Book Review: Motivating Clients in Therapy: Values, Love and the Real Relationship

My initial experience on opening this book for the first time was that of my eye being caught by the words "a word about words". The author's word is that 'many models of psychotherapy have reinvented the wheel.... By utilising existing concepts but giving theirs a different name'. However, in contradiction, he goes on to say that he has invented new ideas and given them new names, thereby, constructing a new text of psycho jargonese. This is disappointing to me, as it is my belief that there are just too many different languages describing the business of doing psychotherapy. This state of affairs serves to obfuscate theory and create mysterious and supernatural claims to know and be the sole arbiter of the truth about human nature and what clients want and need. Later in the text, in fact, the author claims to know what is best for clients and that it is desirable to impart this knowledge to them. Practitioners who are unable to believe in the correctness of their interventions and personal psychological strength are inadequate because the client's inability or refusal to accept the truth of the therapist's belief system overwhelms them. To existential practitioners, no doubt, this stance raises serious questions of ethical practice. There is no room for error on the part of the therapist, and this encourages tendencies toward a manic defence and fantasies of omnipotence and god-like qualities. I find this very scary indeed!

Nevertheless, I like the basic thesis of this writer even though I do not find it to be particularly revolutionary. The core idea of his argument is that, although psychotherapy is into its second century, the majority of its practitioners are unable and/or unwilling to take responsibility for providing the nebulous ingredient of motivation. He believes that we are hemmed in and paralysed by an over zealous submission to the professional rules of engagement or rigid boundary keeping. I experienced this sense of insecurity from the very beginning of my clinical training along with a debilitating fear of being found out. I tried to do as my training lecturers and supervisors wished me to do and I fell flat on my face. That which Rappaport wishes for my clients is that I provide a place of safety, a sense of my trustworthiness so that s/he may be released from the grip of a fear. The fear is that I represent the establishment where expression of so-called negative emotion or psychiatric diagnosable behaviour is an offence punishable by incarceration. Today, I find myself saying things like "When you leave and embark on your round the world voyage, I would appreciate it if you would write to and tell me how you are getting on" and "I know its difficult for you to trust me after what you have been through and I encourage you to be wary. I have to earn your trust and I do not expect you to trust me just because I think you should."

There, the truth is out! I do not actually lie to my supervisor now but I am selective with the truth (I hope he is not a Society member). For me, trust and motivation are the necessary ingredients of a successful therapeutic alliance; they are inextricably linked and one does not exist without the other. For other reasons, though, that I discuss further on, I do not go as far as the author does in providing motivation; I think he advocates the practice of dangerous techniques bordering on the unethical.

On the whole, I have respect for the author's basic philosophy of treatment and this may be the point at which existential practitioners become disenchanted with the author's clinical theories. He writes: 'How does one become self-loving? When a child is born, s/he is at the mercy of their caretaker's capacity and ability to provide love. This love takes many forms: first, bonding, nurturance, and responsiveness (the first year or so) and soon after, regularity, predictability, and protection from harm (the toddler years) and soon after, regularity, predictability, and then teaching, guidance, direction, and expanded opportunities (later childhood). This is a summary of my modus operandi as I go about the business of restoring the trust of the client in another human being, me, which provides the nurturing experience that was denied them in childhood. I have heard it said in existential circles that this role model is not therapeutic; providing an environment where unfettered choices can be made is the requirement for clients. For me, this is denial of the obvious; human children cannot make informed choices as the process of maturation is the being educated so that intelligent decisions can be made. Many people who decide to have psychotherapy are able to make such informed decisions. However, the vast majority of those in therapy are so because society has decided on his/her behalf that this is a good idea. These people are the victims of child abuse, active or by default (negligence) on the part of the child's early caretakers and have been prevented from developing into adults with the uniquely human capacity to think creatively. They are stuck in the repetitious cycle of habitual destructive and/or self-destructive behaviour.

It seems to me that existential practice restricts the practitioner to a purely intellectual exercise void of any capacity to be with the other who has been traumatised to the point of incapacity for self-protection. I am wholly open to the possibility that I have got this completely wrong and I welcome any views from readers who wish to dispel a myth about existential practice that I may hold.

Finally, I would like to say something about the author's writing style. I don't like it. This is an example from the text that is a source of my discomfort: 'It is easier for the internally motivated client to see the intentions of their partner in a more benign fashion, and hence, see the rewording in the larger context of family-of-origin genesis correlates.' First of all, what are the "family-of-origin genesis correlates" and won't less abstruse language do just as well? There are basic grammatical errors for example; the plural preposition "their" does not follow the singular noun "client". There is no word "beingness" listed in the Random House Webster unabridged dictionary. Perhaps this sounds nit-picky to readers and maybe it is. However, I was taught (or brainwashed) grammar and syntax in English and Latin by Roman Catholic nuns; to err was a sign of the venal quality, not punishable corporeal. Nevertheless, it still grates. Every so often, a set of graphs and charts appear in the text with strange nomenclature like "Therapeutic Bonding, Penetration and Transference". I dislike them intensely, as they appear to box up the practice of psychotherapy into time and spatial cubes and understanding it through the function of mathematical formulae. The reading of them was tedious and, in fact, the whole text started to drag in the second half, as the author became more and more repetitive.

But more importantly, that which disturbed me most was the quality of the language that the author advocated and used himself in his dialogue with his clients. Here is an example from a passage of dialogue: 'Therapist: Yeah. Now you can either be smart, take advantage, or be stupid and keep drowning in your shit. What I am telling you now is that there are no more in-betweens.' The author likens the practice of therapy to that of American football coaching and this reminds me of the failed sporting hero who becomes a parent and insists that his child take his place as the quarterback of the Green Bay Packers. This is another piece of American culture that has been spilled like crude into the ocean slowly moving like an oil slick across the Atlantic contaminating and destroying British wildlife. Fortunately, I cannot imagine British practitioners adopting such a brutal style of motivating clients in therapy. At Her Majesty's Prison and Therapeutic Community Grendon where I work as a therapist, if a prison officer were to speak to an inmate (or resident as they are sometimes called) in such abusive language, he or she would be disciplined. Furthermore, it is the author's constant use of the phrase "psychic penetration" which I find so disturbing; it would be repulsive to me if my therapist sought to penetrate my psyche as, for obvious reasons, it would feel like the rape of my soul. As I continue with the piece of dialogue, we read the client's following statement: 'People do what you let them get away with' and this came just as I was thinking about the client-therapist balance of power relationship. The author enlightens his reader on this matter by putting into the text his view of what the client is saying. The client's statement is a request for therapeutic discipline. In other words, the therapist knows what the client is thinking and meaning but the client does not. The author doesn't say who is the undisciplined one and I believe he missed the obvious but covert criticism of him.

For me, this book keeps alive my internal conflict about the real nature of psychotherapy. Is it an exact scientific discipline like medicine or chemistry? Is it an art form guided by the spirit as it moves one? Or is it like a religious faith, the holding of which can move mountains? My jury and muse are still not talking.

Mary Henderson