CHAPTER SIX

Deciphering Motivation in Psychotherapy

In this section of the book, we will look at case examples of various statements made within the context of therapy. The statements may be those made by the clients themselves, or they may be those attributed by the client to other family members. The purpose of the case examples is to show therapists how, by attending to various interpretations of the state­ment, clarification can be obtained as to what is motivating the client and other members of the family system to act in self-destructive ways. We will see how ulterior motives and intrapsychic conflict can be uncovered through the analysis of the client's language. In this introductory chapter, I will look at some general principles of dissecting the various possibilities.

I would first like to re-emphasize the fact that the analysis of various interpretations of verbalizations can lead only to an hypothesis about the underlying motivations. Such an analysis can never be used as the sole criterion for making such a determination. If the therapist is to be confident about being on the right track, the hypothesis must be verified by the patient or the other family members involved. Even if the patient appears to be unduly defensive, a discomfirmation indicates at the very least that the therapist's hypothesis has been poorly presented, that it is incomplete, or that the emphasis is somewhat off the mark. While it is a truism that people are uncomfortable with change and therefore are resistant to new ideas, the fact that they are attending therapy sessions usually indicates that they wish to learn new ways of looking at their lives in spite of their discomfort. Even professional patients who come to therapy to verify their own defectiveness may still hold out some small hope for themselves. If they have no hope, then it matters not what the therapist says or does. The vast majority of patients, who are truly interested in obtaining help, will be able at some point in therapy to honestly appraise the therapist's ideas. The therapist will find out then if the hypothesis is correct.

A second major principle about interpreting ambiguous verbaliza­tions and hidden motivation is one I have already mentioned. It is the assumption that any statement, no matter how absurd-sounding on the

87 D. M. Allen, Deciphering Motivation in Psychotherapy© Plenum Press, New York 1991

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surface, has some underlying logic or reasonableness if the correct inter­pretation can be discovered. In other words, the therapist looks for a way to believe the patient even if he or she feels highly skeptical. Therapists need to ask themselves, "How can this statement be true? In what way does it fit the facts? What missing information would make it more reason­able?"

Hypotheses about the motivation of the various members of the pa­tient's family system most usually concern motivational conflict or ambi­valence, which in turns stems from dialectical issues between the self and the family system. The reason for this is that, according to the theory I am using (Allen, 1988), dialectical conflicts underlie most forms of self-de­structiveness and chronic emotional distress. Therefore, unless there is dramatic evidence to the contrary, persons who seek therapy can be as­sumed to have a motivational conflict: They wish to break free of certain collective constraints but are fearful of doing so. They are not seen as being so cognitively impaired that they do not know, most of the time, what is in their own best interests. Indeed, awareness of the self-defeating nature of their behavior is what usually prompts them to come to therapy in the first place. The anxiety and stress that they feel stem directly from such awareness. Clients seek therapy in order to learn how to solve their difficulties in ways more beneficial to themselves.

In general, the therapist should suspect ambivalent feelings whenever clients make statements which contradict one another or are inherently self-contradictory. Such inconsistency is not always immediately evident. In fact, quite frequently the therapist will be able to see a contradiction only if he or she attends to unusual interpretations of patients' comments. The reason for this lack of clarity is that individuals who are feeling ambivalent often experience a certain degree of rather unpleasant cognitive disso­nance. Their contradictory ideas and wishes make them feel quite anxious, and they naturally wish to avoid this. Since any two statements may be either congruent or discordant depending on how they are interpreted, patients are apt to make it appear to both themselves and their therapist that their ideas are all perfectly consistent. In order to achieve this effect, they may shade meanings, veil references, mix up metaphorical and concrete speech, make puns, or give contradictory messages at widely spaced in­tervals. In short, any of the numerous ambiguities mentioned in Chapter Three can be used to create the illusion of single-mindedness.

In attempting to ascertain ulterior motivation, the therapist must natu­rally take into account the fact that the meaning behind statements made within the context of therapy is to a major degree determined by that context. The patient has a purpose in saying certain things to the therapist at certain times. As I have described earlier, all communications are meant

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to exert some sort of influence over the person who is listening. This is true even of those statements which are also an accurate description of that which individuals are perceiving, or their feelings about it.

I believe that most of the time, in the context of therapy, the client's goal is to provide the therapist with the information necessary to help allay the client's distress or solve his or her problem. All statements made in therapy can be understood in this light. Of course, they can also be inter­preted in a different light. Because of the dialectic nature of language, all statements made in therapy can be used either to move the therapeutic process along or to impede it, to assist the therapist or to put up a re­sistance. Looked at from a different perspective, language in therapy is designed to induce therapists to either strengthen the patient's true self orto reinforce his or her persona. The choice of which way to go belongs to the therapist.

Language allows clients the lUXUry of leaving it to the therapist to decide whether or not to help them change their behavior patterns. Since clients are ambivalent about their behavior in the first place, they really do not know whether they should learn to accept their current status or learn new ways to act. They do not know if the therapist will support their current behavior, much as their families do, or if he or she will push for change. The ambiguity inherent in language is perfectly suited to testing the waters. Similar to the manners of someone from Japan, clients will hint and probe and suggest ideas in ways that will help them to determine where the therapist stands. If therapists are not careful, they can be in­duced to support the patient's role function within the family system.

For example, a patient's verbalizations may, if the therapist allows it, elicit a countertransference reaction that can be used to prove some sort of family myth. A countertransference reaction could easily lend credence to false notions such as authority figures can never be trusted, all relation­ships are trouble, or all men wish to dominate women. Alternatively, the client's statement may create a transference resistance. The patient's words may allow the therapist to focus on the therapeutic relationship instead of focusing on the family system dynamics. Any of these statements made by the patient does not, however, force the therapist into any particular ac­tion. The ambiguity of the patient's language allows the therapist the freedom to dispute the myth or to refrain from supporting the patient's resistances.

A statement that could have led the therapist to either support or undermine the patient's persona occurred in the therapy of Meryl, a wom­an who exhibited behavior characteristic of the borderline personality and who also experienced severe panic attacks. Meryl demanded that I do something to ease her severe anxiety, and I suggested the use of an antide-

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pressant for this purpose. She then looked at me in a most hostile fashion and said, in a voice dripping with sarcasm, "You mean you're going to be messing with my brain chemistry?" She seemed to be implying that I was some sort of mad scientist who was deviously attempting to exert mind control on her, and that my intent was to do her harm.

Had I reacted to that interpretation of her statement, I would have been going along with her hostile, mistrusting, help-rejecting persona. Instead, I reacted only to the lexical content of her question, and took it to mean that she was interested in the mechanism of action by which antide­pressants stop panic attacks. In a matter-of-fact fashion, just as I normally do whenever any patient asks me about how the drugs work, I explained the current notions about how tricyclics do indeed alter brain chemistry. Meryl immediate became less hostile, listened to my explanation, and agreed to a trial of the medications.

To be successful, therapists must attend to both parts of a patient's conflict. This is the beauty of attending to alternate meanings of verbaliza­tions. As we shall see in the case examples in the following chapters, many statements give the therapist information about both the patient's true self and his or her persona. Any utterance has within itself both elements of the bind in which the patient has become embroiled. The countertransference­inducing nature of verbalizations may shed important light on the family system dynamics and the role functioning of the patient, while the alter­nate meanings may shed light on the client's repressed wishes. In the case of Meryl, the hostile interpretation told me that help rejection was a main­stay of her persona, while the nonhostile interpretation indicated that she was not completely closed off to the possibility of change.

RECOGNIZING HIDDEN DOUBLE MEANINGS

In this section, I will look at how a therapist can be alerted when a given statement made or reported in therapy can be interpreted in more than one important way. In general, the therapist looks for any of the ambiguities listed in Chapter Three. As I mentioned earlier, however, ambiguity is not always immediately evident. Useful concepts of word and sentence meaning that can provide clues to the presence of a hidden double meaning are "entailment" and "presupposition."

Entailment

Entailment is defined as follows: "51 entails 52 if, over the whole range of possible situations truly described by 51, 52 would be also true"

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(Dillon, 1985, p. 389). For example, the most important sense of the word "mother" entails the concepts of "female" and "parent." All cases of orga­nisms described by this sense of the word" mother" are therefore cases of females as well as cases of parents. If a patient were to use the word to describe a male, for instance, we might rightfully conclude that the word was being used in some other sense. Motivational ambiguity would be indicated if the patient or a family member seemed to be using the word in the traditional sense, but also seemed to be applying it to a male. Both of these cannot be correct. The therapist might then think about the ramifications of both possible interpretations in order to figure out what the individual really meant and/ or why he or she seemed to be misleading the listener.

As a clinical example, consider the case of a client named Trudy who was attempting to communicate with her mother about the mother's ap­praisal of the institution of marriage. Trudy was trying to discuss an hypothesis that I had come up with, namely, that the mother felt very negatively about the effects of marriage on an individual, and that this negativity about marriage had been contagious. Whenever Trudy thought about going out on a date, she would start to feel doomed to a life of drudgery, and would then find some way to avoid getting involved. In determining the origins of these self-scaring thoughts, I took note of some­thing Trudy had told me earlier on. She had mentioned that her mother was frequently heard to complain about having to cater to Trudy's father. The mother cooked for him, cleaned for him, picked out his clothes, and a lot more, and seemed to get nothing in return for her efforts but the father's inexplicable resentment. I connected Trudy's fears about dating with the mother's oft-heard complaints, as well as with the tension in the parents' marriage.

I coached the patient to bring up the problem with the mother so that the mother would become aware of the effect these statements were hav­ing on her daughter. I was confident that, even if the mother did feel rather oppressed by her own relationship, she would not wish to prevent Trudy from making her own decisions in the matter. In carrying out this assign­ment with her mother, Trudy would of course first need to obtain the mother's agreement regarding the existence of the mother's negative feel­ings. Without it, there would be nothing to discuss. Trudy and I knew that the mother would deny feeling bad about her own marriage if asked about it point blank. Instead, Trudy planned to use comments the mother had made about other people's marriages as examples of the mother's negative feelings. Nonetheless, in the heat of the conversation, Trudy brought up the parents' relationship anyway. When the mother asked for examples of the negative statements to which Trudy had been referring, Trudy listed

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in a somewhat clumsy manner many of the mother's complaints. She then wondered aloud how her mother's marriage could be so wonderful if it was so much work. The mother replied, "But, Trudy, you always have to work at relationships."

This statement seemed to pull the rug out from Trudy's attempts to discuss my hypothesis. With one pronouncement, the mother had redefined her statements about her myriad responsibilities within her marriage. She had indicated that she was not complaining about them, but merely reporting in a matter-of-fact fashion that all relationships require much give-and-take. She had said on numerous occasions that one has to take the good with the bad or the bitter with the sweet. That is not being negative; that is being realistic! Of course, the emotional emphasis of the mother's previous complaints still held far more importance for Trudy than this seemingly rational aside. But how could Trudy argue that point without being accused of totally misinterpreting the mother's opinions?

The concept of entailment provides us with a clue that Trudy had not merely misinterpreted her mother's realism as negativism. Trudy had the impression that her mother believed that there was always more bitter than sweet, and the younger woman had good reason for holding this opinion about her mother's views. Her mother's attitude indicated that she, the mother, felt that she had given up and was giving up far too much for the apparent sake of her marriage, and for what? However, pinning the mother down so that she would admit to even occasionally harboring these feelings was a tricky matter.

The clue to devising a way to help the mother admit to her ambiva­lence was her use of the word work. She was using it in two different senses. To see this, let us look at what the word work entails. In the phrase "you have to work at relationships," as it normally used, the word entails such things as making some compromises, but not unfairly, hammering out disagreements, not running away when things get tough, and so forth. The sense of the word as Trudy was using it, however, entailed such things as slaving over a hot stove, cooking according to one's husbands likes and dislikes but not one's own, catering to the spouse's every whim, and so on. In general, work entailed bending over backwards to let one's husband have his way all the time, and basically being his servant.

The concept of entailment shows us when words are being used in two different ways. In this case, the ambiguity was being used by the mother in an attempt to steer the patient away from a discussion of the mother's negative feelings about the parents' relationship. In spite of this effort, the mother was also revealing herself. In using the two different senses of the word simultaneously, she was quite possibly equating the two senses. This would mean that, to the mother, working on the relation-

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ship was synonymous with making sacrifices. In her world, other types of successful relationships were impossible. The mother saw her choices as being used by her husband or being alone. Believing in this view-a myth that was shared by the rest of the family-provided a mechanism by which the mother mortified her desires for a more egalitarian relationship. She had convinced herself that a better arrangement was unobtainable.

The fact that mother justified her unwillingness to change or leave her marriage on the basis of the family myth became one of the major reasons why Trudy elected to be alone. Trudy had gone along with the myth, hook, line, and sinker, but opted for the choice her mother had not made: being alone. She did this in response to the mixed messages that she was getting. The mother vicariously identified with Trudy's independence (Trudy was in the "savior" role) and seemed to want her to remain single despite protestations to the contrary. If Trudy had instead chosen to have a dif­ferent and better relationship than her mother, the mother would not have been able to live out her repressed wishes through her daughter. The latter course of action would disprove the family myth; the mother would then be confronted with the profoundly disturbing notion that she could have lived her life in a manner far more satisfying. The mother knew that anyway, of course, but could pretend otherwise so long as everyone else in the family accepted or acted out the family myth. Trudy did not under­stand all this, but could sense that her mother was threatened whenever she changed her behavior. Since Trudy would not risk causing her mother to get even more depressed than the mother already was, celibacy was the obvious choice.

Understanding the ambiguity and contradictions inherent in the mother's statements was useful in getting the conversation back on track. Trudy was coached to discuss the confusion of meaning with the mother. The last section of this chapter will explore that process.

Presupposition

Any given remark does not make explicit all of the assumptions that underlie it. The speaker assumes that the listener is aware of certain information that gives the statement context and meaning. If the speaker were forced to spell out everything needed to understand each verbaliza­tion, communication would soon grind to a halt under the weight of hopelessly numerous details. Heatherington (1985, p. 426) looks at the presuppositions behind the statement, "But Jenny has never gone out with a married man before." This statement presupposes that there is a person named Jenny with whom the speaker is familiar, and that Jenny $oes out with men and has recently gone out with a married one. It also pre-

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supposes that Jenny is an unmarried adult female, that she usually does not have affairs, and that the speaker is surprised by this new and unusual behavior. The statement itself states none of this information explicitly.

Motivational ambiguity may be indicated when one of the presuppo­sitions that the therapist thinks is needed to make sense of a client's speech seems to be missing or incorrect. For instance, if a former nun were to state that she had just now come to believe that the reason for her earlier career choice was, "I had a calling from God," this presupposes not only the proposition that God exists but also presupposes that the patient currently believes in Him. If the patient had previously indicated that she was at present an atheist, the therapist would be justified in thinking that he or she did not understand what the patient's answer actually meant. The comment certainly would not mean what most people would think it means. Interpreting the statement would involve finding the correct state of affairs for it. Perhaps the patient is mocking her family's attitude or other nuns, or maybe she is expressing annoyance with herself for having previously believed in the church. The most likely guess is that she is feeling guilty and ambivalent about her new beliefs, and is therefore reluctant to fully commit to them even in her own mind.

Not infrequently, the motive behind a given verbalization is one of the major presuppositions about it, and listeners base their presuppositions on the nature of the conversation in which the statement takes place. For instance, let us take the example of the question, "Why are you doing that?" The motive presupposed by this question would be different if the conversation were taking place between a therapist and a patient that it would be if it were taking place between a young girl with her hand in a cookie jar and her mother. In the latter case, one could assume that the mother's motive for her question is to discourage further cookie raids. The mother undoubtedly believes that the child will be unable to come up with an acceptable explanation for the questioned behavior.

If a therapist asks the question of a patient, he or she is usually asking for some sort of clarification of the motives behind the patient's behavior. The therapist will then presuppose that the answer received is such an explanation, or at least an attempt at one. This presupposition is natural and is based on the idea of utterance pairs (Chaika, 1985). Social norms are such that questions are supposed to elicit answers to the questions just as greetings are supposed to elicit return greetings and commands are sup­posed to elicit acceptance or rejection. Motivational ambiguity is indicated when the answer to a question does not really provide what is expected, or when one is not quite sure which presupposition to use. In many cases, this can be quite subtle. An example of a statement not providing what is expected is the description masquerading as an explanation. An example

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of a question over which presupposition to use is confusion over whether a statement is an opinion or a directive.

Descriptions Masquerading as Explanations

Descriptions that masquerade as explanations are a problem intrinsic to psychological theory building. To show this clearly, let me pick an admittedly trivial example. Let us look at the "explanation" for lack of assertiveness, "He always keeps his anger to himself because he has trou­ble dealing with his angry feelings." This is obviously no explanation at all. It is probably true, but it clarifies nothing. In fact, it is merely another way of describing the very state of affairs it purports to explain. The theory builder and his or her audience probably both presuppose that, in most cases, appropriate expression of one's anger is the best way to deal with it. To say that he has trouble dealing with his angry feelings means the same thing, in essence, as to say that he always keeps his anger to himself.

A slightly better example of a description purporting to be an ex­planation is, "He compulsively washes his hands as a defense against an underlying wish to be dirty." Again, this could very well be true, but it does not explain why the individual has to defend against this impulse in such a manner. We could go on to say, "the impulse is unacceptable to his superego because of internalized parental values." Once again, this may very well metaphorically describe the patient's situation, but does it really explain it? Even if we stay with the psychoanalytic metaphor, we would still have to wonder why the individual cannot or does not handle his problem in a healthier fashion. Many individuals with strong superegos, who also have an unwanted desire to roll in the mud, do not engage in compulsive hand washing. The explanation fails to help us to understand why the neurotic chooses to engage in this particular behavior.

To consider an example from a client in therapy, let us look at the case of a lonely woman who explains her isolation by saying, "I prefer to live alone; I like it better." On the surface, this answer does seem to provide an explanation, albeit one with which the therapist can do very little. The client has indicated that she is basing her choice to live alone on personal preference, much as one might like chocolate ice cream while disliking mocha. One's preferences have to do with the tastes of one's true self, and are otherwise inexplicable. On further inspection, however, it becomes clear that the patient was being evasive in answering the question. Choos­ing isolation over relationships is not a simple choice, but one based on a relative preference. Adults do not dislike living together in the same way that they dislike liver. There are pro's and con's which must be appraised individually and then balanced against one another. Yes, descriptively, the

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patient does prefer to live alone, but why is that? What are the pro's and con's upon which she is basing her decision? More importantly, if some­thing could be done about the con's, would she make a different choice? The patient's evasiveness probably indicates that she is anxious about looking at her choices more closely.

Opinions and Directives

Being in a relationship with one's parents is by its very nature a game without end. In order to rear their children properly, parents have to discipline them. Parents have to tell children what to do and how to behave in various social situations, and parents have to make their chil­dren follow the parental directives. One cannot argue against this. The difficulty is when is this supposed to stop? Does the child suddenly be­come capable of making his own enlightened choices by virtue of having lived eighteen years? Should parents ignore the wisdom of their added years and never advise their adult children about anything? If the parents do persist in giving counsel, how upset are they going to be if the child chooses not to follow their sage advice? If a parent suggests a course of action over a particular issue, will the adult children feel infantilized?

Unless parents and adult children are adept at metacommunicating about this issue, tension is bound to develop. An additional exacerbating factor takes place in those situations where the parents themselves are highly conflicted about the advice they give because they are unsure of their own choices in life. In such a case, two events frequently transpire: the parents bring up the issue involved rather often-because they are pre­occupied with it-and they give out a double message. Whenever this chain of events takes place, a question about the motivation behind the parental advice is created for the child. The child must choose between two possible presuppositions. Either the advice is meant as a directive (a com­mand telling the child how to behave) or is merely the parent's opinion about a controversial issue. The frequency of the advice will most usually indicate to the child that how he or she behaves is a matter of grave concern to the parents. Therefore, the younger family member will pre­suppose that the parents' statements about the issue are directives. They will then make an effort to determine, using the principles of ordering environmental cues, which side of the double message to heed.

Again, consider the example of Trudy and her mother. The mother had said on numerous occasions that marriage was a mixed blessing: one has to take the bitter with the sweet. One could interpret this as sage advice on the wisdom of not expecting perfection and retaining one's equanimity in the face of unavoidable adversity. Nothing in the lexical content of the

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statement indicates that Trudy's mother is commanding her to behave in any particular fashion or make any particular choices regarding marriage or spouse selection. The statement can be viewed as an expression of the mother's opinions about life and as good advice, nothing more.

On the other hand, the fact that the mother seemed compelled to drive this point home by repeating it over and over again suggested otherwise. The statement began to sound like a warning: "You'd better watch out! If you get married, you'd better be prepared for all the bitter you're going to get with any sweet!" Every time the mother talked about the good points of relationships, she seemed to be throwing in a warning about it. Not only that, but her frequent repetitions indicated to the daughter that the mother was very concerned about whether the message had been heard loud and clear. Perhaps she was worried that Trudy had not understood it the first twenty times it was said.

Naturally, Trudy began to worry about the consequences of getting involved with men. She became concerned not only that she might be in for a rough time, but also, for some reason, that her mother might become very upset about it. What Trudy did not realize was that the repetitions indicated that the mother was trying to convince herself, not Trudy. In any event, the motivation presupposed by the mother's statement was in ques­tion, and the patient had been forced to guess which one was correct. A good therapist should be alert to the possibility that Trudy may have guessed wrong.

VERIFYING THE HYPOTHESIS

Often, during the course of therapy, patients make ambiguous state­ments about themselves or another family member that may shed light on an issue relevant to their chief complaint. The therapist should then con­sider various possible interpretations of the statement to see if it might help identify a motivational conflict on the part of the patient or some significant family member. Of course, by the time such a statement is made, the therapist may have already formed a preliminary guess about the nature of the family's bind. The interpretations of the ambiguous statement will then either support this working hypothesis, alter it, or refute it. In other cases, the ambiguous statement may point to a problem that the therapist has not yet identified. In either event, after the therapist generates an hypothesis, he or she must, at some point in the therapy, obtain verification of the hypothesis. We can never be certain that we have guessed correctly without some form of corroboration from the patient.

In cases of countertransference- or resistance-inducing statements,

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such as those made by Meryl, verification may be obtained merely by watching the patient's reactions to the therapist. As I showed in that case, the therapist's hypothesis determines how he or she responds to the pa­tient's verbalization. Once the therapist makes the response, he or she can then observe how the patient reacts in tum. If the patient responds with acting out or increased transference, the therapist's guess is either in­correct, or the patient is feeling in some way attacked or blamed. If the patient responds with a strengthening of the therapeutic relationship, thoughtful discussion, or new information, then the therapist's guess is probably on the right track.

Most of the time, however, the therapist will need more than just the patient's reactions to verify the hypothesis. In the majority of cases, verification is achieved in the following manner: If further data consistent with the hypothesis has not already been collected during the course of general history-taking or during the exploration of the patient's presenting complaints, then the therapist first asks questions that might elicit it. If the answers to these questions do support the hypothesis, the therapist pre­sents the hypothesis to the patient for agreement or disagreement. Let me first address the matter of data collection, and then the matter of presenta­tion.

Data Collection

In developing a general scheme of questioning, I have found it useful to look for two different types of evidence:

1. Data that suggests the patient has powerful mixed feelings about the issue in question. Mild ambivalence is normal in everyone and is rarely the cause of severe emotional distress or maladaptive behavior.

2. Data that suggests the patient's whole family shares the motiva­tional conflict presupposed by the hypothesis. If it were not true that the patient's decision on the issue-no matter which way he or she decides-would cause trouble for someone else in the sys­tem, then the patient's conflictual feelings would probably not be problematic.

In fishing for evidence that the patient has strong feelings on both sides of an issue, it is all right for the therapist to lead the patient on a bit. The patient almost certainly has difficulty even thinking about any significant conflict that may exist, so some priming by the therapist is a necessary evil. Should the patient agree with the therapist's ideas only

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because the patient believes that the therapist is an all-knowing expert who has to be right, or because the patient is intimidated in some other way by the therapist, then the data elicited will eventually break down. It will begin to show evidence of inconsistency or incoherence, or it will com­pletely fail to explain some other relevant behavior within the patient's family system.

Let us now look more closely at the type of questions which can elicit data that will either support or refute the hypothesis. Let us say, for example, that a man makes a statement that seems to imply that he has a great deal of ambivalence about his choice of career. We might first wish to find out if the whole family has such a problem. The therapist can look for openings to ask about the career choices of other family members. Has Mom ever worked or has she ever expressed any regrets about not being able to go to college? Has Dad done poorly in his role of breadwinner? If the therapist has taken a good social history of the patient, he or she will already have a general idea of possible leads to follow. Genograms (McGoldrick and Gerson, 1985) are also quite useful in suggesting ques­tions that the therapist might pose profitably.

For instance, let us suppose that this patient had four older sisters but no brothers, and that his mother was forced to take a menial job outside of the home because the father lost his job when his trade became obsolete. Such a situation might be conducive to career choice conflicts for any of a number of reasons. If the patient had made certain career choices which led to great success, the father might have become depressed and! or envious because of his own relative failure. If the oldest sister had been forced to become a second mother to the other siblings in order to make up for the mother's absence, the patient's choice might have caused her to become envious or resentful. If the mother had been unable to pursue the career of her choice, she might have lived vicariously through her son. The fact that there was only one son in the family might have led both parents to expect only certain types of career choices from him, which might then conflict with the patient's own natural inclinations. The therapist can in­quire about all of these possibilities.

If no evidence for a family system conflict is found, it may indicate that any ambivalence that the patient has about his career choice is not relevant to the patient's troubles. To repeat, a certain degree of ambivalence is present in everyone, and does not necessarily generate either affective symptomatology or self-destructive behavior. Of course, data that confirms the relevance of the hypothesis may show up later on in therapy, so therapists should not automatically assume that their ideas were in­correct. They should put the ideas on the back burner and look for a different hypothesis. If the answers to the questions do indeed suggest that

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the hypothesis is on the right track, then the therapist can look for further evidence.

The therapist should be able to make a good case to the patient that the motivational conflict presupposed in the hypothesis is both present and relevant. The therapist can look for more evidence by reviewing the history of the patient's job choices, asking for amplification of statements made by the patient indicating dissatisfaction, and inquiring about how the patient evaluated and reacted to any family system behavior patterns that were discovered earlier. If such questioning does bring out further data consistent with the hypothesis, then the therapist can bring up the hypothesis to the patient for discussion. Once that is done, the way is paved toward looking for a better solution to the patient's bind.

PRESENTATION OF THE HYPOTHESIS

THERAPIST: "You are ambivalent!" PATIENT: "Well, yes and no."

Presentation of the hypothesis can be quite tricky if the patient has a great deal of anxiety about his or her ambivalence or emotional conflict. Unfortunately, this is usually the case. For example, in the case of the man with career conflicts, he may believe not only that he must follow his family's apparent wishes regarding a career, but also that he must be happy about his choice. If he were to secretly hate his job, this emotion would be very difficult to face and nearly impossible to admit. Of course, it would also be nearly impossible to hide. Whenever some of his true feelings do show themselves, as they will invariably, he is likely to engage in what I refer to as the "take back" maneuver. Such a patient may spend several sessions complaining about how horrible his job is, and/ or ramble on extolling the virtues of some other job he would really like much better than his own. When the therapist confronts him with the extent of his complaints or empathizes with his misery, the patient "takes it back." He may deny that he had said or meant half of what he did say, or he may back-pedal: "Oh, I'm making it sound worse than it is. It isn't that bad. I really do enjoy it much of the time."

Such responses are not lies. As with all patient verbalizations, they are true if viewed from the correct perspective. The patient was indeed mak­ing it sound worse than it was; nothing is that bad. Of course, the patient has also damned his job with faint praise. Saying that something is not especially bad may also imply that it is not especially good, either.

Because of the high level of anxiety associated with dialectical conflict, the therapist must wait until he or she has a great deal of evidence before

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presenting an hypothesis. The evidence should be nearly irrefutable. Moreover, the therapist should wait until the patient is comfortable with the therapist's style. As therapists become adept at spotting evidence of ambivalence and emotional conflicts, they may find that they form a good hypothesis very early in the therapeutic process. The ability to understand the alternate interpretations of statements may lead therapists to quickly fathom the major systemic binds in the patient's family. I have found it advisable to avoid making presentations of hypotheses formed early in therapy. The therapist should continue to search out corroborating data for some time even if already quite certain of the patient's problem. I have had patients terminate therapy when I came on too quickly. Much to the annoyance of third party payers everywhere, and as most therapists know, the formation of trust and a working alliance takes time.

When therapists are ready to present an hypothesis, they must find ways to prevent the patient from minimizing or denying ambivalence. The therapist's attitude is crucial. Therapists to not want to imply that they know more about patients than patients know about themselves. Patients often get very annoyed about that.

"You are angry!" "No, I'm not." "Yes you are!" ''I'm not angry, God damn it!" "Darling, anybody can see that you are angry." (Furman and Ahola, 1988, p. 31)

In order to prevent such a reaction, it is often necessary for the thera­pist to temporarily accept whatever patients say about themselves. If the patient seems to deny ambivalence which is quite obvious to the therapist, the therapist can then go on to express in a nonaccusatory tone puzzlement over the data that seems to conflict with the patient's disavowel. This will have an especially dramatic effect if the therapist has collected a great deal of such conflicting data. The therapist can say, "Well, it may be true that you're happy with your job, but when you say that you like working outside better than indoors, that drafting bores you to tears when that's practically all you do, and that you originally planned on being a lawyer but were talked out of it by three of your sisters, it kind of leads me to wonder, you know?"

Most of the time, patients will begin to examine their mixed feelings after such an intervention. The therapist will then be able to help them to explore the systemic factors which create or exacerbate the ambivalence they feel. However, the patient may instead become unusually closed­minded on the subject, refuse to acknowledge that all of the things he has said do seem to contradict his most recent statement, or make either no effort or only a half-hearted effort to resolve the contradictions. A therapist

102 CHAPTER SIX

who is confronted with these types of reactions may certainly entertain the notion that the patient is making use of the defense of denial. The patient's behaVior does not prove this idea, of course, and the therapist must be careful not to force the hypothesis on the patient. Still, the patient's be­havior is suspicious. In such situations, the therapist should wait until he or she has collected more date which support the hypothesis, or until the patient is more comfortable opening up to the therapist. In addition, thera­pists should consider the possibility that the hypothesis is incorrect or incomplete, and look for a better one.

One additional useful technique for overcoming the patient's denial is to say the following: "Confusion over one's choices in life is extremely common in this day and age, so it would not be that unusual if this were a problem for you. Of course, when I present ideas, I may be completely off the mark, but I would like you to consider them for a while rather than reject them out of hand." Therapists may wonder aloud why the patient was so quick to conclude that the evidence the therapist brought up was not important. They might add, "I wonder if even thinking about whether or not you dislike your job might create a problem?" The rationale for these interventions is twofold: first, to convey the notion that being unsure of oneself is not a weakness because making choices in life is always a complicated matter; second, to find and understand the reasons why pa­tients feel they must deny their ambivalence so that the therapist can then be empathic.

Now let us look at the activities of the therapist when a statement which has multiple meanings is attributed to an important family member who is not in therapy. Once again, the therapist considers various possible interpretations of the statement to see if doing so helps to uncover a motivational conflict within the other individual (or within any family system member). Once again, the interpretations of the statement may lend credence to the therapist's previous ideas concerning the family member, or they may point to a new hypothesis. Verification of the hypothesis is also required. Ultimately, however, verification must come from the in­dividual who made the statement, not the patient. The patient's knowl­edge of the other may serve only as partial verification.

The therapist's job-after an hypothesis about the family member is presented to the patient and the patient has agreed with it to at least some extent-is to teach the patient how to obtain verification. As with any other hypothesis that the therapist makes about other family members, the pa­tient must go back to the source to discuss the relevant issues (Allen, 1988). Early in therapy, patients will be, like the therapist, more like historians. They will ask questions about the family member in order to elicit more data which will strengthen (or weaken) the therapist's hypothesis. Later in

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therapy during the" alternate solution" phase, when the patient is attempt­ing to actually resolve the problem, the patient will present the hypothesis to that family member for discussion.

As I described in my previous work, the therapist coaches patients to use some of the same methods with family members that the therapist uses with the patients. Role playing is used extensively to teach those methods. In order to verify hypotheses concerning role function ambivalence, pa­tients are coached to use their knowledge of their family's history to formulate questions about the therapist's ideas. They make note of and collect statements made by the family members indicating emotional conflict over life choices. They pay particular attention to statements that seem to contradict what others say about themselves when asked point blank about life choices. For instance, if a mother has stated that doing countless favors for her children makes her feel good, but nonetheless has been heard frequently to complain about what a chore that is, then the patient keeps track of several of the mother's grievances. When the time comes to present the hypothesis, the patient adopts the same attitude as does the therapist: "Gee, I know you really care about us kids and would gladly do anything for us if necessary, but when you complain about A, B, and C, I really find it hard to believe that it doesn't get tiresome for you. In fact, I don't really see how it wouldn't be a pain in the neck."

To summarize the chapter, ambiguous or contradictory statements made by patients in therapy often provide evidence of role-function am­bivalence. The therapist can analyze alternate meanings in order to form­ulate or strengthen an hypothesis about the patient or a family system member. The exact same language can induce a therapist to reinforce either a patient's true self or his or her persona. The ambiguity of verbaliza­tions may itself be hidden by the clever use of language. Hidden double meanings can be uncovered through the use of the concepts of contra­dictory entailments and missing or unclear presuppositions. Examples of the latter are descriptions masquerading as explanations and opinions doubling as directives. Once the therapist forms an hypothesis, it must be verified by the patient or by the family member to whom the statement is attributed. Verification is obtained by observing patient reactions, collect­ing confirmatory history, and giving a direct presentation of the hypoth­esis. The therapist must take steps in order to minimize patient denial.

In this chapter I have been discussing statements made in therapy which indicate ambivalence toward various aspects of role functioning. Before discussing more clinical examples of this, I will first look at ex­amples of statements made within the family system that serve as cues or triggers for self-destructive behavior.