shot ten young girls killing five of them.
The story of the forgiveness of the Amish community for the man who committed this unthinkable atrocity is both genuine and truly remarkable.
From my involvement with the community I came to understand something of the healing power of silence.
Each evening after dinner the grieving family opened their door to allow members of the community to “visit”. The visitors were dressed in their Sunday clothes and came silently into the home to offer their “gift of presence” in love and support of the grieving family.
“Often at a viewing many people just shake hands but don’t say anything. When you visit parents during the viewing, it is just your presence. Just a few minutes of silence.” [Kraybille, Molt, and Weaver-Cercher, 2007, p. 35]
Watching the profound impact of silence was moving for me but was not a cure for my anxiety that silence causes me in the therapy room. In my own discomfort with silence I am in danger of interrupting a productive silence not as a well thought out therapeutic situation but rather to alleviate my own discomfort.
For me the boundaries of productive silence and the silence that occurs when the individual is stuck waiting for my leadership are not well defined and are unclear to me.
As a verbal person my fall back position seems to often push me toward relying on my verbal skills rather than to relying on the silence to do the work.
In a session where silence is extremely prevalent I begin to wonder if the individual is receiving the service they had hoped to receive in which they had expended their time, their vulnerability, their confidence and their finance.
I am always aware that I talk too much and listen too little particularly when what is said is said in silence.
I have worked extensively with individuals suffering from MS and ALS. In the terrible last stages of this disorder they are rendered mute and unable to respond. I do not know what they are experiencing or what they need.
What I do offer in this stage of the person’s life is to visit often and interrupt their silence sparingly; only enough to assure them as best I can that they are not alone and that I am standing by.
In the quest to appreciate the human power of silence in 2008 and 2020 I wrote two poems. It is my sincere believe that the silence dictated these poems and that my role was limited to transcribing them.
All Is Quiet On The Western Front
“What? What? I can’t hear you; oh I am sorry you said nothing. Was that nothing the key to all we need to know?
Silence, silence and the beating of our own heart; does its silence scar you? Do you miss what is being said without words when you fill the silence to keep the “boogieman” away from your own head?
Therapists talk; some more and some less but they al talk. How much good work could a mute do in his silence?
Silence heals; every word pushes the real stuff further away.
What? What? I can’t hear you; oh I am sorry you said nothing.
Sweet, sweet healing silence that is always with us and seldom loved.
Silence-listening, silence-listening, silence-listening; all can be known in the silence, some can be repaired.
Silence – listening, silence-listening; silence embraces all in its warm transparent cloak.
Silence.”
[Palliative and Supportive Care “All Is Quiet On The Western Front”, Donald W. Strauss, 2008]
So Loud and Painful
So unbearably loud, shattering decibels, past enduring, a planet filled with noise,
distraction giving birth to distraction, volume always growing; where is the mute button?
What is this life threatening sound? Is it the howling of many monsters; the prelude to Armageddon?
Will the end of time bring death to this hellish sound?
What is this noise so like the wailing of a million lynch mobs?
What is the name of this horror? Does it even own a name?
This terrible brutal sound known to all but recognized by few; can it be found, addressed and deadened?
The ghastly name that can be pronounced only in screaming fear is silence; too dreadful to confront.
Silence, the putrid toxin that rips open Pandora ’s Box of memories and thoughts; welcomed and unwelcomed; invited or unbidden; never subject to control.
Silence the most terrifying of all sounds; all sounds are banished in its wake.
How can it be vanquished? Will it never end?
Even death is no match for the prowess of silence.
Silence is always the victor.
Hush!!
[Donald W. Strauss, Ph.D., 23, March 2020, unpublished]
Endnotes
What I have discussed has been limited to a small sample of the many issues that I have encountered during my long tenure as a therapist.
I am keenly aware that other therapists can add enormously to this list.
I am optimistic that through my personally vulnerable introspection, I have opened the door for other therapists to embrace and examine their private thoughts and feelings to the end of becoming more genuine as a therapist and as a person.
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