What is Therapeutic?

I have received some interesting comments from a couple of friends on my last post about  R. D. Laing which raise a number of questions that go beyond his career and personality.  To be sure, Laing is still capable of stirring controversy twenty five years after his death. But I am not so much interested in Laing here, as I am in the greater issue of the nature of the therapeutic relationship. One friend, a highly experienced psychoanalyst, expressed doubts about Laing's achievements, as well as his moral fitness for practising psychotherapy. He also noted that charisma in a therapist does not necessarily make him an effective one. Another friend sent some material about Masud Khan, a prominent London psychoanalyst and a contemporary (though not an associate) of Laing, who was accused of gross professional misconduct by one of his patients. I won't go into the details of either Laing's or Khan's case, but I will say that therapeutic misconduct in general haunts therapy like a dreadful family secret. Of course, therapy's family secret is no secret at all as case after case of professional and even criminal misconduct by psychotherapists have come to light. In my previous entry I mentioned how Laing's diatribes against medical psychiatry had the unintended effect of bolstering his opponents who rejected psychotherapy in favour psycho-pharmacology. But much the same thing happens whenever any psychotherapist commits an ethical transgression that casts serious doubt on the trust that is essential for therapy. When a therapist proves so dangerously untrustworthy you can see why the pill pushers may suddenly appear in a more attractive light.

Fortunately, most therapists subscribe to a code of professional conduct, which I believe is as essential for psychotherapy as it is for any other profession. While such codes  cannot provide an ironclad guarantee against misconduct, they can and should be used to hold therapists to account for their misdeeds. I also believe that most therapists are ethical enough, which is to say that they can be trusted to abide by the ethical codes to which they subscribe. But is this enough? After all, therapists may be highly ethical, yet still fail to help their clients. So the question of competence or effectiveness must also figure into the question of trust. Therapists, of course,  are supposed to acquire competence by their training which should help them develop essential skills in listening, empathy and the more subtle dynamics of the therapeutic interaction. But talking about competence as if it were a measurable quantity can be somewhat misleading. For competence often involves a certain intuitiveness that escapes any easy assessment. And there is another factor which undercuts any attempt to reduce psychotherapy to a set of teachable methods and techniques. Although good therapists will always try to draw on the skills they have developed, therapy, as Jung observed, depends on the presence of unpredictable influences that are impossible to account for. Still, the question remains, as much for clients as for therapists: how does therapy actually work? Or as Jeff Harrison puts it, what is actually therapeutic?

The question has been central to psychotherapy from its inception, but it should still be asked whenever a course of therapy begins.  Some things, such as the attentiveness and reliability of the therapist, are obvious prerequisites for making therapy work. Yet, although the onus of responsibility is thought to lie primarily with the therapist, in fact therapy only finds traction once the client begins to take greater responsibility for the therapeutic process. A friend of mine states the matter bluntly whenever he begins with a new client. "We are going to have work hard," he says encouragingly. "But by 'we' I mean 'you'. You are going to have to do all the hard work. I am only going to help you."  I think my friend is right. Yet, this shouldn't lead us to underestimate the importance of the therapist's efforts. The therapist has to work hard, too. But how?

I favour the idea of attunement as a way of describing how good therapists work. Once all the necessary background information about the client has been gathered--which is a crucially important skill in itself--there is then the matter of what to do with it all.  Although the next step involves interpreting the client's material, attunement goes far beyond making an interpretation of the client's character.  It also demands sensitive appreciation of the client's experience so that the therapist communicates the depth of his understanding without necessarily making his understanding explicit.  It is a kind of intimacy that respects the client's opinion and point of view, yet maintains a certain critical edge that plies towards truthfulness. Most fundamentally, attunement depends on the therapist's attitude of care for the well being of the client which must begin by being in sympathy with him (David Black's wonderful book Why Things Matter offers a superb analysis on the importance of sympathy for therapy). What makes attunement so difficult is that to maintain the delicate balance of critical attention, good will and sympathy in pursuit of the client' s best personal interest requires ongoing vigilance throughout the course of therapy until its conclusion. Such attunement also requires an openness to those unpredictable factors that Jung observed were so essential for the success of therapy.  
  
This entry was prompted by some critical remarks about Laing which to some degree I endorse. But I have to confess that is spite of his flaws, Laing remains an important influence for me. So let me close with a quotation of his that serves as a motto for me as a therapist: "Psychotherapy must be an obstinate attempt by two people to recover the wholeness of being human through the relationship between them."