Saturday, November 2, 2019

The Harvard Treating Couples Conference: Dramaturgical Problems in Self-Presentation and Reluctance

A paper given November 2, 2019 at the Harvard Treating Couples Conference:

Mistakes in Couples Therapy: 
Dramaturgical Problems in Self-Presentation and Reluctance

I’ll start with two categories of mistakes: One involves personal and professional insistence; the other, supervision.

To do the work I’m interested in, I want to know what really matters to people: I want to understand what they intrinsically value.  I want them to consider where their integrity really counts. And given the particulars of what they are troubling each other about, I want them to be able to acknowledge what they know is not all that important. Are they arguing the proper way to fill the dishwasher; does it really make a difference if the toilet paper unrolls from the top or from the bottom?  (Yes, I know it matters, it should unroll from the bottom.) Since they are going to keep score anyway, it should be more about the vital signal than the noise. 

I want everyone in the room to ask if their concerns are essential to their well-being; where, if they don’t take a stand, they’ll feel abused or violated. This need be clear enough to figure out where they have common ground, where they can appropriately compromise and have some wiggle room.  The devil is always in the details. Does the position they take allow their engagement to proceed? Is it a deal breaker or a game changer?

Working with couples, I need them to attempt to be honest with each other. An empathic honesty that respects their vulnerabilities.  (And that’s not easy). How open are they willing to be with each other and with me? What openness can they tolerate? What would be sadistic to reveal? In contrast, what serves intimacy if held back?

I want to know if they honestly feel their actions reflect their claimed values and self-assigned status. And when their actions don’t, how they account for that. 

Central to the working with couples is understanding what they expect and demand from each other. How well do they understand the roles they cast for themselves and their intimate companion? Do they adequately fit the part? Have they thought this through?  Consider the dramatic difficulty when actors are poorly cast for the parts played: frustrations, disappointments, and conflicts poorly staged. It is rarely a satisfying performance.

My life as a psychoanalyst has taught me the flexible policy of valuing the significance of what a person communicates over their manner of communication. I’m not primarily interested in helping couples communicate better. I might try to be helpful there but it’s a secondary concern. For the moment, I’ll not say more about improving communication but mention why I use the term “policy”.  Policies are principles we follow until or unless we have reason enough not to. Policies are not laws to insistently follow, come hell or high water. The “unless clauses” are important. We improvise with the exceptions.  It is a mistake to approach most things with rigid insistence. It’s akin to rolling with the punches, especially when punching above your weight. Rigidity fractures. That’s the first mistake to avoid. Don’t treat your favorite theories and therapeutic rituals as the gospel truth, written in stone. Don’t assume you have it sufficiently figured out. That’s above your weight. This goes for personal aspirations and claimed values, too. After I’ve made a carefully composed interpretation, clients often tell me “yes, but it’s more than that….” They sense my perspective is too narrow to capture their circumstance, and what it means to them. In a manner of speaking, “it is always more than that”. Even when working with the facts at hand, we never have them all. And even working off the same page, we find our perspectives differ on meanings and significance. 

The fundamental mistake, akin to failures in empathy, involves the competence to accurately recognize the varied perspectives that fit any circumstance and the ones that practically speaking, aren’t serviceable; ones that don’t fit or might, but not very well.

Perspective on perspective is key. This brings up another reminder:

The second mistake is to go it alone. We need a peer to talk through our work. A trusted and competent companion who knows us well; knows where the bodies are buried. This is mutual. We accurately recognize each other. We’ve revealed and demonstrated our vulnerabilities, strengths, and shticks. You need someone like this your entire career. Someone who can challenge your perspective. This is not the evaluating supervisor of your training years. This is the person you can talk over your work, have a drink with, and write it off on Schedule C.   

Keep these themes in mind as I proceed.  In some ways it can be summed in the wisdom of those great moral thinkers, Donald Rumsfeld and Sarah Palin. His, “You go to war with the armies you have” and her refrain, “how’s that working for you?”  We should appreciate what happens to treatment plans in the fog of a couple’s war. 

“The fog of war” is a segue to some practical realities:  The dilemmas of the therapist’s actual status in their client’s world –– and the therapist’s and client’s actual values. The values that actually influence what transpires. Since I’ve already given reference to the IRS, I’ll employ the image of keeping “Two Sets of Books”.  One open to inspection; one hidden from view. Your clients have them and you do, too.

I liken couple’s therapy – for that matter – all psychotherapy, consultations, and supervisions, as improvisations that hinge on negotiation in the form of a moral dialogue. What I mean by moral dialogue involves good faith attempts to be open and clear about our actual values in play, how we actually appraise each other, and given those appraisals, what we are prepared to take seriously. Unless the partners and work are taken seriously, nothing much is likely to change.  And, unless they have an accurate understanding of what the other is really up to, whatever they take seriously is likely run aground. 

So, I have mentioned two connected themes: The revealed values we take seriously and how seriously we take each other. The therapist-couple triangle involves both. Both require attempting authenticity and mutual, accurate understanding. 

Let’s turn to the cast of players:

For the therapist: How well-cast is the therapist for their role with this particular couple?  I run clinical seminars with doctoral trainees where we focus on supervisions and case formulation.  There’s a common group of mistakes made when the supervisee, correctly or not, believes the supervisor expects them to speak in the supervisor’s voice –– a voice more seasoned, older, differently gendered, what have you –– than the one the trainee can get away with.  (I’m not sure that the actual supervisor felt their trainee should talk like them, but the trainee didn’t feel free to explore how it would work in their voice). 

Here the distinction between implementation and significance matters. We want trainees to speak authentically in their voice. When supervising, we may have a game plan in mind, we believe we know what we’d like to see accomplished, but we might not give the trainee the breathing space to think about how the therapeutic goal can be implemented many ways (if it can at all). To have a chance at being successful they’ll need to do it their way. The improvisational therapeutic drama is “character driven”. One size does not fit all. I’ll say more about this shortly. 

Couple therapists interpret, coach, and serve as referee.  They need to be credible playing those parts.

Here’s an image or memory.  Perhaps yours. It is certainly one of mine. I teach students in their mid-twenties. Imagine you’re that age: mid-twenties, single, no kids, no mortgage, just massive student debt. You find yourself facing a late middle-aged couple, your parent’s age, empty nesters but with financially dependent children, struggling with decades of resentment and commitment, facing a just revealed and maybe repeated infidelity.  And they find themselves with you.  Or, consider the issues of supervising this young therapist. 

As they do their jobs, I want supervisees, all of us really, to have these questions close at hand. 

1. What do I evoke in this couple and what do they evoke in me? What versions of this are being played out now?

2. Given my obvious personal characteristics, what are they likely to think I am eligible to do and able to accomplish? When I talk, will I be taken seriously, or will I be dismissed?  (Two more policies: Don’t fake authority and avoid giving advice. Rely more on variations of “help me understand?” Ask for clarity, ask how they understand what the other is saying. Young and old are eligible to ask for clarity, and to indicate how they understand what is offered.)

3. Given my less obvious personal characteristics, what will take more time and effort to demonstrate or establish?

4. What about myself do I need or appear to need validated? (Here, the counter-transferences can intrude).

5. Are the circumstances of the work validating or degrading for each individual? Am I sitting with volunteers, or is participation mandated, forced, or coerced by one or the other of the couple? Coerced relationships invite resistance, insolence, and resigned compliance. And some people are practiced at shining you on.

It is a mistake not to remain alert to these questions.  Always important:

6. What am I unable to hear or address? Does my defensiveness or intolerance look like dismissal, avoidance, or disgust? Is my defensiveness or intolerance degrading and invalidating?

Let’s move from the status dynamics of the therapist and couple, to the psychodynamics, the defensive insistence and avoidance, of each player.  

For the couple

Some basic questions: Who are they to each other? What do they actually know and value about themselves and each other? What are they willing to reveal? What are they able and disposed to change? What perspective do they have on aspiration and what can realistically be accomplished? 

Fundamentally: Given their promises and attempts to change, do they act with good faith? What gets in their way? To illustrate I’ll employ the image of “Two Sets of Books”.

Here’s the “two sets of books”. (Therapists have them, too. That’s why we need an intensive personal analysis and on-going supervision. We need to know ourselves from multiple perspectives.)

The two books I have in mind is the one easily opened, and the other, a hidden volume we are reluctant of reveal to ourselves or anyone else.  The second book presents thorny problems for the couple’s therapist. Negotiating in the manner of moral dialogue involves showing the cards in your hand, none deliberately up your sleeve. Nonetheless, in real play, some are often defensively hidden. These are wild cards that can throw everyone for a loop. You suspect them when something unexpected is triggered. More is at stake than meets the eye.

Let’s look at the first book.  The one opened on front stage. Here, we become acquainted with what each person finds relevant and tolerable to reveal: we learn obvious details, motivations, and props; the first approximation why the couple has come to see us. 

In early meetings, it can be difficult to sort out realistic aspirations from those not in the cards. Individual meetings might fill the gaps. But good luck, even then. And here’s where your peer-supervisor can help sort out yours.

In the open first book, the first act is played. The open book is composed of what our clients are aware of, can think through, and, at least in their own minds, are able to consider. In this first volume there is likely an index the players are reluctant or refuse to disclose. They know they are holding back. They conceal or lie out of self-interest. Perhaps they’ll talk to somebody about these chapters, but not in front of their significant other. The content might never be revealed, it might never feel safe enough.  Offering a few individual sessions might help. It might help to provide an opportunity to more privately confront the question of what might be relevant but not safe to reveal.

Let me say a bit about insistence.  Some personal issues are insistently hidden, while others, revealed or not, are held dear.  All motivational values are not of equal weight. In the first book are flexible priorities open to negotiation, along with those held tight, believed fundamental and intrinsic to what we need honored to be us: where our personal identity, our sense of integrity is always on the line for us to respect our image in the mirror. Tread lightly here.To the observer-therapist, the need to maintain the integrity of these priorities can evidence both sound and/or neurotic character: admirable or problematically narcissistic. 

It’s the therapist-couple’s negotiation with this first text that most of our work is done.  Mistakes are made when this content is not adequately assessed. Beyond therapist errors, when important lies are maintained, or worse, gas lighted, the work suffers without much the therapist can do. The first book might be open, but it requires an “I to Thou” empathy to be edited, revised, and understood.

And then there’s the second book. Because of the second book, the hidden ledger, mistakes, difficult to diagnose and remedy, occur. This is the content we reluctantly know, but try, best we can, to conceal and avoid. This is the domain of reluctance. In his psychoanalytic classic, Free Association, Anton Kris identified reluctance as a dynamic motivational category conceptually apart from real unconscious resistance –– reluctance is not unconscious repression but active suppression.  Our unconscious motivations cannot be reached in ordinary introspection. The stuff we are reluctant to think about can, but mostly isn’t. (In couple’s therapy, good luck ever confronting and working through unconscious resistance unless you’ve got years to play with.)

To maintain self-esteem, to keep face, people hide what they can’t tolerate, manage, or allow others to judge. One way or another, like it or not, our significant others are judgmental. They have the status to affirm or degrade our worth. With those from whom we need love, we can be unwilling to reveal these reluctances, this stuff we self-condemn and approach with fearful vulnerability.

This reluctance produces denial, conscious self-deception, and bad faith. Its content is filled with under-examined, immature, and under-socialized motivations. This is the stuff that bollixes self-regulation and intimate social engagement. Hidden and only reluctantly considered, it is not adequately practiced and exercised in ways that enhance competence. Some of these issues are acquired when we were very young, as family members under the sway of our particular parents. Never adequately mastered, they leave the impression of unresolved childish concerns. Regardless how they are acquired, these are trigger points. What we are unable or refuse to adequately consider, haunted, we tend to continue to engage with incompetence.

Some summary thoughts and an example more aptly explored in individual sessions:  

I’ve sat with people who tell me they don’t understand their transgressions because they take themselves to have a “strong moral compass.” It should be no surprise that the subject is sex. (If not sex, it tends to involve money or violence.) When caught, they act bewildered, maybe panicked, and claim their action was out-of-character, a result of seduction or coercive pressure. Except for those truly coerced, they give lip service to ideals they say guide them while not acknowledging what they’ll do when sufficiently tempted. And when the offense is repeated, they act bewildered that it has happened again.

Some claim they don’t want out of their marriage, that they love their spouse and family. I believe them. Some feel distress only when caught and tend not to feel much guilt even when sheepishly they say they should. Others become preoccupied, fear loss, and are afraid of destroying their families and hurting their spouses. Often enough, they deny understanding how they got involved in this in the first place. I’m not talking about the people who betray their vows, want to get away with it, and know damn well if sufficient opportunity occurs that they’ll go for it. They are not fooling themselves even if they make excuses or claim innocence. They know they are lying.

Here I am interested in self-deceptive people who don’t know they’re lying to themselves about their role. They’ve “two sets of books,”.  I may even tell them that. One ledger filled with the ideals they say count heavily, their “moral compass,” and the second, hidden from inspection, opened only reluctantly but carrying greater motivational weight.

The hidden ledger contains intentions that are denied but nonetheless remain in play. These motivations can’t be self-acknowledged without unmanageable guilt, anxiety, or shame. With sufficient temptation, these motivations become a loose cannon, not secured by other considerations.

All this is made worse when their actual deliberative powers are diminished; “it was the alcohol speaking.” Protesting they weren’t looking for it, they won’t admit their disposition to notice transgressive opportunity and an aptitude to find it. Acting from denied motives, it’s
unsurprising if the outcome is bungled and unfortunate.

Versions of this common drama are presented as out-of-character by the perpetrator but given enough time they seem in-character to the audience. Their significant other might see a pattern denied.

The “return of the repressed”, the repetition compulsions, the “I don’t know what got into me” and “the devil made me do it”, establish a through-line of trouble. If truly unconscious, almost never resolved. But it is a mistake to assume these motives looking for opportunity are actually unconscious; and not themes, problematic through-lines of discord, that if the therapist offers sufficient safely, empathy, and careful judgment – and gets the timing right – might be negotiated. Some awful, shameful motivations are just that, and need to be renounced. But sometimes they look a bit more like the proper way to load the dishwasher.

Given the power of the hidden motivationally significant second ledger, sometimes only individual therapy will bring it to light. Then the thorny dilemma: what to do about that. Can it be brought back to the couple’s session? What to do if it can’t? Some secrets can be worked around, some are or should be deal breakers. Here is another judgment the therapist cannot properly escape. 

This takes me back to peer-supervision. Therapists need to be very self-aware of what they find troubling to acknowledge, their own triggers and avoidances.  They need to recognize what compromises they will accept and when they are engaging in unacceptable collusion. Nonetheless, we need to be paradigms of tolerance. Our self-awareness and tolerances are foundational therapeutic competences, and our fiduciary responsibility. To cook, we’ve got to stand the heat. To do our jobs, we need to appreciate how we look as referee, coach, facilitator, confessor, normalizer. This is very hard without a trusted partner in crime.  Someone we share both sets of books. Someone who knows us well, someone empathically willing to call us out. And then hoist a beer to our failure and success.