collaboration in psychotherapy

what have you got for us today?

—   don haas, jazz pianist and arranger, as he greeted a student to begin a lesson

 

who’s in charge in psychotherapy? some therapists let the client set the direction: “uh, huh…tell me more…i hear you…so you’re saying.” some therapists are even, famously, silent. at the other extreme, some therapists have fixed protocols. they fill the sessions with exercises and assign homework between sessions. i like to work collaboratively.

collaboration has 2 key aspects. most visible is collegiality. when i ask my friend rob, a professor who runs  multi-center medical studies, how he understands collaboration, he answers, “you have to like each other.”  indeed, when i say, let’s be collaborative, i mean let’s be friendly, respectful, considerate as we work together. if we’re not getting along, i think we’re not collaborative (if i’m mad and blaming, i may think you’re not collaborative). 

more subtly, a collaboration involves a significant contribution to the vision from all parties. john lennon and paul mccartney collaborated to write the beatles songs—even when they were fighting.  they joined to create songs that are, to many listeners, better than the songs each wrote separately after the breakup of the beatles.

british painters gilbert proesch and george passmore work together as a team. there is no separate  contribution of proesch or passmore; there is only “gilbert and george.”

emergence

not all teams are collaborations. in sports, a tug-of-war team requires group effort, but there’s little difference, other than scale, between a team of one, two, or 50.  a collaboration is an emergent phenomenon—the team becomes greater than the sum of its parts.  5 good basketball players playing as a team can often beat 5 all-stars playing as solo hot dogs.

the contributors can play different roles. elton john writes the music and bernie taupin the lyrics. but their contribution to the songs is about equal. bernie wouldn’t be a world-class poet without the music, and elton wouldn’t be a world-class singer or pianist doing covers of another artist’s material. their collaboration is an emergent phenomenon

symmetrical and asymmetrical collaborations

lennon-mccartney and gilbert & george are symmetrical collaborations; each partner is a equal leader, and each partner contributes equal time. psychotherapy is asymmetrical. not in time—unlike the occasional research project in which the principal investigator contributes his prestige and funds, but the junior researcher does 95% of the data analysis and writing,  both members of the psychotherapy team stay for 50 minutes each week. there is an asymmetry of role: one partner is a trained professional offering help, the other is untrained (or not using training) and receiving help. psychotherapy is asymmetrical but it can still be collaborative if both partners contribute to the vision.

by analogy, in movies, the director and the actors have an asymmetrical relationship. it’s beyond having separate roles: the director leads, tells the actors what to do. but the director can have a defined vision, which the actors then embody, or the director can—a little or a lot—welcome the collaboration of the actors.

in the film, “secrets and lies,” hortense, a adopted, young, black optometrist, played by marianne jean-baptiste, looks up and meets her birth mother cynthia, a working-class, white woman played by brenda blethyn.  (cynthia apparently wasn’t clear on the father because she had a number of lovers then gave marianne up for adoption without seeing her). cynthia invites marianne to meet the relatives for lunch without telling them marianne is black. director mike leigh withheld this background from the cast and asked them to improvise the meeting, which he films in one take. the scene is delightful and poignant. the surprise awkwardness and caring we see in the characters meeting hortense for the first time is facilitated by the genuine surprise of the actors encountering marianne for the first time. so the director doesn’t tell the actors exactly what to say or feel. he welcomes their contribution.

henry jaglom’s film, “eating” shows a birthday party for 3 women. one of the guests is a videographer interviewing her fellow guests about food, and we see various interviews throughout the film. apparently, jaglom told the actresses at audition that he would use their actual attitudes about food in the film. so in this film as well, the interviews are not scripted, but rather the actresses use their own experiences to improvise their characters’ lines. the director collaborates with the actors to present a quasi-documentary.

teamwork doesn’t have to be a full collaboration or no collaboration at all. the work can be mildly collaborative, quite collaborative, or somewhere in between. comedy improvisation includes a collaboration between actors and audience, the troupe asks for a theme from the audience, then acts out the theme. there is not a full collaboration, but the audience steers the direction more than at a broadway show. in a subtle way the audience at any live theater is more collaborative than at a movie because the response of the audience affects the actors. a live rock concert is more interactive than a recording. the notes are played less precisely, but the mood can be electric. i remember seeing bob dylan on tour with the grateful dead at the oakland coliseum. the first set  sleepy; the second set woke up a bit; the third set had the audience on its feet. first came the collaboration between dylan and the dead, then came the cheering collaboration between audience and the musicians.

Knockin' On Heaven's Door

expectations

expectations are important. in some situations we don’t expect a leader to collaborate. we want the leader to direct us. in war, the officers command.  in sports, with few exceptions the coach chooses the starting line-ups and calls the plays.

in other situations we want to have a say.  when we remodeled our california-mission-style house, i wanted a southwest feel. when designing the living room fireplace, architect james fessenden proposed a prefabricated triple-wall metal unit. i wanted the look of an adobe kiva. james drew up a sketch of a  curvilinear structure, framed in wood and covered with stucco, enclosing the fireplace. i wanted a mantel. he added one to the side, above a seat. he got to use his professional expertise; i got to follow my taste. the result was a fireplace neither of us would have come up with on his own.

liz has mildly elevated antithyroid antibodies, which can signal hashimoto’s thyroiditis and eventual hypothyroidism. right now she is has no symptoms (not cold or tired, not gaining weight), her t4 and tsh hormone levels are normal, and her thyroid is not enlarged. “you have to go on thyroid replacement,” says her endocrinologist. can i wait? she asks. “i start everyone at this stage. you’ll need it eventually.” to liz, the doc is too programmatic, too attached to a protocol. liz gets a 2^nd opinion from a doc who is more collaborative. he listens to her preference and concurs, “no rush to start a med you’ll need the rest of your life; let’s check the levels in 6 months.” both the doctor and the patient contribute to the treatment plan. liz doesn’t return to the first doc.

collaboration, cooperation, and coordination

 organizational theorists have approached collaboration by contrasting it with coordination and cooperation. a world-wide peace rally has events coordinated to start at the same time around the world. i appreciate that the bus line arranges that its last bus to woods hole leaves boston-logan airport one hour after my plane, the last from san francisco, touches down. conversely, my patient complains that her 9^th grader’s school has pushed the start of the class day back from 8:45 to 8:30. since caltrain arrives at the station near the school at 8:35, she now has to drive her daughter to school instead of dropping her at the train station near her house. failure to coordinate.

in cooperation, one party goes along with another’s plans. the parent asks the child, “will you please cooperate and finish your breakfast so we can get out of the house?” or laments, “i can’t get any cooperation around here.”

when a movie scene is filmed on a city street, the producer gets the cooperation of the local police in diverting traffic. but the overall vision of the project belongs with the filmmaker.

let’s consider music videos.  usually, the video is produced after the song—inspired by the song rather than in collaboration with the songwriter. the stop-motion video for mykonos, by the fleet foxes, echoes the imagery of forests, beaches, and greek buildings and men. like the song, the video appears innocent at first, then menacing. and of course, the beat matches. the filmmaker, sean pecknold writes that he received the song, then constructed art to match and enhance it.   there’s coordination of schedules, and the film-makers cooperate by following the mood, theme, and meter of the songwriters.

i see collaboration, in addition to cooperation and coordination, in the music video for bob dylan’s “things have changed,” from the movie “the wonder boys.”  i assume that dylan wrote the song in cooperation with the producers (as we saw in mykonos except that the film came before the music) that is, he read the script and created lyrics and music that echo the mood of the protagonist, a jaded, one-novel-wonder english professor: “i used to care but things have changed.” i presume director curtis hanson didn’t change the film substantially when he heard the song (and if he did, they would then be collaborators on the movie). but then hanson collaborates with dylan to create a music video that blends the film and song in a way that is greater than each. hanson films dylan on several of the sets from the movie. we see dylan sing, then find himself, surprised, right in the movie in place of the star, michael douglas. “who, me?” dylan gestures to katie holmes as she appears to beckon him. then, at the academy awards, when “things have changed” won best song, dylan was out of town, but the show’s producers, in coordination with an overseas filmstage, arranged for him to appear at the right moment, on live video to accept his oscar for best song.

psychotherapy

in psychotherapy we have coordination of schedules. the therapist and client find a mutually agreeable time, then show up at that time. they agree to part after, say, 50 minutes, so there’s a coordination of attention. some therapists rigorously keep a client’s appointments in the same slot, religiously. the consistency promotes safety. i like to accommodate a  patient’s reasonable requests for a time change (many of my stanford students’ schedules change every quarter). in turn i ask may ask a patient the favor of switch times to accommodate another patient’s need. i like the mutual accommodation, edging towards collaboration.

to the extent that a psychotherapist follows a protocol, the therapy requires cooperation. in cognitive-behavioral therapy, the therapist may prescribe homework. the client cooperates in doing the homework and bringing it back into the session the following week.  in psycho-education, the lecturer presents concepts, and the patient cooperates by taking notes and reading handouts and books. a psychoanalyst, for example, can “know” ahead of time that the crucial theme for all his or her clients is separation/individuation as determined by early-childhood relationships with parents. a gestalt therapist can emphasize making “i statements”. the more programmatic the therapist, the less there is room for the patient’s direction, and therefore the less there is collaboration.

therapy is collaborative to the extent that the direction is guided by both the therapist and client.  if my spiritual-counselor patient wants to talk about her relationship with god, i have to drop the “psychological” protocols i learned in residency or institute training to follow her lead. if she in turn, lets me ask about her relationships, feelings and dreams,  and if there’s some blend of our approaches, then there’s collaboration.

i prefer to have a dialogue, talking back and forth, with a give and take of ideas and direction. here’s an example. 

shelley — i got pretty mad at daniel - he asked if i wanted to watch a movie and i said sure.  we were watching and i got up and down a few times to open some mail. and then i was sitting next to him putting some photos in frames, and he told me to stop and just watch the movie.

john — was it a thriller?

shelley — not at all. and i’d already watched one movie all the way through, so he seemed pretty unreasonable. i told him so, but he said he couldn’t concentrate; he needed my full attention.

john — funny, i feel really sympathetic to you, but i must admit actually ask joellen all the time not  to walk up in the middle of  the show. either sit down and watch or go do something else.

shelley — i didn’t want to choose. i wanted to go back and forth. i’d already watched one movie all the way through with my full concentration. this was the second movie.

john — yeah, sometimes i want to have the game on in the background while i’m working at my desk and turn around when something exciting happens. makes me realize i’ve been unfair.  if it’s a football playoff or a scary movie or maybe 24, then you have to sit through and not interrupt, but wih most tv movies, now that you mention it, it should be ok to come and go.

shelley — at the same time as i was feeling angry, i knew that i’m usually the one to be concentrating on the show, and daniel looks at his iphone or gets a poetry inspiration and gets up to write it down in his laptop.

john — then maybe it would make sense to tell him—not when the show’s on—that you want the right to watch with part attention some of the time if you give full attention at other times. i think i’d like to be that flexible. maybe what i’d like back is that joey would ask it as a favor that she come and go, rather than that she just do it. come to think of it, she does ask it as a favor some of the time, and that works better.

shelley — i could ask daniel that as a favor.

when it works, collaboration doesn’t feel particularly special or dramatic; rather, it seems effortless.  the word and theme aren’t on my mind at all as i enjoy an easy, natural conversation working with shelley on her concern. the word is more likely to come up when there’s a problem. 

zeke talks non-stop, i feel restless, uninvolved. i want to contribute, but there’s never a pause. can i approach this at a relationship level? “are we collaborating,” i ask myself.  hmmm…he’s contributing, i’m not. i decide to tease him. as if a student in a classroom, i raise my hand. yes? he asks. may i offer something? okay… i do this 3, 4, 5 times over several weeks, until he spontaneously starts to invite my input.  

i rarely use the word collaboration in a session; i'm content to show rather than tell. but here i enjoy using the word explicitly: antonio is speaking for perhaps the fourth session in a row of how he “works for the money.” i don’t feel much connection between us. it’s not just the repetition—many patients work through issues by coming back to them repeatedly, and i’m right there with them; but with antonio, the conversation just doesn’t feel alive. i address our relationship. 

john — how can i be of use?

antonio — i want to say what’s on my mind.

john — i want you to, also, but somehow i feel superfluous.

antonio – but these things are important to me!

john — may i ask how you would describe our collaboration?

antonio — i want to talk about what’s been on my mind, and you want to talk about the interpersonal.

john — fair enough. maybe i’d offer the friendly amendment that i want to be of use.

antonio — then we’re on different pages.

john — don’t you want me to be touched by what you’re saying?

antonio — it’s just that it bothers me so much to have to work just for the money. last week…

john — (interrupting) i was hoping you’d say “thank you, i’m glad you want to care about what i say.” ok, sure, you’re not obliged to care if i give quality attention. you can say “that doesn't interest me” or “why would i want to do that?” but i’d prefer that you not just change the topic and ignore me.

antonio — actually, i don’t think i want you to be touched by what i say.

john — ahhh…interesting. (we both smile).

by looking at our collaboration, we are able to talk—collegially, without me critiquing him—about a way he keeps others at a distance. in parallel, our conversation gradually becomes more interactive and lively. 

my supervisee presents a case that troubles her. she feels they’re “going nowhere fast.” she describes a session. sounds like he spends the session complaining. yup. what do you have to offer? right, nothing i say gets picked up on. what if you say, “thanks for letting me know these things that concern you. i appreciate your confidence. but i also don’t really get to use my training. you could be talking to anyone. could we maybe spend half of the sessions on your disappointments and the other half in ways i can use my expertise – dreams, relationships, things like that?” she smiles: that sounds a lot more interesting, i’m looking forward to trying that next week.

it’s of course commonplace in exploratory therapy to look at the relationship between therapist and client. since psychoanalytic therapies emphasize healing through understanding childhood, they look at “transference”—how the relationship with the therapist mirrors early relationships with the parents. since i see psychotherapy as (along with getting comfort for pain old and new, and finding new directions) in part learning to get along better with others, i look for aspects of the therapeutic relationship that can be cultivated to improve all relationships.

collaboration in the patient’s outside life

so, with most patients, i’m aiming to be collaborative in the session; and, in parallel, i’m encouraging the patient to be collaborative in the outside world. my interventions take the general form, “maybe you could work on it together,” but “together” can include bickering or competing or dominating. we’re looking for collaborating, and the therapy is in the details. for example:

paula — not only has he never been that into sex, he’s really got a lot to learn. i give him a suggestion, and he says ok; then he never follows up.  i’d really like to just show him some porn videos, give him some ideas.

john — well, careful not to patronize him.  plus, i think you need his active participation. i’d be more inclined to recommend you say, “i think we can have more fun sexually. there’s a lot of possibilities. i don’t want to push you or nag you; so can you please pick some direction you might enjoy – a  porn video, an erotic short story, look in each others yes, breathe together, tie each other up?” he needs to be contributing something to the direction, not just hearing your suggestions. 

here i focus, not on the patient or on her husband, but rather on how they might address a problem collaboratively. another example:

gina wants to get engaged. she’s been living with tom for 3 years.  he won’t talk about marriage, and he won’t go to couple’s therapy.

gina — (crying) he said he’s been thinking about some of his doubts about getting married.  i started to cry and told him we’ve been living together for 3 years, that’s plenty of time for him to make up his mind. my girlfriends say i should just give up.

john — what kind of doubts?

gina — religion, whether i get along with his family. but those aren’t reasonable. neither of us is religious, and i like his family.

john — well, he could mean that he never wants to get married, and he could mean that he’s finally going along with your request and talking about his hesitations so he can work through them. any sense which?

gina — i can’t tell.

john — you feel his issues are minor, so i’d play it that you’re right: they are minor, and he’ll get over them if he talks about them.  you’re likely getting what you asked him for, talking about it; so your task is to follow your own plan, and accept your good results.

gina — but i can’t help but feel it’s unfair. i’ve waited so long.

john — yeah, it is unfair, but what’s 2 more months? if he talks about his concerns and nothing changes, you’ll know then he was making excuses. maybe what you do from your side is to remind him, keep him moving, make sure there’s progress. and what you accept from his side is that he gets to talk through his doubts.

3 days later i receive an email from gina. “tom was certainly grateful that i processed, understood, and then communicated some of the things you and i talked about. he said that much and in turn was more open to my position.”

when parents come to therapy because their kid is in trouble, my focus is not on  communication or intimacy. there’s work to do: a child to help. so i’d like the couple to collaborate. sally and baron describe as son who’s become inattentive at school and disrespectful at home. sally complains that baron gets too angry; baron complains that sally’s too indulgent, she puts all the discipline on him. he sees himself as take-charge, she sees her self as compassionate. i offer that they each have a reasonable approach. why waste time arguing which is better? instead, try working together as “good cop / bad cop.”

too much collaboration

collaboration can be a buzz word, as if it’s always good. it’s not. if the vision isn’t wholesome, working together won’t save it. politically, a “collaborator” might be a local who helped the nazis in world war 2.  the word is apt; it implies he wasn’t “just following orders”; he came up with some creative ways to, say, round up jews and gypsies.

in therapy, nat complains that his friend shelley talked him into co-directing a play. now they step on each other’s toes.  he resolves only to direct solo in the future. but 3 months later the writer-producer of his next play annoys him by attending rehearsal and making suggestions to the actors that undercut his vision as director. “i’m a little afraid to kick her out of rehearsal as it’s her play. plus she’s paying me.” are there some arenas the producer could take charge of that you’d like off your plate? “sure: costumes and lighting.” he speaks to the producer, who – no problem! - welcomes dividing responsibilities. collaboration was a muddled waste of time.

if collaboration is productive and fun, why do we sometimes hesitate? i see an ad on ebay for an old huichol indian yarn painting. the price seems good. i’m going to bid. wait…i haven’t told joey. in fact, i’m reluctant to. i suppose she might talk me out of it. she might say, “we already have enough art” or “we should spend our money elsewhere.” i do show her the listing, she says, “great.” in telling her, i had to let her make the decision with me. but i got the benefit of her perspective and the later benefit that, having bought it together, we’ll enjoy the art more. and in this case, since we got out-bid in the last 5 seconds—grrrrr—i get some commiseration.

a last example. i’m co-leading a group with my friend lu. one member has decided not to return. fine by me – she was disruptive and critical.  2 new members have joined, and i’m eager to move forward. when lu asks the group how they feel about mattie not returning, i hear myself, in my head, i scream, “no!!!!” as if her name were voldemoort, he who shall not be named. but we spend 15 minutes clearing the air, and the group goes on to talk about times they’ve felt haunted by old loves and dead relatives they couldn’t forget. lu took us in a direction i would not have gone on my own. and the group was better for our collaboration.

acknowledgements: jon christensen for suggesting i contrast collaboration with cooperation and coordination; gieve patel for framing collaboration as a mutual contribution to the vision.

Comments

[Barbara]

love this; love you!