During the initial years of training and, indeed, during the remaining course of the clinician’s career, the clinician cultivates a garden of sorts. In this garden, the clinician attempts to develop a variety of perspectives or vantage points from which to gain an increased understanding of the patient. There exists no rational reason for the clinician to become fixated upon one viewpoint. Such a narrowing of perspective is suggestive of the gardener described by Hesse above, who does not comprehend the beauty inherent in each flower, and so heedlessly discards that which may be of most value.
Instead, like the gardener who realizes that a rose delights the eye but a lowly tomato more suitably satisfies the stomach, the maturing clinician begins to understand the advantages of differing viewpoints and schools of thought. Moreover, the maturing clinician avoids over-investment in personal beliefs, always allotting ample time for a good laugh at himself or herself, because taking oneself too seriously is perhaps one of the most common and treacherous traps awaiting the budding clinician.
The perspective of person-centered interviewing engenders a variety of useful vantage points for the maturing clinician to utilize. By vantage point I am referring to the idea that during any specific moment of the interview, the clinician can consciously and intentionally concentrate upon different aspects of the ongoing interview process. These viewpoints can be classified broadly into two clusters – attentional vantage points and conceptual vantage points.
For instance, four common attentional vantage points are: (1) the clinician attempts to look at the patient using as objective a lens as possible; (2) the clinician attempts to listen with the patient, empathically seeing the world subjectively through the patient’s eyes; (3) the clinician attempts to look at himself or herself, in order to understand the manner in which the clinician may appear to the patient; and (4) the clinician attempts to look within himself or herself in order to gain an understanding of the patient from the clinician’s own emotional responses and spontaneously appearing intuitions and fantasies. These four attentional vantage points may be viewed as forming two axes upon which the clinician may rapidly and flexibly move during the course of the interview (Figure 21.1). Each vantage point can provide information that the others may easily miss or may literally prevent from being accessible to the clinician.
Beside these four attentional vantage points, numerous conceptual vantage points can be utilized. Indeed, the number of conceptual vantage points is at least as large as the number of differing theories of counseling and psychotherapy – hardly a small dinner party. In this chapter, three of these conceptual vantage points will be explored, including the perspective concerned with attempting to evaluate the patient’s suitability for dynamic psychotherapy, the perspective concerned with deciphering the underlying personality structure of the patient using Kernberg’s structural interviewing, and the clinician’s ongoing use of intuition and spontaneity. Earlier, in Chapter 4, we examined in detail a fourth conceptual vantage point, facilics, which represents an attempt by the clinician to focus attention on the structuring of the interview as it actively unfolds in order to create an engaging, conversational feel to the interview.
Each of these conceptual vantage points represents a rich new vista from which the clinician may gain fresh insights. The more of these perspectives with which the clinician feels comfortable, the more flexible the clinician’s style and the more fascinating the art of interviewing becomes. The clinician becomes constantly surprised by new pathways to follow suggested by the developing characteristics of the immediate interview.
Some clinicians seem to move effortlessly between these various vantage points, with little or no conscious awareness that such movements are being made. Such a natural gift for utilizing varying perspectives is not typical. The more usual course consists of slowly learning about the advantages of each perspective, first in a didactic sense and subsequently through experience. As clinicians consciously employ differing vantage points, these clinical perspectives gradually become increasingly more natural, eventually becoming integrated aspects of the interviewer’s style. As more experience is gained, frequently the shifts become spontaneous and more intuitive, leading to the sense of surprise, mentioned above, as the clinician happens upon an insight that was not viewable from a previous perspective.
As this stage of integration occurs, clinicians frequently report experiencing more vivid feelings while interviewing, and, indeed, the practice of interviewing is never the same again. Gratifying transformations in the psyche of the interviewer unfold. To the clinician adept at switching vantage points, clinical challenges, such as encountering potential points of disengagement and even anger, tend to evoke more intellectual excitement than they do fear. In this regard, talented interviewers enjoy their work, as evidenced by the spontaneity of their mannerisms and wit. As we have seen in the first two chapters of Part IV, this ability to effortlessly shift vantage points is an advanced skill, for it requires a relatively well-developed observing ego.
Our quest now becomes one of discovering a practical method of incorporating the ability to change vantage points into the development of the clinician. We have already found Sullivan’s concept of participant observation to be quite useful in this regard. I would like to share a similar concept to that of Sullivan’s. But this concept sheds a slightly different, and, I think, insightful light on the topic. And it came from a far different field than mental health. Towards this end, let us now briefly wander into the somewhat enigmatic world of the “philosopher” G. I. Gurdjieff.1
Gurdjieff was born in the 1870s in the Caucasus region of what is now Russia. He eventually found his way to Western Europe, where he established the Institute for the Harmonious Development of Man in Fontainebleau, France. Controversy and fanatic fervor were destined to follow Gurdjieff throughout his career more dependably than his own shadow. He would be called everything from a philosopher and sage to a charlatan and fraud. In the last analysis, there may have been a good deal of truth in all of these attributions. No doubt exists that Gurdjieff, at a minimum, was gifted with both creativity and wit. We turn to a study of him, not because of his more occult and suspect beliefs, but because Gurdjieff developed a remarkably modern view of human psychology, much of his thinking focusing on the interpersonal matrix as well as man’s abilities to develop increased self-awareness.
He felt that most people operated, during their moment-by-moment existence, in a habitual fashion, seldom “awake” to both what they were doing and why they were doing it. In such a state, he postulated that it was impossible to effectively alter behavior or patterns of thought, owing to habit acting as a protective shell against self-growth. Consequently, Gurdjieff attempted to help people gain an awareness of their spontaneous thoughts, emotions, and body movements.
In one famous exercise, as his dancing troop performed a strenuous routine, he would intermittently clap his hands. At the sound of the clap, all dancers were to hold their positions no matter how complex. Difficult to do, I might add, if one happens to be mid-air at the time of the clap. With this exercise, Gurdjieff attempted to instill in his dancers an immediate awareness of the normally unconscious movements and positionings of their bodies.
Although quite serious about his beliefs, Gurdjieff had a knack for making sure that neither his students nor those who came to observe his training programs took themselves too seriously. With regard to the above exercise, it is said that during one performance, he sent his dancers racing towards the audience. Gurdjieff clapped, rather late it would seem, and his dancers froze into human statuettes as they soared into the front rows of the audience. The startled audience had clearly expected the dancers to be halted before takeoff, as did the dancers. But then Gurdjieff did not generally work from the realm of the expected.
Of more importance to us, Gurdjieff further developed his idea of increasing self-awareness into the concept of “self-remembering,” a phrase ideally suited for application to the arena of clinical interviewing, as we shall soon see. Periods of self-remembering occur when people suddenly become aware of their own immediate activity and existence. These periods represent the breakdown of mere habit and are frequently accompanied by a sense of awe or wonderment. For interviewers it is that moment when they become aware of their own participation in the interviewing process. An important distinction must be made here. At these moments of self-remembering, clinicians are not just listening to the patient, they are aware that they are listening to the patient. This ability to step outside of the process itself is similar to the analytic concept of developing an observing ego as well as the Eastern concept of mindfulness – the ability to look at one’s own actions as they are unfolding.
Now we can see why it is worthwhile examining the beliefs of Gurdjieff, because during periods of self-remembering, the clinician can consciously choose varying vantage points, at times with an amazing rapidity. The ability to insert periods of self-remembering into the interview itself provides the solvent that loosens the ties of habit binding many untrained interviewers. In this regard, several times during the scouting period, the clinician can consciously move into interludes of self-remembering, during which various vantage points may be explored. During the remainder of the interview, I find it useful to insert at least four or five other periods of self-remembering.
In the early stages of training, clinicians generally must consciously insert periods of self-remembering while consciously utilizing differing vantage points. Eventually, however, interviewers become adept at entering them with ease. Soon enough, these periods of increased awareness appear spontaneously as well. For skilled interviewers, there is a feeling of being at home during these periods, as if all their resources were suddenly at hand, which is indeed the case. It is a moment of balance, the natural poise that marks the style of a veteran clinician.
These moments of self-remembering are at the very heart of psychotherapy. Through them the therapist changes vantage points, utilizing various conceptual frameworks or shifting into a purely intuitive mode. At these interludes, the therapist’s own fantasies are transformed from distractions into avenues of insight. These interludes of self-remembering, through which the clinician flexibly adopts various vantage points, represent true bridges into the psychotherapeutic process itself. To the degree that the clinician can develop an ability to frequently experience periods of self-remembering, this will, in some respects, determine the clinician’s ultimate potential as an interviewer or a psychotherapist.
It sounds simple, but this ability remains one of the most elusive skills for the beginning clinician. Some clinicians never obtain it. To further our understanding of the uses of self-remembering, in the remaining sections of this chapter we shall examine in detail the four attentional vantage points and the three conceptual ones mentioned earlier. With these discussions providing an operational framework, it is hoped that the reader will then apply these vantage points in the actual interview situation during periods of self-remembering, for only experience can act as the real mentor at this stage of development.
Exploration of the Attentional Vantage Points
Looking at the Patient
We are already well versed in this important attentional vantage point, for it was the entire focus of our discussion in Chapter 16 on the impact status and mental status. Some may view this attentional vantage as the most obvious and simplistic: looking at the patient. But, as we saw in Chapter 16, this vantage point is far from simple; nor is it easy to attain. It requires a true discipline in order to utilize it effectively. Sensitive clinicians are frequently drawn toward the vantage point of looking with the patient in an empathic sense. Naturally, this empathic perspective is extremely valuable and, in a sense, is critical for success. But it can be a trap if the clinician over-utilizes it to the detriment of other vantage points, such as looking at the patient.
As we saw in Chapter 16, two slightly different approaches are useful when attempting to observe the patient with a sensitive eye – the “impact status” and the mental status. It is worth reviewing them just briefly to remind yourself of their distinction. If you will recall, the impact status refers to the immediate behavior and affect of the patient at any single moment of the interview. Thus, the impact status represents a quick “mental take” on the patient, in which the clinician focuses upon the immediate impact on the patient of both the patient’s inner world and of the behaviors of the clinician. In contrast, the mental status is a composite snapshot of all the observations made during the course of the interview.
Since we have already explored both the impact status and the mental status in Chapter 16, I refer the reader to that chapter if interested in a review of the topic. Consequently, it is now best to turn our attention to the next attentional vantage point, one that is familiar for all empathic interviewers – looking with the patient. But it is a vantage point that holds many more clinical nuances than its familiarity might suggest.
Looking With the Patient
Looking with the patient, the second attentional vantage point, is frequently viewed by many clinicians as the most natural and appropriate during interviewing. It is the perspective of empathic listening. Its importance cannot be overstated. I have never seen an accomplished interviewer who was not adept at it. This vantage point remains so integral to the interviewing process itself that we have already discussed many aspects of it in the previous sections of this book.
Pertinent concepts discussed thus far include the engagement process, blending, unconditional positive regard, empathic statements, the empathy cycle of Barrett-Lennard, the phenomenological perspective, tracking, the use of natural and referred gates, and the numerous nonverbal techniques utilized for conveying empathy to the patient. In this section we will not emphasize these concepts again. Instead we shall look at some new ideas, which provide further avenues for understanding the patient’s experience of living. These concepts include somatic empathy, the linguistic techniques of Grinder and Bandler, and counterprojective techniques as described by Leston Havens.
Somatic Empathy
Somatic empathy was alluded to in the chapter on nonverbal techniques. It is based on the precept that the posturing of the patient’s body not only reflects the defenses and feelings of the patient but also serves to foster a way of experiencing the environment itself. For example, a tight-fisted man who sits persistently grinding his jaw will, by the very act of grinding his jaw, experience the world in a “tight-jawed” fashion. One is reminded of the work of Wilhelm Reich, who discussed the term “body armor,” a term suggesting that body positioning may itself represent a type of defense mechanism or manner of coping with the stresses of the environment.2
In its most effective form, somatic empathy is fostered by literally assuming the position of the patient. Thus, it is usually done not in the presence of the patient but between therapeutic sessions. By assuming the patient’s posture or mannerism, the clinician obtains an actual feeling for what the patient was experiencing in the session itself. Clinicians can allow their imaginations to wander freely in the assumed position, noting everything from spontaneous fantasies to muscle tensions. It is sometimes quite surprising to experience the peculiar sensations of rigidity and tension that many patients literally carry around with them. This simple exercise, if carried out in an uninhibited fashion, can provide a powerful experience for the clinician, producing a peculiar sense of closeness with the patient – as if suddenly understanding, for the first time, what the patient had been saying.
I am reminded of one woman who spoke with a flutter of gesticulations, as if her wrists were floppy hinges. At times during the initial interview, she would hang her arms down over the arms of the chair. From this position they would jerk around, banging loosely against the arms of the chair as she spoke, a human Raggedy Ann. After the session, when I actually attempted to mimic these movements, I was surprised at the unsettling sensation of being out of control that such posturings could produce. The patient’s world was just such a “theater of the helpless.”
At times during the session itself the clinician may note a small gesture of the patient, perhaps a way of holding his or her hand, that can be mimicked immediately without the patient’s awareness. This exercise may help move the clinician into a more empathic understanding of the patient at that moment in time.
Deep and Surface Structure
Leaving the world of nonverbal behavior, the focus can move to a method of increasing an understanding of the patient’s world, determined by the patient’s language itself. Decades ago, Grinder and Bandler developed a conceptual model that has proved to be a valuable adjunct for both initial interviewers and therapists. Their framework helps clinicians to move more effectively into the world of the patient. The following description provides a brief introduction to these techniques, and I urge the reader to look at the original work itself.3
At one level, language results from the experience of the human organism as it attempts to translate information into a code that can be immediately understood by other organisms. But the code itself may ultimately begin to determine the manner in which the organism experiences the surrounding world. In a sense, humans begin to limit their interpretations of their experience to those that can be encoded by the language. Unfortunately, as this process unfolds, the language begins to limit experience as opposed to describing it. Stated somewhat differently, the range of actual human feelings and perceptions is vastly more complicated than the language can describe.
By way of example, if there exist only four words to describe snow, then the person will probably pay little attention to the numerous variations among different types of snow. On the other hand, if there existed 20 nouns to represent snow, the human would, by the nature of the language itself, need to pay more attention to what type of snow was encountered in order to communicate the experience clearly.
Such is the case with downhill skiers, who have developed a variety of words for describing snow, for their enjoyment of the sport has much to do with the “conditions” of the snow (e.g., hardpack, powder, corn, icy, crud, slush, etc.). In a similar sense, although the number of words in the Inuit and related languages for snow is roughly the same as in English, the structure of the language allows speakers to effectively describe numerous subtleties in the characteristics of the snow itself, characteristics that can have a profound impact on their travel and livelihoods. Whether it is the actual number of words for snow (skier) or the variations attached to each word (Inuit), a person armed with 20 words and/or nuances for snow may notice the characteristics of the snow much more intensely than a companion limited to two words.
Experience can literally be determined by language. In this sense, it becomes crucial for the clinician to listen to the language utilized by the patient, for the possibility exists that the patient’s language may be creating a framework that is detrimental to the patient, because it limits or distorts the patient’s view of actual circumstances.
The language used in daily conversation tends to represent a “shorthand” of what the person is actually thinking. Large amounts of the actual message may be left unstated and lost to the receiver of the message, in this case the clinician. Even more disturbing is the possibility that the patient will begin to conceptualize the situation via the limiting framework of this shorthand message.
At first, these ideas may appear somewhat abstract, but they become clearer if one views language as having two different levels of meaning, depending on the completeness of the message communicated. Based on the study of transformational grammar, Grinder and Bandler describe these two levels as deep structure and surface structure. A very simple and effective method of seeing the world more clearly through the patient’s eyes consists of gently probing the patient’s surface statements until both the patient and the clinician discover the deleted deep structure (Figure 21.2).
An example may serve to clarify. Suppose the patient makes the following statement: “People constantly hurt me.” This statement has emerged from a specific substrate that is potentially ripe with powerful information to the clinician but is currently unavailable. There must exist a deep structure, as illustrated below, from which the patient’s comment was transformed.
The deep structure holds many important secrets. Is the patient referring to all people, people at work, his parents, or his siblings? Is the pain the “hurt” of rejection, shame, inferiority, or abandonment? Grinder and Bandler maintain that by gently seeking answers to such questions, the clinician will gradually uncover progressively more important material, and, at times, the patient may be surprised by the implications of the deep structure. For instance, the patient may have been unaware of feeling rejection or the pain of sibling rivalry. Such discoveries may eventually change the patient’s perception of the related experience itself. In any case, at the very least, the clinician gains a better view of what the world looks like to the patient. Let us see the technique in action:
Pt.: People constantly hurt me.
Clin.: Exactly which people are you talking about?
Pt.: Oh, my wife and her brother, I hate him so much.
Clin.: What other people are you referring to?
Pt.: Well I … Let’s see, her sister is pretty nasty too.
Clin.: What about your own family?
Pt.: Well, my brother is hard to get along with, but my parents are actually pretty supportive. (pause) You know, come to think of it, my parents really have been pretty nice to me recently.
Clin.: It sounds like that seems different to you than in the past.
Pt.: (patient chuckles) To tell you the truth, a year or so ago I’d have been telling you how much I hated my parents, but they really seemed to change back then. (Undoubtedly the patient, either consciously or unconsciously, is referring to a specific time or event by the word “then,” so the clinician probes for the deep structure.)
Clin.: When did you notice the change?
Pt.: Back when Jan and I moved out of their house. I don’t know, maybe living with them was a strain on all of us. It really was too crowded, uh, felt cramped, sort of like a crowded bus station?
Clin.: Do you think your parents realize that you appreciate their new attitude?
Pt.: Hmmm, I really sort of doubt it. Maybe I ought to give them a call sometime, maybe.
Clin.: Let me make sure I have this straight. You’re having increased problems with some specific people in your life, like your wife. On the other hand, your relationship with your parents has matured and is actually stronger?
But what a different nutshell than the patient began with. By uncovering the deep structure, the patient has come upon information that is both revealing and comforting. The original statement, “People constantly hurt me,” was a gross distortion caused by generalization. Since the patient came to believe this generalization, the situation seemed worse than it was in reality, because, in truth, some good things were also occurring. By probing for the patient’s deep structure, the clinician has clearly gained a more accurate perception of what the world looks like to the patient. Yet there is more to the story, because the patient is now viewing the situation in a slightly more positive light. The therapeutic process itself has begun.
These uncovering techniques described by Grinder and Bandler serve as another bridge into the therapeutic process, for the patient may “stumble” upon a more realistic and less threatening perception of reality. These uncovering techniques are similar to the principles behind therapeutic modalities such as cognitive therapy or rational emotive therapy.
In this example, the clinician chose to explore the subject of this sentence but could have just as easily chosen to explore the deep structure beneath the verb or the adverb. In fact, by exploring what the patient meant by the word “constantly,” the patient may very well have discovered that his wife is not always mean to him, a realization that may be of some importance.
Grinder and Bandler state that two of the more frequent transformations that occur between the deep structure and the surface structure are deletions and generalizations, as illustrated in the dialogue above. Although this uncovering technique appears at first glance to be almost too simple, it is remarkably powerful. In order to use this technique well, the clinician must be able to switch vantage points.
Counterprojective Statements
The next technique, our third and final one from the vantage point of looking with the patient, is the use of counterprojective statements. It yields yet another method of improving the engagement process as the clinician attempts to see the world with the patient.
Counterprojective techniques were developed by Leston Havens for use in psychotherapy itself as well as during the initial interview.4 Their use is described in detail in his highly informative and entertaining book, Making Contact.5 More recently, Havens re-addressed counterprojection, adding new nuances for its effective use.6
Counterprojection is utilized when a guarded or actively paranoid patient is beginning to project hostile impulses onto the clinician. At these moments it is very difficult to view the world through the patient’s eyes, because the patient’s focus is on the clinician, who may appear to the patient as representing an antagonistic “other.” For engagement to proceed, the clinician must switch the focus of the patient off of the clinician and onto a common “screen” that both the clinician and the patient can look at together. Put more colloquially, the clinician wants the heat off himself or herself. In our chapter on transforming points of potential disengagement, such as MADs (moments of angry disengagement) and PDQs (potentially disengaging questions), we caught a glimpse of counterprojection being effectively utilized (see pages e57–e58). At present, let’s examine the nuts and bolts of how to actually use this technique, in the detail it deserves.
The goal of the counterprojective statement is to deflect the projection off of the clinician before it becomes stabilized and difficult to defuse. In the specific context of the initial interview, the goal is to immediately deflect the patient’s suspicions while subsequently sidetracking the patient to a new topic that is away from a focus upon the clinician. It is hoped that this sidetracking will provide the clinician with enough time to shore up the engagement process, resulting in a more trusting alliance. In a simplistic sense, the principle works upon the adage that one should not try to stop two people from arguing, for, soon enough, the two will turn on the newcomer as the common enemy. With counterprojection, one attempts to find a common antagonist or topic on which to focus the attention of both the patient and the clinician. Let us watch the technique in action:
Clin.: What were some of the problems that have been particularly upsetting to you, Mr. Hughlings?
Pt.: They’re really quite specific and relate to the needling behavior of my wife, who has to know everything.
Clin.: What are some of the specifics?
Pt.: That’s rather difficult to say. She’s got her own problems, if you know what I mean.
Clin.: What are some of the things that are most unsettling to you, that you came here today about?
Pt.: I don’t really see why the details should concern you; I don’t like it when people ask too many probing questions, if you catch my drift.
Clin.: I don’t like it when people push me to talk about things that I don’t feel like talking about either. (counterprojection) Let’s back off for a moment. I take it your wife has been pushing and prying recently. (sidetracking back to the wife) Is that correct?
Pt.: Yes, she’s gone further than she should, if she knows what is good for her.
Clin.: She’s always on your case then.
Pt.: Absolutely, I’m really tired of it.
Clin.: Is this a totally new behavior for her or is this sort of a long-standing trait that has gotten worse?
Pt.: It’s gotten much worse, but I think she’s always been part busybody; it’s in her genes.
Clin.: Her family was also like this?
Pt.: You better believe it. In particular, her mother was a real busybody. Right from the start I knew I was heading for some tough times. You know, the problem is that you don’t just marry a person, you marry the whole family and this one came from the cheapest level of the bargain basement.
In the beginning of the dialogue, we find the patient answering with the vagueness that frequently typifies a guarded or paranoid patient. As the interviewer attempts to clarify some of the muddy waters, a curious process begins to unfold. The patient’s anger towards his wife is beginning to be projected onto the clinician himself. The situation is personalized by the comment, “I don’t really see why the details should concern you.” Immediately the patient and the clinician are becoming two separate worlds oppositionally staring at each other, in contrast to two people jointly observing the world “out there.” An antagonism is rapidly brewing as the paranoid attitude begins to solidify a projection onto the clinician.
To make matters worse, the patient proceeds to accuse the clinician of the very same behaviors that the patient perceives in his wife – “who has to know everything” – with the comment, “I don’t like it when people ask too many probing questions, if you catch my drift.” At this point the clinician is rapidly becoming enmeshed in a sticky unconscious flypaper. It is time to make a retreat, to deflect the projection.
To accomplish this task, the clinician responds, “I don’t like it when people push me to talk about things that I don’t feel like talking about either.” The clinician reports feeling a very similar emotion to what the patient has expressed. Suddenly, the clinician and the patient are part of the same camp, which is looking out at all those people who are “too pushy.” It is very difficult for the patient to continue attacking the clinician for a behavior that the clinician also dislikes and claims to be seeing in others. Subsequently, the outside focus is solidified by the clinician identifying a specific new object for the joint focus of the patient and himself. The clinician gently moves the focus back onto the patient’s wife, the original focus of the patient’s ire, with the statement, “I take it your wife has been pushing and prying recently.”
At this point the heat is off the clinician. Both he and the patient focus their attention on the patient’s wife. The follow-up statement, “She’s always on your case then,” is also enhancing the counterprojective process by further focusing the patient’s attention on an object removed from the clinician. The projection has been successfully deflected. The interview proceeds on course. Note that the clinician does not accuse the wife, but merely reflects back the sentiments expressed originally by the patient earlier. Clinicians must be careful not to join the paranoid process, but rather to simply deflect it away from themselves.
Havens points out that three elements must be present for a counterprojective technique to function effectively. First, the object that is chosen for the new focus of attention must be “out there,” thus ensuring that the patient’s projection will move to a new focus of attention. Second, a specific object or concept (as opposed to a vague generalization) needs to be mentioned so that the patient’s attention will become firmly focused. The interviewer can generally create this sense of specificity without directly naming specific people or organizations, for it is best to avoid doing so, unless the patient has already done so (as illustrated in the dialogue above). And, third, the clinician relates feeling an emotion similar, if not identical, to that being felt by the patient. In this fashion, the clinician and the patient are plopped into the same worldview, both of them looking out at those nasty objects that upset them. From this more common ground the clinician can then work to establish a more well-grounded alliance.
In contrast to the above dialogue, counterprojective statements generally are phrased in the third person, such as, “he always seems interested only in himself,” or “they never seem to understand you.” The third person stance emphasizes the concept of directing the patient’s projection away from the interviewer so that there is something “out there” to be discussed and jointly observed by the patient and the clinician. Havens also notes that these third-person clinician statements may convey an empathic quality.
In the dialogue above, we can see counterprojection being demonstrated when a patient has been describing a paranoid or angry attitude towards a specific person. In such a case, in order to avoid being clumped in with the patient’s perceived persecutor, the counterprojective technique is used to distance oneself from that person.
Much more frequently, clinicians use counterprojections in a more generic sense, attacking “bad things or situations” commonly viewed as problematic in the culture. For instance, if one becomes suspicious in the scouting phase that a patient is paranoid, counterprojective statements can be used to pro-actively establish a collaborative stance with the patient early on in the interview. This type of proactive use of counterprojective statements can decrease the likelihood that the patient will throw a paranoid projection onto the interviewer. Proactively employed in this fashion, the counterprojective statements are once again usually third person in nature and sound something like this, “Everybody’s running around looking out only for themselves,” or “It’s tough out there, hard to get a fair break.” Also note that with these type of counterprojective statements a clinician can create a sense of specificity (Haven’s second requirement for effective counterprojection) without actually naming specific people or organizations.
As illustrated above, in some instances the clinician may opt to utilize first-person statements (as opposed to third person). Such first-person statements tend to amplify the shared quality of the emotion expressed by the clinician with the emotion being felt by the patient. Sounds good; but there’s a potential significant problem if one chooses to use first person. First-person statements carry the risk of backfiring by inadvertently focusing the patient’s attention back onto the clinician, because with first-person statements you really need “to own” the statement. For instance, in the above dialogue, after the clinician said, “I don’t like it when people push me to talk about things that I don’t feel like talking about either,” the patient could have interrupted saying, “Then why are you doing it?” This experienced clinician avoided this possibility by quickly, and effectively, sidetracking the patient with, “Let’s back off for a moment. I take it your wife has been pushing and prying recently. Is that correct?”
In any case, first-person counterprojections should be utilized judiciously and I recommend that they be employed only after interviewers have thoroughly become familiar with using third-person counterprojections. But in some situations, first-person counterprojections can be remarkably effective. For instance, a talented psychiatric resident described the following interaction. An actively paranoid woman interrupted an initial session with an accusatory tone, “Is this office bugged?” The resident responded, “It would upset me greatly if my office were bugged. No it isn’t.” The patient accepted this counterprojective deflection readily, and the session continued in a fruitful manner.
We have now reviewed three techniques for enhancing the ability of the clinician to move into the vantage point of “looking with the patient.” Essentially the two vantage points explored so far, looking at the patient and looking with the patient, lie at either ends of an axis whose focus is the patient. The same type of attentional axis can be conceptualized using, not the patient, but the clinician as the focus of attention. Just such an axis is the topic of the next two sections.
Looking at Oneself
This section focuses on the vantage point through which the interviewer attempts to objectively look at himself or herself. The ultimate goal is for clinicians to develop an accurate sense of how they appear to the patient. In this sense, clinicians search for their own identifying persona. Naturally, the interviewers cannot know for certain in what ways their persona may be affected by the patient’s process of parataxic distortion, but clinicians should possess at least a baseline understanding of their own typical appearance and behavior. From this increased self-awareness, interviewers may be able to ward off certain aspects of parataxic distortion before significant problems with blending occur. For instance, a clinician who tends to be rather warm and extroverted may purposely tone down his or her style when initially encountering a paranoid patient, because the clinician is aware that the paranoid processes of the patient may predispose the patient toward distorting the warmth into a sinister attempt to “trick me into trusting you.”
Two aspects of this vantage point complement each other. First, during the interview itself the clinician needs to be able to utilize periods of self-remembering, which enable one to ask, “How do I appear to the patient at this moment?” As mentioned in the chapter on nonverbal behavior, this “watching attitude” can be facilitated by imagining a mirror dropping in front of oneself during the interview. This concrete exercise can increase the interviewer’s ability to rapidly assume this specific vantage point. The second aspect of this vantage point concerns gaining a knowledge of how one appears, not through imaginative techniques but via feedback provided by outside observers.
In this regard, the importance of supervision cannot be overemphasized. Four types of supervision are particularly powerful in helping clinicians to gain an understanding of how they come across to patients. These four types of supervision include (1) video-recorded supervision, (2) behind-the-mirror supervision (which sometimes includes “bug-in-the-ear” ongoing comments from the supervisor behind the mirror), (3) direct in-the-room observation by a supervisor, and (4) feedback obtained from observing peers (collegial supervision). The numerous advantages offered by video-recorded supervision and behind-the-mirror supervision are well known, but the latter types of supervision are probably equally of value.
Direct supervision, in which the supervisor sits in on the interview itself, provides a chance for the clinician to be directly observed during actual clinical conditions. The supervisor can also immediately demonstrate techniques, by temporarily becoming the interviewer, as potentially disengaging points, angry confrontations, or awkward moments spontaneously arise. To watch a supervisor demonstrate methods for gracefully transforming such challenging moments is invaluable and never forgotten by a trainee. Despite the naturally occurring unease trainees experience at the idea of having a supervisor directly in the room observing, I have found that many frequently request large amounts of this type of supervision once they have experienced it.
Obtaining feedback from peers provides a fourth avenue through which a wealth of information can be gained, because each observer tends to notice different aspects of style. Naturally, the observers learn as well, for each trainee brings fresh techniques that may be modeled by other trainees.
In this light, it should be emphasized that it is also useful to supervise others. Besides providing an opportunity to observe potentially useful techniques developed by others, the act of supervision trains the clinician to accurately observe the interviewing process. If one cannot first learn to astutely observe the styles of others, then it is highly unlikely that one will be able to effectively study oneself. In this sense, it is frequently invaluable to find a peer with whom one can trade-off the supervisory role.
In any case, by utilizing the above techniques, clinicians work towards a sophisticated understanding of their own appearances. Interviewers should ultimately be able to describe their styles along various continua including the following:
