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Stop, Drop, and Roll When Therapy Gets Heated

A simple scheme for monitoring and addressing communication patterns

A therapist has many plates to spin. She must develop and constantly revise a case formulation that makes the therapy relevant to changing the patient. She must listen to manifest content while attending to metaphor. She must manage the frame of the therapy while observing her own reactions to everything the patient does or says. And all this must occur within the context of collaborative bonds with the patient, who can be counted on to mess up the hierarchical and ambiguous therapy relationship in his characteristic manner.

A good place to start in this confusion is to develop some idea of what a therapy relationship is like, through reading, discussion, and especially one’s own therapy (if you can find a therapist who knows the difference between therapy and friendship, between therapy and a professional consultation). One then can use this idea as a template to monitor the therapy. This idea will be clarified by visiting Bateson’s distinction between report and command functions.

Every communication transfers information (its report function) and also defines a relationship between sender and receiver (its command function). When people complain that it’s not what you said but the way you said it, there is a conflict over the roles you are in and the expectations you have of those roles. For example, I expect trainees to be emotionally resilient and intellectually courageous, and I try to communicate with them as if they are smart and tough. When I write, I imagine a reader cut from that same cloth. Embedded in every communication is an effort to establish a particular definition of the relationship. You can convey the exact same information in a way that makes the other person into an underling, a superior, a friend, a lover, or a stranger.

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Couple’s therapists have less to do than individual therapists. A couple’s therapist is like a basketball coach and an individual therapist is like a player-coach. A pretty good model of couple’s therapy has the therapist doing little more than monitoring the clients’ talk and calling a timeout whenever either party says or does something whose command function conflicts with the therapist’s model of how a couple behaves. During the timeout, the couple and the therapist can discuss whether in fact the client breached the couple’s idea of how partners behave and, if so, the client can restate the communication in conformity with the couple’s relational expectations. For example, a straight husband says to the therapist, “The kids are acting up lately.” The therapist makes a timeout gesture and says, “Am I missing something, or is that somehow a dig at your wife?” The wife looks relieved and the couple can now explore whether he knew the statement would make her feel defensive versus not knowing enough about her to anticipate her reaction, whether it is within their concept of marriage to take potshots at each other, whether the costs of such a culture are too great, why he might be angry at her, and whether he can express that anger as a husband does with a wife.

Back to individual therapy—the therapist can monitor communications for their conformity with the way patients and therapists should talk to each other. When the patient departs from his role, the therapist can ask herself if the departure is in fact a departure. This is where reading, consultation, and one’s own experience of therapy as a patient come in. If it is, the therapist can invite discussion of what is going on in the moment analogous to the couple’s therapist’s invitation to metacommunicate about the interaction. When the therapist departs from her role, she can explore the patient’s reactions (not by asking, or not solely by asking, but that’s a different subject) and realign herself with the role of therapist.

There are many disagreements about what is in conformity with and what is out of conformity with the therapeutic roles. But monitoring communications for departures and discussing them together is a good foundation for listening and intervening as you refine your understanding of which versions of these roles work best. When therapy gets heated, apply the old fire safety advice: stop, drop what you were about to say, and roll out a discussion about what just happened. And this is perfectly safe to try at home.

Michael Karson, Ph.D., is a professor of psychology at the University of Denver.

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