Psychotherapy

Volume 36/Fall 1999/Number 3

BECOMING A PSYCHOTHERAPIST: THE PERSONAL NATURE OF CLINICAL WORK, EMOTIONAL AVAILABILITY AND PERSONAL ALLEGIANCES
TIMOTHY J. ZEDDIES
University of Texas, Austin

Becoming a psychotherapist is a challenging and exciting process. There are many important facets of training in the development of a skilled therapist. Emotional availability and personal allegiances are two interrelated areas of a therapist's development that might be underemphasized relative to other areas of training in many graduate clinical training programs. This article offers a conceptualization for emotional availability and personal allegiances, presents a view of the treatment process that places emotional availability at the center of therapeutic responsiveness, and argues that personal allegiances may limit a student-therapist's emotional availability with clients. This article addresses the concepts of emotional availability and personal allegiances primarily from a contemporary psychodynamic theoretical perspective, but key ideas from the cognitivebehavioral viewpoint are also used to illustrate their significance in a therapist's development, however. These concepts are suggested to have relevance for students, supervisors, and more seasoned therapists of varying theoretical orientations.

Correspondence regarding this article should be addressed to Timothy J. Zeddies, Ph.D., 319 Parland Place, San Antonio, TX 78209.

The Personal Nature of Therapeutic Work The process of therapeutic change involves many factors. One of these factors which has been relatively underemphasized in graduate clinical training programs concerns the psychological and emotional process the therapist undergoes while treating clients. In particular, one of the most challenging aspects of clinical work is the necessity at times for the therapist to understand how his or her own psychological and emotional dynamicsincluding personal values, beliefs, theories, and commitmentsinfluence the therapeutic approach with clients. Mitchell (1997) suggests that psychotherapy is "a unique, extremely powerful, personally transformative experience, for both parties" (p. 35). From his perspective, meaningful and lasting therapeutic change "entails new understandings and transformations of the client's old relational patterns in the transference, as well as new understandings and transformations of the therapist's customary relational patterns in the countertransference" [italics added] (p. 52). According to this view, therapists must not only facilitate a client's growth, but a key element of clinical work requires that, at the same time, they must also allow themselves to be changed in important ways over the course of the therapeutic process. The therapist's dual roleas agent and subject of changewas first formulated in Sullivan's (1954) notion of the "participant-observer," which refers to the therapist as an ongoing and inseparable element of the therapeutic field while at the same time being primarily responsible for observing and facilitating that field. Being able to provide this kind of therapeutic experience depends greatly on the therapist's capacity for forming interpersonal attachments, experiencing life in emotionally rich ways, and being able to tolerate the vulnerability and exposure that are inherent to the therapeutic process.

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Althoug the therapist certainly has ideas about what general directions the treatment may (or should) go, he or she needs to remain psychologically and emotionally available to engage aspects of the therapeutic process that cannot be necessarily known or expected in advance. In addition to knowledge and expertise, tolerating or being comfortable with ambiguity is a crucial feature of therapeutic responsiveness (Pica, 1998). Along these lines, Stern (1997) argues that the act of learning (for therapist and client) requires a gap between what is (unconsciously) anticipated and what is (consciously) experienced, between what I think I know and what I expect will happen. Otherwise, experience "is invisible . . . because the impression it makes coincides exactly with expectations one does not even know one has" (p. 242). Creating a gap between the familiar and anticipated and the new and unexpected requires that the individual articulate often unconscious expectations and assumptions: "Learning is impossible precisely to the extent that expectations cannot be brought into language" (Stern, 1997, p. 243). According to this view, what therapists know is no more important than their comfort in not knowing and their openness for learning something new. In order to become more fully engaged in the therapeutic process, which entails openness to change and to the unknown or unfamiliar, therapists must be aware of how their own personal biases and theoretical viewpoints inform their perception of clients and their beliefs about what clients need to heal and grow. This seems to be ample cause for therapists to "hold theory lightly" and always to concentrate on being prepared to change or revise their ideas, opinions, and views in response to new information (Orange, 1995). Neither client nor therapist can anticipate what exactly will happen over the course of their work together. The therapist may encourage the client to loosen attachments to what he or she knows and experiment with different ways of thinking, feeling, and interacting. To capture the client's interest in a genuine and meaningful way, the therapist must be held to the same expectation. An important feature of engaging the therapeutic process at a deep level is the therapist's ability to, at times, shift attention away from what she thinks she knows toward the unfolding relational process. A therapist's capacity for understanding and therapeutic effectiveness is determined, in part, by the ability to become engaged psychologically and emotionally with clients. How clients heal and grow is thus facilitated by the therapist's clinical skills and who she is as a person. Relying solely on the application of concrete therapeutic techniques may not be enough in certain clinical moments. It seems likely that, in addition to the development of particular cognitive skills, "mastering" the art of psychotherapy involves developing a high level relational and emotional responsiveness to clients (Jennings & Skovholt, 1999). I suggest that a therapist's capacity for emotional availability is central to the task of providing clients with an optimal therapeutic experience. Following the work of several writers in psychoanalytic psychotherapy (Ehrenberg, 1996; Orange, 1995; Spezzano, 1993; Stolorow, Brandchaft, & Atwood, 1987) and psychoanalytic infant research (Beebe & Lachmann, 1998; Emde, 1988a, 1988b; Stern, 1985), I conceptualize emotional availability in two interrelated ways. First, it refers to the therapist's willingness to make deep and sustained emotional contact with a client. This involves the therapist's capacity to accept, tolerate, and contain the client's difficult, painful, and even overwhelming feelings, which of course may trigger corresponding feelings of pain and distress in the therapist. Emotional contact by itself may not be sufficient, and it might also be necessary for the therapist to give symbolic meaning to the client's emotional experience and communicate his or her affective understandings to the client. Second, emotional availability refers to the therapist's capacity to use personal emotional experience to understand or appreciate something about the client that he or she might not be able to communicate verbally. In this sense, it is the therapist's ability to draw on his or her own reservoir of experience, both intellectual and emotional, that forms a basis for understanding the client and for generating therapeutic interventions. Based on this conceptualization, it is suggested that emotional availability represents a major factor in the therapeutic alliance, and that it is central to therapeutic action in that it is fundamental to facilitating the client's healing and growth. The centrality of the therapist's emotional availability within the therapeutic process can represent a difficult developmental task for graduate students and young therapists. Studenttherapists come to recognize, as Bromberg (1984) observes, "that [therapeutic] skill is derived not

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[only] from what you do but from who you are" (p. 33).' In their efforts to be competent and helpfill therapists, however, students may compromise their emotional availability with clients because they are disproportionately focused on what they themselves are doing in the session, which can limit their ability to understand their clients' feelings and help them work through difficult issues. This kind of emotional misattunement is probably common for students in clinical training, for while they are struggling to form identities as therapists they are bound to be somewhat less spontaneous, relaxed, and open with clients than are experienced therapists. To be sure, emotional misattunement and therapeutic misunderstanding remain as possibilities even for experienced therapists, particularly if the therapist has not continued to be reflective about his or her subjective experience and personal dynamics. In such cases, the experienced therapist may defensively adhere to a particular theory or manner of conducting therapy because it shields him or her from looking deeply or honestly at difficult or painful personal issues. If a therapist is haunted by unresolved and disavowed psychological or emotional issues, he or she becomes less able to help clients face their own threatening or hostile emotional areas. As Spezzano (1993) observes,
To the extent that the [therapist] cannot hold very well a particular affect or set of affects, she will be limited in her ability to make therapeutic use of certain events and communications in the [therapy] . . . In that sense, the [therapist] as an affective container establishes certain limits to where on the human affective landscape she and the [client] can usefully go together, (p. 212)

Furthermore, as the work of William Henry has illustrated (Henry, Butler, Strupp, & Schacht, 1993; Henry, Schacht, Strupp, & Butler, 1993; Henry & Strupp, 1994), the therapist's own hostile introjects may prevent disengaging from maladaptive patterns with the client, which very likely will reinforce the client's pathogenic relational patterns and possibly be retraumatizing to the client. It is important to keep in mind, however, that deep and sustained engagement in the therapeutic process does not mean that the therapist never addresses complimentary interpersonal patterns or concordant identifications with the client. It can be all too easy for the therapist to become hooked into a client's maladaptive interpersonal patterns. Thus, the therapist should be careful not to lose touch with his or her own subjective experience even though it may be necessary to relax some personal defenses and resistances in order to become fully engaged with the client. Because psychotherapy is a deeply engaging process for both therapist and client (Mitchell, 1997), a central developmental task for students, as well as for therapists of all levels, would seem to involve developing a therapeutic style that is both genuinely personal and professional. Emotional Availability and Personal Allegiances Because therapists draw on their personal emotional resources in attempting to understand clients, being emotionally available in clinical work may be predicated on being emotionally alive more generally. It is reasonable to suppose that a critical relationship exists between professional emotional availability and personal emotional maturity. As therapists deepen their understanding of themselves and work through personal emotional issues, they should improve in their ability to help clients do likewise. If this is true, then the training experiences of students probably go a long way in determining how they use their own psychological and emotional resources in their own work as therapists. The remainder of this article focuses on how a student-therapist's emotional availability is related to, and perhaps even limited by, personal allegiances, which refer to a student's attachment to or identification with a supervisor, theoretical perspective, or therapist.

While Bromberg's perspective speaks well to how clinical work can nave an absorbing effect on therapists, and notes that at times therapists may become involved in the therapeutic process in a way that feels quite personal, his view may appear to reflect a false dichotomy between who therapists are as people and what they actually do in their work as therapists. There is an important and inescapable relationship between the two, because the techniques, interventions, and theoretical viewpoints that a particular therapist endorses are very likely to be meaningful on both a personal and a professional level. Being a psychotherapist is not simply an activity that one does, but is something that lives and breathes in one's bones. The relationship between a therapist's personal and professional identity is thus continuous. Viewing the therapeutic process in this manner does not imply that therapy works best if the therapist has a charming or persuasive personality. It should never be assumed, as Hoffman (1994, p. 193) cautions, that clients get better from merely spending time in the presence of their therapists. Thus, it seems better to regard therapeutic skill as reflecting a dynamic interrelationship between what is meaningful or significant to therapists on a personal level and the technical interventions that they learn and refine over the course of their professional work.

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An important consideration emerges in light of the relationship between personal emotional development and clinical emotional availability, the process by which students expand their capacity to understand and accept their own emotional experience likely will inform their beliefs about how clients should resolve psychological and emotional issues. In other words, a student's personal experiences (including formal clinical training, as well as informal, social experiences) have a great influence over what kind of therapist he or she is. While the personal aspects of a student's therapeutic approach is beneficial to clients in many respects, such as providing a basis for empathy with a client's experience, it is also true that the student's beliefs about mental healthy may reflect personal experiences in his or her own therapy and supervision in a way that limits the student's capacity for understanding and therapeutic helpfulness. Kohut (1984) observed that "each person becomes 'addicted' to his particular kind of mental health . . . and the addiction to a particular kind of mental health will affect [the therapist's] capacity to change [and] to examine new ideas, new theories, and new techniques to which he is exposed" (p. 166). If a student's beliefs about mental health are rigid and resistant to change, the possibility exists that he or she will ignore, misunderstand, or even devalue ways of being that do not conform to a personal (often unconscious) working model of psychological and emotional health. One reason why a student might have difficulty appreciating or understanding a client has to do with the student's personal allegiances. Allegiances are evident in situations in which a student has a strong identification with his or her own therapist or supervisor, or with a personally meaningful theoretical perspective. By themselves, allegiances are a vital and necessary aspect of a student's development as a therapist, but they can also be harmful when the student is unconsciously overinvested in viewing clients only along the lines prescribed by a certain theoretical perspective or therapeutic approach. When personal allegiances are unacknowledged or defended, the student's capacity to engage in and facilitate an open-ended therapeutic inquiry decreases, and the likelihood of developing blind spots in therapeutic perception increases. For example, a student may repeat to a client, almost verbatim, what his or her own therapist or supervisor said. Sometimes the results with clients are positive, sometimes not. In the latter cases, it is possible that the student prematurely assumed that what was so meaningful and helpful personally would certainly be so for anyone else. In those moments the student might be unconsciously invested in remaining connected to a moment of insight or intimacy shared with his or her own therapist or supervisor and attempt to recreate a similar experience with a client. In situations where personal allegiances operate in this way, students risk imposing their own personal meanings onto their clients' worlds rather than helping clients weave meanings from the texture of their own subjective experiences.2 As a corrective for interferences in therapeutic understanding and responsiveness that might arise as a result of personal allegiances, Kohut (1979) suggested that therapists should strive for a "dispassionate attitude toward mental health." By this he meant that therapists must become somewhat decentered from their own personal experiences of mental health so that what a particular client needs to heal and grow might emerge clearly. The notion of "decentering" should not be interpreted to mean that therapists must abandon theory or empirical knowledge as a prerequisite for understanding their clients better. As mentioned above, a therapist's training in various psychotherapy theories and empirically validated treatment approaches represents an indispensable interpretive template that informs his or her therapeutic understanding and responsiveness. Rather, decentering reflects a special kind of clinical sensibility that enables a therapist to be increasingly reflective about how personal theoretical commitments and relational-history (i.e., with a therapist, a supervisor, family, and friends) influence the therapeutic process in general and an understanding about

2 It is important to be mindful of the possibility that a student's therapist or supervisor might (consciously or unconsciously) pressure the student to conduct therapy in a manner that conforms to the therapist's or supervisor's own personal values, beliefs, and commitments. It is difficult to draw a neat line between mentorship in the service of the student's personal development, on the one hand, and a therapist's or supervisor's personal investment in advancing or perpetuating personal allegiances through the student. In terms of the latter, it is quite possible that the student's therapist or supervisor is also under the sway of an unconscious personal allegiance that interferes in work with the student. In this situation, the therapist or supervisor unwittingly perpetuates allegiances in a way that limits or skews the student's development as a therapist.

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clients in particular. Decentering in this manner does not totally prevent the therapist from being influenced by personal experiences. This would be impossible. But by becoming increasingly reflective about the sources of meaning and motivation in his or her own life, the therapist will be less likely to unwittingly inject personal values and beliefs into the therapeutic process and better able to appreciate clients' subjective worlds in all of their nuances and complexity. The notion of decentering points to a delicate balance that therapists strike between working from a theoretical or empirically-based perspective (or perspectives) and responding spontaneously. Therapeutic understanding and responsiveness is informed by, but should never be consumed by, a particular theoretical or empirically-based approach. This is not to suggest that theory and empirically-validated techniques necessarily saturate a therapist's authenticity and spontaneity; but rather that these can, in certain clinical moments, be used defensively to avoid or minimize establishing and maintaining an intimate and personal connection to clients. For the most part, various psychotherapy theories and empirical treatment approaches allow therapists to be available to help clients with their problems. But when this knowledge is held rigidly it can create an impersonal and authoritarian atmosphere that restricts the range of therapeutic understanding and effectiveness. Implications for Graduate Clinical Training Developing a therapeutic style that is both genuinely personal and grounded in theory and empirical techniques is a complex professional developmental achievement for student-therapists. Students often gain support and guidance in this task from their own therapists, supervisors, and fellow students. But while struggling to strike an optimal balance between applying the tools acquired through clinical training and responding in a personal, authentic way in the heat of the moment-to-moment clinical exchange, students cannot simply turn around and ask someone else what to do or say. As Hoffman (1987) cogently observes, "the interaction within the session is continuous; there are not time-outs" (p. 212). Therefore, in addition to instruction in various psychotherapy theories and empirically-validated treatment approaches, graduate training programs should help student-therapists deal fully with the personal nature of therapeutic work. This might involve coming to terms with the idea that, at times, therapeutic technique cannot be prescribed. From this perspective, there is no one way to facilitate a therapeutic process. As Greenberg (1997) points out, therapists "simply cannot determine a priori what is going to work best for another person" (p. 338). The practice of psychotherapy cannot be universalized in a way that prescribes certain techniques and methods as true for all times and places, with all clients and by all therapists. Thus, it may be helpful for training programs to promote a kind of "self-reflective responsiveness" (Mitchell, 1997) or "reflection-in-action" (Aron, 1996, 1999), which would encourage students to find meaningful ways to think about what is happening in a particular session. Students would be helped to develop increased awareness and sensitivity about how their own personal histories, commitments, beliefs, and values underlie the kinds of psychotherapy theories and therapeutic techniques they find useful and appealing. In addition to acquiring the theoretical and empirical knowledge necessary for effective therapeutic work, students would also be taught the value of "not-knowing." This approach to the therapeutic process would help students shift their attention away from what they "know" (i.e., slotting the client's material into predetermined categories of meaning and understanding) toward the uncertain, unknown, and unpredictable, which are inescapable features of the therapeutic process. By structuring clinical training along these lines, graduate training programs could equip studenttherapists to become increasingly emotionally available to their clients. To be sure, training that assists students in dealing fully with the personal nature of therapeutic work and that promotes an attitude of selfreflective responsiveness should not take place at the expense of abandoning theoretical and empirical knowledge. Training in these areas should always be a central and indispensable aspect of our clinical training programs. For example, certain therapeutic issues (e.g., panic disorders, substance abuse, sexual dysfunction) require a comparatively directive and educational clinical approach, which cognitive-behavioral therapy seems best suited to provide, and the therapist's self-reflective responsiveness may not play a significant role in the treatment. While students should strive to be maximally aware of their experience of the therapeutic setting and the client,

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the needs of the client, however circumscribed or brief in nature, should always be viewed as the fundamental, orienting force in the treatment. At the center of the therapeutic contract is the client, who is overwhelmed in one way or another with a problem and seeks the paid service of a mental health professional to provide time, care, attention, understanding, knowledge, expertise, and respect. The intent of this article, in emphasizing the clinical importance of emotional availability and personal allegiances, is meant to complement the existing content of many of our graduate training programs. Students may become overwhelmed by a desire to "get things rights." This can initiate two divergent kinds of therapeutic behavior that may be experienced by clients as unhelpful or even destructive. First, because they are relative novices at establishing the parameters of a treatment, students may become overly focused on their own level of competence rather than on the client's concerns. When students focus too much on their own activities and subjective sense of comfort and competence, the therapeutic process likely will be affected in a negative way because their needs for achievement and validation prevent the client from articulating his or her own needs. In serious cases, the therapeutic process becomes a traumatic repetition of other relationships in the client's life in which his or her needs were subordinated or sacrificed as a result of efforts to provide validation and support to others. Students must be aware of this possibility and strive to achieve a full sense of reflective self-awareness about their participation in the therapeutic process, thereby increasing their capacity to provide therapeutic help to clients. A second problem is that a student might be so consumed by a fear of making mistakes that he or she becomes hesitant or reluctant to apply theoretical and empirical knowledge in a way that the client needs. A focus on developing a deep sense of reflective selfawareness does not mean that students should necessarily adopt a passive or recessive therapeutic style. One is reminded here of the stereotypical traditional Freudian analyst who says very little, offers no recommendations or suggestions, rarely confronts the client's behaviors, has a facile ability for turning a client's questions back on the client, and has an obsessive thirst for analyzing everything, however seemingly insignificant. A therapeutic approach defined mainly in terms of reflective statements probably will not be of lasting benefit to a client, and may very likely create artifacts in treatment (i.e., iatrogenic effects) that distort the clinical focus from the client's real issues in life outside of the consulting room. In general, as Marsha Linehan (1997) argues, therapy works best when the therapist is able to strike a balance between acceptance and challenge, support and confrontation, validation and critical inquiry. Many voices clamor for attention in a studenttherapist's head during a session, and in the developmental process from student to seasoned clinician, a therapist learns to become a better listener of himself or herself and of clients. Bromberg (1984) suggests that as students progress through clinical training they develop an increasingly sensitive "third ear," which aids them in becoming attuned to the ever-shifting tenor of the therapeutic process. The concept of the "third ear," which is based on Sullivan's notion of the "participantobserver" and on the work of Reik (1949), refers to the student's capacity to be a fully engaged participant in the therapeutic process while maintaining a wide perspective of the entire therapeutic fieldincluding his or her own participation in it. This is a demanding task, for while clients are invited to become deeply involved in a therapeutic process, students must do likewise at the same time as attending to and facilitating that process. This "two-tiered" participation in the treatment process requires a heightened level of psychological and emotional responsiveness, which results from a student's professional and personal development. The blend of professional and personal elements in clinical work is one aspect of training and development that makes becoming a therapist so complex and difficultand so rewarding. References
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