Nuevos vídeos de la APA sobre sesiones de terapia

http://www.apadivisions.org/division-39/publications/review/2011/10/gloria.aspx
DIVISION/Review | October 2011

FILM / VIDEO

Gloria - Fifty years on

Two new APA videos on contemporary psychotherapy, Three Approaches to Psychotherapy with a Male/Female Client—The Next Generation, are reviewed and discussed

By Bill MacGillivray, PhD, ABPP

Three Approaches to Psychotherapy With a Male Client: The Next Generation, hosted by Jon Carlson, PsyD, EdD; and Gary R. VandenBos, PhD, with Judith S. Beck, PhD, Leslie Greenberg, PhD, Nancy McWilliams, PhD. Washington, DC: American Psychological Association. ISBN 13: 978-1-4338-1030-5.

Three Approaches to Psychotherapy With a Female Client: The Next Generation by Hosted by Jon Carlson, PsyD, EdD; and Gary R. VandenBos, PhD, with Judith S. Beck, PhD, Leslie Greenberg, PhD, Nancy McWilliams, PhD. Washington, DC: American Psychological Association ISBN 13: 978-1-4338-1029-9.

[Nota: lamentablemente, no están disponibles en Youtube y son carísimos. Ver http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=Three%20Approaches%20To%20Psychotherapy%20With%20A%20Male%20Client%3A%20The%20Next%20Generation]

Most of us who trained in the '70s and '80s eagerly viewed the "Gloria films", identifying with the approaches of one or the other of the three famous therapists that interviewed a young woman, Gloria, who volunteered for the groundbreaking project. It promised to open a window into the secret world of the consulting room and allowed us to vicariously experience what it was like to be a therapist (or a patient). The three therapists selected to interview Gloria were at the top of their game, with Carl Rogers arguably the most famous and both Fritz Perls and Albert Ellis in the course of developing a strong following, amounting almost to cult status at times. I never had personal contact with any of these famous men, although my cousin, a Jesuit theologian, once recounted an unsolicited conversation with Ellis while the two happened to be traveling on the same train. Ellis evidently harangued my cousin throughout the journey, attempting to disabuse him of his irrational religious convictions.

One limitation to the films was the absence of a psychoanalytic approach to psychotherapy. Although all three therapists had started out their careers more or less influenced by psychoanalysis (Perls was analyzed by Wilhelm Reich; Ellis was analyzed by Charles Hulbeck, an analysis and of Hermann Rorschach; Rogers, although never analyzed, credited Otto Rank as the inspiration for his "here and now" approach to treatment). As a result, we were exposed to clinicians who had developed their distinctive alternatives to psychodynamic treatment: Rogers's "person-centered" approach, Perls's Gestalt Therapy, and Ellis's Rational Therapy (as he termed it at the time, morphing finally into Rational Emotive Behavior Therapy). I assume most readers of this review are quite familiar with Ellis and Rogers; but Perls has faded a bit over time, although his famous Gestalt Prayer1was in many ways the hallmark of the '60s generation, determined to "do its thing" regardless of social conventions or propriety.

It was also a time when the evidence basis for the effectiveness of psychotherapy was more or less assumed. While Hans Eysenck was busily denouncing psychoanalysis, Carl Rogers and his colleagues were producing a body of research concluding that the therapy relationship was the central curative aspect in psychotherapy, conclusions that have more or less stood the test of time. Although Albert Ellis and his colleagues would eventually make alliances with the emerging behavior therapy movement, all three therapists were content to conclude that their approach did not require laboratory proof. Randomized clinical trials and claims of the "gold standard" for research validity were in the future.

These new DVDs are an update of the original purpose of the "Gloria films" to showcase three contrasting psychotherapeutic approaches, with viewers encouraged to look for similarities and differences among the therapists rather than succumb to the urge to turn viewing into a "horse race" to proclaim a winner. The DVDs are far more in-depth than the original and are structured in the following manner:

Each volunteer client was selected and interviewed by Jon Carlson, and a tape of this interview was made available to the therapists. Also notable is that both clients either were in therapy or had been in treatment and the issues they brought to the therapists were real, current life difficulties.

Each therapist was interviewed by Jon Carlson and asked to describe their approach to therapy and to define their particular theoretical orientation and evidence-based research that supports their approach.

Each therapist then conducted two interviews with each client.

The therapists then participated in a discussion with the hosts, Jon Carlson and Gary VandenBos, viewing excerpts from the interviews and commenting on the similarities and differences they observed.

Finally, Jon Carlson also interviewed the clients after their sessions, and they provided their perspective on their own sessions.

Before moving on, I want to note what I consider a drawback of the way the DVDs were produced and marketed. First, the viewer only gets to view one of the interviews of each client, evidently the one chosen by the therapist. As it happens, we then are only able to view Les Greenberg in his initial interview with both the female and the male client; but Judith Beck and Nancy McWilliams selected their second interviews. There is no explanation as to why one or the other interview was selected, other than therapist choice. Another limitation of the DVDs is that they are packaged and marketed separately, with the result that both contain the same therapist interviews describing their approach to therapy, an unnecessary duplication for someone who wants to see both DVDs. I think anyone who wants to purchase these DVDs would be well advised to select both, despite the duplication (and doubled price), because the contrast between the clients' personality styles is markedly evident, and I would suggest important, in considering the differing approaches of the therapists.

Before reviewing further, some self-disclosure is called for. Beyond the evident fact that I am a psychoanalytic psychologist reviewing for a psychoanalytic publication, I should note that I have known and respected Nancy McWilliams for over ten years, and I am pleased to call her a friend. I shall try to keep my admiration in check (as well as my hopefully well-analyzed envy of her skill and renown). That said, here goes.

I will first address the contrast among the therapists. All three are clearly accomplished in their area of expertise and they conducted their sessions in a way that made more or less transparent their theoretical and practical orientation to their work. Before moving on, I should clarify: Les Greenberg terms his approach Emotion-Focused Therapy (EFT); Judith Beck's2 stance is Cognitive Therapy (CT), originally developed by her father, Aaron. In this era of "initial envy", psychoanalytic psychotherapy has failed to develop a consistent "handle", but I will use the term being touted by some psychoanalytic researchers these days, Psychodynamic Therapy, or PDT.

Throughout the interviews you could really "see" how the therapists were thinking, reacting, and "moving" with their clients (and you can also hear them comment on their interview in a later section of the DVDs). At the same time, this clarity presents a somewhat false picture, not only of how a "typical" CT, EFT, or PDT therapist actually operates; but also how they would operate in a "real" therapy situation. All three were much more explicit about what they were doing and thinking than they might normally be. Both the therapists and the clients were clearly "on show" and aware of the taping, likely even coached beforehand on ways to partially disguise identities of friends and colleagues. So when the male client reports his difficulty with a "female friend", the viewer is left uncertain as to whether this is an idiosyncratic way of speaking or a conscious decision due to the unusual nature of the session. Some of these concerns were addressed in the post session interviews, and both the therapists and clients noted that awareness of being taped would shift from foreground to background during the sessions. As I noted above, Les Greenberg selected only his first interviews to be shown, and so his interviews started more or less "cold" as he then worked to identify a specific issue or concern the client was willing to work on. Judith Beck and Nancy McWilliams chose to show their second interviews, and typically began these sessions more or less "in the middle", at times bringing up new or only lightly covered material, based on the previous session. This contributed to a sense that the therapists were attempting to condense as much as possible into one session. At times it was my impression that you could "see them sweat" as they worked to move the interview into more productive areas much faster then they would likely have done. These are minor caveats, however, but I note them because less-experienced therapists might feel quite discouraged to view how much "movement" could be elicited in one session.

Les Greenberg is a terribly interesting sort. He is a Canadian but emigrated there from South Africa, and his background is not in psychology but in engineering; he came to psychotherapy rather late. He notes that he comes from the land of the behaviorists Arnold Lazarus and Joseph Wolpe, and so was not particularly interested in psychotherapy as a young man. His theoretical background is rooted specifically in Fritz Perls and more generally in the humanistic school of therapy. He certainly looks the part, a stocky man with unruly pure white hair and full beard and a benign and calming presence that to me is a marker of the humanistic manner. He describes his Emotion-Focused Therapy (EFT), however, as a rigorous, research-based approach with its foundations in neuroscience and emotion and attachment theory. His research group has developed specific interventions and identified specific cues that result in interaction sequences the therapist can rely on to guide the treatment.

His manner and approach throughout the interview will not come as a complete surprise to an experienced therapist, although his directive stance and "coaching" (his term) of the client is exemplified in his repeated admonition that ideally the therapist is to "stay one half step ahead of the client". During the interview with the female client, Chi-Chi, this approach appeared highly effective in eliciting her core narrative structure of her life, moving swiftly from her self-critical stance and failure to reach life goals to an exploration of family dynamics, including the use of the "two chairs" technique as she alternated from one chair to the other to allow her to give voice to conflicting feelings and beliefs about herself. One notable aspect of how he works is his subtle shift from saying "you" in speculating what the client is feeling to making "we" statements to encourage more emotional depth.

However impressive he was with the female client, my sense in viewing the interview with the male client, Kevin, was that Greenberg was working "too hard", and that the client, more than willing and able to access intense feeling states, was actually far more elusive in being able to capture a narrative, or a way to place his feelings in a lived context. My sense was that Kevin was, in a sense, too comfortable with emotional expression and this resulted in his revealing less of himself overall.

Judith Beck's approach appeared at first to me as a kind of caricature, not only of a CT stance, but also of an old-fashioned psychoanalytic approach, as she spent a lot of time writing down what she thought important in what her client was saying (the only difference is that she also encouraged the clients to write during the sessions). Hers is a kind of "no-nonsense" approach, quickly framing the client's concerns as problems to be solved through action. With Chi-Chi, this approach seemed to be really soothing, helping Chi-Chi organize and focus on her problem of procrastinating (rather, perhaps, than the messy feelings of a somewhat messy life in constant opposition to others and her own dreams and ambitions). Beck kept the focus on concrete measures to develop better discipline and clearer focus in pursuing artistic ambitions; and in the later discussion makes clear that she felt the therapy needed to begin with the development of these techniques and only explore further if these interventions failed.

With Kevin, I stopped watching after 20 minutes, as it became too painful. Consciously or not, he seemed to be almost parodying Beck's solution-focused stance, eagerly coming up with ideas that were certainly wide of the mark. Perhaps he was just eager to please, which is also what I thought he was doing with Greenberg. Perhaps only psychoanalytic therapists can be so sensitive to the negative transference in the overly cooperative client. On the other hand, Beck's idea of "choice" in the session seemed to be to praise what Kevin suggested but to encourage him to "freely choose" the topic she selected. She praised his selection of a topic for discussion, but was able to "wonder" about the usefulness of her suggestion long enough until, it seemed to me, Kevin got the hint and agreed to discuss the issue she selected.

I will "jump ahead" before describing Nancy McWilliams's interviews, because a comment Beck makes in several places during the DVD deserves attention. As noted, she is quite clear that CT is a practical treatment rooted in teaching commonsense approaches and strategies, including exercises (i.e., "homework") for the client to work on between sessions and presumably for life, integrating instructions into new coping skills. All well and good from my perspective. Beck commented several times, however, that if a CT approach does not work with a particular client, that is a clue that the work may need to "go deeper" into character problems and trauma issues; and the CT therapist can then resort to psychodynamic and/or gestalt techniques to foster greater emotional awareness. The eminently sensible statement, however, implies two major premises rarely admitted by CT therapists as presented in both the popular and professional literature. Her comments first of all note that a clinician must be able to develop and apply diverse techniques and strategies and that one size does not fit all. Secondly, and more breathtakingly, she observed that she would be able to utilize these techniques without any sense that she needed to have or develop such expertise. I applaud her recognition that clinical work is not research, contradicting the mantra of the CT scientists and others who imply that incompetent and lazy psychotherapists are incapable of making any changes in treatment protocols that come from the research lab. Her conclusion that she is capable of using these techniques, however, seems naive if not dismissive of the years of experience and training required.3

Nancy McWilliams's description of the basics of psychoanalytic treatment in the course of a 20-minute interview is a tour de force in which she is able to capture the complexity and depth of psychoanalytic work in simple language without the preciousness or cliché remarks that too easily fill our attempts to describe our work. It is well worth the price of the DVD as an introduction to psychoanalytic work. Because she is currently working on a companion volume to the DVD and generously provided me with a draft, I encourage those who purchase the tapes to also buy this companion volume.

As noted, the actual interviews on the DVDs are her second interviews with both clients and therefore more or less a continuation of the first. In her interview with Chi-Chi, I found McWilliams to be working "too hard" to summarize and conceptualize what she understood to be the client's issues. She certainly hit the right notes (as reflected in the material revealed in the Greenberg interview), and in many ways provided a more complex (I would say complete) accounting of this woman's difficulties. Briefly, in the Greenberg interview, what emerged as a central conflict for this woman was her relationship with her actual (and internalized) mother, who repeatedly found her "good, but not good enough" in her pursuit of her artistic ambitions. Failing to pursue more conventional success while not quite succeeding in her artistic goals was both a submission and rebellion against her mother. Although Greenberg's formulation strikes me as true, I was troubled by the sense that he only addressed Chi-Chi in her struggle for autonomy. My sense was that McWilliams was struggling with the fact that this narrative was incomplete, eliding the client's self-destructive past and her ongoing provocativeness in work and romantic relationships. I believe McWilliams sensed she would be unable to "go there" with the client, certainly in the context of their limited relationship, yet wanted to allude to the emotional territory this woman would need to traverse. She encouraged the client to consider longer-term treatment than she had previously been willing to pursue in order to really address the full range of her concerns.

Although these comments appear to be highly accurate and were delivered with exquisite tact, it seems clear on the DVD that the client remained little affected by McWilliams's encouragement. During the "exit interview" with Jon Carlson, the client offered faint praise for McWilliams and even remarked that she did not feel as "safe" with her as with the others. My sense of what she meant by feeling "unsafe" is that McWilliams's comments struck quite deep in ways she was not prepared for. As we learned in the interviews, Chi-Chi, as the daughter of a diplomat, had been traumatized by the repeated disruptions of having to move every few years, yet had enacted this pattern in her life in her relationships and even her preference for short-term therapy.

McWilliams's interview with the male patient is in marked contrast to the interview with Chi-Chi. Although McWilliams is clearly aiming to touch base with all aspects of a psychoanalytic treatment in one interview, I can only conclude she succeeded in all respects in conveying what ideally would emerge in a successful treatment conducted over several years. She was able to link past and present conflicts in a way that was specific, emotionally alive, and evocative. This was clearly, however, collaboration; and his willingness to play out all the many aspects of his conflicts, emotions, and defenses was remarkable as well.

Briefly, the male patient related a current conflict of waking up with intense anxiety, feelings that were linked both to the impact of his father's death when he was 9, his current life situation, having just celebrated a birthday that meant he has lived longer than his father, and his impending separation from his daughter, who will soon be going to college. More striking for me was the way both the client and McWilliams were able to live through an intense emotional "storm" during the interview while being able to also note his use of emotions as "performance" and his overall determination to please others, especially women, as being enacted in the session.

One last "gotcha" I cannot resist noting. CT practitioners often dismissively insist that they are "practical", while other therapists waste time with explorations of the past. As far as we know, however, the McWilliams interview all but ended the male patient's anxiety attacks. He wrote to her after the interviews to relate that he had shared his therapy experience with his daughter, had explained that he was pushing her away because he feared losing her, and revealed that they both were able to talk about this with considerable relief and cessation of the anxiety symptoms.

Although this interview standing alone is compelling and highly revealing, I am not sure it would have the same resonance without seeing all the interviews and the contrasting styles among the clients and therapists. I would be reluctant to recommend viewing only one of the DVDs (or certainly, only one of the approaches). More to the point, I would be concerned with anyone viewing the DVDs "cold," without being able to have or develop a context for understanding what is being shown. I would strongly suggest these DVDs would need to be utilized in the course of a seminar with both readings and instruction to "unpack" the necessarily condensed presentations. This is especially true with the likely intended audience for these DVDs: the beginning or inexperienced therapist. Students are increasingly exposed to only the most superficial aspects of therapy approaches. They may assume they have sufficient understanding without having to delve further into the ideas and concepts that underlie these approaches. This is especially true for psychoanalytic therapy.

I will end on a final warning note. In the therapist discussion, Judith Beck stated that both clients were more or less "normal", in that they had no diagnosable DSM-IV condition on either Axis I or Axis II. She noted this as a justification to keeping her approach more "on the surface", and that she would have to "do more" if the clients had a diagnosable mental illness. This jarring note, introduced and just as quickly gone from the discussion, stays with me, because it goes to the heart of what we mean by psychotherapy treatment as well as our notions of cure. Freud had many insights, many of which he abandoned, many abandoned by others. One central insight not all that often noted, perhaps because it is so much in our bones, is his emphasis on the essential normality of all psychopathology, and the essential psychopathology of all normality. Psychoanalysis stands or falls on the conviction that psychopathology is our common fate; and our common task and right is to love, work, and play. Wittgenstein famously concluded that our task in life was to get the fly to come out of the fly bottle. However we come up short in this goal, it appears the only one worth spending time on.

1. I do my thing and you do your thing. I am not in this world to live up to your expectations, And you are not in this world to live up to mine. You are you, and I am I, and if by chance we find each other, it's beautiful. If not, it can't be helped. (Perls, 1969)

2. Judith Beck is the daughter of the psychoanalyst and originator of the CBY movement, Aaron Beck, so the psychodynamic roots of CBT are one generation removed.

3. Charles Cohen, one of my teachers, remarked that years ago, while working at the Houston VA, a psychotic patient was admitted whom no one was able to effectively reach. The staff finally succumbed to the family's insistence that a shaman be brought in to work with the patient. The patient soon recovered. When asked by the amazed staff if the shaman could instruct them on what to do in the future with such a patient, he observed that that would require years of study and practice.

About the Author

Bill MacGillivray, PhD is in private practice in Oak Ridge, TN and adjunct professor at the University of Tennessee, Knoxville. Currently serving as president of the Division of Psychoanalysis, he is the former editor of Psychologist-Psychoanalyst, the Division 39 newsletter, and a contributing editor of DIVISION/ Review.