Adapted from Nomadic Reflections of an Existential-Humanistic Psychotherapist

On a very basic level, psychotherapy is about the interaction of two psychological forces coming together, that of the therapist and that of the individual seeking recognition of the therapist, to achieve a certain end. Dr. James Bugental (1999) suggested that as therapists we must be constantly aware of what the client is doing to us. Preceding the business of what the client is doing to the therapist lies the concern of what the health care system is doing to the therapist and to psychotherapy in general.

Language reflects the tenor of the times. It is through our language that we gain insight into our thought processes, hence our own evolution; language guides our own paths of being.  All definitions are found in The American Heritage Dictionary of the English Language, third edition; Boston: Houghton Mifflin Co., 1992.Agreeing on a vocabulary gives us a foundation for discussion. "Behave" is to "conduct oneself in a specified way." Behavior then is the "actions or reactions of a person in response to external or internal stimuli." The root of behave is "have" or "to be in possession of." Behavior, logically, then is a possession, apropos for a society that espouses material gain.

"Mental" means "of or relating to the mind."  The Mind: "The human consciousness that originates in the brain and is manifested especially in thought, perception, emotion, will, memory and imagination." The terminological shift from "mental" health to "behavioral" health is significant. Behavioral health points towards a fascist approach to treatment, which dismisses human vagaries such as emotions, will, and imagination.

I do not use the term "a fascist approach" lightly or simply to create shock value. Fascism is a political philosophy based on a centralized authority of "oppressive dictatorial control." Interesting, the term fascist comes from the Italian via Latin meaning a bundle of sticks that has been bound together and typically used in the construction of fortresses, sea walls, and dams. Thus, the implication is that individuality is dispossessed for a common utilitarian purpose. Indeed the mental health's systemic preoccupation with behavior-based treatment plans and short-term behavioral goals, and medication compliance aim toward submissiveness with system regulations. This utilitarian approach has little to do with psychotherapy. It has a lot to do with treating individuals as their diagnosis. The language of the behavioral health system is utilitarian and evokes linear efficiency. Clients have plans and goals congruent with what the system thinks is in their best interest.

The language of the system points to an antilogy or self-contradiction. The terms "SMI" (seriously mentally ill) and "CMI" (chronically mentally ill) are still widely used. Yet, "behavioral health systems" have replaced "mental health systems." I have yet to hear either the terms "seriously behaviorally ill" or "chronically behaviorally ill." Thus, it appears that at some level we still view behavior as being under the influence of mental processes, perhaps even driven by mental processes. Yet, current consideration of the problem points toward alleviating behavioral rather than mental processes.

I am a practicing psychologist. Practice-a word rich with meanings. On one hand it refers to the profession in which I am engaged. The dictionary defines practice in several ways: "to do or perform habitually or customarily; to do or perform repeatedly in order to acquire or polish a skill; and to work at, especially as a profession. The first meaning is problematic when the practice of the system, that is, what it does habitually or customarily, and practice of the psychologist are incongruent. The system wants to fix. Schools train therapists to assemble a toolkit. Psychotherapy focuses on processes of listening to and of relating to clients in their own moments, their own presence. It involves allowing clients freedom to trust in their own decisions, and to honor their own paths. As a practitioner in the system, I ask myself if it is possible to work in this situation? More importantly, to do the authentic work in this system.

I recently met with a woman, a consumer in the behavioral health system, in her home just once. I used to do in-home therapy. "I want you to tell me what to do," she stated. "I want tools." Not a unique request. Inwardly I tried to recall the location of the nearest hardware store. Outwardly, I suggested I did not know what she should do, but I was willing to help her figure out what she wanted to do. After I left, she contacted her case manager and demanded another therapist. I recommended that she work with a very brief solution-focused therapist. Still, two thoughts crossed my mind: First, I am curious to know what kind of individual would so readily turn over control of her life to a stranger to be fixed-much as we might turn, in the event of a roadside emergency, turn our vehicle over to a AAA mechanic. She stated she did not want to be listened to. That was a waste of her time. Nevertheless, the emergency roadside mechanic seems an apt metaphor for what treatment has become. Second, Psychotherapy appears to be a matter of fixing problems. People want tools to make their lives run more smoothly, but seem reluctant to understand mechanisms that interfere with their the smooth purring of their lives. It is one thing to talk about the tools of the mechanic, quite another to engage in the learning process of being a mechanic.

Tools. Toolkits. Objective Measurements. Charts. Plans. The language we have adopted to describe therapy is one of problem-solving, much the way one would go to a hardware store and consult with the staff about the correct size and threading of a screw or length and width of a nail to secure the fixture. As therapists, we are expected to carry a toolkit. Our clients want tools. They want services. The logical direction of this discourse is that the therapist is a service center.

My limited experience has taught me that helping people fix their lives, or worse, telling them how to fix their lives, usually has one of two outcomes: They will follow your directions to the word, and then blame you because the resulting assemblage does not work; or, they will not do as you suggested because that would require they change, and the requirement would be imposed on them from with out. Perhaps both of these responses germinate from a desire in each of us to see ourselves as unique individuals. Kierkegaard (1959) comes to mind, speaking far more eloquently than I, relying on clichés: "One must know oneself before knowing anything else . . . it is only after a man has thus understood himself inwardly, and has thus seen his way, that life acquires peace and significance."

Instead of focusing on gathering a weighty toolkit of the trade-to achieve a utilitarian end, I prefer to think that as psychotherapists, we should be building our vocabularies-our communication skills, our skills at therapy to help integrate the fragmented conversations (maladaptive or problematic behaviors) of our clients. Tools in the hands of a master roofer will help him or her construct a watertight covering, which is useless without walls of the house.

In 1967 R. D. Laing admitted a woman, Mary Barns, to London's Kingsley Hall, the home of Laing's "anti-psychiatric" movement. Joseph Berke, a psychiatrist, treated her, not with medications, but with an authentic relationship. He had the presence of mind, and training, to recognize in her smeared feces an attempt to communicate. "Mary smeared shit with the skill of a Zen calligrapher. She liberated more energies in one of her many natural, spontaneous, and unselfconscious strokes than most artists express in a life time of work . . .. I remember the words of John Thompson [a psychiatrist], ‘Be aware of the ways by which men will reveal themselves!'" Berke gave her paper and crayons. Through psychotherapy she found a way back to a meaningful life. At the publication of her account of her journey through illness, she was living independently. "Joe reminded me, Ronnie [R. D. Laing] says, ‘Life is therapy and therapy is life.' . . .In a particular way, Joe recreated me, reformed me. I was able to let him, because I trusted him. This trust has been rewarded. Since the spring of '67 I have grown up. To an increasing extent I have become much more involved with people both at Kingsley Hall and in the outside world. Also I have had two successful exhibitions of my paintings. Sometimes I have felt like going down again, but never so strongly as before" (Barnes & Berke, 1971 p. 212).

I position myself as a practicing existential-humanistic psychologist, even in the system. To establish an authentic relationship with the client means that I must first accept her at the point where she is, not where she is going with treatment goals, just as Dr. Berke accepted Ms. Barnes's smearing feces on the living room wall. That was where she started her journey back. By not imposing goals from without, but by allowing her to blossom from within, she met her treatment or recovery goals of living independently, engaging in socially accepted behaviors, and so on.

Being present also means I must also figure out who I am with this client. Can I be empathic? What kind of commitment can I make to this relationship? Am I able to make a commitment to this relationship? Although these may sound like academic questions, they are very real ones for me and perhaps for anyone who has spent any amount of time engaged in the psychotherapeutic process. No matter how long or short the therapeutic encounter may be, presence can still be a quality of the moment. Bugental (1986) defines presence as "the quality of being in a situation in which one intends to be as aware and as participative as one is able to be at that time and in those circumstances." Starting with the present moment is the beginning of being authentic with myself and to the other person. It is in this moment that we have come together. I posit that it is possible to be an existential-humanistic psychotherapist within the mental health system. The system is not responsible for the personal qualities of authenticity and presence that we bring to the therapeutic hour. If we are authentic, and being authentic means owning our own moments-our feelings, our decisions, in short, our practice-then it is important to be on guard against falling into the pit of "blaming the system." It is too easy to dismiss the hassles and shortcomings of mental health treatment on the expectations of the system.

To blame the system seems to be creating resistance, which may then interfere with practice of psychotherapy. The existential approach is to create my own space within the system. Define my own terms. Define my own meaning. It goes back to the issue of mental versus behavioral health. The system cannot control my mind: how I perceive the clients, and how I hold them in my presence. It can set limits on the time I have with the clients. It cannot set limits on authenticity I bring to the therapeutic encounter. That is my responsibility.

Through our work, we create the reality in which we perceive and behold our clients. Psychotherapists also comprise the qualities of emotion, perception, will, and imagination. The imagination, Kierkegaard (1959) stated, "is what providence uses in order to get men into reality, into existence, to get them far enough out, or in, or down in existence. And when imagination has helped them as far out as they are meant to go-that is where reality, properly speaking, begins (p. 243). Imagination refers both to the holding of a mental image that is "not perceived as real nor present to the senses." Through imagination, we hold the mental image of hope for our clients. They may come to us thinking that they are flawed and that the flaws are inevitable and indelible. We see in their struggles for meaning fertile ground for a richer life. Imagination also refers to the "ability to deal with reality through the creative power of the mind." Psychotherapists, it seems, should be intimately in tune with imagination, that process and that quality in us that allows each of us to perceive each individual as a unique apotheosis of mental and behavioral processes.

I find the core of my practice remains the same, and embraces presence, holding and caring for the client, challenging he client, and confirming the client's increased sense of self. How that looks alters, and should alter, from client to client if I am being truly authentic. It is when I find myself voicing platitudes and becoming more worried about meeting system requirements and identifying clients as service plans that I realize I forfeit my own authenticity and presence. Bugental goes on to say "Presence is carried into effect through mobilization of one's inner (toward subjective experiencing) and out (toward the situation and any other person/s in it) sensitivities."

Through presence, through our imaginative faculties, we watch the boats, our boats, participate with the current. We watch them skip along the water, be shuffled by rocks and twigs and floating beer bottles, and trust in the meaning of our work. Practice is what allows us as psychotherapists to take in the whole river. I like to think that more authentic the therapeutic alliance is, the longer the boats will float.

References

© 2005 by Deborah Partington, Psy.D. All rights reserved