Psychotherapy Clients as…Humans

“Psychotherapy clients as human phenomena” — what a strange title, I thought, when I came across Janet L. Etzi’s article in the American Journal of Psychotherapy (Vol. 62, No. 1). What else would they be but human — human experiences, human stories?

Etzi suggests that in psychotherapy, often the client is “a case to be explained”, not a person to be understood, and makes a passionate case for the latter. It “shifts the therapist’s focus to a more complex and interpersonally engaged process, which includes the therapist’s interior life as well as the client’s”. Etzi recommends the “practice and discipline of attending to, noticing, and understanding the human subject”.

In 16 years of working with clients, and many more years of learning and thinking about psychology and therapy (when I grew up, I thought everyone’s parents had psychoanalysts for friends), I have come to learn that I need primarily to see therapy as a mutual process of learning and experimenting. “We often think of psychotherapy as ‘the cure’ or ‘the treatment’”, says Etzi. And I guess there is some merit in this. As a client, when I suffer from insomnia because I can’t get my difficult boss out of my head, or when I finally pick up the phone to call a counsellor because I suspect that my lack of motivation may actually be a depression — well, of course I want to be treated, of course I want a cure!

I suppose what we associate with words such as ‘cure’ or ‘treatment’ is, ideally, a quick fix. Take two Prozacs and call me in the morning. I’d be the last to say that that doesn’t work — sometimes.

And then sometimes — often? — such a quick fix doesn’t work. Etzi gives this example:

An example may help to illustrate the confusion that can occur when psychotherapists are unaware of their implicit presuppositions regarding their practice objectives. A nine-year-old boy is brought into a child mental health clinic where he is evaluated and diagnosed with conduct disorder and attention deficit disorder. He is given a trial prescription for Ritalin. Certain well-defined symptoms are targeted and successfully treated. After a few weeks, the psychotherapist seeing this boy hears from his parents that he “has a lying problem.”

How should this new information, i.e., symptom, behavior problem, be addressed? What is the psychotherapist’s task in relation to the boy’s lying? What is the role of observing in this context? What is the role of diagnosing? Is it not necessary for the observer of human phenomena to have an understanding of lying in children? Perhaps not so much from a clinical point of view, but from the child’s point of view; in other words, for the purpose of understanding the subject’s experience? Can lying be viewed as a clinical issue? What would this mean? What function does lying serve in children? More important, what function does it serve in this particular nine year old, who is not complying with conventional rules and who expresses anger and frustration in relation to his particular family and peer group?

[Editor's Note: In this and the subsequent quotation a little farther down, grammatical eccentricities of the original paper are reproduced without modification.]

These are interesting questions. I’m particularly intrigued by this: “What is the role of observing in this context? What is the role of diagnosing?” I think all too often, observation falls by the wayside. I’d include in this both the therapist’s observations and those of the client. There is a huge difference between true observation (which is closely related to the “attending” Etzi refers to) and a quick run-down of a symptoms checklist. True observation implies curiosity and open-mindedness, and the acute awareness that observation can never be detached from the observer. That means, among other things, that I can only see what I can see (e.g. what my eyesight allows me to see) and what my experience enables me to see (e.g. if I’ve never seen an airplane, I couldn’t identify as such). Here is what Etzi relates when she observes with an open mind:

As a psychotherapist, it is my job to work to understand this particular child’s reasons for lying. I may find that what his parents call lying is something else all together for this boy. Human beings are far too complex to reduce their behaviors to symptoms. Explaining a behavior, such as lying, as a symptom is a very different undertaking from understanding it as part of this child’s personhood, experience, self-concept, etc.

What I find remarkable in situations like this is that taking the time to truly observe, to be genuinely curious about “what/who is this thing/experience/person?” can actually save time, money, and, most importantly, heartache. After such an observation, it is often much easier to make a “treatment” decision. Perhaps more Ritalin is still the best way to go. Or maybe what’s needed is for someone to just listen and hold the other — the “client” — in a respectful, attentive and compassionate gaze.