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Doing Therapy: A Source of Therapist Well-Being

Tapio Malinen, M.A.
Frank Thomas, Ph.D.

Abstract

Mindfulness has become prominent in the field of psychotherapy. Therapy as a reflective process tied closely to mindfulness invites an investment of oneself that varies greatly from a modernist views of self, therapy, and well-being. In this article, the authors offer an idea of well-being that is tied both to mindfulness and to the self-of-therapist. Exercises that promote therapist reflection are included.

 


Doing Therapy: A Source of Therapist Well-Being

Can therapy be a practice in which therapists constantly revitalize their own well-being? Can certain types of understandings of knowledge, self, language and our position of power – and the practices related to them – work as tools for mental growth for the counsellor? Can therapy act as an ethical exercise in which the therapist have the privilege of creating something true and good with their clients so that the work can become as a mutually energy-creating and transformative action?

For many years, we have been interested in work as a source of the well-being for the professional. Some years ago, after getting to know the practice of mindfulness based stress reduction (MBSR) by professor Jon Kabat-Zinn (1990) and participating in a ten-day meditation retreat, the first author started to pay more and more attention to the facets in his work that maintain and add to his inner well-being. The second author began to study therapist well-being out of curiosity and as a direct influence of his practice of aikido, the “loving” martial art (Thomas, 2007). In this article, we will discuss the work of the therapist as a source of mental well-being as well as describe the theoretical starting points with which we can develop our work as a possibility of a burn-in instead of a burn-out phenomenon. In addition, we will offer some practical exercises that may help therapists maintain and add to their well-being during the therapy process.

Knowledge of Well-Being

There are at least three factors related to the therapist's well-being during the therapy process. These factors – according to many different authors (Augusta-Scott & Brown, 2007; Epstein, 2007; Gergen, 2006) and our own experience – are very significant. The first factor is the concept of knowledge upon which we base our work. The second factor is the idea or experience of “self” that therapists have of themselves. And the third – which is connected to the two previous factors – is the way therapists position themselves with regard to other people while working. To be able to differentiate the therapist's well-being in connection with therapy, we must answer at least the following questions: 1) where is the knowledge in a therapeutic relationship and how is it produced? 2) what or who is the “self” we are taking care of while doing therapy? and, 3) how is this “self” positioned while we work with people, searching for the constantly shifting balance between connection and detachment, merging and separation, immersion and individuality?

The traditional idea of learning is based on the assumption that an independent reality exists, a reality about which we can obtain objective knowledge with the help of scientific research methods. The traditional mission of language is to re-present, to describe this reality with as much accuracy as possible, and to transfer that knowledge from one person to another. In other words, knowledge is something independent that exists outside of us, a sort of “thing” that we can move into the storage memory of a person (Gergen, 1999). John Shotter's (2004) term for ideas based on this view of knowledge is “aboutness thinking.” In this dualist mindset, another person is an object outside of us who we can explore objectively. An example of this is the diagnostic culture, which often reifies a human being into an object without consciousness. The therapist is an “expert” who has the heavy responsibility for seeing that the therapy process proceeds in the “correct” way.

Lynn Hoffman, a well-established family therapy historian, has presented a view that deviates from this concept of knowledge (Hoffman, 2007a). She anchors her own therapeutic work into two “wisdoms.” The first wisdom suggests one assume an attitude of not-knowing, and the second wisdom is reflective processing (see below for more on the latter). A few years ago, Tapio conducted an interview with Harlene Anderson, who (along with Harry Goolishian) first used this phrase to describe a clinical stance. She defined not-knowing in the following way:

”It has to do with the way you position yourself with what you know, and how you offer what you know and with what intention. Our expertise is not in terms of what the better story might or should look like, but that our expertise was/ is in the ability to create a space and invite others into what I call the collaborative relationship in the dialogical conversation. Our intention is towards particular process rather than towards particular content or outcome.” (Malinen, 2004)

The attitude of not knowing makes one relate to reality as conjointly created without forcing it to align with one's own preconceptions and theories.

In other words, not-knowing refers to a certain kind of approach to the other person. In the state of not-knowing, therapy techniques and encountering another human being become one. The techniques are a means of expression through which the therapist influences the meeting by creating an openness for change, an inner space in which there is (ideally) no fear. In the history of Zen-based martial arts, this fear-less inner state is connected to the mushin state of mind, which enables spontaneity, the non-doing or the wu-wei (Deshimaru, 1982). In the mushin state, there are no concepts of a separate “me” or “you,” fear, or desire. The mind and body are one. Spontaneity is not an unthinking re-action but rather a natural appropriateness brought on by any given moment. Techniques are used spontaneously, freely, and playfully without clinging to images or explanations of the final outcome. When the therapist gives up the goal of achieving something predetermined, both therapists’ and clients’ actions become congruent expressions of their empty selves and integral change often emerges naturally. This state approaches what Rosenbaum and Dyckman discuss in their article “No Self? No Problem!” (1998), about the place of techniques in mindful practice:

“Approaching self as empty does not generate a list of things to do, but rather encourages a certain attitude toward the encounter between therapist and client. Technique, from this standpoint, is not some thing we as therapist perform “on” clients with the expectation of making some thing happen. Rather, technique is a vehicle for expression, a particular framework to facilitate the encounter...technique is a way of “calling” the client and “clearing” one’s self to create an unforced openness to change.” (p. 264)

In a more traditional or intentional way of working, the therapist follows the movements of the client's mind and finds ways of helping. It is the therapist who plans what to do or say next. This stance is often guaranteed to make the work straining. The mind stops when it receives thoughts of the final result of the action or selfish thoughts of, for instance, the wish to be a good therapist. The state of not-knowing, on the other hand, is a state where we are mindfully present, a condition where the mind flows from one place to another like water, filling even the smallest holes. When disturbing thoughts are gone – including the thought of self (see anatta below) – one cannot find a difference among oneself, the technique, and the client. We no longer evaluate, categorize or plan but rather encounter and experience the other in her (1) suchness, (i.e., tathata [beyond all concepts and distinctions]) (Ficher-Schreiber, 1994) without twisting our perceptions with our own theories or preconceptions. In this mode of being, techniques simply happen and the therapist becomes one with her client (Segal, Williams, & Teasdale, 2002.) There is no “knower” and “known,” just the process of knowing; there is no separate “doer” and “deed,” just doing. In the being mode there is a sense of freedom and freshness, an unfolding of experience in new ways. It is responsive to the richness and complexity of the unique patterns that each moment presents. In doing mode, by contrast, the multidimensional nature of experience is reduced to a unidimensional analysis of experience in relation to a goal state. The non-
dualist experience of the being has often been described in religious and martial art-related literature but rarely when discussing therapy. In fact, in the field of therapy this kind of experience has been seen as a pathological dissociation with the exception of the transpersonal approach.
_____
(1) We attempt to use plurals whenever possible, but to avoid the awkwardness of “him/her,” we use the feminine pronoun throughout the document when referring to the therapist and masculine when referring.

For well-being of the therapist, it makes a great deal of difference how we have tuned in to perceive and experience this moment we call therapy. In the dualist world where subject and object are separated, we might only experience therapy from the mode of doing: doing diagnoses, doing hypotheses, doing evaluations, doing questions, doing therapy, doing long days, and so on. Our self appreciation is linked only to our achievements. We are inadequate the way we are and detached from the natural perfection of being (Loy, 1997). In a non-dualist world where subject and object are one and part of a greater whole, we can also experience our work from the mode of being: we are the therapy, we are our words, we are our gestures, and we are the consciousness that watches the world with the help of our gaze at the moment. We are resting in our practice while also making a difference. This state is often accompanied by a deep feeling of equanimity, joy, and well-being.

Why do we speak? What are our intentions in our conversations with our clients? Do we ever notice the effect our words have on ourselves? From the point of view of the therapist's well-being, there are two kinds of speech: living and dead (Olson, 2000). Dead words are often born from the needs of our unexamined self. They usually prevent a direct touch with reality; they manipulate, maintain power structures, and create monologues. The nature of living words on the other hand is flowing, uncontrolled, shared, and unpredictable. These words are often born from mindfulness, a conscious and accepting presence, and they help to create an embodied dialogue. Connect to a meaningful part of your therapy experience with this exercise:

EXERCISE: Think back to a situation at work when you felt more lively than usual. You perhaps felt connected to yourself, your client and life. You felt that you weren't doing therapy techniques, but instead the techniques were happening through you. You were openness through which life simply manifested itself at that moment. What skills did you use to create such a moment of being in your doing? How did you do your being?

Increased Existence

The other “wisdom” Hoffman relates to therapy is the reflective processing. This is what Tom Andersen, a recently deceased professor of social psychiatry, called “withness practice” (Hoffman, 2007b, p. 7). This type of practice usually creates space in therapy for dialogical interaction. Knowledge is created through language in our mutual interaction: therapy is not seen as an event where knowledge is transferred but rather as the collaboration between the therapist and the client, which adds to the options for action in both parties. An increase in knowledge, in this way of thinking, means an increase in existence and possibilities for new kinds of practices. The goal is not to produce change but to give space for a dialogue. The goal is also not to seek the kind of understanding that would prove the therapist's theories to be true. Led by the “expertise” of the client, the therapist instead has to question her own way of thinking (Anderson & Goolishian, 1992). In addition, it is important for our well-being that we can, through our conversational partners – people who are exactly like us, suffering creatures who strive for happiness – constantly clarify our understanding and views of ourselves and our lives. Expertise becomes a joint action with new expertise developing for both client and therapist in the ensuing conversation. The goal is not “curing” someone; it is about being useful to a person, facilitating a process where the possibility to accept who he or she is at the given moment arises (Lax, 1996).

Language and thinking do not simply reflect reality. They are also a movement of reality. A thinking, knowing person is simultaneously a living process of knowing and the product of this process. In other words, there is no separate landscape and map; the map in itself is movement in the landscape it is trying to describe (Wilber, 2007). According to this social constructionist way of thinking, reality and its perceiver cannot be defined as separate from each other; knowledge is a construction created by knowing. It is a process between the creator of the knowledge and the created knowledge.
What effects do these different practices of knowledge have on the well-being of the therapist? To address this question, we will compare them in the following table.

TABLE 1

Aboutness Thinking < ------------------------------- >Withness Thinking

Distance is maintained Distance reduced, closeness increased
Greater responsibility to “help” Shared responsibility for the outcome
The therapist has a privileged position in terms of knowledge and power The therapist and the client are mutually privileged; power is freely shared as much as possible
The therapist determines the meanings The meanings are negotiated together
Didactic, strategic, guiding Conversational, generative
Control Unpredictable
Cures Cares

The reader should note that these continua have no absolute point, free of context and relations that would be best for the well-being of the therapist. Change does not happen by adopting new stories but rather by exploring the effects of different stories on the therapist's life and by developing experience-based, direct knowledge on how she relates to them. As these relations become clearer and clearer, it is possible for us to make more and more free and responsible choices about our identity conclusions (Gehart & McCollum, 2007). We offer the following as you continue this story:

EXERCISE: Become aware of your breathing. Ask yourself: Am I, at this moment, acting in accordance with my deepest values? Do I feel I am being authentic? How do I experience my inner energy at this moment? What kind of balance do I have between the mindsets of doing and being? Am I resting in my work, in myself, and in my breathing, or do I feel tense and shattered? How is my work affecting my fellow human beings at this very moment?

Who and Where is the “Self?”

If we think and feel the “self” as an autonomic, separate entity, we also assume that the therapist has an identity in the core of her personality that defines her professional and human existence. By controlling the therapy process, the main task for therapist is to change either the structures of other “selves” or to create some “filling self-practices” that increase (for example) the “self-esteem” of our fellow human beings and give them new “ego-strength.” This was the dominating idea about the self before postmodern therapies (solution-focused, narrative and collaborative therapies) became more prominent in the field. This essentialist concept of the ”self” often includes the idea that we have a sort of “tank” or reservoir inside each of us containing different amounts of energy at different times. Following this reasoning, distinct practices of taking care of ourselves are necessary so that we can “recharge our batteries” from time to time and have the energy to work at our demanding profession as therapists. This machine metaphor easily makes us think of our clients as “others” who constantly wear out or suck the energy from our “tanks.” It thus becomes our central mission to control and protect ourselves. To stop the “self” from burning out, we must practice different types of “self”-recharging and -refilling practices outside of the dualist and reified relationship we call therapy. This way of thinking has its roots in the modern liberal theory, in which the “self” is a manifestation of an internal and private property. It is everyone’s mission to “engage in the internal farming of our lives through self-cultivation, and to take up internal mining enterprises that have us digging deep to get in touch with our personal resources, and to excavate these resources so that they might be brought to the surface, put into circulation and capitalised on” (White, 2001, p. 39).

An entirely different way of understanding the “self” is derived from ancient wisdom traditions, especially Buddhism, and the modern-day non-structuralist and social constructionist theories (Gergen, 1999). According to these wisdom traditions, there is no separate entity that we could call “self.” The “self” does not have its own inherent nature. In this sense, self is no-self (anatta) or empty (sonyata) (Ficher-Schreiber, 1994). Phenomena gain their meanings as a part of a greater whole, just like the twirl of a stream is a part of the water masses surrounding it. The “self” is understood – and experienced – more as a continuing process which does not have an independent, stable existence outside its relations and different contexts. The self is constantly changing in different contexts in a continuous process of becoming, which constantly arises in immediate experience of the present moment. In this state of mind, the therapist's inner well-being means the ability to see reality in its suchness at any given moment and not in the way we understand or wish it to be.

The nature of the “self” is essentially conceptual. It is continually being constructed, deconstructed, and reconstructed. It can be defined as an experience of me-ness which is born when a person identifies with different components of the body-mind-process, (e.g., sensory perceptions, thoughts, emotions, memories), the image one has made of oneself (Goleman & Epstein, 1983). Identifying with the contents of the mind, however, leads to a completely different experience of well-being than if we identify with a consciousness, the Seer who is aware of the constantly changing contents that are made up of perceptions, thoughts, and emotions.

Therefore, practices of taking care of oneself are actions that help us become aware of the “emptiness” of our self (i.e., that all things are empty of separate essence) because such practices are unstable and only exist in relation to other things. In this state of consciousness, there are no preconceived notions about things tying us down. Instead, we can let life be the way it is without clinging to pleasant experiences or pushing away unpleasant ones. Nor do we have to go outside our work space to fill our imaginary “tanks” to be able to do our jobs. We can give up our tiresome and insatiable desire to control life and achieve a certain result. Our techniques are nothing but manifestations of our empty selves in different interactions with other people. In such interactions, change often happens by itself without the pollution of purpose. A therapist recreates herself while recreating her client, and the client recreates himself while creating the therapist. In order to be in this state of consciousness, which the Vietnamese monk Thich Nhat Hanh (2001) calls interbeing, we need to constantly train our minds. Therapy therefore becomes a constant and endless exercise in mindfulness. This lifelong practice opens a new way of creating our well-being as therapists – while working.

EXERCISE: Bring yourself into this moment by straightening your body and sitting in a dignified and yet acceptance-exuding position. Ask yourself: What am I experiencing at this very moment? What kinds of thoughts am I having? What kinds of emotions? What kinds of feelings in my body? Acknowledge and accept your feelings, whatever they are like. Direct your attention to your breathing, to every inhalation and exhalation. For a moment, let your breathing act as an anchor to the present and feel how it helps you tune into mindfulness. Next, broaden your attention so that you are momentarily aware of your breathing, the position of your body and its perceptions, and your environment. You can do this alone or together with your client.

Unruly (Wild) Power

Power is inseparably connected to all human interaction, including therapeutic relationships. In these relationships we are – whether we want to or not – always linked to the network of power/knowledge, where it is impossible to act outside of power. Therapists are often so used to their power as experts that they tend to completely forget about this. However, in our therapist-client relationships, we are inevitably both under the influence of power and influencing with the same power. According to Johnella Bird (2004), even when we are trying to equalize or minimize our power as postmodern therapists we in fact make our power invisible instead of removing it from the therapy relationship. After we have some awareness of complex interpersonal power relations, it is important to ask (a) how to work by using power relations in a way that benefits both ourselves and our clients and (b) how to work so that our awareness of power relations could increase. Instead of asking who has the power or who is using it, it is more useful to ask what types of practices make power relations possible in therapy. The critical thing is to recognize how power is used and that it can be used in either a helpful or a hurtful way.

Particularly within the field of narrative therapy, there has been a lot of research on how the positioning of the therapist in a therapeutic power relation is connected with her well-being (White 2007; White & Morgan, 2006). White argues that we can be in four kinds of positions in relation to people who come to therapy, outlined in the table below (White, 2005).

The Position of the Therapist

TABLE 2

Decentred and Influential Centred and Non-Influential
Decentred and Non-Influential Centred and Influential

When the therapist takes a centred and influential position in the power relations, she detaches people from their own experiences and independently takes the responsibility for fixing any problems with her expertise. This position is often very exhausting for her. If, on the other hand, she is in the centred and non-influential position, she listens to others but keeps making her own interpretations based on professional knowledge. The therapist leads her client in the direction she assumes, as an expert, to also be important for the client. Often the conversation cannot proceed only through the assumptions of the professional, and this is when the therapist experiences the situation as exhausting. When the therapist works in a decentred and non-influential way, she is passive and does not take responsibility for how the therapy goes. Everything sort of happens, but no one has the responsibility for how the
conversation proceeds. In this position, the therapist often ends up in ethically doubtful situations, which burden her.

Being in the decentred and influential position gives the practitioner a possibility to experience her actions as potentially energizing. The therapist's professional knowledge is not in the centre of the process. The clients or family act as the experts in their own lives, and their knowledge, skills, preferences, and commitment are important. The therapist works actively and critically, constantly reflecting her own work alone and together with the client. She is influential, not by imposing a preconceived plan for the therapy process but by creating questions that give the client a possibility to experience his own knowledge of life and practices of living, opening up new alternatives to the actual predicaments. The therapist is not neutral. It is her responsibility to acknowledge and perceive her own power and constantly explore its effects in the therapy with the client. It is crucial to recognize the discourses that inevitably have an effect on the therapist – gender, age, sex, the Western idea of human nature and self, and so on – and make them visible. Whenever the therapist acts deconstructively, opening up power-knowledge relations, more room is created for the mode of being, and the therapist has greater opportunity to be as she is in the work. This experience has a positive effect on our well-being because power issues are often related to the ways in which we protect and construct our “self.”

As therapists, we often strain ourselves in an effort to take away insecurity and ignorance. On the other hand, the burden of the “truths” we know is something to which we give little thought. Maturana defines violence in the following way: “the holding of a
view by one person or group to be true so that another person’s or group’s view is untrue and must change” (Sanders & Tomm, 1989). The illusion of safety and clinging to orthodoxy are part of violent thinking, not thinking that respects the other person. In a practice where we create well-being and constantly question our own actions, living in insecurity can be seen as an ethically valuable human feature.

EXERCISE: While in a therapy session, answer one of the following questions in your mind from time to time. Am I mentally evaluating people, or am I helping them evaluate how I am working as a therapist? Does my work as a therapist separate or unite people? Am I acknowledging and expressing my values, beliefs, view of people so that others can evaluate their effects in therapy? Are my questions supporting dominant social practices, or are they creating alternatives? Which is more important, what my colleagues think of me or how my clients experience me?

Closing Comments

The occupation of being a therapist is privileged. Depending on our view of knowledge, what kind of idea we have about the “self,” and how we are positioned in a therapy process, we can experience our work either as a humane activity that creates our well-being or as a tough and wearing job. As we become experienced at doing therapy mindfully, looking outside the work context for our well-being and energy diminishes. In our achievement-driven societies, the mode of doing has often become dominant. However, as we give up our own self-importance, we can also experience our work as a constant mental exercise that energizes us. In this way, doing therapy can offer us an experience of transformation, where the therapist's way of looking at the world and experiencing it changes. Rather than being agents of change, we can be changed agents, affected by therapeutic interactions and gaining personal agency (Lax, 1996). We can be transported through our clients to places that open up our views, curious and exited about the possibilities where our work and lives show themselves as unique and inspiring adventures.



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