A Heuristic Figure for Explaining the Need for Deeper Therapy.

ABSTRACT: A simple and brief intervention for explaining to clients and third-party payers the need for deeper therapy is described.

Introduction

The need for working at deeper levels to produce personal transformation is often more evident to the therapist than it is to the client, or the client's insurer. My experience is that clients most frequently come into therapy having abundance issues they do not recognize as being treatable. They ask pointedly about cost, and expect briefer interventions than can reasonably be expected to be successful. Third party payers express many of the same issues and beliefs.

This is a time when surface level interventions are in vogue. Clients and their insurers know about "brief therapy", and often ask for it as if they were ordering from a menu. Both clients and insurers often seem unaware that studies reporting positive outcomes to brief interventions utilize inclusion criteria which would select out many of the typical private practice clients. Certainly clients who have experienced repeated trauma and/or abuse in the family of origin would not usually be included as subjects in studies oriented toward promoting typical brief interventions as effective and valid therapeutic tools. This is especially so if the emotional feelings surrounding the experience in the family of origin have been suppressed or repressed by the client.

For example, one typical criterion for inclusion of subjects in impact studies of brief interventions is that the client be able at the outset to identify their problem in some detail and with clarity. My experience is that the clients who come here do not typically meet this criterion. For example, calls are frequently received from people who say that their problem is that they wish to quit smoking. Even a cursory telephone interview quickly discerns that these people do not need help quitting smoking. They have quit repeatedly over the time they say they have been smokers, and are ready to quit again. The problem is that, having quit, historically they repeatedly have started smoking afresh. So, the problem they state is not the problem they have. They do not need help to quit smoking. They need help to keep from returning to the habit once they have stopped. They appear to be unable to identify the problem clearly, even for a simple addiction such as smoking. In all likelihood, brief (surface level) interventions would not work.

Over the years, I have tried a variety of methods for explaining the reasons why, in the usual course of events, therapy needs to go "deep". The impact of the different methods has been variable. Recently, I have been using a simple diagram developed here. This diagram appears to have great impact on the clients who walk through my door seeking help. In a matter of a few minutes, the client who was protesting that she just wants to "get on with her life" and doesn't want to dig around in the past and blame anyone (especially her parents, who "did the best they could") opens to the idea that a deep intervention is needed, together with all the exploration and soul-searching such an intervention entails.

This figure is typically drawn in the presence of the client, the therapist developing the details of the figure while a brief narrative is recited. In the paragraphs which follow, the narrative is presented in more or less the same form as it is used with my clients. Actions taken by the therapist are in ordinary typeface. The narrative text is in italics.

[Figure ILLUSTRATION OMITTED]

The therapist asks for permission to sit next to the client, for the purposes of drawing a diagram.

Any theory of development divides time into epochs or stages. For example, Freud's (1925)psychosexual stages of development (oral anal, genital latency, adolescent, and adult) describe development over the first 20-25 years of human life. Don't worry; we're not going to go into detail on those stages. It's simply an example of a developmental theory; one you've probably heard parts of, yes?

Now, Freud had a student named Erik Erikson, who was quite interested in human development. He argued that human development continues throughout life, and described several stages of development which characterize different times during adulthood (Erikson, 1950).

The therapist draws a box and writes "Stage I" in it.

I want us to look at his first stage, because it serves as a model for any developmental stage, whether you go along with the rest of Erikson or not. Most people relate to it, and find it easy to understand.

Erikson's Stage One starts at birth and continues for six months. (The therapist writes the age range in the Stage One box.) There is a challenge associated with each stage. The challenge of the first stage is "I cannot meet my own needs". (The therapist writes the challenge as shown in the figure, and continues adding elements to the figure in accord with the ongoing discussion.) Make sense? And, depending on what happens, the outcome of Stage One development is either positive or negative. If needs are generally met reliably by loving caregivers, Stage One ends in the positive outcome of an attitude of "Basic Trust". Basic Trust is a technical term meaning a gut-level sense that the world is essentially an okay place, that my needs are going to get met, and that others are reliable and helpful.

On the other hand, if needs are met unreliably by caregivers who abuse and/or neglect, the outcome of Stage One is negative, with the development of an attitude of "Basic Mistrust". This, too, is a gut-level sense that the world is a dangerous place, that people are not to be trusted, and that my needs often go unattended.

Now we leave Erikson behind, taking along only the idea that development is across stages presenting challenges which result in generally positive or negative outcomes/beliefs.

Let's go to some Stage "N". (The therapist draws two boxes with "Stage N" written inside, and continues adding outcome arrows and labels in accord with the narrative.) Let's say that Stage N is the stage of development the client is experiencing at the time she comes to therapy. Stage N is the present day stage. Stage N, too, has its challenge, and development proceeds toward either a positive or a negative outcome. However, Stage N differs from Stage One, in that it is preceded by the outcome of another stage. If the outcome of the preceeding stage is positive, it is much more likely that the outcome to the Stage N will be positive. (The therapist labels the upper Stage N outcomes "More Likely" and "Less Likely", in accord with the narrative.) If the outcome of the preceding stage is negative, it is more likely that the outcome of Stage N will also be negative. (The therapist labels the lower Stage N outcomes "Less Likely" and "More Likely", in accord with the narrative.) That is, the outcome of each previous stage has a predictable impact on the outcome of the next one.

The therapist draws a box around the outcomes of Stage N, labelling it "Present Day".

So, a client comes in for therapy. That's you. Now, you probably aren't here because you are experiencing a positive outcome in the present day. You didn't get up this morning and think "Gee, things are going so swell I think I'll go check in for some therapy". No. You came here because you're experiencing some negative outcome. You are therefore at one of these two negative outcomes in the present day.

At this point, the positive outcomes in the present day are crossed out. The therapist points to the two negative outcomes in the present day.

You will notice now that it is more likely that you are here (point to the lower negative outcome, which is already labelled "More Likely") than it is that you are here (point to the upper one, already labelled "Less Likely").

The therapist now draws the vertical arrows labeled "A" and "B".

So-called "surface" level interventions seek to bump a person from a negative to a positive outcome without looking at or dealing with issues arising from the past. Such interventions include drugs, behavior modification, cognitive therapy, authoritarian hypnosis, and the like. They are more often called "counseling" than "therapy". They are more likely to work at point A than they are at point B. That is, surface interventions are most likely to work under the conditions which are least likely to be the case. (The therapist stresses this point emphatically, making sure the client understands.)

Interventions which explore the connection between present day dissatisfaction/ misfortune/difficulty and parallel problems from the past (the therapist draws the arrow labelled "C") are more commonly called "therapy" than they are called "counseling". Exploring this connection is what makes an intervention "deeper". This connection itself is called a "coex" (short for "condensed experience"; Grof, 1988). Because it connects negative or traumatic experiences, this particular one is called the "coex of linked trauma". Exploring the coex of linked trauma is the hallmark of deeper therapies such as psychoanalysis, exploratory hypnotherapy such as Heart-Centered Hypnotherapy (Zimberoff & Hartman, 1998), Breathwork (Lampman, 1998; Taylor, 1994), and the like. Deeper interventions are much more likely to be effective in cases such as yours.

My experience has been that this brief intervention usually evokes immediate and clear interest in deeper therapies, even among resistant and anti-intellectual clients. Clients seem to get the sense of this drawing, and the reality it describes readily. Although my intent is to offer the drawing to them to take home at the end of the session, more often than not clients eagerly ask "May I have that?" before I have made the offer. They take it home and they look at it, sometimes returning with questions. Their interest in deeper work is piqued. As a result, they open more easily to deeper interventions. The only clients I have had refuse the drawing state simply that they have understood it so well that they do not need to take it with them.

I have yet to fax a copy of this figure to a third party payer and then present the explanation over the telephone. However, I imagine that approach will prove just as useful with any honest beaurocrat. Those of us who specialize in deeper explorations with our clients need all the tools we can gather to work in these times of managed care and de rigeur brief interventions. In the spirit of sharing what has worked well for me, I offer this heuristic both for discussion and practical use.

References

Erikson, E. H. (1950). Childhood and Society. New York: Norton.

Freud, S. (1925). Collected Papers. London: Hogarth.

Grof, S. (1988). The Adventure of Self-Discovery. New York: State University of New York Press.

Lampman, C. (1998). Hypnotherapy and birth. Journal of Heart-Centered Therapies, 1 (1), 60-68.

Taylor, K. (1994). The Breathwork Experience. Hanford Mead.

Zimberoff, D., and Hartman, D. (1998). The Heart-Centered Hypnotherapy modality defined. Journal of Heart-Centered Therapies, 1 (1), 3-49.

Paul S. Sussman Psychological Services, Suite 2707--Toronto Dominion Tower, Edmonton Centre, Edmonton, Alberta, Canada T5J 2Z1.