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Therapeutic communication: Principles and effective practice
ClinicaiPsychologyReview,Vol. 14, No. 6, pp. 605-610,1994 Copyright0 1994 ElsevierScience Ltd Printedin the USA. All rightsreserved 0272-7%X3/94 $6.00 + .OO
Pergamon
BOOK REVIEWS Therapeutic Communication: Principles and Effective Practice. By P. L. Wachtel. New
York: Guilford Press, 1993. 308
pp.
($32.00).
Although there are many helpful books available on the process of therapy, very few of these books focus on “the framing of therapeutically effective comments” (p. 2), what the therapist actually does or says in the room that facilitates or gets in the way of helping patients to resolve their difficulties. One of the strengths of this book is the elucidation of what makes a therapist’s intervention effective at “opening doors the patient has felt he needed to keep closed” (p. 89). Another strength is to provide the reader with such a complex understanding of the dynamics of the therapeutic process without using psychological jargon. Every therapist has had to deal with issues such as how to approach a patient who tenaciously avoids talking about anything painful or who is consistently self critical. Paul Wachtel explains how to approach these patients and how to understand the intense conflict and anxiety underlying their problems rather than to pathologize the patient. He not only gives numerous examples of how to elicit “cooperation rather than resistance” (p_ 3), to decrease defensiveness and to enhance selfesteem while also asking the patient to confront his or her difficulties, but he also articulates overall principles for choosing an appropriate intervention. By clearly outlining the thought processes behind his suggestions, Wachtel helps the reader generalize to other situations. The first two chapters in this book provide the theoretical background for the strategies suggested in the later chapters. The model is grounded in Wachtel’s theory of cyclical psychodynamics that integrates psychodynamic theory with systemic and behavioral theories focusing on the reality that “these deeper (psychologiiuZ)structures not only influence daily interactions and experiences but are influenced by them and/or symbolically represent them” (p. 19). In other early chapters, he discusses the centrality of anxiety and the nature of insight and transference within a cyclical psychodynamic framework. Because of his emphasis on therapist’s interventions that target conflicts and anxiety linked to the avoidance of unacceptable feelings, thoughts, or impulses, he seems to have a psychodynamic view of his patients, Nevertheless, he may be better characterized as an “integrationist” because he addresses at least two additional psychotherapeutic perspectives. At the systemic level, he suggests that both patient and therapist be aware of the role of “accomplices” in the patient’s life in perpetuating maladaptive interactions and the need to discuss together the likely reaction of those significant others to changes the patient may make. At the behavioral level, he will not hesitate to use techniques such as exposure and providing direct advice as appropriate. Wachtel’s primary focus in many of the subsequent chapters is on the often %nnoticed or unexamined” meta-message that coexists with the message the therapist
Book Reuiews
606
intends ta convey. Wachtel states that therapists’ meta-messages,
“the attitude about
what is being conveyed therapeutic describing, munications
in the focal message,” have the “greatest potential for either transfurmation (or therapeutic failure)” (p. 2). His cunt~bution is in
delineating,
and focusing careful attention on how those subtle metacom-
in therapists ’ ‘6neutral” comments are likely experienced by patients. In one of the most interesting and useful chapters, he outlines the difference between
inherent
accusatory
(critical)
and facilitative
(permission
giving)
therapists’
com-
ments contrasting statements like: ‘350~ are defending against feelings of dependency= versus SI% sem to ex$& ~~#~~~~ &r&&z to ~~~ rfrozl have an;r w%i to be lak8n care c!f (P. 73). Wachtel suggests that the core of patient’s difficulties is self-deception and selfalienation in order to avoid anxiety. Thus, it is difftcult for the therapist to help the patient to come to terms with these issues without the patient experiencing
the ther-
apist’s attempts as simply criticism and interrogation. In his view, good interpretations are permission oriented, they help the patient to accept the disavowed. Wachtel offers different ways to help patients become both more aware of their fears about particular anxiety provoking experiences and to be more open to the experience of forbidden feelings and thoughts. For example, in the difftcult situation of trying to address a patient’s tendency to “sabotage success,” he might suggest saying “What is it that you do that, if you weren’t careful, might have the danger of letting you succeed? And what do you do to pull the fat out of the fire, to make sure that doesn’t happen?” Wachtel goes on to explain that “in contrast to a direct statement that she seems to be working hard to fail, this (logically equivalent, but connotationally different) set of questions conveys that if you are not careful you might succeed” (p. 84). Wachtel details additional principles for effective intervention strategies. In one chapter, he advocates a focus on the patient’s strengths and the recognition of the importance of small steps during treatment. He would label a patient’s despair at finding her/himself back in old familiar ways of interacting as simply ‘?esiduals” of old tendencies, rather than as evidence of regression or as something to blame oneself for. Such an intervention helps to highlight the change the patient has made and creates a distinction between past and present behavior. In another chapter, he gives examples of how attributing or suggesting a feeling to a patient that the patient is nut yet aware of having helps to delineate the underlying conflict. This iabelling of the conflict
leads to its potential
resolution
by increasing
the awareness of the conflict’s
effects on the actual behavior and emotional experiences of the patient. For example, Wachtel suggests saying to one patient who avoided any serious discussion in therapy, “I’m amazed you’ve been able to do it all these years, and I’m not surprised that you’re now finding it a bit exhausting” (p. f.57). The patient had nut reported distress about this pattern, but this comment alludes to some question or doubt the patient may have about the rigid role she finds herself in which provides space for exploration. Wachtel also incorporates techniques such as reframing and paradox with the hope that patients will become intrigued by the irony that they are ending up creating the situations they desperately
wish to avoid.
Every time Wachtel advocates the use of approaches, such as af%mation, suggestion or even therapist self-disclosure, that he anticipates other theorists or practitioners will disagree with, he provides his rationale for choosing to use them which allows the reader to evaluate the basis for one’s agreement or disagreement. At different parts of the book, Wachtel reviews the writings of other theorists regarding the approach or technique he is advocating to put his suggestions in context or in contrast to others in the field. There are those who will likeiy disagree with Wachtet about
607
Book Reviews
his use of specific techniques or his integration of various paradigms, but in all cases the
reader
will be provoked
to examine
his/her
assumptions
which
is one of the
book’s many strengths. Our experience is that it is often difftcult to get novice clinicians to be aware of and to report the subtle variations in wording and intonation they used in a session unless video or audiotapes did not understand
of sessions are used. Instead, therapists sometimes say that they the patient’s unusual or over-reaction to their supposedly %eu-
tral” interpretations, or they tend to blame the patient’s resistance to change. In fact, one of Wachtel’s most powerful messages is that patients are not simply resistant, hastile, or uninsightful, patient feel that s/he
but that instead the therapist
has not yet found a way to help the
is safe to address terribly painful and often shame inducing
ways
previously adopted to avoid knowing or experiencing parts of themselves. We highly recommend this book to therapists at all levels. It is, however, an especially excellent resource for those who are involved on both sides of the training and supervision process. LYNNE SIQUELAND JACQUES P. BARBER Center for Psychotherapy Research University of Pennsylvania
Abnormalities of Personality: within and Beyond the Realm of Treatment. By M. H. Stone. New York: W. W. Norton & Co., 1993.546 pp. ($50.00).
Michael Stone’s engaging text on personality and psychopathology is written primarily for clinical practitioners. Sufficient theoretical discussion and empirical data are presented to make this book of interest to a much wider audience. The book is divided into three major parts, each with considerably different content and purpose. Part 1 is a review of recent theoretical and research efforts involving both normal personality and disorders of personality. Substantial effort is devoted to discussing empirical findings. Part 2 consists of treatment recommendations for the various personality disorders listed in the DSiVGZZZ-R In Part 3, traits that may be “beyond the realm of treatment” erably less emphasis on research
are addressed. Compared to Part 1, there is considfindings in the latter sections.
In Part 1, frequently cited genetic and biologic studies of personality disorders are reviewed. Much of the research in this area concerns borderline, antisocial, and “schizophrenia-spectrum” the majority of discussion. adaptation
personality disorders. These disorders, therefore, occupy A chapter on the influence of traits on species survival and
is also included.
Long-term
outcomes
for personality
disorders
are dis-
cussed. Interesting data from the author’s research program are presented, with sub categories proposed that have particularly poor prognosis. Part 1 concludes with an integration of biologic, ethologic, and environmental influences on trait develop ment using the five-factor model of personality structure. Part
2 is a compendium
of treatment
approaches
for the personality
disorders
described in the DSM-ZZZ-R The author’s psychoanalytic training and experience is reflected throughout much of this section, especially in the clinical vignettes provided.
Pergamon
BOOK REVIEWS Therapeutic Communication: Principles and Effective Practice. By P. L. Wachtel. New
York: Guilford Press, 1993. 308
pp.
($32.00).
Although there are many helpful books available on the process of therapy, very few of these books focus on “the framing of therapeutically effective comments” (p. 2), what the therapist actually does or says in the room that facilitates or gets in the way of helping patients to resolve their difficulties. One of the strengths of this book is the elucidation of what makes a therapist’s intervention effective at “opening doors the patient has felt he needed to keep closed” (p. 89). Another strength is to provide the reader with such a complex understanding of the dynamics of the therapeutic process without using psychological jargon. Every therapist has had to deal with issues such as how to approach a patient who tenaciously avoids talking about anything painful or who is consistently self critical. Paul Wachtel explains how to approach these patients and how to understand the intense conflict and anxiety underlying their problems rather than to pathologize the patient. He not only gives numerous examples of how to elicit “cooperation rather than resistance” (p_ 3), to decrease defensiveness and to enhance selfesteem while also asking the patient to confront his or her difficulties, but he also articulates overall principles for choosing an appropriate intervention. By clearly outlining the thought processes behind his suggestions, Wachtel helps the reader generalize to other situations. The first two chapters in this book provide the theoretical background for the strategies suggested in the later chapters. The model is grounded in Wachtel’s theory of cyclical psychodynamics that integrates psychodynamic theory with systemic and behavioral theories focusing on the reality that “these deeper (psychologiiuZ)structures not only influence daily interactions and experiences but are influenced by them and/or symbolically represent them” (p. 19). In other early chapters, he discusses the centrality of anxiety and the nature of insight and transference within a cyclical psychodynamic framework. Because of his emphasis on therapist’s interventions that target conflicts and anxiety linked to the avoidance of unacceptable feelings, thoughts, or impulses, he seems to have a psychodynamic view of his patients, Nevertheless, he may be better characterized as an “integrationist” because he addresses at least two additional psychotherapeutic perspectives. At the systemic level, he suggests that both patient and therapist be aware of the role of “accomplices” in the patient’s life in perpetuating maladaptive interactions and the need to discuss together the likely reaction of those significant others to changes the patient may make. At the behavioral level, he will not hesitate to use techniques such as exposure and providing direct advice as appropriate. Wachtel’s primary focus in many of the subsequent chapters is on the often %nnoticed or unexamined” meta-message that coexists with the message the therapist
Book Reuiews
606
intends ta convey. Wachtel states that therapists’ meta-messages,
“the attitude about
what is being conveyed therapeutic describing, munications
in the focal message,” have the “greatest potential for either transfurmation (or therapeutic failure)” (p. 2). His cunt~bution is in
delineating,
and focusing careful attention on how those subtle metacom-
in therapists ’ ‘6neutral” comments are likely experienced by patients. In one of the most interesting and useful chapters, he outlines the difference between
inherent
accusatory
(critical)
and facilitative
(permission
giving)
therapists’
com-
ments contrasting statements like: ‘350~ are defending against feelings of dependency= versus SI% sem to ex$& ~~#~~~~ &r&&z to ~~~ rfrozl have an;r w%i to be lak8n care c!f (P. 73). Wachtel suggests that the core of patient’s difficulties is self-deception and selfalienation in order to avoid anxiety. Thus, it is difftcult for the therapist to help the patient to come to terms with these issues without the patient experiencing
the ther-
apist’s attempts as simply criticism and interrogation. In his view, good interpretations are permission oriented, they help the patient to accept the disavowed. Wachtel offers different ways to help patients become both more aware of their fears about particular anxiety provoking experiences and to be more open to the experience of forbidden feelings and thoughts. For example, in the difftcult situation of trying to address a patient’s tendency to “sabotage success,” he might suggest saying “What is it that you do that, if you weren’t careful, might have the danger of letting you succeed? And what do you do to pull the fat out of the fire, to make sure that doesn’t happen?” Wachtel goes on to explain that “in contrast to a direct statement that she seems to be working hard to fail, this (logically equivalent, but connotationally different) set of questions conveys that if you are not careful you might succeed” (p. 84). Wachtel details additional principles for effective intervention strategies. In one chapter, he advocates a focus on the patient’s strengths and the recognition of the importance of small steps during treatment. He would label a patient’s despair at finding her/himself back in old familiar ways of interacting as simply ‘?esiduals” of old tendencies, rather than as evidence of regression or as something to blame oneself for. Such an intervention helps to highlight the change the patient has made and creates a distinction between past and present behavior. In another chapter, he gives examples of how attributing or suggesting a feeling to a patient that the patient is nut yet aware of having helps to delineate the underlying conflict. This iabelling of the conflict
leads to its potential
resolution
by increasing
the awareness of the conflict’s
effects on the actual behavior and emotional experiences of the patient. For example, Wachtel suggests saying to one patient who avoided any serious discussion in therapy, “I’m amazed you’ve been able to do it all these years, and I’m not surprised that you’re now finding it a bit exhausting” (p. f.57). The patient had nut reported distress about this pattern, but this comment alludes to some question or doubt the patient may have about the rigid role she finds herself in which provides space for exploration. Wachtel also incorporates techniques such as reframing and paradox with the hope that patients will become intrigued by the irony that they are ending up creating the situations they desperately
wish to avoid.
Every time Wachtel advocates the use of approaches, such as af%mation, suggestion or even therapist self-disclosure, that he anticipates other theorists or practitioners will disagree with, he provides his rationale for choosing to use them which allows the reader to evaluate the basis for one’s agreement or disagreement. At different parts of the book, Wachtel reviews the writings of other theorists regarding the approach or technique he is advocating to put his suggestions in context or in contrast to others in the field. There are those who will likeiy disagree with Wachtet about
607
Book Reviews
his use of specific techniques or his integration of various paradigms, but in all cases the
reader
will be provoked
to examine
his/her
assumptions
which
is one of the
book’s many strengths. Our experience is that it is often difftcult to get novice clinicians to be aware of and to report the subtle variations in wording and intonation they used in a session unless video or audiotapes did not understand
of sessions are used. Instead, therapists sometimes say that they the patient’s unusual or over-reaction to their supposedly %eu-
tral” interpretations, or they tend to blame the patient’s resistance to change. In fact, one of Wachtel’s most powerful messages is that patients are not simply resistant, hastile, or uninsightful, patient feel that s/he
but that instead the therapist
has not yet found a way to help the
is safe to address terribly painful and often shame inducing
ways
previously adopted to avoid knowing or experiencing parts of themselves. We highly recommend this book to therapists at all levels. It is, however, an especially excellent resource for those who are involved on both sides of the training and supervision process. LYNNE SIQUELAND JACQUES P. BARBER Center for Psychotherapy Research University of Pennsylvania
Abnormalities of Personality: within and Beyond the Realm of Treatment. By M. H. Stone. New York: W. W. Norton & Co., 1993.546 pp. ($50.00).
Michael Stone’s engaging text on personality and psychopathology is written primarily for clinical practitioners. Sufficient theoretical discussion and empirical data are presented to make this book of interest to a much wider audience. The book is divided into three major parts, each with considerably different content and purpose. Part 1 is a review of recent theoretical and research efforts involving both normal personality and disorders of personality. Substantial effort is devoted to discussing empirical findings. Part 2 consists of treatment recommendations for the various personality disorders listed in the DSiVGZZZ-R In Part 3, traits that may be “beyond the realm of treatment” erably less emphasis on research
are addressed. Compared to Part 1, there is considfindings in the latter sections.
In Part 1, frequently cited genetic and biologic studies of personality disorders are reviewed. Much of the research in this area concerns borderline, antisocial, and “schizophrenia-spectrum” the majority of discussion. adaptation
personality disorders. These disorders, therefore, occupy A chapter on the influence of traits on species survival and
is also included.
Long-term
outcomes
for personality
disorders
are dis-
cussed. Interesting data from the author’s research program are presented, with sub categories proposed that have particularly poor prognosis. Part 1 concludes with an integration of biologic, ethologic, and environmental influences on trait develop ment using the five-factor model of personality structure. Part
2 is a compendium
of treatment
approaches
for the personality
disorders
described in the DSM-ZZZ-R The author’s psychoanalytic training and experience is reflected throughout much of this section, especially in the clinical vignettes provided.