Improve Therapy Outcomes For Poor Relationship Patterns
Quite Short, Do Read: The Takeaways
A. Get better data — from other people
As a therapist, ask to hear from other people close to your client — their family, partners, friends. As a client, ask if your people would support you by offering their perspective to your therapist. You need this to check the veracity and the completeness of the description of personal events you will use for symptoms and diagnosis. This seems to be common practise for private therapy or school-based counselling for children, not so much for adult therapy. If you don’t do this, you have a single instrument — a single source of data — and reliance on a single source of data is bound to lead to failure.
B. Validate your diagnoses
Check your hypothesized set of diagnoses against the symptoms you’ve gathered from past personal events. You are not just looking for a diagnosis to “make sense” or that each diagnosis explains a symptom. That is a very weak criteria. Given our tendency towards confirmation bias, don’t latch on too quickly to a diagnosis. The process for evaluating hypotheses has to be much more rigorous:
- Are almost all the important symptoms explained by the set of diagnoses? Are there symptoms or behaviors left out that need additional diagnoses
- Are there diagnoses that are unnecessary, in that the symptoms they explain are adequately covered by other, more powerful, diagnoses?
- Less critically, do the hypothesized diagnoses predict other behaviors that should be looked for, even if they haven’t manifested?
C. Do practise problems
The goal is to improve future performance, right? And theory isn’t enough — not in the physical sciences, not in athletics, not in music nor in art. You need deliberate practise. In therapy, unlike in the physical sciences, you can’t set up experiments in unexplored domains to test your hypotheses or predictions; you can’t solve large banks of problems, or do drills or repeatedly play or sing music. Unlike in the social sciences, you can’t even set up Randomized Control Trials or A/B tests on yourself or your client. So how do you develop the skills you’ve learned about, and need ingrained but for which you don’t yet possess muscle-memory? In the words of Rebecca Solnit, “It would be really meaningful to review the personal events of August 1997 in the light of what you know now.” (From her July 2013 essay We’re breaking up in The Encyclopedia of Trouble and Spaciousness, pg 262.) What this means: For every personal event in the past, given the same external situation, the choices you faced, the outcome of your past actions and your desired outcome, analyse what you would do differently in the light of your diagnosis, and what outcome your hypothetical actions would lead to. Is this your desired outcome or not? Remember, this is deliberate practise, so “look in the back of the book to see if you got the right answer”, namely, get feedback from the therapist or from your (the client’s) people!
We’ve all known or know people, either individuals or couples, who seem to have been in relationship therapy or counselling for years, and it often appears that all they can show for it is a changing language for describing themselves or their condition, a new diagnosis every so often, usually following the publication of some new self-help book.
Let me be clear that I am only talking about relatively “less serious” mental and emotional health issues having to do with inter-personal issues, and at that, issues which are not fundamentally caused by past trauma or current substance addictions. A lot of the resulting discontent and unhappiness arises from unBuddhism: too much attachment to the outcomes and not enough attention to the path — demanding from the universe what we haven’t prepared it to give. By this last I don’t mean that clearing out your garage and making room is going to magically or quantum mechanically provide you with a second car, as some claim.
So, back to the people who have the privilege of long-term therapy. They seem to achieve ever-more sophisticated levels of self-awareness, while simultaneously remaining just as unchanged in how they make their inter-personal or relationship decisions and in their resulting degree of unhappiness or discontent. Why is that?
I think there are two reasons for this, which I will explain in the context of “model-thinking”, or simply, science. Yes, I’ve been through a recent break-up; also, I’ve been reading The Model Thinker by Scott E. Page.
In resumen, “Model-thinking” consists of
- Data: The (collection of the) most fine-grained facts, e.g. “A ball of size s and mass m dropped from h height above the earth’s surface at time T took a duration t to reach the surface.”
- Information: A pattern that encapsulates or describes most of the data, usually conditional, e.g. “For small objects dropped from small heights h near the Earth’s surface the duration of the fall t is given by h= 12g t2 where g has a ‘universal’ value … .”
- Knowledge: A model or an explanation for the pattern, including the conditions under which the explanation or the pattern breaks down, possibly with a dependence on other knowledge or theories or models, e.g. “Objects are attracted to the Earth by a ‘gravitational force’ which depends inversely as the square of the distance from the center of the earth, this can be approximated for the near surface conditions, combined with Newton’s 2nd Law of Motion and with the calculus required to solve the resulting equation, to derive the above observed pattern.” (The boundary between information and knowledge is dynamic.)
- Wisdom: Being skeptical of the knowledge and knowing when to apply it. Recognizing the limitations of the theory, by going back to the facts and checking whether the theory explains them all (retrodiction), expanding the collection of facts to other conditions (“What happens on high mountaintops?”), universalizing it to other seemingly unrelated phenomena (The moon’s orbit around the Earth, the tides.) and predicting the outcomes for as yet unobserved conditions (“If we were to drop the same stone from the same height above the Moon’s surface, it would take almost 2.5 times as long to hit the ground.”). In the human and social realms, wisdom is using the knowledge we have to change our actions and hence get improved outcomes.
How do I intend to apply this model to therapy?
As an important aside, yes, it is necessary that the client be motivated and committed to change. All I am saying is that this is not sufficient, and the additional necessary bit is this “model thinking” approach.
For a concrete example to discuss, let me now switch gears and briefly describe the relationship I was in that just ended. Then we will come back to those two opportunities for improving therapy outcomes that I promised earlier.
K and I started dating more than three years ago, with a 50 mile drive between our homes in the SF Bay Area. Soon after, in addition to full time contract work in her previous career, K started going to grad school full time, to herself be trained as a therapist. This would take two years, with weekly evening classes and full weekends in class every three weekends or more often, plus reading and assignments. I have two children who at the time were both school-age and with me alternate weeks. One day a week when I didn’t have them I would work from K’s house so we could have time together at the beginning and at the end of the day. On weekends that I didn’t have my kids I would be at her house, on other weekends, occasionally, she would come over.
Overall, we were very compatible — politically, in our values, sexually, physically and in our interests and activities. Very early on, she said we were different “characterologically”, referring, I think, to how much independence we wanted and how much time we wanted to spend together.
See here. It is very personal.
I believe that some information can be extracted from the data by intelligent lay people who are not subject matter experts, but certainly not all. I’ll just describe the patterns I saw, I am sure you can add more if you look at the data, as would a good therapist. The main purpose of going into any detail is so we have some symptoms (the information in the model as applied to therapy) against which to hold up the set of diagnoses.
(The E#s refer to events in the data that support the symptoms.)
S1. Early and quickly waning enthusiasm (E1, E14, E16)
S2. Demonstrated lack of eagerness to spend time in relationship by either not making time or chipping away at it at both ends (E2, E11, E13, E16)
S3. Keeping me apart from her family (E2, E13, E19)
S4. Not trusting my commitment to her (E2)
S5. Need for “space” (E2, E5). One of those American relationship pathologizations, like codependency etc.
S6. Dishonesty about schedules or timelines (E3, E5, E10, E15, E16, E17)
S7. Not making me a priority (E4, E5, E12, E16)
S8. Approval seeking from father-figure (E5)
S9. History of wanting and maintaining relationship-sabotaging levels of independence (E6)
S10. Out of sight, out of mind (E5, E6, E12)
S11. Lack of consideration for me (E6, E9, E16)
S12. Seeking reassurance about the relationship (E7, E14, E18)
S13. Delaying pleasure in the relationship (E15, E20)
S14. Selfishness (~ “I want what I want, when I want it, and nobody tells me otherwise!”) (E9, E10, E11, E18)
S15. Unwilling to prioritize relationship building (E10a, E13, E14, E16)
S16. Lack of commitment to her own stated needs, self-sabotage (E8, E9, E11, E11a, E12, E14)
S17. Projecting previous relationship baggage onto me (actually it was more like large furniture than baggage) (E8, E17)
S18. Savior complex, compelling need to feel she was solving someone else’s problems (E12)
S19. Complicated relationship with mom (E5, E12, E13)
S20. Fear of not being busy, and hence overscheduling, leaving no buffer, resulting in time chaos (E10, E12, E20)
S21. Fear of knowing oneself (E14)
S22. Fear of being alone (E15, E18)
S23. Attachment to remote relationships instead of proximal ones (E2, E4, E5, E12)
S24. Contradictory visions of herself as a globe trotting conflict journalist vs. a more settled vision.
Knowledge (The diagnosis by her therapist, as related by K to me)
Complicated Grief (5 deaths in two years, but never dealt with or grieved fully.)
Anxious-Avoidant attachment (Obvious, right? A cat person in romantic relationships.)
Abandonment anxiety (Probably based on the history that K’s mom broke up her family twice.)
Love addiction syndrome
Wisdom (What do you do with all this knowledge?)
My understanding is the therapist has encouraged her
- to resign her current position in a cooperative practise,
- to indefinitely postpone the whole fostering idea (this doesn’t require a lot of wisdom: people with no psychology training whatsoever, but those who know K’s reality a little bit, have seen instantly something her therapist and her friends have been unable to see for years — K is in no state to foster a child.),
- to seek help in some kind of intensive in-patient program for complicated grief just so she can unlock herself to work on her other issues. Initially there was some idea to go to group therapy or support group for grief or attachment issues; I’m glad that ineffective path has been discarded.
I have no “therapy” wisdom to add about what should be done with all this knowledge. However, if I compare the diagnoses to the symptoms, I do see some mismatch and hence room for improvement.
The diagnosis of “love addiction syndrome” was quickly discarded when I pointed out to K that it wasn’t supported by any of the symptoms. It wasn’t that hard, I just searched for it and found 2–3 articles that seemed to make sense.
Based on the symptoms and my readings, the objection I have to the diagnosis of “Anxious-Avoidant attachment” is that the structure of “adjective-noun personality type” seems to imply helplessness and “syndromization”. I would separate them and bring the client’s agency back:
Attachment Avoidance (This is behavior that K displays repeatedly. It is a choice.)
Attachment Anxiety (This is a feeling and will need to be dealt with cognitively. But the anxiety is not about forming an attachment or being in a relationship, it is about what she stands to lose in a relationship. So we see that it is this anxiety that causes that avoidance. This makes much more sense to me — now it is clear what has to be treated — the cause!
Abandonment behavior (hey not just with me, she essentially abandoned her rescue dog months after getting it, for 4 months, and the shelter tells you you have to commit for a year! Some of this came up in discussions about how she imagined life would be like with a foster child.)
Approval seeking from Dad (based on Kim’s relating that he didn’t appreciate her work and didn’t support her through her studies, although he invested in her brothers’ real estate deals.)
Guilt over not having done enough for her brother.
Saviour complex (stray cats, dogs, children, renters, being disappointed when her second brother or her ex didn’t ask for her help with health issues.)
My additional two bits: Mommy abandonment issues? Get over it. K has a decently amicable but co-dependent relationship with her mom, she needs to set boundaries. Daddy approval issues? Well, too late now, but also, it was never going to happen — their politics and values are too different and it never seemed to me that her father was capable of valuing someone for themselves.
Any wisdom for myself? As Karen Nimmo’s article helped me see, K loved me but didn’t need me. Well, until she did.
Opportunities for improving therapy outcomes
Wisdom consists of being skeptical of the knowledge, only trusting it so far as it explains the information. And wisdom lies in knowing how to apply the knowledge, to get in the case of therapy, better outcomes.
- Check the Dx against the Sx: does the collection of diagnoses explain most of the symptoms, or is something left out? All too often we get excited by a new diagnosis. It brings some new clarity, probably marginal, but we feel the same rush we felt when we were first diagnosed. We feel it now “explains everything”, “it all makes sense!” and of course things hadn’t been working so well before, because we were missing this key element, but now things will be different. But have we been rigorous in checking the Dx against the symptoms? There are two aspects to this, but the more critical one is whether the Dx explains most of the important known facts. This requires us to go down the list of symptoms and evaluate whether each is covered by a diagnosis. When people first hear this they make the mistake of going through the list of diagnoses and checking, effectively, only whether there is a symptom it explains. This is not enough, it just leads to confirmation bias. In the very personal case of K above, I think the diagnoses don’t explain everything — anxiety, avoidance, abandonment, approval, grief … none of them explain why she chose to move forward with decisions whose hurtful consequences she’d been made aware of. There is a missing ‘A’ in the diagnoses: Arsehole.
- In therapy, unlike in the physical sciences you can’t do experiments in unexplored domains to test predictions based on your theory, unlike in the social sciences, you can’t even do an RCT with a holdout/placebo/control group. In the physical sciences, or in sport or music, it is not enough to know the theory, in order to perform well in the future you have to practise deliberatively! All the problems you can get your hands on, all the drills, practise games, playing the score as many times as you can. You can’t really do that in therapy. So what can you do to improve outcomes in the future? your Having identified your true long-term needs, knowing your propensities and having become cognitively aware of your diagnoses and having the distance from the events, how would you do things differently to get your desired outcomes?
Checking the diagnoses individually against the symptoms, it seems to me that the diagnosis of anxious attachment was too hasty. It is true that there is a lot of obvious anxiety there, but only once was it possibly associated with the relationship — when K wanted to get back together 2 days after breaking up. But that was just shock (hers, because I was so blase about it?) and depression and loneliness and impending loneliness and “loss of best friend who you always talk to about stuff”. That’s just normal for anybody and you have to push through it with other company. Anxious attachment would have more typically manifested as asking when I would next visit her when I left or — this is what I would habitually do — get concerned about our lack of time together when K made too many independent plans. On the positive end of the spectrum, I think this would have bled into eagerness to make plans with me or to see me at the end of one of our independent trips or some effing indication that she was thinking about me when we were apart. Did she have anxieties within the relationship? Yes, but they were usually anxiety about the wants she might have had to give up within the relationship: principally a) her want for independence to take-off whenever she wanted to for wherever within whatever timeframe and b) her long expressed and strong desire to foster a child, but one she’d avoided for 7 years before she even knew me.
However, the wisdom depends on the knowledge, which depends on the information which depends on the data. So even if your processes for moving from data -> information -> knowledge -> wisdom are sound, if your data is corrupt so will be your wisdom. There are two areas of doubt about the data:
- Is the data you have true (representative, free of bias etc.)?
- Is it complete, does it give you the whole picture?
One way of getting around these is to get data from one or two additional independent instruments. In most adult therapy, one is completely dependent on one source for the data, and the therapist has no instrument to measure either veracity or completeness.
No matter how committed the client is, they are biased towards themselves; to be truthful and complete about relationships requires a level of honesty and lack of shame/guilt that most people simply don’t possess. Most clients are self-serving in the extreme.
Both the issues of veracity and completeness of data can be improved greatly by the instrument of the therapist talking to other people! The incidents that have been described by the client, is the client’s the only perspective? How did other people see or experience them? (Murakami’s Rashomon is a great movie by the way!) Are those the only relevant incidents? Did something else happen that the client is failing to mention?
Numerous studies show that you get much better outcomes when you take the consensus of three random experts rather than the point of view of whoever you mistakenly believe to be the top in their field. The therapist may believe the client is the expert in their own experiences and this is erroneously reinforced to the clients themselves, but both client and therapist are uselessly limiting their own data and allowing it to cloud their information and knowledge.
So, as a therapist, ask to hear from other people close to your client — their family, partners, friends. As a client, ask if your people would support you by offering their perspective to your therapist, on your dime, of course.
In the American therapy model, this is a no-no! No therapist ever invites in a partner or close friend to check on the data. But there are exceptions: as my daughter pointed out, a child therapist or counsellor, either private or through school, often invites in the child’s adult caregivers to provide their perspective. Why? I’ve heard therapists use terms like “manipulative, child’s perspective, not the complete picture, distorted memories” etc. to justify (rightly, but for the wrong reasons) bringing in and listening to the parents. Why not for adult therapy? Are adults not susceptible to being “manipulative, having their own incomplete perspective, not the complete picture, distorted memories” etc.?