In our last entry, we examined why the dominant therapeutic paradigm of technique-focused learning and approach is incomplete and inadequate. I likened techniques to musical scales—useful, but incomplete without knowing the rhythm and key. Rather than just focus on techniques, I’m arguing (along with a lot of research, bee tee dubs) that one needs to identify the correct treatment attitude in which to offer those techniques. The correct treatment attitude is one tailored to each individual patient to help them feel emotionally safe and secure. This is highly individualized, however, so it’s not just generic niceness and support. These case examples will demonstrate how different these can be.
So let’s flesh this out so you know what I’m talking about and revisit our earlier client. Let’s imagine two clients come in with the exact same story—heavy drinking, recent mugging, marital problems. The first we’ll call “Jimothy” and the second we’ll call “Jomothy.” I’d like to stress that these are fictionalized cases. You do not know these people as real people. They do not exist as real people. But they’re very much true to my personal clinical experience and consulting experience supervising and advising other therapists.
Also, who the hell is named “Jomothy?” C’mon.
Jimothy:
Jimothy enters the office smelling vaguely of booze. His stomach pokes out from under his Harley t-shirt while his biceps challenge the elasticity of the sleeves. He snorts derisively as you offer him green tea. He looks at the diploma on the wall and asks if you’re “actually a real doctor.” He doesn’t take his sunglasses off in session but you can still feel him roll his eyes when you ask him how he feels about something.
He’s surprisingly open about his life, though he betrays no emotion beyond disdain and a wry sense of humor about the details. He was abused by his father, who was an asshole but “at least made him tough.” His father left when Jimothy was 8. His mother was depressed and a heavy drinker too. Jimothy basically did whatever he wanted after his father’s absence as his overwhelmed mother quickly gave up trying to manage a strong-willed, aggressive kid. School was a disaster, except for sports where he excelled, and partying where he also excelled.
The only time his presentation shifts is when you ask about the marital problems. He’s more subdued here. He knows he’s hurting his marriage. He doesn’t want to lose his wife. “She’s the only one who’s ever been on my side.”
Jomothy:
Jomothy slouches into the office, smelling of cheap beer. His clothing is stained and rumpled. He’s disengaged in the session, answering in clipped sentences, noncommittal noises, and vagaries. His father was abusive and violent, and left when he was 8. Jomothy was profoundly relieved by his absence, but his mother never recovered. She stayed depressed and drank heavily, rarely having the energy to parent him. He would sit next to her and watch TV for hours.
Jomothy becomes visibly shaken at the question of the recent assault, becomes tearful and overwhelmed, but tells you “it’s fine, I’ll be fine.” His long period of unemployment is threatening his marriage. When asked what the challenge has been, he shrugs.
Same Problems, Different Keys
Both clients have identical presenting problems, pretty similar trauma histories, and comparable family-of-origin issues. In a technique-focused approach, they’d likely receive similar treatment protocols. EMDR for the trauma, or IFS if you’re “on the cutting edge.” CBT for the drinking. Or, maybe you’ve had the misfortune of absorbing the virulently stupid misconceptions about substance abuse still infecting our field and you just make a referral out for substance abuse treatment because “that can’t be treated in individual therapy” and “people can’t change until they hit bottom.” Whichever technique you offer though, it’ll probably take off like a lead balloon if you don’t nail the correct treatment attitude.
Jimothy is all bluster and challenge. His core belief may be something like “The world is full of abusers and wimps. I’m not a wimp. I’m alone out here.” He’s testing whether you can handle him, whether you’ll crumble under his disdain like so many authority figures before or try to overpower him. Jomothy responded to similar circumstances by going in a different direction. His core belief is probably something like “I’m alone in the world because no one cares enough about me to notice my suffering. The best I can do is fly under the radar and hope for table scraps.” He is collapsing inward, testing whether you’ll abandon him or even notice his suffering.
These are different adaptive strategies, useful at their time of creation, forged in the crucible of childhood trauma and refined over decades of relationship experience. They require completely different therapeutic approaches.
Playing in the Key of Jimothy-Major
With Jimothy, the worst thing you could do is what most therapists are trained to do: be warm, empathetic, and supportive right out of the gate. He’s spent his whole life learning that authority figures are either weak (like his mother) or abusive (like his father). Your gentle therapeutic demeanor will slot you immediately into the “weak” category, and he’ll lose respect for you before you’ve even begun. He’ll start to punk you right in your own office. And you may deserve it! What is that, some sort of generic buddha art you got at Pier 1?
Jimothy needs you to thread a needle — you need to be tough and competent enough that he can’t just steamroll you, but it’s also imperative you don’t try to squish him with aggression or status. There’s probably a couple of different approaches that would work. You could try what we might call “respectful sparring.” He needs to know you can handle his aggression without either collapsing or retaliating. You might say something like: “Look man, I’m not here to convince you of anything but I am interested in actually helping you with what you want. Do you just want to jab at me or do we want to focus on what you need?” Personally, I’m a big fan of humor. You could use that to roll with the punches in a way that demonstrates you’re robust enough to take a ribbing but also don’t feel the need to puff up and hit back. “Yeah, I became the type of doctor that’s useless on airplanes and still disappointing to immigrant parents. But I’m also the type of doctor that can help you not get divorced if you give some of my B.S. a chance.”
This isn’t being mean or confrontational, this is what he needs to feel emotionally safe. You’re acknowledging his reality, demonstrating that you won’t be intimidated, and connecting to what he actually cares about (his marriage). Only after establishing this foundation could you begin to offer something else.
Playing in the Key of Jomothy-Minor
Jomothy is an entirely different animal. Where Jimothy needs firm boundaries and the straight-talk express, Jomothy needs careful attunement, persistence, warmth, and pursuit. He’s spent his life being ignored, overlooked, and left to manage overwhelming emotions alone. The last thing he needs is a therapist who matches his energy level and accepts his minimization at face value or applies a “psychoanalytic frame” and leaves him in silence.
With Jomothy, you need to be proactive, persistent, undaunted, and warm. You need to bug him about how he feels, to stay with it until he’s finally able to name something, or to take a stab at helping him put it into words even if you aren’t sure what’s going on.
This is what Jomothy needs to feel safe—the experience that he’s not alone, that someone cares enough to notice him, that someone cares enough to nudge him and get him moving.
The Technique Trap
Obviously, and critically, what’s important here is that these attitudes are not interchangeable. Treating Jomothy like Jimothy would be a disaster—you’d just wind up bullying the poor guy into further paralysis. And the same thing is true for Jimothy. You hit him with that gentle, persistent warmth that Jomothy needs and he’ll be up and out of there.
This is why technique-focused therapy so often fails. EMDR might be helpful for both clients, but if you don’t first establish the correct relational foundation, they’ll never get to the point where they can engage with the technique meaningfully. Applying EMDR like widget A into patient slot B not only isn’t as effective, it’s actually harmful because you’re in the completely wrong key and rhythm.
The Art of Therapeutic Attunement
What I’m describing isn’t rocket science, but it does require something most graduate programs don’t feel is in fashion: the ability to read people’s attachment strategies, adapt one’s own therapeutic attitude and approach, and respond accordingly. It requires setting aside your default therapeutic persona and asking: “What does this specific person need from me right now to feel safe enough to change?” It requires rigorous, thoughtful analysis of a person’s individual history, their presenting problems, and an awareness of who you, the therapist, are and how you come across. It requires the synthesis of all of these things to adjust to the key of the person before you start playing scales.
In future posts, we’ll examine the neuroscience behind this way of understanding therapy, how it connects to evolutionary theory, and how it harmonizes disparate therapeutic approaches. I’d also like to dunk the persistent and prevalent bad ideas about substance abuse treatment in our field. And let me know what else you’re interested in. At this point in the substack adventure it’d be exciting to be bullied into producing specific pieces of content for an audience.
