HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals


  • Katia CharalabakiPsychiatrist, Family Psychotherapist, coordinating director of Family Therapy Unit of Attica Psychiatric Hospital
  • therapeutic relationship
  • scientific prediction
  • unpredictability
  • ecology of the session
  • Part of this paper was presented at the 5th European Convention of E.F.T.A, Berlin 2004


Therapists who are trained or devoted to serving scientific prediction have been forever anxious to perfect their theoretical and practical ability to achieve safer therapeutic outcomes. Yet there are moments in therapy when certain elements —such as emotional encounters, verbal or sensorial resonances, chance events imposed on the context— unexpectedly invade the process and divert the therapy from its initial prediction. Based on the power of the therapeutic relationship and its open exploration, the therapist gains a new freedom to focus less on the "corpus" of the therapeutic narrative, i.e. the products of the collective therapeutic course, and be more open to exploiting its ‘by-products’. This takes advantage of the ecology of the session which allows the unpredictable to enrich it and offer new issues to process.

**Key-words: ** therapeutic relationship, scientific prediction, unpredictability, ecology of the session

A woman rings the Family Therapy Unit and requests an appointment because she has trouble controlling her anger. Among other information she reports having sought therapeutic help earlier and being treated by a therapist with whom she had been unable to form a good rapport. Always according to her, that therapist got on her nerves, especially when he resorted to certain techniques that seemed senseless to her, such as making her take his place or speak on his behalf, etc., so that she felt that instead of resolving her issues she was additionally burdened and left the sessions more frustrated than before. When she asked those in charge of the facility to allow her to change therapist she was refused; this angered her and she ended the collaboration with the therapist. One year later she approached the same facility again, and this time she was seen by a new therapist, but when she said that she had gone to the same facility again in the past the therapist told her she should either see the same therapist or go to another facility.

**#  ** I was on a ship on my way back from a holiday on the Greek islands when there was a request for a doctor over the speakers. I prayed that some colleague would answer the call before me, as anyone is “more of a doctor” than a psychiatrist, but I was the only one on board so an officer took me to the patient, and I soon realised I was the right kind of doctor for the occasion. A woman was half-lying on a deckchair with her eyes closed and an expression of suffering on her face. She was stressed because of a fight with her family. I sat next to her and strove to communicate, asking questions and trying to strike a conversation by being “friendly” and “human”. The lady answered reluctantly, with her eyes always closed. She kept repeating “I don't want to live like that, it’s too hard”. She never turned to look at me once, answering my persistent questions with fragments from a disjointed family story. Every now and then a very agitated young man would rush towards us sobbing, shouting and begging, while her sister, who seemed very worried, was sitting silent next to her, crying and sighing. From what little information I had, I gathered that the lady lived together with her sister and her nephew, whom she had raised, and this nephew had said something terribly insulting about his aunt. The deck was full of curious onlookers. As I stood above the lady who didn’t want to live, next to a ship officer (the true client or co-therapist?) the family-in-crisis which seemed to be experienced as insufferable, the annoyed tourists, I felt that the problem was that we were all part of a scene where nobody really knew anyone else and nobody related to any other. We were all under the influence of the impersonal, and there was much loneliness in that crowd ... I turned suddenly to the lady and said, “let me ask you something—what do you think of me?” The woman seemed to wake up abruptly. She raised her head, looked at me for the first time with a surprised, searching gaze —in what was her first contact with me— smiled and said: “Thank you, I feel better”. It was a momentary therapeutic relationship.

Katia Charalabaki

**The ** **therapeutic relationship ** in systemic therapy and the therapist’s role. A historical overview

If we brought this incident into a therapy room, it could be the first meeting with the family and a first attempt at connecting and establishing a relationship between therapeusants and therapist. Some of the key questions to arise are—how can we define the therapeutic relationship? What are its constituent elements? How do we bring it up during the sessions? How is it differentiated within the family, the couple, the individual or another group? Should therapeusants have the right to choose their therapist in a public facility? To what extent do we allow an open discussion of the difficult feelings that often arise in sessions on either the therapist’s or the therapeusants’ side?

In the first incident we described, when the therapeusant came for her first appointment the information she gave to the therapist about her life story gave a new meaning to the original therapist’s approach. As she said, she had grown up in a single-parent family, father unknown. So the therapist and the facility may have unwittingly joined her in reproducing a faceless, bureaucratic therapy and neglecting to acknowledge her personal needs, thus resonating the absent father’s failure to provide emotional cover and recognition. The therapeusant left the session recycling her feelings of anger and reaffirming her traumaticlife scenario. The new therapist is thus called upon to contain and give meaning to the therapeusant’s traumas and deficiencies and her resultant emotions, using the therapeutic relationship as an opportunity/challenge for a more restorative scenario. The road ahead of them is hard and painful yet promises hope and growth.

Looking back in history we could say that systemic therapy, in its early days and perhaps in an attempt to differentiate itself from psychoanalysis, deemphasised the therapeutic relationship in favour of the therapeusants’ relationship with their significant others. In the first cybernetic model the therapist is seen as an objective observer, external to the observed system which he monitors and directs from a hierarchically higher position in order to change families on the basis of normative models of normality. The notion of control and predictability is important. The therapist exists not as a person but as a specialist role.

Later and under the influence of postmodern trends (constructivism-constructionism) there emerges an image of the therapist as a non-objective observer who is within the system under observation, and his observations are self-referential because they contain his own personal values and beliefs. The therapist and the family or the individual jointly create a reality with the aim of generating alternative perspectives which will enhance their potential. The therapist cannot change or steer the families, but he can provide stimuli for the families to exploit through their self-organisation. A more cooperative attitude of the therapist is recognised, and there is greater emphasis on the therapeutic relationship.

Mony Elkaim (1997), evolving Foulke’s concept of “resonance”, erected a unique bridge between the therapist and the members of the family, turning the self-referential paradox from a hindrance to a helpful tool for the therapist. According to Εlkaim, resonances emerge from the realities constructed jointly by the members of the therapeutic system including the therapist, hence the therapist learns to exploit the emotions and perceptions expressed by the individual or the family in a way that allows them to expand their potential and experience alternative ways of interaction which dispute the dominant and restrictive world-constructions.

It is worth noting that the postmodern approaches initially emphasised the therapeusant’s own experience while the therapist’s participation was deemed suspect, since it could result in his marginalising the therapeusant’s experience and imposing his own viewpoint (Rober and Seltzer, 2010). The therapist is described as not knowing (Anderson and Goolishian,1992). Not knowing is all about his stance in the conversation with the therapeusant, and is communicated through that attitude which treats the therapeutic knowledge as open to questioning and revision. A therapist without preconceived ideas does not impose his viewpoint but promotes the therapeusant’s experience and makes room for new meanings. Yet this concept was criticised even by postmodern therapists for not reflecting the mutual and shared action in the therapeutic relationship, since it suppresses and fails to acknowledge the role of the therapist’s experience in building the therapeutic relationship (Paré, 2002).

Around the turn of the 21st century the figure of the therapist reappears in the therapy room through the emergence of the concept of dialogue and the development of dialogical therapy (Andersen, 1995, Seikkula, 1993, 2008, Seikkula & Olson, 2003, Rober, 2005a), under the influence of the ideas of Bakhtin (1981, 1984, 1986), Volosinov (1973) and Vygotsky (1962). The therapist turns into himself and reflects on his experience. He contacts his inner voices, performs his internal dialogue (Rober, 1999, 2002, 2005b), reflects on what he feels about the issues raised by the therapeusants and tries to respond in a way that creates room for new meanings and stories untold (Rober, 2011) and, thus, enriches the therapeutic process.

So, when the lens focuses on the therapist as an individual, there are several consequences. The therapist is freed from the need to make plans and devise techniques to respond to what he believes that others believe of him. His emotions and the team’s emotions about what the therapeusants think about the session are no longer hypothetical and based on observations of the non-verbal interactions or the hints of the therapeutic system’s members about it. Any thoughts, emotions, ideas, images, fantasies or dilemmas that emerge during therapy are treated by the therapist as sources of information, contemplated and exploited to the benefit of the therapeusant or the family. The therapist thus acquires a more human aspect and takes a more experiential and active part in forming a context of exploration that reinforces the therapeutic relationship.

The concept of unpredictability

The idea of the importance of the therapist’s self, as well as of the unpredictable, and its use in therapy is not new among the various therapeutic approaches. In “The Interpretation of Dreams”, Freud, talking about transference, speaks of a “shift of meaning and intensity”. This shift, says Kristeva, concerns two dimensions: the one touches upon the order of logic, as a play with the meaning of words, the other touches upon the economic order, as a shift of love to a stranger who plays the role of a mere substitute. The conclusion from this is that this relationship involves a dynamic of three parties: the therapeusant (subject to analysis), the other (the imaginary or real object of the therapeusant’s love) and the third party, the substitute for the potential ideal, the potential authority—this is the position held by the therapist, and it is a position that is supposed to require knowledge of —and relationship with— the therapeusant. Due to this position, during therapy the therapist becomes the highest object of love and the prime victim, the meaning of speech.

This means that the therapy as a process is not fixed into a referential inequality but becomes a process of self-organisation of the therapeutic relationship (Kristeva 2011). In that sense the various contingencies and errors of speech (of life) do not constitute failures but are part of the therapeutic process, making it more complex and autonomous as they are introduced through speech into the process, give meaning to symbolisms, link to the therapeusant’s life and history and promote the realisation of the variety and complexity of his psyche, i.e. his autonomy. The therapeutic process then “…ushers in […] a literature lacking a social code, as disturbing and intense as the cathartic effects of great art.” (Kristeva, “Tales of Love”). Similarly to von Foerster’s theory of “open systems”, where opening up to the other is key to a species’ survival, evolution and maturity, the human psyche under psychotherapy is also an open system connected to another, and only thus can it be renewed.

Nevertheless, the therapist often feels trapped in his own scientific capacity. Thus he may come into therapy with certain preconceptions about the value of scientific prediction. The capacity to predict is the matrix of our creativity, as it provides a structure to contain spontaneity within a context. It can be seen as the therapist’s subjective and inevitable burden in any therapeutic intervention.On the other hand, academic tradition and the schools of psychotherapy have left a vast area which cannot yet be explored, thus allowing their followers to continue to work in this field and bring new ideas. In the systemic therapy of the successive cybernetic models the principle of equifinality introduced the idea that “a cause can generate different outcomes”. It introduced also uncertainty and doubt. Thus the unpredictable started to become an object of observation, not just as an element integral to any process (in therapy as well as in life), but as an element that can be used in an ecological sense and constitute an innate factor in the “economy” of a session.

The term ‘unpredictable’ became part of our everyday professional idiom through experience. Despite the improvement in professional skills, it was increasingly evident that there are special times in therapy when certain elements invade without warning and divert the therapy from the original prediction. These may be strong feelings of surprise, emotional encounters or certain words which produce special meanings, i.e. verbal and/or sensorial consonances or even chance events imposed on the context. For instance, a family or a couple with whom we had done “a great job” would give up therapy, quite unexpectedly and without warning. In other cases our negative feelings of difficulty or frustration (especially in what we call “violent cases”) where belied when therapeusants achieved much more than what we pessimistically expected. At other times we have seen that the random intrusion of an element from the “outside world” into the therapeutic session could create the setting for an entirely different therapeutic dynamic. These unforeseen moments may give the therapist a new inspiration to momentarily abandon his scientific prediction or the safety of his theoretical preconceptions and ‘flow’ with the unpredictable. At such times the therapist needs to be open and respond to the present moment in therapy. Tom Andersen (2007) referred to a perception of a “neither-nor reality” in therapeutic practice where things may be invisible yet existent; things that we can feel happening but we have no verbal description for them. We say that it is neither one nor the other, but we do know that something is happening. He cites the example of the handshake as a physical experience of the present moment in a session which is not commented with words. Daniel Stern (2004) also emphasised the importance of the present moment in therapy and proposed the shift from verbal to the non-verbal knowledge that occurs in the present moment as a predominantly physical experience without words. At such times we are not guided by pre-existing sensation, allowing instead ourselves to be guided intuitively by what we are experiencing.

The unpredictable as part of the therapeutic process may be what reminds us of the singular and complex aspect of human nature, and it is important for the therapist to exploit it as a source of new issues for processing. Freud (2001) recommended an evenly hovering attention as the ideal therapeutic attitude, which meant not focusing on specifics, not predicting and not recapping. Systemic therapists on their part propose the notion of irreverence (Cecchin et al., 2009), which urges the therapist not to adhere to the safety of his theoretical constructs but be ready to revise them, promoting uncertainty, questioning preconceptions and being open to human experience. Irreverence essentially saves the therapist from sticking to the dominant ideology of his scientific model or the facility in which he works and urges him to remain alert to the true needs of his therapeusants and provide alternative viewpoints and meanings.

In the Open Dialogue approach the main challenge for therapists is to be meaningfully present in the sessions with families and answer everything that is said to validate the therapeusants as individuals, since “for the word (and consequently for a human being) there is nothing more terrible than a lack of response” (Bakhtin, 1984). According to the principles of Open Dialogue therapists focus mainly on responding to the clients’ expressions in the context of the presence of both therapist and family as physical entities. Therefore the therapists’ interventions are not made on the basis of a preconceived map about the clients’ stories; they are responses by fully physical entities who are genuinely interested in what clients say, avoiding any hint or comment which might suggest that someone said something wrong. In this process whose main trait is tolerance for uncertainty, all members are encouraged to find their voices and contribute to a polyphonic picture of events, at the same time acknowledging their inner polyphony (Seikkula et al., 2009).

We would say therefore that it is important for us as therapists to avoid a defensive resorting to diagnosisand safe prediction every time we are faced with difficult emotions or dilemmas in therapy, essentially shrinking away from listening to and conversing with the pain and the vulnerability of people who come to us for help with their difficulties. Instead of adhering to the models of our training, it is important to make creative use of our experience, retain our curio­sity and function with openness and understanding for our therapeusants, joining them in opening up new paths for resolution through the processing and the interpretation of their experiences.

Vignette 1[1] The absurdity of a relationship

The family is rather wealthy but extremely deteriorated. Father bizarre looking, white-haired, carries some personal effects in a garbage bag. Mother dressed in black, looks like the step­mother in Disney’s  Snow White . The 26-year-old son, labelled as psychotic, wears a Walkman headset, seems uninterested in the procedure of therapy but looks like the more sane family member. The therapist uses her joining techniques but cannot help feeling aversion and dislike. They seem so helpless but at the same time regressed and disqualifying. The session room has even got an offensive odour, as if the whole place were an extension of the garbage bag. The weird picture of the family erects the first dividing walls in the therapeutic system.

Communication with the family proves to be an arduous and noisy process that magnifies the distance. The parents often talk simultaneously, blaming each other. Their speech is chaotic, confusing.

Incidents from the past are discussed as if they were current, while events from the present remain vague and irresolute. While the parents are fighting, the son, who is sat between them, keeps nervously taking his headset on and off, his movements looking more meaningful than his parents’ endless verbal exchange. The therapist thinks that if the son were to speak, he would have to combine two seemingly contradictory statements: “I cannot stand listening to you, but I cannot stand not listening to you, either”.

When the son is  finally able to speak, in an interval of the parents’ simultaneous monologues, he describes divided situations. “My mother is good and caring, my father bad, antagonistic and jealous.” The therapist feels the divided parts of her own self. She is the good one, representing health, and healing possibilities, and the family are bad, monsters, cannibals. Or is she the bad one who dislikes these poor, suffering souls and they are the good ones who are lonely survivors in an alienated world that marginalises what it cannot fit into its norms? Therapist and team find themselves in a double bind. If the therapist is in touch with her feelings of dislike, she cannot possibly give help. If, on the other hand, she sticks to her professional abilities, she is trapped in a social role and thus unable to do real, empathetic work with them. Once the family has left after the first session, the therapist opens the window to let in some fresh air, and is almost certain they won’t be coming back.

Despite the therapist’s prediction (or even wishful thinking), the family attends the next six sessions, arriving in time and expressing their interest in continuing. During the seventh session, and as the therapist wonders about the goals of this therapy, something attracts her attention. The father is wearing a huge, shiny ring. Possibly out of the need to escape the heavy, dull atmosphere of this family and with the aim of experimenting and exploring alternative aspects of reality which might reveal other, hitherto marginalised sides to the family, she asks to know the story of that ring. For the first time the son removes his earphones to listen to a new narrative. It is the first time that the son takes off the walkman and listens to a new narration. It is like a fairy tale, a story about seamen, strange lands, a big estate in the countryside (now abandoned and haunted), dreams of a career and artistic interests. Talking about the old times, the couple seem more relaxed, almost moved. The son is motivated to participate, asking questions and commenting that he likes to see his parents talking calmly, feeling good with each other and leaving him alone. Humour surfaces for the first time in the session room, almost eliminating the family’s bad odour. As they communicate a brighter, more carefree side of their life, they become more likeable and the prospect of their coming back does not loom as disagreeable as it was in the early days of therapy. It is early summer, and they are preparing to go to their island. The session ends with the proposal that the father would show his son the photos from his travels, during which time the mother would do something pleasant for herself. The emotional atmosphere among themselves as well as with the therapist seems to have changed.

The family returns in September for the next session, which proves to be the last one. They talk about their holiday and its relatively calm atmosphere. The son had a good time on his own, but had not been able to collaborate with his father about the photos: the father was negative, reluctant to show them. The father himself says he doesn’t want to remember the old days, it upsets him. He is even more upset with his son’s condition, who seems unable to stand on his own feet and still needs his parents at his age. His wife steps in to remind him there are some small improvements: the son goes to the family store to help, whereas before he used to sleep all morning, and takes his medication himself. The father retorts that he finds his son to be neither better nor worse. The discussion now turns to the family’s property on the island, which remains unused. The father says he used to look after the land before his illness; now it lies abandoned, has lost its value and the son will never be able to manage it, since he ended up ill himself. His wife reminds him that the issue is not the land but their son; he, annoyed, blames her for squandering their money... The atmosphere changes back to the usual game of mutual destruction between the couple, with loud screams and gestures. The son suddenly opens the door of the session room and walks out. The room falls silent. The mother, looking at the door dumbfounded, whispers “my son doesn’t want us, none of us wants the others any more”; the father asks, “what would you do with a child like that?” and has his own answer ready: “You either accept things as they are or you withdraw”. The deep pain in their family surfaces for the first time. The therapist feels deeply for them, and reflects on a pain so insufferable that they prefer to fiercely attack each other rather than face it. The son, trapped in the impasse of his parents’ relationship, joins them —since they are together to look after him or be looked after by him— but also divides them, as they cannot agree on him or anything else; their only agreement is that he is sick, psychotic, and he needs them or they need him—or both.

After this session the family stops the therapy without warning, leaving the therapist and the team with unanswered questions. The paradox is that as soon as the therapist acquires, in addition to strategies, a more positive feeling about this family and feels a more human connection, quite unexpectedly (always from the therapist’s perspective) they stop the therapy.

This clinical example raises several questions around the therapeutic relationship. In what terms can we define it? How does it work in long-term as opposed to short-term therapy? What remains after the end of therapy (explicit or otherwise)? Another major preoccupation for us was what happens after the end of each session: How does one render visible the triangulations among members of the therapeutic system which did not emerge during therapy but took place in-between sessions and were probably never revealed in conversation? Families go back home and may well discuss in private some of the issues that came up in therapy. On the other hand, we –as a team– will also discuss among ourselves what happened in therapy and how we evaluated certain issues that arose, and will probably ponder on potential interventions and therapeutic design. Indeed, we often vent the strong emotions triggered by the therapeusants by talking among ourselves or resorting to diagnoses and predictions. Yet all these private discussions remain secret to the other side, thus limiting the channels of communication among the parties in the therapeutic system. It is no accident that in the 1980s the reflecting team of Andersen (1987) introduced the open discussion among the therapists in the family’s presence. The members in Andersen’s team talk among themselves and often pose questions without certainty, avoiding a clinical language that classifies and inculpates and looking for an exploratory language that leaves room for multiple meanings.

So our attempt to explore more reflecting paths and bridge this gap in the concept of communication between therapists and therapeusants led us to a key question: why don’t we explore the therapeutic relationship directly? Some of us used to ask therapeusants “How do you feel?”, but this had to do with the therapeutic context and process and not with the therapist personally. So why is the therapeutic relationship hinted at instead of being clearly expressed? Why is it forbidden, almost “illegal” to talk about it? Why should we be sensitive about what therapeusants think of our ideas and thoughts and not about ourselves as individuals?

A review of the bibliography on the therapeutic relationship shows as the key finding of various studies that the quality of the therapeutic relationship is one of the best indicators of the outcome of psychotherapy (e.g. Bachelor and Horvath, 1999; Martin et al. 2000; Orlinsky et al. 2004). What troubled us, however, was the realisation that therapists and therapeusants have different views on how this relationship is perceived (Golden & Robins 1990, Gurman, 1997, Horvath & Marx, 1990, Horvath et al., 1990, Tichenor & Hill, 1989). What therapists consider as important or critical elements in the process of change were often entirely different from what therapeusants deemed useful and important for them. Therapists examine the relationship on the basis of their theoretical background, while therapeusants seem to assess the therapeutic relationship in comparison with other close personal relationship or against their expectations from an ideal therapist (Mallinckrodt, 1991). So if we want to expand and enrich the therapy and make it more effective, we ought to take into account the viewpoint and the experience of our therapeusants. Relatively recent studies have shown the importance of meta-communication between therapist and therapeusants about the therapeutic process (Bischoff et al., 1996, Shilts et al., 1997, Todd et al., 1990). Indeed, in some cases therapeusants found these interviews more therapeutic than the therapy itself (Gale et al., 1995, Μaione and Chenail, 1999).

Thus we began to give the self-referential position a “centre-stage” place. As he abandons the position —at once protected and insecure— of a role, the therapist opens himself to judgment and openly discusses his emotions from the therapeutic relationship. Questions like “how do you see me”, “how do you feel with me in therapy”, “what do you believe about me” or even “how do you perceive me”, addressed to all members of the therapeutic system and almost in every session, started to lead to some interesting deviations fromthe‘main body’ ofthesession.

Based on the above, we could say that if we had given some room for the family we presented to talk more about how they felt about our sessions, how they saw their therapist, how they evaluated their progress till then or even how many more sessions they believed would take for things to improve in their family, their decision to stop the therapy without warning might not seem so illogical and so removed from what the therapist herself felt about the course of their relationship. That was a turning point in our decision to talk openly about what we exchanged within the therapy room. People showed more commitment and at the same time a sense of freedom and responsibility in the sessions. They seemed interested in this revelation of thoughts and concerns about the relationships from different perspectives. The therapist grew beyond his role into an individual. He began to turn towards himself as well, inquire into what he thought and felt during the sessions and exploit them to the therapeusants’ benefit. We could say that this “legitimation” of an open expression of the therapeutic relationship allowed cyclicality to enter a narrative which also includes the therapist’s self.

In order to explore the therapeutic relationship we even resorted to images and metaphors, as in the following clinical incident.

Vignette 2: The therapist within the image

A couple, after completion of a two-year therapy, requested a session on account of a depression relapse of the wife which led to her involuntary hospitalization in the psychiatric ward. The man is angry and bitter towards his wife and the woman is helpless and in despair. She feels very lonely and appeals for her husband’s greater emotional presence which he declines, presenting himself as “fed up”. The therapist asks them to think of an image which could represent this feeling of solitude.

Woman: I am alone in a forest. I’m afraid that the wild beasts will devour me.

Man: I am standing in the middle of a long queue in a bank. The people are restless and irritated.

Therapist: What would you do?

Woman: If I had a cell phone, I’d call my husband to come and rescue me.

Therapist: But he is standing in this queue in the bank, he is irritated and is in no mood to do so (she reminds her that he is “fed up”).

Woman: Then I’d call the fire brigade.

Therapist: So, I am the fire brigade. I can rescue you in a crisis. But I am no more than a service. (To the husband:) And where am I in this bank?

Man: You are a chartered accountant checking if the accounts are in order. I feel that at this moment the accounts are not under control. I cannot handle the situation, but I made this clear from the very beginning. I shall keep distances and get less and less involved.

Woman (to the husband): But it is now that I need you to be closer to me and you are becoming more distant.

Therapist (to the wife): Given that your husband is trapped in the queue at the bank and I am no more than a firefighter, how can I help you? How can you contact a firefighter?

Woman: I have known you for over two years and see you as a good friend who can ease my pain.

Therapist: So, I can give you a bar of chocolate to sweeten your bitter taste.

Woman: It’s strange but after our sessions I do not feel any better.

Man: On the contrary, at the end of the sessions I always feel I have gained something. An idea, an opinion, some new thoughts.

Therapist: Might these be a few pieces of chocolate?

Man: Yes.

Therapist: This, I think, is something. You (to the woman) do not finally take the chocolate from your good friend and can share your suffering in our conversation. And you (to the man) allow a chartered accountant to sweeten your solitude in the queue. Is that so?

They both agreed.

This was a first step in diversifying stances. The man stopped behaving as if “he had no personal needs” and controlling his wife’s “health”. The woman appeared more capable of managing her own feelings of despair. The therapist, as part of an image, used herself and acquired a position between the couple, and this allowed aspects of their relationship, as well as potentials which were concealed under rigid interactions, to become explicit and visible.

These vignettes illustrate the effects of the transformation of relationships, when the therapist’s self is used directly, enabling those involved in therapy to open up new communication channels and thus identify, through a “surrogate mother”, their own personal way of relating.

There was, however, another consequence. Once the therapist began to be less vigilant to being “scientifically and politically correct” (and hence less defensive to unpredictable traps or failures), he feels more comfortable, flexible and open and can thus pay more attention to the ecology of the therapeutic work, especially that of each session. Let us try to clarify what we mean by “ecology of the session”. The therapeutic process, emerging through conversations or interventions of any sort, unfolds around the central themes of the therapy, the stories of the “central avenue”. In a cooperative metaphor, production is in progress. The products are derived from collective productive work. This, however, may lead to the establishment of “narrative rules” which can subsequently consolidate “therapy models”, thus reducing the dynamics of the transactional process.

What happens with the byproducts of the process, though? Should they be discarded? We do know that waste can generate pollution. Notwithstanding that one (the experienced and honest therapist) would never throw away the baby along with the tub water, the water could also be spared and recycled.

Vignette 3: Fear outside the session room

Danae, 32, is a designer at an architect’s office. After six months of therapy, she has begun to build a therapeutic relationship with her therapist. She usually spoke about the burden of assuming too many responsibilities vis-à-vis her family (parents, younger sister and brother, all living together), her colleagues at work, her friends, and even her neighbours. Yet, she often felt guilty for “troubling” her therapist with quotidian “insignificant little things”. She associated this feeling of guilt –which she thought was behind all the burdens in her life– with her character “which was excessively responsible and strict”. The only area where she could not be steady was her love life. She only had few and short-lived relationships with men (though she was active in mixing with friends and enjoyed several artistic pursuits) and felt very lonely. She thought at great length about this guilt and her tendency to feel responsible for everyone, including her therapist, and at the same time to feel sad and nurture the impression of “not knowing” the people with whom she related.

Danae once came early for her appointment. Some repair work was in progress in the waiting room and she was asked to sit outside the session room, where an ongoing therapy session with a couple had reached a “very hot point”. The noise and disturbance annoyed the couple; the therapist, embarrassed at the lack of respect or “invasion”, suddenly jerked the door open to see what was going on. As the door was opening, the woman made a gesture of fear, as if to avoid a blow, putting her hand in front of her, with an expression of terror on her face. The therapist was astonished at this reaction. Her first question in the session which started soon after the incident was what had caused so much fear. The therapeusant was bewildered.

Therapeusant: I don’t know. I was scared.

Therapist: I opened the door to see who was out there because the people I was talking with spoke very loudly and I was concerned they might be heard.

Therapeusant: I never hear other people’s stories. I turn totally deaf.

Therapist: But why should  you  go deaf? Was it  your  fault that you were asked to sit there or that we spoke so loudly?

On hearing this comment, the therapeusant had a kind of “flashback”.

“There’s something that just came to my mind. I was still at high school when, one day, while my parents and sister were not at home, my brother suddenly came into my room and sexually assaulted me. I pushed him off me and then gave him whatever cash I had in my purse and asked him to leave. It’s strange I should have forgotten about this, as I was not little. It was this fear that brought it back.” This recollection led to the revelation of a stressful relationship with her brother. Although there were no further instances of sexual harassment and even though the brother was financially independent and had his own work, he often asked her to give him small amounts of money and she did. Moreover, he used to tell her new friends that his sister was “capricious” and not “virtuous”. Although she felt offended, she invariably made excuses for him.

After this session, a new narrative perspective emerged for her therapy. Until that point she had presented herself as a person who always wanted “to control others” by being overprotective. She now saw herself as someone who “bribes” her assaulter and “buys” his silence (she pays so she can turn deaf) which, of course, she never manages to accomplish. There were others who were also deaf in this family. Her parents, for instance, who insisted that the “good little siblings” should keep close to each other and that they should all stay together “till the day they would get married”, and who would grumble when Danae was not there for lunch. But she then began to see that she had a choice as to how she would relate with her brother and with the other members of her family. She had a choice to feel angry or to forgive him. She has a choice as to whether she would take him along when she went out with her friends or if she would continue staying at her parents’ home till she left as a “merry little bride”.  And she saw that she was not under any obligation to secretly give him pocket money.

The therapist also realized that the therapeutic relationship was leading her to stop being deaf to “collateral damage” in the context.

In conclusion

In closing, we could say that the open exploration and discussion of the therapeutic relationship creates a setting which allows unexpected, unpredictable elements to enrich the therapeutic process as long as the therapist manages to exploit them in an ecological way.

Our aim, as we try to become better therapists, is not to check the unpredictable and exert control over the spontaneous emergence of elements that lie outside our theoretical repertory. According to Larner (2004), to be scientific is to maintain an investigative curiosity about how and why therapy works and to accept that science may never be enough to explain the process. It is thus important to create room and welcome the unpredictable as an agent of instability which upsets the balances in a non-technical, non-authoritative fashion.

Besides, as therapists we are in the strange position between our scientific knowledge, our need for reliable clinical explanations and predictions, and the art of listening to our therapeusants with sensibility and understanding and offering them meaning and relief.

In Greek mythology the oracle was an authority as well as a point of balance among city-states. The prophecies had the necessary ambivalence to cover different takes on reality and the non-predictability of future events. When Croesus, king of Lydia, sought a prediction before starting a war against the Persian Empire, he was told: “You will destroy a great empire”. He went ahead with the war, and the empire he destroyed was his own.


[1] This vignette was published in  Metalogos,  no. 16, December 2009.


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ARTICLE 6/ ISSUE 5, October 2014

“Life… full of sound and fury, signifying nothing”. Macbeth and Shakespeare: moral versus active nihilism

Evangelia Andritsanoui, Systemic individual, family and group therapist, Athens
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