I first became aware of Mardi Horowitz’s work when I was
researching adjustment disorders many years ago. As an acute care psychiatrist that is one of
the disorders that ends up on your unit that you must separate from severe
mental illnesses and significant risks.
I wanted to do more than just make the diagnosis. I also wanted to assist these folks with
psychotherapy that might prove useful, even if I ended up discharging them the
same day. Dr. Horowitz has written
extensively about that and many other topics.
I decided to buy his recent book Clinician Technique in Personalized
Psychotherapy. In the introduction
he mentions watching decades of watching psychotherapy videotapes and trying to
figure out what helped people change.
In the forward by Roberta Isberg, MD – she mentions that
therapists might see something in the book that they have been doing in
practice for years. That happened to me
when I read the Chapter Confronting Dilemmas by Assertion of the Therapeutic
Alliance. In fact, I had mentioned
this intervention just a few hours earlier in psychotherapy seminar that I
coteach. In that seminar I discussed how making the therapeutic alliance
explicit could be useful in resolving impasses.
Dr. Horowitz’s chapter uses a dyadic diagram of the therapeutic alliance
(p. 103) that is good in that it delineates the roles of both the patient and
the therapist and what the expected exchanges might be. For example, the patient is disclosing and
focused on problems while the therapist is intervening, supporting, and
emphasizing adaptive changes by the patient.
Dr. Horowitz also
presents a table of Common Dilemmas for a Psychotherapist. He defines dilemmas as binaries where both
poles are unlikely to be helpful. A
common example is encouraging further elaboration of a problem that the patient
may find very problematic in terms of external relationships, the relationship with
the therapist, or longstanding internalized patterns of thinking and
behavior. In the table he presents ten
common dilemmas, the therapist’s intervention, and how it might be interpreted.
In the case of these dilemmas, he
suggests clarifying the situation and trying to reach a middle ground: “ The middle ground between the binaries of
the dilemma may be reached if the therapists state the properties of the
periodically experienced therapeutic alliance.” (p. 100).
I thought I would present a frequent acute care dilemma as a
vignette, but before doing that borrow another definition from Dr.
Horowitz. That is the idea that the
vignettes are fictionalized composites of multiple therapeutic
encounters. In the case below it is
hundreds of encounters:
Patient: “Are you the one holding me here? Are you the one I have to talk to to get out
of here? I want to be released as soon
as possible.”
MD: “I am the person who will make
that decision….”
Patient: “Well
what’s the hold up? You can’t just keep
me here. There is no reason why I should
be sitting in this hospital.”
MD: “I will do what
I can but I have to be able to make an independent assessment in order to do
that….”
Patient: “Look – I
don’t care about that. You have no right
to hold me here. I want to go home right
now and you are in my way.”
MD: “OK – this is
the first time I am seeing you. None of the people who brought you to the
hospital or admitted you to my unit have been in touch with me. I have nothing to do with who is admitted to
my unit and in fact have been told that I am supposed to discharge people as
soon as possible. But I can’t do that
unless I am fairly certain that they will be safe….”
Patient: “So you’re
just covering your ass doc? Really? You are just worried about getting sued?”
MD: “I am not
worried about getting sued, but I do worry about not getting people the
assessments and treatment they might need. The way this is supposed to work is that you
and I talk about what happened and try to determine if you have any problems
that I can help you with. It is not me against you or you against me. It is you and I working on an agreed upon set
of problems. Do you think we can do
that?”
Patient: “I
suppose…”
MD: “OK let’s give
it a try.”
This is an example of a situation that many physicians find
impossible to approach because their authority is questioned and the potential
for escalation. That escalation depends largely
on the physician not taking the critical comments as a personal attack but
rather as a process issue. It requires
the ability to remain neutral in addition to confronting the dilemma and
establishing a middle ground to proceed on. This skill is critical in acute
care psychiatry as well as in crisis outpatient situations. And before I get too grandiose like all
things in medicine there are no guarantees – only probabilities. There are situations that will rapidly
escalate out of control despite your best efforts – but in my experience they
are rare.
There are many other dilemmas facing therapists during
assessments and in ongoing therapy. More
common examples arise from the situation where the patient is reluctant to
disclose the details of certain events or has expectations of the therapist
that are not consistent with the reality of the therapy situation. The standard cinematic approach of reflecting
the problem back to the patient (“well how do you feel about that?”) is
generally not an optimal response and it is one that most people see as cliché
these days. Clarifying what is going on
in the room and in the therapy is probably a better strategy.
I have written about the therapeutic alliance in several
areas on this blog. Here is a post from 2012
and 2017. I also posted diagrams of the therapeutic
alliance in those posts and include my most recent modification below. In the diagram I am using MD as the therapist
since almost all the therapists I interact with are psychiatrists or
psychiatric residents, but it also applies to non-physician therapists.
Intersubjectivity provides a more comprehensive look at what
happens in the therapeutic alliance than seeing the interaction as orchestrated
solely by an objective therapist. The
therapist and patient have complementary roles.
For example, empathy is a critical dimension of the therapeutic alliance
and a critical skill for the therapist.
Empathy is also required on the part of the patient and its presence can
be palpable to varying degrees. Does the
patient really understand what the therapist is trying to do? Does the patient experience the therapist as
a person who is trying to be helpful?
Intersubjectivity does not reduce the value of traditional concepts like
transference and countertransference. Both
can exist in this intersubjective space.
It provides a more comprehensive framework for understanding.
Intersubjectivity has developmental origins, is considered
adaptive from an evolutionary perspective, and therefore most people have it to
one degree or another. An exception might be autism where the absence of an
intersubjective process has been considered as a deficit or a defense. Along the same lines varying degrees of
severe mental illness can impact it.
In a therapy session, the process and content of the session
are co-created rather than being dependent on the therapist. As the therapy progresses the process may be
more important than the content. This is
an obvious departure from criteria based diagnoses and highlights the social
determinants of the problem. The underlying assumption of how the mind operates
on an intersubjective basis is that the primary goal is to form object
relations or real relationships and their internalized representations. That
differs from some other assumptions of mind goals such as discharge for
pleasure. Like many technical terms used
in therapy there is often confusion based on how they are used by different
authors. For example, when I have
written about empathy on this blog I have used Sims
very precise definition (par. 10). In the chapter I have referenced here,
Stern suggests that intersubjectivity subsumes many dimensions including all
the imprecise definitions of empathy, sympathy, and mind reading as ways
to appreciate the subjective experience of another. To further complicate matters, there are
other descriptions of this phenomenon that are difficult to separate. One is folk psychology which is
defined as the intuitive way people understand and predict the behavior of
others. Folk psychology (3) could be seen as the result of a long series of
intersubjective encounters – the success of which will depend on both the
quality of the interactions and the inherent properties of the subjects.
Before I get too far afield, I will add a brief comment
about confusion over the objective and subjective in psychiatry. When
physicians start out, the objective is highly valued. What are the reproducible elements of
diseases and treatments? Physicians leave medical school with a sense of
medical science being like any other science until they start practicing and
realize they are seeing hundreds of conditions that defy description and
standard treatments. In psychiatry there
has been an historic move from an attempt at the highly objective approaches of
the late 19th century to the subjective wave of psychoanalytical
dominance and back to the attempted objectivity of brain-based precision
psychiatry. That pendulum swing is more
rhetoric than reality. The reality is
that in psychiatry we are privileged to work with the most complex organ in the
body. The brain has an obvious complex
physical basis and an equally complex psychological basis. Both must be understood as completely as
possible. That is difficult in that it
takes a lot of time and effort – but that is the job.
On a practical note, what about the rest of the book and
should you buy it? I was pleasantly
surprised to find what I have done for decades was recommended by an academic
psychiatrist who is an expert in the field.
I am certain that most people who have been engaged in providing
psychotherapy will find the same thing.
The overall advantage in this book is that it is an information dense
text of 115 pages with additional pages for 84 references, an index, and a
glossary. It is set in what appears to
be 10-point font and you can read it in one long sitting. There is no elaboration on the history and
technical details of schools of psychotherapy.
The chapters are matter-of-fact and straightforward. Every concept has a
concise definition and definitions are added as needed as footnotes on the
respective pages. Since the author is a
psychotherapy researcher there are some unique conceptualizations and jargon contained
in the book. There were well explained
and not an impediment to understanding.
The model of therapy described is described as an
integrative cognitive-psychodynamic approach that consider both conscious and
unconscious elements. He takes the secret
handshake elements out of psychotherapy by clearly stating what he is doing
and providing many clinical examples. When
therapists are starting out especially in psychodynamic therapy – the goal of
therapy is often not very clear. It can
seem like therapy hinges on definitive interpretations of unconscious wishes
and the residuals of past interactions. Even
when a therapist gets to the point where they feel more competent to make those
interpretations, they may be skeptical of their accuracy and concerned that
they be trying to convince the patient to accept an inaccurate interpretation. Dr. Horowitz is very clear that
interpretations are not necessary for change and reviews several cognitive and behavioral
interventions that can be useful. I counted about 39 of these interventions in
the obvious places, but there are probably more. In some spots it assumes that the reader has
working knowledge of basic behavioral interventions (breathing techniques, relaxation,
etc) for application in the early stages.
This method of therapy – supportive interventions used
initially and intermittently in association with more interpretive therapy is
often not explicit in therapy texts, but I am convinced that it is the norm for
people who learn psychodynamic therapy and apply it outside the context of
psychoanalysis. There are clearly times
when people being seen strictly for therapy or psychiatric treatment are in
crisis and need supportive interventions for stabilization or to assist them
toward an intersubjective state consistent with more exploration and
interpretation.
The book benefits
therapists at both ends of the training and practice spectrum.
If you are starting out – it is a good overview of the topics and skills
that you need to provide psychotherapy.
If you have been working in the field for years or decades, it leads to
reflection on what you have been doing, whether there is potential for
improvement, and how what you are doing fits into the general scheme of things.
Either way Dr. Horowitz does not disappoint.
George Dawson, MD, DFAPA
References:
1: Horowitz MJ. Clinician Technique in Personalized
Psychotherapy. American Psychiatric
Publishing, Inc, Arlington, VA, 2025.
2: Stern D. Intersubjectivity. In: Person ES, Cooper AM, Gabbard GO. The
American Psychiatric Publishing Textbook of Psychoanalysis. American Psychiatric Publishing, Inc,
Arlington, VA, 2005, 77-92.
3: Hutto, Daniel and
Ian Ravenscroft, "Folk Psychology as a Theory", The Stanford
Encyclopedia of Philosophy (Fall 2021 Edition), Edward N. Zalta (ed.), https://plato.stanford.edu/archives/fall2021/entries/folkpsych-theory
