“Good Therapy” and self-as-instrument

What are the necessary conditions for good therapy to take place?  In the absence of already having a sense of what I want to be writing about, this is the place where I will start and we will see where we can go.  

Now it would seem to me that the necessary conditions for good therapy would actually have very little to do with the patient.  They certainly don’t have nothing to do with the patient.  The patient's various wants, needs, desires, wishes, and the like are all going to play a considerable role in driving the therapy, as are their defenses and the particular conglomeration of concerns that are bringing them to see you in the first place.  Though to my mind, each of these are the factors that will drive the therapy.  They will determine things like direction, outcome, pacing, and other things that will be revealed through the interaction of therapist and client.  Whether or not these things are appropriately calibrated will likely have some impact in our understanding of whether or not we are doing a good job understanding our client, but are all outcomes and not necessarily sufficient conditions, though I could see where some therapists might be inclined to think otherwise.

Good therapy then, and setting the appropriate conditions for good therapy, must have something to do with the therapist.  The immediate concept that comes to mind is the notion of self-as-instrument and, in borrowing another word with ties to notions of the production of music, at-tune-ment.  A quick google search weirdly seems to want to credit the idea of self-as-instrument to the world of Organizational Development and books written in the late 90’s and early 2000’s.  That said, James Bugenthal specifically uses the idea of therapist as artist/instrument in his The Art of the Psychotherapist from 1987, and I feel certain I’ve seen the term published elsewhere in humanist/gestalt/existentially leaning analytic texts.  Though they don’t employ the specific term, many of the interpersonalists and object relation analysts also highlight and use metaphors related to music, attunement, and the instrument of the therapist’s personality (or being if they were feeling freely creative) in the process of doing therapy and/or conducting an analysis.

I want to be really careful about the use of ideas related to instruments and attunement here.  There is an ungenerous interpretation of all of this which could be reduced to some idea that the therapist “plays” the client, which when understood that way is objectifying and dismissive of the client’s overall being and sense of agency in crafting the therapeutic process.  In recognizing artistry, what these theorists are trying to acknowledge is the role a therapist’s own personality, history, temperament, attitudes, demeanor, etc. play in determining the unique ways in which they might approach therapy and potentially be useful to any individual client.  See Clara Thompson’s “The Role of The Analyst’s Personality in Therapy” (1956).

I want to extend this musical metaphor a bit to better flesh out some ideas that I think could be relevant here.  From the age of about 12 on, I played the drums and was a pretty devout student of the instrument through most of teens with my interest becoming a bit more casual into adulthood as other aspects of life beckoned.  That said, in my late teens and into my 20’s, I played in a number of bands with some other very talented musicians, a portion of whom went on to make some kind of career of it or came quite close.  If you are doing it well, there is a tremendous amount of listening that goes into the process of playing with other musicians.  There are also limitations any one member of an ensemble or band has in driving the sound that ultimately gets produced for—and experienced by—the audience.  Behind the drums, there were certain dynamics in the music I had some influence and authorship over, such as keeping time and setting the tempo, influencing shifts in volume or attack, and finding and holding down what drummers call “the pocket” (which is essentially the feel of the rhythmic qualities of the song).  Aspects of a song related to things like melody or key changes were not within my purview.  However, whatever that experience we were trying to produce was, it was going to be far more pleasing to the listening audience if there was some conscientious approach to how those various components overlapped and interacted with one another.  Similar to what I was just saying with therapy, a lot of this had to do with the particular approach (or we could say musical personality) of the musician(s).  The better they all were at simultaneously putting their particular imprint and applying their specialized approach and skill set towards the music, while also listening and being responsive to what was happening around them, the higher quality the piece of music they produced.  I often credit this for the reason why I can sometimes listen to music outside of the respective genres I find most personally appealing and still have a deep appreciation for sensing that what I’m hearing is “good” music.  You can tell as a musician when other musicians are really listening to each other and thinking about the overall product that comes out of that process.  It’s why, I think, musicians are drawn to things like progressive rock and jazz.  The technical wizardry is often astounding, but what really sets the music apart is the way in which the musicians listen to each other in their efforts at crafting that kind of music.

I think about this process often when conceptualizing what it is I might be trying to accomplish in a therapeutic session, sometimes quite literally recalling my time as a musician when I’m sitting with a client and find myself more acutely aware of the process of navigating play and listening simultaneously.  So the conditions for good therapy would seem to have something to do with the quality of listening and actively modulating or calibrating oneself.  I think the best way to think of it is in a hermeneutics of leading and following.  Leading and following can hold a lot of metaphorical weight in the process of doing therapy.  Leading can be offering a direct interpretation, inquiring in a particular direction, completing a thought on behalf of a client with some kind of empathic reflection related to where they might be going, or simply posturing and positioning one's body in a certain way (remarkable the number of ways we can “play” ourselves!).  We follow when we offer direct reflective statements in the Rogerian mold, when we empathical attune or mirror, when we calibrate our level of verbal activity to our sense of what the client needs.  Of course, the reason I call this a hermeneutic, is you can see it is not strictly binary.  There’s a dance a play.  We can only ever lead based on where the client has already taken us.  The ways we choose to follow may either purposefully or inadvertently lead the client in some direction or other.  I swirl with a certain amount of discomfort just thinking about how difficult this process can be sometimes, its disorderliness, and of how undefinable and impossible to compartmentalize into simple components it is.  It is this kind of anxiety that I think any therapist worth their salt needs to allow themselves to be comfortable sitting with.

I want to offer one other reflection which borrows a bit from this idea of musicianship, and am recognizing as I continue to write this that I might only answer my initially posed question obliquely at best, but hopefully that is sufficient.  I was recently watching a talk where the esteemed Boston area psychiatrist Leston Havens was memorializing his time working with another of the local giants, Elvin Semrad.  Havens notes in his talk that, due to particular elements of his personality and ways in which that intersected with the personality of those around him, Semrad was often held by others to the lofty position of being a kind of guru, which seemed to me to mean that he had a remarkable capacity for knowing what to say and when to say it that seemed to exist independent of any specific technique.  This was interesting for me to hold in relationship to Havens, whose students have uploaded massive quantities of his lectures and supervisions at Mass Mental to YouTube, and to whom I had recently found myself affixing the label of “virtuoso” due to his seemingly vast stores of technical knowledge and ability to vamp for hours on the history of psychiatry; psychotherapeutic technique; research and research methods; diagnosis; and on and on.

These distinctions had me thinking about the relationship of virtuosity and “feel”.  Virtuosity is a bit easier to define and cultivate.  Part of the conditions for being able to provide good therapy is rooted in being curious enough to study what is often called the “art and science” of psychotherapy itself.  Good therapists should read widely within the field and should read deeply within their particular areas of interest.  We should pursue conferences, good supervision, reflect upon the craft of our work, spend time analyzing our cases and better understanding ways to attune and respond to the folks who might come into our office.  To go back to my days as a musician, no one just sits down and plays.  You study the craft by playing along to tracks, repeating various scales or rudiments (depending on your instrument), learning the fundamentals of different genres, developing your capacity to control the dynamics of your instrument, and training your body to do things that are initially awkward or uncomfortable.  That last one is important.  We must be willing to try things that are outside the normal bounds of what we might otherwise already be conditioned to do.  However, all of these things are simultaneously used to inform and are informed by how the experience (and I will use this next word here as it applies to both making music and “making” therapy) feels.

Those who knew Havens are quick to point out that he at times also seemed like a bit of a guru and was incredibly adept at saying what both his patients and supervisees might need to hear at any moment.  Conversely, though Semrad’s work is harder to come by, for all his reputation of being someone with an incredible feel for the therapeutic process, we also shouldn’t forget that Semrad was in fact a board certified psychiatrist and that there was a rich philosophy behind his approach to the work.  One could maybe stumble into the process he used to connect with and help his patients, but one cannot stumble into being the one responsible for teaching this technique to decades worth of training psychiatrists at a hospital affiliated with one of the most prestigious universities in the country.  

What are the necessary conditions for good therapy to take place?  It seems an odd though apparently interesting structural question for trying to say something about the work that we do.  Hopefully, if I have come to communicate nothing else, it seems apparent that “good” therapy is (somewhat tautologically) employed by “good” therapists.  And, not to be too religious about it, but I do think that “good” here means something about having an ethical relationship to the work that prioritizes the needs of the patient and is informed by a deep commitment to recognizing the extraordinary stakes of our work and putting in the time and effort towards making sure one is always refining one's skill at the craft or finding ways to deepen their own understanding of and relationship to this thing we call “the human condition”.