One of the participants in our training program brought up the issue of non-directive therapy versus directive psychotherapy. In a way similar to the artificial distinction between “insight” and “supportive” therapy, featured in the last TIFT, another distinction with a long history is between “directive” and “non-directive” therapy, where non-directive carries the connotation and judgment of a superior, more thorough kind of psychotherapy. In this post I’ll talk about the benefits an pitfalls of both ends of what I see as a spectrum.
Making a binary distinction between nondirective and directive psychotherapy is neither clean, nor useful. Those terms represent the extremes of a spectrum where the degree of each has effects and consequences. Let’s look at what happens at both ends of the spectrum.
Effects of being non-directive
With a non-directive approach, we are doing something quite unnatural and unusual. We are telling the patient that therapy is a time for taking no action other than producing words, and doing so for the purpose of pulling aside the thin curtain that otherwise divides conscious and non-conscious thought.
With enough time and frequency of visits, it is true that the inner child will show his or her true colors. When the plans and wishes of the inner child are revealed, there is an opportunity for the mechanism of Memory Reconsolidation to mediate the inner child’s maturing by updating old schemas of how the world works in the light of what is explained and/or experienced in therapy. This includes coming to acceptance of desires that can’t be fulfilled in the adult world.
More concretely, when inner children are not able to find fulfillment of emotional needs experienced as necessities, the inner child, experiencing the warmth, compassion, and acceptance of the therapist, will hopefully be able to let go of old wishes such as physical comforting and attention, identified much earlier as substitutes for the understanding and compassion that were missing. The childlike mind might also discover that when feelings like anger are understood by an empathic other, the need to put them into action is no longer compelling or necessary.
In essence, the experience of being heard by a compassionate and non-judgmental other fulfills the gold standard of emotional support, the need for empathic attunement, understanding, and compassion. That is where nondirective therapy stops. While childhood development includes teaching healthy and satisfactory patterns of interacting and coping in the world, nondirective therapy leaves that to the patient to invent. Patients vary in their ability to do this.
Shame and guilt: The flies in the ointment
The first and biggest problem with this idyllic picture of therapy is that one of the most powerful solutions to childhood deprivation is to build shame-barriers against impulses and actions that would lead to pain. I call those “internal electric fences.”
If one examines comments from Howtherapyworks.com, readers with intense needs for closeness to their therapist usually feel extremely ashamed of their neediness and have great trouble sharing this with their therapist. Even if the therapist urges them to speak freely and not to filter their free associations, these most important revelations tend to remain secret.
The section of the non-conscious problem solver mind that produces pride, shame, and guilt, works very hard to avoid potential pain by giving out punishment in the form of shame for any words or actions that tend to reveal dangerous needs. You can guess that these wishes, the ones most important to the therapy, will be the last to be revealed. Somehow the flow of free associations will tend to cover up as much as it reveals.
That’s why classic psychoanalysis uses 4-5 sessions a week to make sure spontaneity will overcome shame and the truth will come out. But how well does it work and is that the only way? Unfortunately the answer is that this method, though elegant and appealing, is indeed expensive in time and money and the crucial truths can still stay hidden.
Advantages of being directive
A patient I have known for some time, but don’t see often, complained that his asthma was acting up and he couldn’t understand why. We knew from before that his asthma was directly related to anxiety. I (directively) asked what his anxiety was all about. He immediately replied, “abandonment.” I suggested that now, in his sixties, he, who emphasized extreme aerobic fitness and business success, was starting to experience limitations and to be aware that he would not be able to keep up the level of performance he had been used to in past years. He had been depending on performance to establish his value and reassure himself against the fear of abandonment. This immediately resonated with him, and gave him a pathway to work on accepting the reality that life is limited, and to make use of the antidote to his anxiety, that the important people in his life are attached to him and will not abandon him regardless of his performance.
Another important place for being directive is when behavior functions to reinforce entrenched maladaptive patterns. A patient berated herself intensely and punished herself by deprivation every time she failed to perform some task or duty to perfection. This made her feel so bad and to be so preoccupied with self-hate that it caused her to fail in tasks and duties, leading to a new round of self-hate. It helped for her to have ongoing encouragement to refrain from self-criticism and not to deprive herself. Had she not been “directed,” my feeling is that the pattern would have continued considerably longer.
Disadvantages of being directive
A therapist who is too quick to draw conclusions will not only miss a great deal and make serious mistakes, but will convey to the patient that he or she is not really interested in the full truth. The patient may conclude that the therapist has an agenda independent of the patient’s own needs and the positive therapeutic relationship may be damaged.
In a scientific spirit, we need to hold our own ideas and beliefs with a very light touch and be our own harshest critic while listening carefully for indications of whether we are on the right track.
Cat and Mouse
Another very important dynamic is little known in the context of individual work, but well known in family dynamics. When one person takes on a role, the other tends to let it go. Here are some common examples:
- The codependent partner of an addict urges reform and the addict makes it his or her responsibility to do the opposite.
- A therapist argues with the patient not to commit suicide and the patient becomes more suicidal.
- Parents urge their young adult child to “grow up” and the young person acts even less adult.
Where there is a tendency towards becoming passive or passive-aggressive, directiveness on the part of the therapist is an invitation to a configuration where the therapist is responsible for the good behavior and the patient responsible for the bad behavior. In the game of cat and mouse, the mouse usually wins.
A currently popular way to avoid this is Motivational Interviewing, where the therapist carefully avoids pressuring, while remaining more subtly but still clearly directive. This works best for the group for which it was designed, people who are allergic to being told what to do.
Conclusion: A Spectrum
Harry Stack Sullivan said that we therapists are “participant observers.” What that means is that we are inevitably drawn into the interaction as participants. When we are, we are no longer in a good position to help, but we can learn a great deal by listening to our own feelings. An important tipoff is that the therapy is not moving, yet we feel somehow responsible. The feeling of responsibility simply means we have been pulled in as a participant. The answer is to begin to ask ourselves and out patient what exactly is the dance we have become part of. As we begin to formulate answers to that question, we have automatically moved into the position of observer. This is one special prerogative that therapists have, to vary our position and to retreat from participant to observer. Here is a diagram:
What does that sound like? Perhaps, “I’m feeling a tug to somehow get this therapy moving, but I can’t think of anything successful I could do right now. I wonder if in some way you have been waiting for me?” And indeed, the inner child may have been hoping to avoid painful acceptance or responsibility for doing the hard work.
Jeffery Smith MD
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