In Practice

A Practicing Doctor's Views on Psychiatry and Contemporary Culture.
Peter D. Kramer is a psychiatrist and author. His books include Against Depression and Listening to Prozac. See full bio

Sports Talk: Getting Out of the Back Seat

Sports metaphors, for better and for worse.

Not Dr. KramerDavid Brooks lays out some sports instruction in his op-ed column, winding up with a weak effort to turn the admonition “focus on the task” into anti-liberal sentiment. In the process, Brooks takes a slap at psychotherapy (or its social influence), implying that it makes people narcissistic: “Not long ago, Americans saw the rise of a therapeutic culture that placed great emphasis on self-discovery, self-awareness and self-expression. But somehow the tide seems to have turned from the worship of self . . .” Thanks, David; we needed that.

(Vaguely) apropos: It’s not only pundits who like metaphors drawn from coaching. Training gives rise to powerful images, and we use them where we will. My own favorite, for psychotherapy, comes from skiing. It goes: “If you are way in the back seat, and you move up to a little bit in the back seat, you are still in the back seat.”

That sentence appears in The Athletic Skier, by Warren Witherell and David Evrard, in a chapter titled “80/20 : 20/80.” Witherall and Evrard say that when you change your balance, “The first 80 percent of correction provides a 20 percent gain in performance. The last 20 percent of correction provides an 80 percent gain in performance.”

Two weeks back, I found myself in a ski class. I had business in Maine. The snow was record-setting this year, and so between obligations, I fit in a day on the slopes. There must have been a promotion in play, because a group lesson came with the lift ticket—and there I was.

I’m a fanatical mediocre skier—addicted, but not naturally graceful. An instructor once complimented me on my balance. To carry so awkward a stance down the mountain was, in her view, a sign of some endowment. Still, I’ve stuck with the sport long enough to have inched my way into the advanced group. Even at that level, it’s the same damn thing. You cheat, you hold back, you don’t let your body head down the mountain.

The techniques of skiing have changed, because skis have changed in shape and composition. Probably half of what’s in the Witherall and Evrard book no longer applies. And then there’s local wisdom, Stowe versus Taos. How to initiate a turn, how to vary its shape, how to distribute forces on the skis—oddly, opinions on these issues differ. What remains constant in lessons is the encouragement, against all (non-athletes’) instinct, to stay forward. That’s why you face down the fall line, set your hands low and level, bend mostly from the ankles, and the rest — to get your weight over the skis. It’s never just one element, it’s all of them. If you obey everything the instructor says and then you jut your butt back, to hold your weight uphill—you’ve defeated the exercise. You need to do ten things right, which is to say you need to do the one big thing right, getting out of the back seat.

So much adaptation fails because it is partial — uncommitted. A husband will stop making endless small cutting remarks, limiting himself to a few really undermining ones. An alcoholic will slash his consumption by a third. An intrusive parent will phone four times a day instead of six, and then be hurt when the child seems not to notice. Nothing counts as change unless it can be experienced as change. It’s the final 20 per cent.

Of course, it’s the therapist’s job to acknowledge the first 80 per cent while reminding the patient that no one else is likely to. The first 80 builds skills. The last 20 makes things happen.

On the other hand, if you leave the back seat before the basic skills are in place—before you’ve developed some justified confidence—you’ll injure yourself. Therapists need to remember that often patients are in the back seat because they know that if they moved forward, disaster would ensue.

I should say that I try not to use this favorite metaphor, just as I try not to ask patients how something feels. That question puts people on their guard. So does any image that comes from the therapist’s private stock. Tropes should be tailored to the patient.

The followers of Milton Erickson teach this point. Erickson was a hypnotist whose adherents, in the 1970s and after, elaborated his practice into a school of treatment. I attended an Ericksonian seminar in the early 1980s. The instructors taught students to listen: Is the patient’s speech urban or rural? Spare or flowery? Commercial or literary? Musical or muscular? The therapist responds in kind, conducting treatment in that sort of language.

The approach is a form of what my mentor, Leston Havens, a Harvard-based psychiatrist, calls “imitative empathy.” The therapist joins the patient by mimicking his or her inner speech. (Havens remarks that this technique is a good thing not to be caught at.) Imitative empathy is rediscovered periodically, most recently by experimental psychologists, who have confirmed its utility as an aid in social bonding.

This nod in the direction of exact attunement is a way of postponing my confession that now and then I find myself speaking in my own tongue and discussing with a patient what it would mean for him or her to get out of the back seat. When I do, I try to avoid sounding like a right-wing, up-by-your-bootstraps scold. I’d prefer for change to evolve not from exhortation, but from self-discovery, self-awareness and self-expression.



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