Gremlins have attacked my computer. Normal service will be resumed as soon as possible.

There has been some discussion recently amongst BABCP members in private about whether or not it is desirable to record therapy sessions, either just the sound, or on video. Whatever your views on the subject, I’m sure you’ll agree that it’s good to know that professionals discuss these matters amongst themselves and learn from each other in the process.

There are arguments for and against.

Arguments for

Some of the arguments for the recording of sessions are that it can make supervision of the therapist more effective, and that it can make the therapy more effective for the patient.

The argument that it can make supervision of the therapist more effective is based on the idea that a supervisor needs accurate information about how the therapist does his work. It’s not enough for the therapist to report his own recollection of the sessions — he might be wrong.

For example, a therapist might report to his supervisor that he has an excellent therapeutic alliance with all his patients. On listening to the tapes, however, his supervisor might realise that this is not quite true. The therapist might be imagining a good alliance that does not really exist, or he might have some fault that he is not aware of.

The argument that it can make therapy more effective for the patient is based on the realization that patients do not always remember everything that is said to them in their therapy sessions. If everything is on tape, and they can take the tape home and listen to it, it will help them to remember things that they would otherwise have forgotten.

These seem to be tempting arguments for making recordings…but they are only tempting if you’re not a thoughtful and competent therapist.

Protecting congruence

If you are a thoughtful and competent therapist, you will understand that a vitally important quality that you bring to therapy is what’s called congruence — a quality of being genuinely yourself. How does supervision fit with that?

A supervisor has to be able to work with a therapist as-is, without creating conflicts for the therapist. That’s not to say that supervision cannot cause change. Supervision very often causes significant change. But any change that it causes must be completely absorbed, accepted, integrated by the therapist.

If the supervisor instead creates conflicts for the therapist, and if the therapist brings those conflicts to the next session with the patient, it means that the patient now has a therapist who is no longer congruent, no longer genuinely himself because part of him is trying to act the part his supervisor wants him to play.

A recording either confirms everything the therapist remembers of the session (in which case the recording is useless), or it conflicts with the way the therapist remembers the session. If it conflicts, it can create a serious problem for the next session.

You might think that checking the observable facts is the most important thing in supervision, but you’d be wrong. In psychotherapy, perceptions and relationships are far more important than observable facts.

Supervisors who jeopardize a therapist’s congruence are not taking their supervisory role seriously enough. It’s vital for effective supervision that supervisors work with therapists’ perceptions in a focussed and empathic way, avoiding the risk of conflicting material that could damage the therapist’s relationship with his client.

So supervisors who use recordings are barking up entirely the wrong tree. The best that can be hoped for is that the recordings make little or no difference.

Promoting growth

If you are a thoughtful and competent therapist, you will also understand that an important part of what happens in therapy happens between sessions. Patients do not attend a session simply to memorize the advice that is given to them. They attend in order to create starting points for personal growth. But their personal growth does not take place in the sessions. It takes place in the space between the sessions.

When you make recordings of sessions for a patient’s use, you focus therapy too much on the content of the sessions themselves. Instead of moving forward and growing between sessions, the patient listens to the tape and is dragged backwards to the context of the last session.

An insidious side-effect of this dragging-backwards is that the patient comes to the next session in much the same state of mind as the therapist remembers him at the end of the last session. So for the therapist there is an apparently comforting feeling of continuity between sessions. Each session seems to start well because it is a seamless continuation of the last. But while this makes life seem easy for the therapist, it is at the patient’s expense.

The practice of recoding sessions for patients to listen to turns therapy into mere advice-giving, and turns the therapist into some kind of guru whose every word is to be treasured. Good therapy explores many ideas that are then discarded. The ones that survive in the patient’s mind survive by a form of natural selection. The patient is in charge. The patient decides what to build on and what to ignore. Therapists who use recordings stifle this process, and stifle their patients’ growth.

Evidence

The current fashion for ‘evidence based’ medicine makes it seem natural to ask what research evidence there is for or against the use of recordings. Little evidence for it seems to have emerged so far.

As usual in discussions like these, some of the research quoted does not bear close scrutiny. For example, a study was conducted to try to assess whether supervisors’ feedback on audio taped sessions helped therapists to become more competent in a specific technique. The study was a randomized controlled trial. It is described in an online abstract, Strengthening Motivational Interviewing, and you can also see the slides of a symposium presentation about it.

Unfortunately the participants in the trial, both the therapists and the clients, were selected in advance so as to exclude those who did not want their conversations taped. This meant that the people taking part in the trial already felt more positive than average about the value of taping, before the trial even started. A positive outcome for taping was virtually inevitable because of this selection bias in the research design.

The therapists who taped their sessions had worksheets and extra telephone supervision that the control group did not have. It is impossible to say whether the use of tapes was a significant factor in the outcome, because the study entangled three separate factors without adequate controls. Again, this was because the research was inadequately designed.

It is even impossible to say whether the feedback itself was significant, because although the control group had agreed to be taped they were not actually taped. This makes it impossible to disentangle the effect of the feedback from the effect of taping itself. It could be that the very fact of having a tape recorder running changed therapists’ or clients’ behaviour, perhaps without their being aware of it, but the design of this study deliberately obscured all that information too.

The study took place in a training scenario. The aim was to increase the therapist’s general level of skill in a very specific technique, not to facilitate the therapist’s treatment of individual patients, which is the proper aim of clinical supervision. Even if the study had been designed competently, the relevance of any results obtained in a training context to supervision in clinical practice is very questionable.

Finally, the study did not even measure the outcome using real patients, but instead used actors. The level of therapists’ skill was not measured in terms of outcomes for patients, but only in terms of subjective ratings by observers of role-playing exercises.

All in all, the design of the study was a shambles from start to finish. Despite this, the magic words “randomized controlled trial” seem to make some people, people susceptible to magical thinking, imagine that the study provides useful information about the value of taping.

Discussion

Still, it’s good to know, isn’t it, that therapists do discuss subjects like this amongst themselves. The only trouble is, the discussion is taking place after the BABCP’s ruling élite of academics, representing the training industry’s interests, have decided the matter amongst themselves.

Audio or video taping of sessions, or the actual presence of a supervisor in the sessions, is already compulsory for accredited BABCP therapists. Having the discussion now is completely pointless.

Lack of evidence in support of recording does not matter any more. The harm it may do to patients does not matter any more. All that matters is that some trainers thought it would be a good idea (and it possibly is a good idea in training), so it was made compulsory for everyone in clinical practice.

By the way, my own solution is that no recording ever takes place. All therapy sessions are off the record. A supervisor is actually present to observe a proportion of interactions with patients. However, patients do not know (unless they were to press the point) that the extra person present is a supervisor. The patient’s perceptions of what the word ’supervisor’ means might distort the relationship between patient and therapist. This fudge complies with the BABCP’s foolish and irresponsible requirement while minimising harm to patients.

Market saturation is when the producers of a product or service are producing just enough to satisfy demand, but no more. It’s much easier if businesses can control demand to match their production capacity, and this is what sophisticated marketing aims to do. Sophisticated marketing of this kind dominates CBT in the UK, but you probably don’t notice it.

To learn how to see this marketing in action, there are three steps. First, follow the money.

Money

CBT in the UK is overwhelmingly paid for by the NHS. You might not think that if you have been fighting your GP for five years to get on to a two-year waiting list for treatment, but it is nevertheless true.

The gradual roll-out of IAPT (“Improving Access to Psychological Therapies”) by the government had led to extra funding for CBT in the NHS, increasing the already large market share that the NHS accounts for. The NHS is where the money is.

Influence

Second, think about what marketing does. An easy question — it influences purchasing decisions. So this invisible marketing must be influencing the NHS’s purchasing decisions.

CBT is not like nurses’ uniforms or floor polish, though. The NHS’s purchasing decisions for CBT are not made by bureaucrats in procurement departments. CBT is a treatment. The NHS’s purchasing decisions for treatments are made by bureaucrats in NICE (the National Institute for Clinical Excellence).

Evidence

Third, think about how NICE works. It works by considering scientific evidence. The only way to influence NICE is to submit scientific evidence to it.

Scientific evidence comes from research. The scientists who do research are not marketing agencies, they don’t work for business, do they?

Well, yes they do. They work for the same organizations that provide CBT training — universities. The training industry and the scientists are the same folks.

The invisible marketing that drives CBT in the UK is the training industry’s output of research. The research influences NICE. NICE influences the NHS. The NHS buys the end product of the training. Woot!

Depression

Gordon Brown’s official website had to remove the word ‘depression’ at the weekend, replacing it with ‘downturn’, according to a news report, presumably because the original headline might have reminded people about the rumour the Prime Minister is taking antidepressants to help him cope. Whether you call the government’s economic disaster a depression or a downturn, it’s bad for businesses, and very very bad for businesses that rely on government money. That means it’s bad for the CBT training industry.

There are already reports that IAPT funding is being stealthily diverted for other things. The market for CBT training will shrink. Marketing, in the form of research evidence, will not prevent the shrinkage. A different business strategy is called for.

Diversification

When production capacity exceeds demand, one way for the business to adapt is to divert production into other products whose markets are not yet saturated. Applying this logic to the CBT training industry, you would expect to see its marketing machine promoting related products.

But what products are related? How can the NHS be persuaded to buy the product of some other kind of training related to CBT? What other training is there?

What there is, and what you will increasingly see being marketed to the NHS, is additional training in relation to IAPT. This will not just be the training that’s needed so that IAPT workers can do their jobs. It will be additional, unnecessary training to help absorb excess capacity in the training industry as primary sources of funding go into decline.

The initial reasons given to persuade the NHS that this training has to be purchased will be a pick’n'mix of the usual blather that everyone is used to from politicians — to protect the public, to save the planet, for the sake of children everywhere, to help those least able to help themselves etc. etc. — known in the US as “motherhood and apple pie” reasons. The blather will soon be followed up by “research evidence”.

For starters

Kicking off this marketing drive, the NHS employees formerly known as ‘low intensity’ workers, who provide minimal support and self-help materials to patients with the very mildest of anxiety and depression, have been rebranded ‘psychological wellbeing practitioners’ (PWPs).

The BABCP has put in place what it calls an ‘accreditation process’ for them:

PWPs are essential to the success of the IAPT programme and we are proud of the way new training courses following a National Curriculum have been established. It is essential that the unique PWP role is properly recognised and protected with an accreditation process.

You can read more on the front page of the BABCP’s in-house magazine CBT Today (if it ever appears online, that is — at the time of writing the current issue has not been made public).

The article begins:

As Psychological Wellbeing Practitioners (PWPs) make a significant impact upon the nation’s mental health…

This despite the fact that PWPs don’t actually treat anyone.

As you read this self-congratulatory drivel, you can count off the training industry folk it names — academics from the universities of (in order of appearance): Exeter, Nottingham, Sheffield, York, King’s College London and Sheffield (again). Only one other person is named in the article — a bureaucrat employed by central government via a quango.

At least, in five years’ time, if you are still fighting your GP to get on to a two-year waiting list for genuine psychotherapy, you will know where all the money went.

Ever since I started writing here, I have thought of myself as an anonymous blogger. That’s not the case at all, it turns out, as two separate things that happened to me last week revealed. The two experiences illuminated opposite sides of what it means to have an identity, and why identity is important for psychotherapists.

I don’t mean by this that there has been some kind of exposé in which my real name has been revealed, though that could easily happen at any time. Although I have never told anyone explicitly that I write here, there are certainly a few people who now have enough information to work it out, if they chose to take the trouble. Perhaps it is only a matter of time before that happens.

No, what I learned last week was more fundamental than that. It concerns the way all of us, me included, present ourselves to the world as internally consistent people.

Congruence

This sense of being internally consistent and presenting yourself to the world in that way is similar to what Carl Rogers termed ‘congruence’ in a therapist who is (On Becoming a Person, p. 282, original emphasis):

…exactly what he is—not a façade, or a role, or a pretense.

The way it works in practice is not as simple as it seems. For example, if I want to promote CBT (which I do), I have to do that by describing CBT in a consistent way. A large part of what makes me congruent as a writer here is that I use try to language in a consistent way so that readers gradually build up a sense both of me and of what I’m writing about. If I used a term like CBT inconsistently, sometimes to mean one thing and sometimes another, that would make it more difficult for readers to relate to me as a consistent person.

Indeed, a fair amount of what I write here is explicitly to do with the meaning of the term CBT. I often describe things that I think are real CBT, and things that are fake CBT. Anyone who reads what I write about real and fake CBT gets a pretty clear picture, I hope, of what I think about the issue, and at the same time a pretty clear picture of me as a fairly consistent person.

So a side effect of writing here in a way that presents a fairly consistent point of view is that I come across as a person. Congruence creates the identity. It’s not that I’m a person who happens to be congruent. It’s that congruence makes me become a person. And, of course, the identity is not anonymous. The identity, the person, has the name CBTish in the present context, and other names in other contexts.

One of the things that happened to me last week was that I found myself in a situation in which I took the identity CBTish outside the blogosphere — not far outside, but far enough that it felt strange and new. It felt as strange as if the lady in the post office where I get a morning paper had greeted me as CBTish, or by a childhood nickname, instead of by my usual real-world name.

The notion I had previously had, that CBTish is in some way just binary data, some kind of bot that generates articles and comments in the blogosphere, suddenly evaporated as CBTish became a person in the moment, in the here-and-now. It was somewhat surreal but strangely liberating. I never expected to walk up to someone and exclaim, “Charles Bradwell Tish, at your service!”, adding conspiratorially, “But you may call me Charlie”, and that’s not what happened, but suddenly it felt that it could happen.

Terminology

In writing here, one of the factors that helps to maintain identity is consistent use of terminology. I think this is much more important than it often seems, and that is why I feel it is so important to define the term CBT meaningfully.

The second thing that happened last week was that I came across a published but anonymous opinion in a magazine article, an opinion about terminology, about the difference in meaning between the terms ‘psychotherapy’ and ‘counselling’.

The meanings that I assign to those terms are very specific, and they relate to the broad CBT model of mental illness. In the CBT model, people adopt ways of relating to the world that seem to work at the time. They can normally adapt to new circumstances by changing the ways they relate to the world in whatever respect is necessary. But there are times when the connections that provide for normal adaptation get lost somehow. Then the person may be stuck with ways of relating to the world that don’t work any more, and that are resistant to change. That’s mental illness.

CBT, which is a psychotherapy, applies specific techniques to identify and restore those lost connections. These specific techniques lie within what is called the CBT formulation (a.k.a. conceptualization) of the patient’s problems, which gives the patient a conscious, intellectual, common-sense grasp of the ways they relate to the world, and which empowers the patient to change.

Once in possession of that common-sense grasp, the CBT patient is in the position of understanding that some things have to be changed, understanding what they are, and understanding how they got to be that way. It might still be useful for the patient to have some help and support in making the actual changes to themselves. That’s counselling.

Counselling helps people who are not mentally ill, whose connections have not got lost, or have been found again, and who understand the external events that make them feel and behave the way they do. These people just need help and support in the everyday process of adaptation.

Therefore, in my model of psychotherapy and counselling, counselling is for helping people to change themselves and adapt to life; psychotherapy is for helping people to understand what it is about themselves they need to change, and what it is about life that they need to adapt to. The difference between psychotherapy and counselling lies in what they are for, in their purpose.

Orientations

Although I explained what I mean by psychotherapy and counselling with reference to CBT, my view of them translates quite well to other orientations. Orientations are the collections of theories and methods that inform the work of a body of therapists. CBT is an orientation, psychodynamic methods are an orientation, humanistic methods are an orientation. There are many others, and many subdivisions.

No matter what orientation you adopt as a therapist, I think it’s useful to distinguish between clients who know what they need to do and just need help doing it, and clients who don’t realize what it is they need. My definitions of counselling and psychotherapy make exactly that distinction.

But the magazine article I came across takes a different view. It proposes:

Psychotherapy focuses on the [...] as a ‘tool’ of the therapy whereas counselling relies on [...] to focus on a system for change.

I omitted some phrases to make the meaning of this quite clear. It is saying that the difference between psychotherapy and counselling lies in the methodologies that they use.

Differences in methodology, however, already have their own terminology — the terminology of orientations. There is no need to dedicate other terminology for that purpose. Using the terms psychotherapy and counselling to refer to orientations simply makes those terms redundant, because we already have ways to describe orientations.

Also, those orientations that (unlike CBT) include both psychotherapists and counsellors make almost exactly the same distinction between psychotherapy and counselling that I do. Psychotherapy is very generally used to mean the treatment of illness (although definitions of illness vary slightly), while counselling is very generally used to mean help with the challenges of everyday life for people who are mentally well.

Mysteries

It seems to me that the article’s proposal is very poorly thought out, but there is more to the article than that — it contains some mysteries.

One is the use of “We” in several places, implying that the author was some kind of committee, not an individual. (Or, if an individual, one who suffers from a DID-like delusion.)

Another is the phrase:

…those who would control the work we do…

Who is it who would control the work of therapists? The article doesn’t say. Paranoia, perhaps? Is there a conspiracy I don’t know about? Is it just a reference to the recent idiotic collusion (that I have written about several times, for example in Jeopardy) between the UKCP and the HPC? There’s no way to tell.

And another is:

…the way pathology has been used to differentiate titles…

The meaning of this is opaque, but it seems to hint at an anti-pathology standpoint — a view that mental illness does not exist — without sufficient courage to come out and say so.

Then there are some of the words I omitted from my earlier quotation:

…dynamics of the relationship between practitioner and client (patient)…

This is a thinly disguised reference to the psychodynamic orientation. The proposal is really that psychodynamic orientations are proper ‘psychotherapy’ while other orientations are just ‘counselling’.

Finally, there is the extraordinary sentence:

This [attitude] is developed during the training which evolves a state of mind that is congruent with the understandings used in the practice of the profession.

It is reminiscent of the kind of English you get from machine translations like Google Language Tools.

Taken together, these mysterious elements give the article an unreal quality, a feeling that it cannot have been written by someone who is completely in the same world as the rest of us. Significant clues in making sense of this are the way the proposal is in conflict with the general everyday meaning of the terms psychotherapy and counselling, and in the veiled reference to the psychodynamic orientation.

Some detachment from the real world, some paranoia, a delusional feeling of being a ‘we’ rather than an ‘I’, and some loss of the theory of mind that normally enables people to use language with conventional clarity — these are all typical of victims of addictive long-term psychodynamic treatment. A simple defence against the realization that the treatment is causing harm is to come to believe that mental illness does not really exist, that its encroaching symptoms in oneself are a form of insight. Could the article be a cry for help?

A final twist

In a final twist, the article invites comment. This is a classic double bind, a psychological trap of the kind that I explained recently in Cake.

Double binds have three components — two logically conflicting statements, often made simultaneously but in different forms so as to disguise the conflict, and a requirement that prevents resolution of the conflict.

In this case the logically conflicting statements are 1) that the article was not written by anyone (as it has no identified author, not even a pseudonym), and 2) that the article was indeed written by someone (as it does seem to express a point of view of sorts, and even hints at the author’s difficulties with life).

It would be simple for readers to make up their minds one way or the other, to resolve the paradox, but for the third component, which is the invitation to comment. In order to comment, you have to accept the article as a whole, you have to swallow the paradox whole without resolving it.

And then, in a final final twist, the article appears in a magazine whose principal theme is the work of the late R.D. Laing, a psychiatrist who wrote compellingly about double binds and their effect on people (and whose work I mentioned nearly a year ago in Marx). So a final final interpretation of the article is that it is in fact a hoax, an illustration of a double bind inserted in homage to Laing.

You can find the article here (page 35 in print, 37 in PDF): Defining psychotherapy and counselling

Identity

Well, not quite final final either. My own interpretation of the article is that it’s a warning to therapists by being an example of everything not to do.

As a therapist, it seems to me that you have to be fully in the moment as a coherent individual. You have to be able to relate to other people with congruence and consistency, to be open to experience (rather than paranoid), to be self-actualizing (rather than threatened by others’ control), to have a strong theory of mind that enables you to use language with clarity, to be sensitive to meaning, to be able to gauge where difficulty crosses over into illness, and perhaps above all never to create double binds. You have to have an identity, to be a person, and you have to have a name. Any name will do.

A neuroscientist at University College London has explained how CBT works using coloured dots.

That is, his explanation uses coloured dots. CBT doesn’t use coloured dots (though if some wacky ‘third-wave’ therapy based on coloured dots turned up next week heralded as a new form of CBT it would not surprise me one bit).

Actually, Beau Lotto doesn’t mention CBT at all. His work in UCL’s Institute of Ophthalmology concerns vision. But the underlying ways in the the brain processes information are the same no matter what kind of information it is. Vision is just one example:

The light that falls on to your eye — sensory information — is meaningless, because it could mean literally anything. And what’s true for sensory information is true for information generally. There’s no inherent meaning in information. It’s what we do with that information that matters.

The quote is from (04:16) a TED talk that’s embedded below. It uses optical illusions (some of which are similar to the one I used here last month in Socks) to illustrate how our brains process information.

Usefulness

The key idea is that your brain creates meaning out of information, and it does this in ways that it has learned are useful. Here’s an example he gives. Try reading this (04:54):

What are you reading? Half the letters are missing…There’s no a priori reason why h has to go between that w and a, but you put one there. Why? Because in the statistics of your past experience it would have been useful to do so. So you do so again. And yet you don’t put a letter after that [next] t — why? Because it wouldn’t have been useful in the past, so you don’t do it again.

That’s the key idea behind CBT, too. You have learned to process information in a certain way because it is useful, and your brain uses the information to create your perception of reality (11:40):

The senses aren’t fragile. And if they were, we wouldn’t be here. Instead, color tells us something completely different, that the brain didn’t actually evolve to see the world the way it is. We can’t. Instead, the brain evolved to see the world the way it was useful to see in the past. And how we see is by continually redefining normality.

If the way your brain processes information ceases to be useful (causing mental illness), then you can easily learn to process the same information in a different way that’s more useful to you you in the present. Your perception of reality changes, even though the incoming information is the same. Your world seems a different place.

In the video there’s a startling example of how quickly (thirty seconds) your visual processing can change. The changes produced by CBT (weeks or months) in processing thoughts and emotions can be equally startling.

A quote from the very start of the talk could apply to mental illness just as well as to the coloured dots (00:20):

…to win this game, all you have to do is see reality that’s in front of you as it really is…

Formulation

What CBT does is create an actual change in the way your brain processes information. It seems to you that reality has changed, as if the way you thought about things before while you were ill was some kind of illusion.

If you’re a patient and you’re having some kind of therapy that doesn’t do that, it’s not really CBT. Or if you’re a therapist and you’re not doing that for your patients, then whatever it is you’re doing is not really CBT.

The way CBT achieves this change is by uncovering the reasons why you were processing information in a certain way — why it was useful. This component of CBT, this understanding, is known as a formulation or conceptualization. Once you understand why your way of processing information was useful, and why it is no longer useful, you can develop a new way of processing information that’s more useful now.

There is nothing unnatural or artificial about learning to process the same information in new ways. Your brain does this all the time. In the talk, Lotto says (12:04):

So how can we take this incredible capacity of plasticity of the brain and get people to experience their world differently?

It’s that incredible capacity of plasticity of the brain that makes CBT possible.

The talk

Here’s the TED talk, Optical illusions show how we see:

This little gem of a sketch raises interesting questions about imbalance of power in the relationship between therapist and patient, the influence of the therapist’s own fears in informing intuition and advanced empathy, and more…or perhaps less.

If you don’t much care about any of that, it’s also funny:

What do flowers and grapes have to do with mental health? It’s usual, when reviewing a newspaper article, to add some comment, but I think this one speaks for itself…

…since that day I have never, and I mean never, seen a single card – let alone a bunch of flowers – on a psychiatric ward.

Max Pemberton’s Spare a thought for psychiatric patients is in today’s edition of The Daily Telegraph.

The flowers and the grapes can be found on ‘Get well soon’ cards on sale from The Royal College of Psychiatrists.

My recent ranting about fundamental difficulties with the psychodynamic approach to counselling and psychotherapy has one last twist.

Someone told me that they thought my recent posts about psychodynamic counselling, Cake and Hot babes were “going for the jugular”. In the light of my allusion to vampires towards the end of the second piece, I wonder how much I should read into the remark!

Anyway, to reiterate, it’s not that I think psychodynamic theory is necessarily mistaken, or that psychodynamic methods are wrong in themselves. I can see that the theory is a plausible framework for understanding people’s mental lives, but I also see that in practice therapists find it difficult to apply, very often impossibly difficult to apply, with the result that patients do not recover. Furthermore, instead of adapting to these difficulties and resolving them, a common psychodynamic approach seems to be to deny them and to indulge instead in a kind of sham therapy where the therapist, not the client, generates the emotional content of the sessions.

Something similar happens in CBT. There’s a plausible theoretical framework for understanding people’s mental lives, and a practical methodology for applying it. Yet there are therapists who do not understand the methodology, and instead of learning how to do better, they play at ‘CBT techniques’ in a kind of sham CBT.

The crucial difference is that while psychodynamic methods are inherently difficult, so that very few people can acquire the skill to apply them effectively, CBT methods are inherently simple. As a result, effective CBT is pretty common, and effective psychodynamic therapy is pretty rare.

Compulsory therapy

A recent discussion amongst CBT therapists brought out some of these issues. The question raised was: Should it be compulsory for CBT therapists to have therapy themselves as part of their training?

It’s not compulsory at present, and there are no plans for it to be. The basic reason for this is that CBT is designed to treat mental illness. There is no such thing as CBC (‘cognitive behavioural counselling’) for helping mentally well people with the problems of everyday life. The fundamental difficulty with compulsory CBT for trainees that there’s no illness to treat, so it would simply be going through the motions in a limited and pointless way.

Disappointingly, the view was expressed in this discussion that CBT is just a bunch of techniques for living life, and that anyone at all, mentally ill or mentally well, can learn techniques. I think it’s extraordinary that someone with so little understanding of how CBT works should be found piping up in what was meant to be a serious discussion. It’s as I wrote above — even in an orientation as simple as CBT there are therapists who do not understand the methodology.

Another disappointing view was that because there is no hard evidence one way or the other on whether compulsory therapy as part of training makes for better therapists, the idea should be considered to have potential. This is a little like saying that the jury is still out on whether the moon is made of green cheese, until such time as samples from the moon’s central core are obtained and analysed. It’s difficult to imagine how anyone with such a chaotic view of scientific evidence could be effective in helping patients to be rational.

Supervision and mental ill-health

It should be pointed out that what’s called ’supervision’ of therapists is, or should ideally be, a completely different thing from therapy. Therapists use supervision for a variety of reasons (which I discussed recently in Buddy), but it should never be a pointless exercise.

It is probably unwise for a supervisor to provide actual therapy to help the therapist to resolve personal mental health issues, because a supervisor’s goal is to ensure that the therapist provides effective therapy. Having some other goal makes the supervisor’s role very complex and difficult.

Mental ill-health, however, does not in itself prevent someone from being an effective therapist. Past mental ill-health and recovery is probably a big advantage, because it is easier to convey the possibility of recovery to patients if you have experienced it yourself.

Even current mental ill-health is not necessarily a barrier to being an effective therapist, unless it is severe. For example, an effective therapist might be paranoid-schizophrenic, hearing persecutory voices at times of emotional stress, but this need not interfere with work as a therapist, which does not normally cause therapists to experience emotional stress.

Therapy without purpose

Some orientations, particularly the psychodynamic ones, do make it compulsory for trainees to have therapy themselves. They might even make compulsory, or strongly encourage, therapists having continuous therapy themselves after training. What does this achieve?

One thing it achieves is that it legitimises therapy without purpose. Because the therapist has experienced therapy for its own sake, without any overall therapeutic purpose or final goal, it is easier for that therapist to conduct therapy in the same way with clients.

Putting this from a client’s point of view, if you are seeking therapy for some specific reason, then therapists who are themselves having continuous therapy, or who have had compulsory therapy as part of their training, are much less likely to deliver what you hope for. On the contrary, they are much more likely to involve you in a pointless examination of the parts of your life that don’t need any examination, and this is likely to continue without any end ever coming into sight, until you eventually walk away.

Addiction to therapy

In the extreme, it is not unknown for therapy that has no specific goal to create a state like addiction. This is because of the temptation to conjure up emotional intensity between client and therapist so that the therapy seems to have some justification. Psychodynamic theoretical constructs like transference and counter-transference are easily adapted to give conjured-up emotional interactions the appearance of validity.

The problem with this for both client and therapist is that normal relationships can start to seem dull by comparison. Both participants begin to feel that the life they have in therapy sessions is real, and that real life is just an unsatisfactory filler between sessions. This state of mind exactly parallels psychological dependency in substance abuse. It is, alas, quite common.

It seems clear to me that the methods of psychotherapy have real power. It seems equally clear that such power has the potential to cause harm. The most likely scenario for harm is when there is no strong focus on doing good, no specific mental illness to cure.

Therefore compulsory therapy for mentally well trainees only gives them experience of a potentially harmful scenario. Continuous therapy after training does nothing but reinforce it, making addiction to therapy and withdrawal from real life more likely for both therapists and their clients. The twist in the tale of the psychodynamic approach is that it’s theoretical basis can so easily be misapplied to allow this to happen.

For all these years I’ve been lacking the most important skills to succeed with hot women. In fact, I’ve been acting like a BNB (‘boring nervous bonehead’) around them. But now, at last, I’ve discovered how to get sex with hot babes.

My new-found knowledge is from the seduction manual How To Be The Bad Boy Women Love (full text online). This sequel to How to Succeed with Women reveals that creating deep rapport and a deep connection is not always enough to get a hot babe into bed. The authors’ most successful students are masters at both connection and disconnection (p. 48):

…once you have the tool of disconnection at your disposal, you’ll be shocked by how much faster and easier your seductions of hot women are.

Truth disconnects

The book is full of great detail about techniques for disconnecting. For example, the first basic technique is called a truth disconnect (p. 55):

A truth disconnect is a disconnection that you make with a woman by drawing attention to the truth about her mood, her behavior, or your experience of her.

Here’s an example of a truth disconnect (p. 55):

We were walking down a street in a bar area around midnight. We saw three girls together, and one of them looked really angry and upset. David said “hi” to her, and she just grunted back. So David simply reflected back what was actually going on with a truth disconnect.

He said, “Wow, that’s pretty rude. You look really angry.”

Canned disconnects

The other basic technique is the canned disconnect (p. 57, original emphasis):

A “canned disconnect” is a disconnecting phrase that you’ve memorized and practiced (hopefully out loud) until you can say it no matter how scared or intimidated you are. You then deliver this “canned disconnect” to women who need it, and let it work its magic.

Here’s an example of how it can work (p. 57):

Brian was in a bar and talking to a woman who was extremely beautiful, but incredibly stuck-up and rude. After a couple of minutes of talking to her and having her be so bitchy, he said, “Hey, you know what. You’re a really rude woman, and I’m not going to talk to you anymore.” He then turned on his heel and walked away.

If you are like most men who have never disconnected from a woman, then you probably think the interaction with her was over. Quite honestly, he did, too. But he felt good about himself, and was telling himself that that was enough.

But about a half-hour later, when Brian was getting ready to leave, that same girl came up to him. She told him she was sorry for being a bitch, and offered him her phone number.

More examples

I found some more examples of disconnects in an unusual place. Remember that book about psychodynamic counselling I mentioned in my previous post, Cake? In the book’s case studies there are two clients, the first of whom is Hannah. Here’s part of Hannah’s first session, starting from the very first words she speaks (p. 1):

‘Are you a psychoanalyst?’, she said…

I paused a second… The brief silence gave me some space to frame my reply: ‘What does “psychoanalyst” mean to you?’

The short answer would have been ‘No’, by the way. The author is not a psychoanalyst. What was moment of silence all about then? And why not just answer the question? This was a canned disconnect. Allow a moment’s silence, then refuse to answer the question and throw it back by asking, ‘What does [whatever the client asked about] mean to you?’

On the same page, there’s another one (original emphasis):

‘I hoped I’d be able to see a woman.’ …

‘You hoped you’d be able to talk to a woman,’ I said gently, ‘and you find yourself talking to a man. And you’re afraid I will only be interested in sex.’ It was a slightly risky comment…

Not just a risky comment, that was a truth disconnect. Look above on this page to the definition of truth disconnect from the seduction manual to see how well this example fits.

These types of disconnects are not the only ways in which the counsellor appears to be following the seduction manual.

Reward and punishment

To be successful at seduction you have to be a ‘Hard to Get Man’ (p. 21):

The Hard to Get Man is unpredictable in the things he talks about, the way he behaves, and the way he expresses himself. As a result the Hard to Get Man is flexible in his approach with women and is able to deal with the inherent chaos involved in relating to women.

And your unpredictability involves reward and punishment (p. 67, original emphasis):

One of the key skills of being a Hard to Get Man is having the ability to both reward and punish women. In fact, a Hard to Get Man constantly rewards and punishes women. The Hard to Get Man is flexible in his approach with women and is constantly rewarding women when they are treating him well. He is generous with his rewards and enjoys the reward process. The Hard to Get Man also does not hesitate to punish a woman when she is nasty or mean. He goes in and holds his ground.

The seduction manual goes into great detail about types of reward (body language, attention, compliments, and time) and types of punishment (withdrawal of attention, commenting on her bad behaviour). It explains that holding your ground means tolerating emotion (p. 73, original emphasis):

Remember, emotion is good. Extreme emotion is even better. Women thrive in situations that are highly emotional. So, when a woman gets extremely angry, happy, or sad she’s engaged. One of the reasons BNBs are so boring is that they avoid emotions. Therefore, pushing up intense emotions with women is good. You might not be comfortable with a woman getting upset with you and “losing it.” But trust us when we tell you that if you are able to ride the wave of intense emotions with women, sex is often on the other side and/or a deeper connection.

More examples

Back in Hanna’s counselling sessions, her counsellor also confronts her with unpredictable rewards and punishments in order to generate emotion. They are more difficult to give examples of in a few quotes, but they parallel the techniques of the sexual predator exactly.

Here’s an example of an unpredictable punishment. Hannah attempts her own disconnect from the counsellor, which is punishable, but punishing it immediately would be predictable.

So instead, the counsellor changes the subject, first to sex (which doesn’t get much of a response), and then to Hannah’s doctor. When the counsellor changes the subject back to Hannah, he delivers the punishment (p. 19, original emphasis):

‘I’m not sure I can tell you.’ She frowned, and looked anxious again.

‘Perhaps it’s difficult to tell me because I’m a man?’

Hannah nodded, but said nothing. She looked a little sad.

‘You wanted to go on seeing your doctor?’ I added.

‘She hasn’t got time, I know. There are a lot more people who deserve more attention than me.’ Her eyes had begun to moisten.

‘That sound [sic] confusing for you. You’re not sure you can speak to me; but part of you wants someone to pay attention to what you’re feeling; but you aren’t sure whether you’ve got any value compared to other people…’

I spoke slowly, separating out the several conflicting feelings within her. As I spoke, Hannah looked more upset; when I stopped speaking she buried her head in her hands and began to cry.

Note how the counsellor is completely in charge throughout this exchange, changing the subject three times. Also note that when Hannah finally breaks down in tears it is not in response to feelings that she herself has expressed — it’s in response to feelings the counsellor has expressed on her behalf.

Resistance, transference and coercion

Psychodynamic theory explains the emotional content of counselling and psychotherapy in terms of concepts like resistance and transference. But this theory assumes that the counsellor is a kind of blank sheet who does not influence things. When the counsellor is using strongly coercive techniques similar to those used by sexual predators in bars to pick up hot babes, the theory breaks down.

Resistance is taken to be when the client’s unconscious predispositions make it difficult for her to process certain material in her life. But when the counsellor is using unpredictable disconnects and punishments, apparent resistance could very easily be generated by the counsellor’s own weird behaviour.

Transference is taken to mean that the client’s feelings towards the counsellor are being unconsciously transferred from some other significant person in the client’s life. But a counsellor who routinely uses bar-room seduction methods with clients is very likely to create strong emotion, especially attachment, out of thin air.

I am not saying, by the way, that the counsellor in this case study was actually trying to get Hannah into bed with him. The strong parallels between his methods and the methods of sexual predators almost certainly have different purposes, but only slightly different.

The sexual predator wants to create attachment and emotion as a means to an end, as a strategy for getting sex. The coercive counsellor wants to create attachment and emotion as an end in itself, to give the impression that his counselling is ‘deep’ and worthwhile without attempting the much more difficult task of pinpointing and helping with the client’s difficulties.

Although you might not think it from the way the seduction manual is written, the sexual predator’s methods create solid relationships. Hot babes, just like everyone else, really do want relationships with people who are honest and perceptive, who genuinely value them as human beings, and who are prepared to be themselves in every way, in addition to liking sex.

Coercive counsellors, on the other hand, create phoney relationships where the emotion and the attachment are manufactured by the counsellor’s deliberately weird behaviour. Clients in those relationships are victims of wierdos.

Warning signs

The warning signs of coercive counselling relationships can be deduced from the counsellor’s payoff, and from the ways in which these counsellors are tempted to overstep professional boundaries. The commonest payoffs for coercive counsellors are emotional vampirism and money. Sexual payoffs are probably very rare.

The emotional vampire is a counsellor who gets a kick out of emotional clients. It’s easy to spot if the counsellor often becomes emotional during sessions, although some emotional vampires are able to remain flat during the sessions. Some may have only a few victims amongst other clients whom they treat normally. If the same emotions continually recur in session after session, particularly if the counsellor seems to be participating in the emotion, or feeling satisfied at the end of emotional sessions, it could be a bad sign.

The ones who do it for money create attachment so that their clients keep returning week after week, usually for at least several years. Clients may become addicted to the feeling, learning to reject normal relationships and seeking similar counsellors for more of the same.

Professional boundaries normally prevent counsellors from rewarding their clients very much. The rewards of attention and empathy during sessions are limited. So coercive counsellors may be tempted to give more potent rewards.

Extra time and attention outside scheduled sessions, for example, is a tell-tale sign. Regular e-mails, telephone messages, ‘chance’ encounters in everyday or social situations, and contact on the Internet’s social networking sites would also be a strong indicator that the counsellor is trying to coercively reward inappropriate feelings of attachment.

Learning How To Be The Bad Boy Women Love has turned out to be even more revealing than I thought.

According to the proverb:

You can’t have your cake and eat it.

According to another proverb:

There’s no such word as “can’t”.

What happens when you do have your cake and eat it? And how can you do that anyway?

The problem is that the cake is a thing to be valued in itself. It’s a celebration, a reward, a prize. But to take part in it, to engage with it and make it part of your life, means obliterating it by eating it. To both have your cake and eat it is a logical impossibility, a paradox.

Well, this post is not really about cake. It’s about relationships between people. What happens if you both have your cake and eat it in a relationship? It creates a paradox for the other person in the relationship.

There’s nothing particularly interesting about paradoxes you impose on other people. The other person only has to look at the whole situation clearly, see that it’s a paradox, and explain to you that you have to make a choice: “one or the other, you can’t have both.”

But something particularly interesting does happen when you introduce a third element. Suppose there’s a rule that says the other person is not allowed to look at the whole situation, cannot deal with it by explaining it to you as a one-or-the-other choice.

In that case the other person’s problem becomes insoluble. There is nothing the other person can do. They are trapped. Faced with this kind of trap, most people disengage and freeze up. They may even experience intense feelings of distress, unreality and emptiness. The disengagement can cause amnesia about the situation they were in, so that they cannot remember the details afterwards.

That’s a very strange phenomenon. I’m not talking about mentally disturbed people here. I’m talking about people who are psychologically normal. Presented with a situation in which a simple paradox is combined with a rule forbidding looking at the big picture, perfectly normal people can experience feelings of distress, unreality, emptiness and amnesia that are oddly similar to severe mental illness.

Double binds

The kind of situation I have described is known as a double bind. It has three elements. The three elements of the double bind are created by one person, whom I’ll call the perpetrator, and imposed upon another person, whom I’ll call the victim.

The first and second elements are things that cannot logically exist at the same time. They are the bind. They create a paradox. A paradox is not a big problem in itself, because it can be resolved by stepping back and looking at the whole picture.

The third element is a rule that makes it impossible to step back and look at the whole picture. This rule is what makes a double bind into a psychological trap.

The effect of all three elements together is that the victim cannot act without being inconsistent with one or other parts of the bind. Also, the victim cannot escape by seeing the big picture. The victim can only disengage from the situation, disengage from reality.

In well-known example given by Gregory Bateson in Steps to an Ecology of Mind, a mother is the perpetrator and her son is the victim (p. 165):

A young man who had fairly well recovered from an acute schizophrenic episode was visited in the hospital by his mother. He was glad to see her and impulsively put his arm around her shoulders, whereupon she stiffened. He withdrew his arm and she asked, “Don’t you love me any more?” He then blushed, and she said, “Dear, you must not be so easily embarrassed and afraid of your feelings.” The patient was able to stay with her only a few minutes more, and following her departure he assaulted an aide…

The two elements of the paradox here are the way the mother expresses in words that there is love between herself and her son, while at the same time expressing through body language that there is no love between them. To make it into a double bind, the third element is a rule that, as a son, he cannot simply challenge his mother about her inconsistency. Instead, mother challenged him about the situation. The distress that this caused led to a relapse.

Some secondary characteristics of this example are common in double binds. The two parts of the paradox are expressed in different ways — one in words, and the other in body language. This is what makes it possible to make two statements that together create a logical conflict, without it being obvious. The entrapment rule that prevents the victim from seeing the conflict clearly is based on the mother’s higher status and the son’s dependency on her. These characteristics are not necessary to make the situation into a double bind, but they are often seen when double binds are picked apart in therapy.

Why would a mother do this? It’s because she wants to have her cake and eat it. She wants to be the kind of mother who loves her son and is loved in return, but at the same time she does not want to participate in loving her son for real. So the spoken message that she gives is that there is love between them, but the body language message is that she does not want to participate in life with him.

Again, this not wanting to participate is a secondary characteristic of double binds that is not necessary, but often seen. The commonest paradox is formed by wanting to have something but not to participate and make it part of life, just like wanting to have your cake and eat it.

Schizophrenia and other disengagements

The effect of double binds is to force victims to disengage from reality. Also, the more a victim is exposed to double binds the easier it is to cause that disengagement. So some psychiatrists have suggested that habitual double binds in childhood might be the cause of mental illnesses like schizophrenia, which involve a recurrent or permanent withdrawal from reality or feelings of detachment from life.

In schizophrenia, the patient feels present in the world but the patient’s world is not entirely real. In other possibly-related conditions, the patient’s world is real enough but the patient feels not present in the world. The hypothesis is that these difficulties come about because the patient as a child was repeatedly exposed to double binds in which disengagement from reality was the only possible course of action. Over the course of years, disengagement becomes easier and easier to trigger, until eventually everyday life and memories of childhood are sufficient to trigger it.

It’s not very useful in practice to hypothesize about childhood experience like this. Knowledge of double binds is much more useful when working backwards from a patient’s current symptoms. Suppose a patient describes a situation in which he freezes up and feels detached from reality. Working backwards, it is useful to look for a perpetrator who might have caused that by setting up a double bind.

A secondary clue to look for is when there are different levels of communication that would allow conflicting messages to be sent out without the conflict being obvious. And an imbalance of power or dependency is all that’s needed to create the third element — the rule that prevents escape.

The window

In a strange little book, Psychodynamic Counselling in Action, a psychodynamic therapist, Michael Jacobs, outlines the basis of the psychodynamic approach by using two fictitious case studies based on characters from Charles Dickens’ novels.

In his first case study, Hannah (Little Nell from The Old Curiosity Shop) is referred to him by her doctor (p.1):

Hannah perched nervously on her chair as the session began. She looked out of the window for a second…

In his second case study, Karl (Dr. Manette from A Tale of Two Cities) sees him after trying many other kinds of help (p. 23):

He turned to look at me…and I felt that his quick but penetrating gaze threw down something of a challenge. But then he shifted his head, staring out of the window, and continued, less hurriedly…

What is it about this window?

To understand it, you have to work backwards. The clients in these case studies both look out of the window early in their first sessions. We’re not told of anything particularly interesting out there that they are looking at. They look out of the window in order to disengage from their situation in the room.

What could be happening in the room to make them disengage? A double bind is the kind of thing that makes people disengage. A double bind requires three elements — the two conflicting messages that form the paradox, and the rule that creates the trap.

The rule that creates the trap here is easy to guess. Patients who come for therapy see the therapist as someone who can help them, someone more knowledgeable, someone more powerful. They have invested time, money and hope in therapy. They do not feel that they can challenge the therapist about the therapist’s own behaviour, particularly in the first session. So when therapist behaves paradoxically, the patient is prevented from seeing the big picture and dealing with the paradox.

What is it about the therapist’s behaviour that could be paradoxical? Jacobs doesn’t tell us directly when he describes his sessions with Hannah and Karl, but he does explain that one of his aims is to be as invisible as possible. Sigmund Freud would sit behind his patients so that they could not actually see him, and to this day there are psychoanalysts who will behave in that way. Jacobs does not go that far, but even so (p. 26):

The psychodynamic counsellor does hold back from revealing her- or himself, and so provides the opportunity for the client to imagine all manner of things about the counsellor. Of course, because the counsellor’s facial expressions can easily be seen by the client, he or she has to…prevent feelings being shown…

In terms of physical reality, the therapist is present in the room. At the same time in terms of human relationships, the therapist is not present in the room. These are the logically conflicting statements that form the paradox. The patient is trapped by being unable to confront the therapist directly about this conflict, and the only escape is to disengage and look out of the window.

Patients’ distress resulting from double binds in psychodynamic therapy is easily misinterpreted in terms of psychodynamic theory. One part of the theory is that patients find ways to withhold information from their therapists. This is known as resistance (the patient resists disclosing information). Another part of the theory is that patients come to see their therapists in terms of other significant people in their lives. This is known as transference (the patient transfers feelings about someone else on to the therapist). Confused therapists, whose own weird behaviour has caused their patients to feel bad and act strangely, often blame resistance and transference for what happens next.

Escape

Escaping from double binds is easy if you know how, but it takes some practice and nerve.

The first step is to understand that your mind will block the paradox, so that you will not be aware of it at the time. You might even find it difficult to remember afterwards. Therefore, escaping by resolving the paradox is not an option. This is the know-how that you need to escape.

The next step is to learn to recognize the feeling that you get when you are the victim of a double bind. It’s a different feeling for different people. It can be like an oppressive sense of the world closing in, or it can be like the world is far away and you are not really part of it. It might make you stare out of the window, not paying attention to anyone else in the room, it might make you very bored and tired, or it might make you curl up and sob. Whatever it is for you, it has the effect of making you disengage — it’s an automatic mechanism in your mind that cuts you off in order to protect you. Learning to spot the feeling fast is the practice that you need to escape.

The weak point of a double bind is its third element, the entrapment rule. That’s where you can break out of it. So the third step is to ask yourself the question, “What rule forces me to put up with this feeling?” — and then break the rule. The rule might be your own commitment, a decision you once made. It might be another person’s power over you. It might be a threat of consequences. This step often takes nerve.

Some perpetrators will react badly to having their victims escape. They might try to impose psychological punishments, including further double binds. By escaping you are telling them that they cannot have their cake and eat it. Tantrums are to be expected.

Notice that escaping does not require you to resolve the paradox. You only have to recognize the feeling and break the entrapment rule. You can optionally pick apart the paradox afterwards if you want, and in doing so you will get to understand the kind of cake that the perpetrator wanted to both have and eat. This might tell you more about the perpetrator’s underlying motives and problems, and it might help you to have a different relationship with the perpetrator, if that’s what you still want.

A little Zen

There is a Zen kōan known as Gantō’s Ax, (from Gyomay M. Kubose, Zen Koans, here as quoted by Douglas R. Hofstadter in Gödel, Escher, Bach, p. 197, and requoted by lemuru here):

One day Tokusan told his student Gantō, “I have two monks who have been here for many years. Go and examine them.” Gantō picked up an ax and went to the hut where the two monks were meditating. He raised the ax, saying, “If you say a word I will cut off your heads; and if you do not say a word, I will also cut off your heads.”

I have only quoted the first part. If you have understood this post, you can work out what must happen, and if you follow one of the links and read how the kōan ends you can see whether you were right. But Zen is Zen, of course, and it is never so simple as that. You will see that you were right, and also that you were not right. Are you trapped?