Zeddies, T. - Becoming a Psychotherapist- The Personal Nature of Clinical Work, Emotional Availability and Personal Allegiances

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Psychotherapy Volume 36/Fall 1999/Number 3

BECOMING A PSYCHOTHERAPIST: THE PERSONAL NATUREOF CLINICAL WORK, EMOTIONAL AVAILABILITYANDPERSONAL ALLEGIANCES

TIMOTHY J. ZEDDIESUniversi ty of Texas, Austin

Becoming a psychotherapist is achallenging and exciting process. Thereare many important facets o f t rain ing inth e development o f a skilled therapist .Emot ional availability an d personalallegiances are two interrelated areas o fa therapist 's development that might beunderemphasized relative to other areasof t rain ing in many graduate clinicaltraining programs. This article o f f e r s aconceptualization fo r emotionalavailability an d personal allegiances,presen ts a view of the treatment processthat places emotional availability at thecenter of therapeutic respons iveness , an dargues that personal allegiancesmaylimit a student-therapist 's emotionalavailability with clients. This articleaddresses the concepts of emotionalavailability an d personal allegiancesprimarily from a contemporarypsychodynamic theoretical perspective,but key ideas from the cognitive-behavioral viewpoint are also used toillustrate their significance in atherapist 's development , however. Theseconcepts are suggested to have relevancefo r students, supervisors, an d moreseasoned therapists of varyingtheoret ical orientations.

Correspondence regarding this article should be addressedto Timothy J. Zeddies, Ph.D., 319Parland Place, SanAnto-nio, TX 78209.

The Personal Nature of Therapeutic WorkThe process of therapeutic change involvesmany factors. One of these factors which has been

relatively underemphasized in graduate clinicaltraining programs concerns the psychological andemotional process the therapist undergoes whiletreating clients. In particular, one of the mostchallenging aspects of clinical work is the neces-sity at times for the therapist to understand howhis or her own psychological and emotional dy-namicsincluding personal values, beliefs, the-ories, andcommitmentsinfluence the therapeu-tic approach with clients. Mitchell (1997)suggests that psychotherapy is "a unique, ex-tremely powerful , personally transformative ex-perience, for both parties" (p. 35). From hisperspective, meaningful and lasting therapeuticchange "entails new understandings and trans-formations of the client's old relational patternsin the transference, as well as new understand-ings an d transformations of th e therapist's cus-tomary relational patterns in the countertrans-ference" [italics added] (p. 52). According tothis view, therapists must not only facilitate aclient's growth, but a key element ofclinical workrequires that, at the same time, they must alsoallow themselvesto be changed in important waysover the course of the therapeutic process. Thetherapist's dual roleas agent and subject ofchangewas first formulated in Sullivan's(1954) notion of the "participant-observer,"which refers to the therapist as an ongoing andinseparable element of the therapeutic field whileat the same time being primarily responsible forobserving and facilitating that field. Being ableto provide this kind of therapeutic experience de-pends greatly on the therapist's capacity for form-ing interpersonal attachments, experiencing lifein emotionally rich ways, and being able to toler-ate the vulnerability and exposure that are inher-ent to the therapeutic process.

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Timothy J. ZeddiesAlthoug the therapist certainly has ideas aboutwhat general directions the treatment may (orshould) go , he or she needs to rem ain psychologi-cally and emotionally available to engage aspectsof the therapeutic process that cannot be necessar-

ily known or expected in advance. In additionto knowledge and expertise, tolerating or beingcomfortable with ambiguity is a crucial featureof therapeutic responsiveness (P ica, 1998). Alo ngthese lines, Stern (1997) argues that the act oflearning (for therapist and client) requires a gapbetween what is (unconsciously) anticipated andwhat is (consciously) experienced, between whatI think I know and what I expect will happen.Otherwise, experience "is invisible . . . becausethe impression it makes coincides exactly withexpectations one does not even know one has"(p. 242). Creating a ga p between the fam iliar andanticipated and the new and unexpected requiresthat the individual articulate often unconsciousexpectations and assumptions: "Learning is im-possible precisely to the extent that expectationscannot be brou ght into langu age" (Stern, 1997,p. 243). According to this view, what therapistsknow is no more important than their comfortin not knowing and their openness for learningsomething new. In order to become more fullyengaged in the therapeutic process, which entailsopenness to change and to the unknown or unfa-m iliar, therapists m ust be aware of how their ownpersonal biases and theoretical viewpo ints informtheir perception of clients and their beliefs aboutwhat clients need to heal and grow. This seemsto be ample cause for therapists to "hold theorylightly" and always to concentrate on being pre-pared to change or revise their ideas, opinions,and views in response to new information(Orange, 1995).Neither client nor therapist can anticipate whatexactly will happen over the course of their worktogether. The therapist may encourage the clientto loosen attachments to what he or she knowsand experiment with different ways of thinking,feeling, and interacting. To capture the client'sinterest in a genuine and meaningful way, thetherapist must be held to the same expectation.An important feature of engaging the therapeuticprocess at a deep level is the therapist's abilityto, at times, shift attention away from what shethinks she knows toward the unfolding relationalprocess. A therapist's capacity for understandingand therapeutic effectiveness is determined, inpart, by the ability to become engaged psycholog-

ically and emotionally with clients. How clientsheal and grow is thus facilitated by the therapist'sclinical skills and w ho she is as a person. Relyingsolely on the application of concrete therapeutictechniques may not be enough in certain clinicalmoments. It seems likely that, in addition to thedevelopment of particular cognitive skills, "mas-tering" the art of psychotherapy involves devel-oping a high level relational and emotional re-sponsiveness to clients (Jennings & Skovholt,1999).I suggest that a therapist's capacity for emo-tional availability is central to the task of provid-ing clients with an optimal therapeutic experi-ence. Following the work of several writers inpsychoanalytic psychotherapy (Ehrenberg, 1996;Orange, 1995; Spezzano, 1993; Stolorow, Brand-chaft, & Atwood, 1987) an d psychoanalytic in-fant research (Beebe & Lachmann, 1998; Emde,1988a, 1988b; Stern, 1985), I conceptualize emo-tional availability in two interrelated wa ys. First,it refers to the therapist's willingness to makedeep and sustained emotional contact with a cli-ent. This involves the therapist's capacity to ac-cept, tolerate, and contain the client's difficult,painful, an d even overwhelming feelings, whichof course may trigger corresponding feelings ofpain and distress in the therapist. Emotional con-tact by itself may not be sufficient, and it mightalso be necessary for the therapist to give sym-bolic meaning to the client's emotional experi-ence and communicate his or her affective under-standings to the client. Second, emotionalavailability refers to the therapist's capacity touse personal emotional experience to understandor appreciate something about the client that heor she might not be able to comm unicate verbally.In this sense, it is the therapist's ability to drawon his or her own reservoir of experience, bothintellectual an d emotional, that forms a basis fo runderstanding the client and for generating thera-peutic interventions. Based on this conceptu aliza-tion, it is suggested that emotional availabilityrepresents a major factor in the therapeutic alli-ance, and that it is central to therapeutic actionin that it is fundamental to facilitating the client'shealing and growth.The centrality of the therapist's emotionalavailability within the therapeutic process canrepresent a difficult developmental task for gradu-ate students and young therapists. Student-therapists come to recognize, as Bromberg (1984)observes, "that [therapeutic] skill is derived not

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Emotional Availability an d Personal Allegiances[only] from what you do but from who you are"(p. 33).' In their efforts to be competent and help-fill therapists, however, students may compro-mise their emotional availability with clients be-cause they are disproportionately focusedonwhatthey themselves are doing in the session, whichcan limit their ability to understand their clients'feelings and help them work through difficult is-sues. This kind of emotional misattunement isprobably common for students inclinical training,for while they are struggling to form identities astherapists they are bound to be somewhat lessspontaneous, relaxed, and open with clients thanare experienced therapists.

To be sure, emotional misattunement and thera-peutic misunderstanding remain as possibilitieseven for experienced therapists, particularly if thetherapist has not continued to be reflective abouthis or her subjective experience and personal dy-namics. In such cases, the experienced therapistmay defensively adhere to a particular theory ormanner of conducting therapy because it shieldshim or her from looking deeply or honestly at diffi-cult or painful personal issues. If a therapist ishaunted by unresolved and disavowed psychologi-cal or emotional issues, he or she becomes less ableto help clients face their own threatening or hostileemotional areas. As Spezzano (1993) observes,To the extent that the [therapist] cannot hold very well aparticular affect or set of affects, she will be limited in her

1 While Bromberg's perspective speaks well to how clinicalwork can nave an absorbing effect on therapists, and notesthat at times therapists may become involved in the therapeuticprocess in a way that feels quite personal, his view may appearto reflect a false dichotomy between who therapists are aspeople and what they actually do in their work as therapists.There is an important and inescapable relationship betweenthe two, because the techniques, interventions, and theoreticalviewpoints that a particular therapist endorses are very likelyto be meaningful on both a personal and a professional level.Being a psychotherapist is not simply an activity that onedoes, but is something that lives and breathes in one's bones.The relationship between a therapist's personal and profes-sional identity is thus continuous. Viewing the therapeuticprocess in this manner does not imply that therapy works bestif the therapist has a charming or persuasive personality. Itshould never beassumed, as Hoffman (1994, p. 193) cautions,that clients get better from merely spending time in the pres-ence of their therapists. Thus, it seems better to regard thera-peutic skill as reflecting a dynamic interrelationship betweenwhat is meaningful or significant to therapists on a personallevel and the technical interventions that they learn and refineover the course of their professional work.

ability to make therapeutic use of certain events and communi-cations in the [therapy] . . . In that sense, the [therapist] asan affective container establishes certain limits to where onthe humanaffective landscape she and the [client] can usefullygo together, (p. 212)Furthermore, as the work of William Henry hasillustrated (Henry, Butler, Strupp, & Schacht,1993; Henry, Schacht, Strupp, & Butler, 1993;Henry & Strupp, 1994), the therapist's own hos-tile introjectsmay prevent disengaging from mal-adaptive patterns with the client, which verylikely will reinforce the client's pathogenic rela-tional patterns and possibly be retraumatizing tothe client. It is important to keep in mind, how-ever, that deep and sustained engagement in thetherapeutic process does not mean that the thera-pist never addresses complimentary interpersonalpatterns or concordant identificationswith the cli-ent. It can be all too easy for the therapist tobecome hooked into a client's maladaptive inter-personal patterns. Thus, the therapist should becareful not to lose touch with his or her ownsubjective experience even though it may be nec-essary to relax some personal defenses and resist-ances in order to become fully engaged with theclient. Because psychotherapy is a deeply engag-ing process for both therapist and client (Mitchell,1997), a central developmental task for students,as well as for therapists of all levels, would seemto involve developing a therapeutic style that isboth genuinely personal and professional.Emot ional Availability an d Personal Allegiances

Because therapists draw on their personal emo-tional resources in attempting to understand cli-ents, being emotionally available in clinical workmay be predicated on being emotionally alivemore generally. It is reasonable to suppose thata critical relationship exists between professionalemotional availability and personal emotional ma-turity. As therapists deepen their understanding ofthemselves and work through personal emotionalissues, they should improve in their ability to helpclients dolikewise. If this is true, then thetrainingexperiences of students probably go a long wayin determininghow they use their own psycholog-ical and emotional resources in their own workas therapists. The remainder of this article focuseson how a student-therapist's emotional availabil-ity is related to, and perhaps even limited by,personal allegiances, which refer to a student'sattachment to or identification with a supervisor,theoretical perspective, or therapist.

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Timothy J. ZeddiesAn important consideration emerges in light of

the relationship between personal emotional devel-opment and clinical emotional availability, the pro-cess by which students expand their capacity tounderstand and accept their own emotional experi-ence likely will inform their beliefs about how cli-ents should resolve psychological and emotionalissues. In other words, a student's personal experi-ences (including formal clinical training, as well asinformal, social experiences) have a great influenceover what kind of therapist he or she is. While thepersonal aspects of a student's therapeutic approachis beneficial to clients in many respects, such asproviding a basis for empathywith a client's experi-ence, it is also true that the student's beliefs aboutmental healthy may reflect personal experiences inhis or her own therapy and supervision in a waythat limits the student's capacity for understandingand therapeutic helpfulness. Kohut (1984) observedthat "each person becomes 'addicted' to hisparticu-lar kind of mental health . . . and the addiction toa particular kind of mental health will affect [thetherapist's] capacity to change [and] to examinenew ideas, new theories, and new techniques towhich he is exposed" (p. 166). If a student's beliefsabout mental health are rigid and resistant tochange, the possibility exists that he or she willignore, misunderstand, or even devalue ways ofbeing that do not conform to a personal (often un-conscious) working model of psychological andemotional health.One reason why a student might have difficultyappreciating or understanding a client has to dowith the student's personal allegiances. Alle-giances are evident in situations in which a studenthas a strong identification with his or her owntherapist or supervisor, or with a personally mean-ingful theoretical perspective. By themselves, al-legiances are a vital and necessary aspect of astudent's development as a therapist, but they canalso be harmful when the student is unconsciouslyoverinvested in viewing clients only along thelines prescribed by a certain theoretical perspec-tive or therapeutic approach. When personal alle-giances are unacknowledged or defended, the stu-dent's capacity to engage in and facilitate anopen-ended therapeutic inquiry decreases, and thelikelihood of developing blind spots in therapeuticperception increases. For example, a student mayrepeat to a client, almost verbatim, what his orhe r own therapist or supervisor said. Sometimesthe results with clients are positive, sometimesnot. In the latter cases, it is possible that the

student prematurely assumed that what was someaningful and helpful personally would cer-tainly be so for anyone else. In those momentsthe student might be unconsciously invested inremaining connected to a moment of insight orintimacy shared with his or her own therapistor supervisor and attempt to recreate a similarexperience with a client. In situations where per-sonal allegiances operate in this way, studentsrisk imposing their own personal meanings ontotheir clients' worlds rather than helping clientsweave meanings from the texture of their ownsubjective experiences.2As a corrective fo r interferences in therapeuticunderstanding and responsiveness that might ariseas a result of personal allegiances, Kohut (1979)suggested that therapists should strive for a "dis-passionate attitude toward mental health." By thishe meant that therapists must become somewhatdecentered from their own personal experiencesof mental health so that what a particular clientneeds to heal and grow might emerge clearly. Thenotion of "decentering" should not be interpretedto mean that therapists must abandon theory orempirical knowledge as a prerequisite for under-standing their clients better. As mentioned above,a therapist's training in various psychotherapytheories and empirically validated treatment ap-proaches represents an indispensable interpretivetemplate that informs his or her therapeutic under-standing and responsiveness. Rather, decenteringreflects a special kind of clinical sensibility thatenables a therapist to be increasingly reflectiveabout how personal theoretical commitments andrelational-history (i.e., with a therapist, a supervi-sor, family, and friends) influence the therapeuticprocess in general and an understanding about

2 It is important to be mindful of the possibility that astudent's therapist or supervisor might (consciously or uncon-sciously) pressure the student to conduct therapy in a mannerthat conforms to the therapist's or supervisor's own personalvalues, beliefs, and commitments. It is difficult to draw aneat line between mentorship in the service of the student'spersonal development, on the one hand, and a therapist's orsupervisor's personal investment in advancing or perpetuatingpersonal allegiances through the student. In terms of the latter,it is quite possible that the student's therapist or supervisoris also under the sway of an unconscious personal allegiancethat interferes in work with the student. In this situation, thetherapist or supervisor unwittingly perpetuates allegiances ina way that limits or skews the student's development as atherapist.

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Emotional Availability and Person al Allegiancesclients in particular. Decentering in this mannerdoes not totally prevent the therapist from beinginfluenced by personal experiences. This wouldbe impossible. But by becoming increasingly re-flective about the sources of meaning and motiva-tion in his or her own life, the therapist will beless likely to unwittingly inject personal valuesand beliefs into the therapeutic process and betterable to appreciate clients' subjective worlds in allof their nuances and complexity.The notion of decentering points to a delicatebalance that therapists strike between workingfrom a theoretical or empirically-based perspec-tive (or perspectives) and responding spontane-ously. Therapeutic understanding and respon-siveness is informed by, but should never beconsumed by, a particular theoretical orempirically-based approach. This is not to suggestthat theory and empirically-validated techniquesnecessarily saturate a therapist's authenticity andspontaneity; but rather that these can, in certainclinical moments, be used defensively to avoidor minimize establishing and maintainingan inti-mate and personal connection to clients. For themost part, various psychotherapy theories andempirical treatment approaches allow therapiststo be available to help clients with their problems.But when this knowledge is held rigidly it cancreate an impersonal and authoritarian atmo-sphere that restricts the range of therapeutic un-derstanding an d effectiveness.Implications for Graduate Clinical Training

Developing a therapeutic style that is both gen-uinely personal and grounded in theory and em-pirical techniques is a complex professional de-velopmental achievement for student-therapists.Students often gain support an d guidance in thistask from their own therapists, supervisors, an dfellow students. But while struggling to strikean optimal balance between applying the toolsacquired through clinical training and respondingin a personal, authentic way in the heat of themoment-to-moment clinical exchange, studentscannot simply turn around and ask someone elsewhat to do or say. As Hoffman (1987) cogentlyobserves, "the interaction within the session iscontinuous; there are not time-outs" (p. 212).Therefore, in addition to instruction in variouspsychotherapy theories and empirically-validatedtreatment approaches, graduate training programsshould help student-therapists deal fully with thepersonal nature of therapeutic work. This might

involve coming to terms with the idea that, attimes, therapeutic technique cannot be pre-scribed. From this perspective, there is no oneway to facilitate a therapeutic process. AsGreenberg (1997) points out, therapists "simplycannot determine a priori what is going to workbest for another person" (p. 338). The practiceof psychotherapy cannot be universalized in away that prescribes certain techniques and meth-ods as true for all times and places, with all clientsand by all therapists.

Thus, it may be helpful for training programs topromote a kind of "self-reflective responsiveness"(Mitchell, 1997) or "reflection-in-action" (Aron,1996, 1999), which would encourage studentsto find meaningful ways to think about what ishappening in a particular session. Students wouldbe helped to develop increased awareness andsensitivity about how their own personal histor-ies, commitments, beliefs, and values underliethe kinds of psychotherapy theories and therapeu-tic techniques they find useful and appealing. Inaddition to acquiring the theoretical and empiricalknowledge necessary for effective therapeuticwork, students would also be taught the value of"not-knowing." This approach to the therapeuticprocess would help students shift their attentionaway from what they "know" (i.e., slotting theclient's material into predetermined categories ofmeaning and understanding) toward the uncer-tain, unknown, and unpredictable, which are in-escapable features of the therapeutic process. Bystructuring clinical training along these lines,graduate training programs could equip student-therapists to become increasingly emotionallyavailable to their clients.

To be sure, training that assists students in deal-ing fully with the personal nature of therapeuticwork and that promotes an attitude of self-reflective responsiveness should not take place atthe expense of abandoning theoretical and empiri-cal knowledge. Training in these areas shouldalways be a central and indispensable aspect ofour clinical training programs. For example, cer-tain therapeutic issues (e.g., panic disorders, sub-stance abuse, sexual dysfunction) require a com-paratively directive and educational clinicalapproach, which cognitive-behavioral therapyseems best suited to provide, and the therapist'sself-reflective responsiveness may not play a sig-nificant role in the treatment. While studentsshould strive to be maximally aware of their expe-rience of the therapeutic setting and the client,

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Timothy J. Zeddiesthe needs of the client, however circumscribed orbrief in nature, should always be viewed as thefundamental, orienting force in the treatment. Atthe center of the therapeutic contract is the client,who is overwhelmed in one way or another witha problem and seeks the paid service of a mentalhealth professional to provide time, care, atten-tion, understanding, knowledge, expertise, andrespect. The intent of this article, in emphasizingthe clinical importance of emotional availabilityand personal allegiances, is meant to complementthe existing content of many of our graduate train-ing programs.

Students may become overwhelmed by a desireto "get things rights." This can initiate two diver-gent kinds of therapeutic behavior that may beexperienced by clients as unhelpful or even de-structive. First, because they are relative novicesat establishing the parameters of a treatment, stu-dents may become overly focused on their ownlevel of competence rather than on the client'sconcerns. When students focus too much on theirown activities and subjective sense of comfortand competence, the therapeutic process likelywill be affected in a negative way because theirneeds for achievement and validation prevent theclient from articulating his or her own needs. Inserious cases, the therapeutic process becomes atraumatic repetition of other relationships in theclient's life in which his or her needs were subor-dinated or sacrificed as a result of efforts to pro-vide validation and support to others. Studentsmust be aware of this possibility and strive toachieve a full sense of reflective self-awarenessabout their participation in the therapeutic pro-cess, thereby increasing their capacity to providetherapeutic help to clients. A second problem isthat a student might be so consumed by a fear ofmaking mistakes that he or she becomes hesitantor reluctant to apply theoretical and empiricalknowledge in a way that the client needs. A focuson developing a deep sense of reflective self-awareness does not mean that students shouldnecessarily adopt a passive or recessive therapeu-tic style. One is reminded here of the stereotypicaltraditional Freudian analyst who says very little,offers no recommendations or suggestions, rarelyconfronts the client's behaviors, has a facile abil-ity for turning a client's questions back on theclient, and has an obsessive thirst for analyzingeverything, however seemingly insignificant. Atherapeutic approach defined mainly in terms of

reflective statements probably will not be of lastingbenefit to a client, and may very likely create arti-facts in treatment (i.e., iatrogenic effects) that dis-tort the clinical focus from the client's real issuesin life outside of the consulting room. In general,as Marsha Linehan (1997) argues, therapy worksbest when the therapist is able to strike a balancebetween acceptance and challenge, support andconfrontation, validation and critical inquiry.Many voices clamor for attention in a student-therapist's head during a session, and in the devel-opmental process from student to seasoned clini-cian, a therapist learns to become a better listenerof himself or herself and of clients. Bromberg(1984) suggests that as students progress throughclinical training they develop an increasingly sen-sitive "third ear," which aids them in becomingattuned to the ever-shifting tenor of the therapeu-tic process. The concept of the "third ear," whichis based on Sullivan's notion of the "participant-observer" and on the work of Reik (1949), refersto the student's capacity to be a fully engagedparticipant in the therapeutic process while main-taining a wide perspective of the entire therapeu-tic fieldincluding his or her own participationin it. This is a demanding task, for while clientsare invited to become deeply involved in a thera-peutic process, students must do likewise at thesame time as attending to and facilitating thatprocess. This "two-tiered" participation in thetreatment process requires a heightened level ofpsychological and emotional responsiveness,which results from a student's professional andpersonal development. The blend of professionaland personal elements in clinical work is one as-pect of training and development that makes be-coming a therapist so complex and difficultandso rewarding.ReferencesARON, L. (1996). A meeting of minds: Mutuality in psycho-analys is . Hillsdale, NJ: Analytic Press.ARON, L. (1999). Clinical choices and the relational matrix.Psychoanalytic Dialogues, 9, 1-29.BEEBE, B., & L A C H M A N N , F. (1998). Co-constructing innerand relational processes: Self- and mutual-regulation in in-fant research and adult treatment. Psychoanalytic Psychol-

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Zeddies, T. - Becoming a Psychotherapist- The Personal Nature of Clinical Work, Emotional Availability and Personal Allegiances