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The Current Column:
Mutual Attunement in Psychotherapy

(Part 2 of: “What’s Therapeutic About Therapy?”)

by Jay Einhorn, Ph.D. The process of evolving mutual attunement between therapist and client is endlessly fascinating, and, in my opinion, the source of the effectiveness of psychotherapy. All forms of psychotherapy, whatever their theory, methods, or rationale, work, when and to the extent that they do, because the relationship between client and therapist somehow facilitates the client’s ability to cope with, and adapt to, challenges and opportunities that he (the generic “he”) couldn’t before. There are many schools of therapy, each claiming to know the best way, creating an “Elephant in the Dark” kind of situation, which obfuscates the centrality of the relationship. The claims and counterclaims of the various schools, and the egos and power struggles of their founders and followers, provide the anthropology and folklore of psychotherapy, which also has its fascination. But I am more interested in the active therapeutic relationship. Two people meet in an office; the client feeling stuck somehow in his life, the therapist because he (again the generic “he”) is supposed to be able to help people get out of being stuck, through conversation. Therapy begins with this meeting and proceeds through the evolution of this relationship. Mutual attunement evolves as therapist and client work together to understand the client’s personality, and world, in light of his impressions about himself and others, and his decisions and behavior both inside and outside the therapeutic relationship. As client and therapist discuss the dilemma that the client brings to therapy, their conversation is both text and subtext, both what is actually said and what is implicit, “between the lines,” of their conversation. Some levels of interaction, more or less deep within the subtext, can be made explicit during therapy, through insightful interpretation by either therapist or client. Sometimes it comes afterward: years after therapy is over, therapist or client might have an “aha” experience about the meaning of something that happened or was said. Other levels of communication remain permanently nonverbal. II The therapeutic relationship begins in an apparent paradox: the client wants the therapist’s help to change in order to cope better with obstacles or challenges in life, but he also seeks the therapist’s confirmation of his view of self and world; which is itself partly responsible for the problems that bring him into treatment in the first place. The therapist, presented with multiple, often conflicting, needs by the client, tries to craft a treatment relationship which simultaneously supports and challenges him; allying himself with the client in some ways in order to help him make adaptive changes in others. The therapist empathically experiences the client’s inner world at the same time that he learns about his outer one, and begins to construct a model of the client’s self and world which is valid enough to begin to indicate where changes might be necessary or helpful, and what steps might be taken to move toward them. The client becomes a partner, with the therapist, in the construction of this impression of what his self and world are like. I have described this as a kind of “sculpture of impressions,” which the therapist and client work at together, and which is one of the main tasks of therapy. If the sculpture is realistic enough, apt enough to the client’s life and situation, it will provide a basis for the client to go about changing himself and his world in ways that will be healthier and more adaptive. The client-therapist relationship is analogous to that between a consultant and a corporate CEO; the consultant helps the CEO better understand how his organization works, what environment it has to compete in, and how it could be improved, but he needs the CEO’s help to understand enough about the organization and its environment to be useful. In psychotherapy, as in consultation, it is ultimately up to the client to decide what to accept, and what to do about it. The therapist never knows more than a part of the client’s self, life and world, and the client always remains free and responsible. The therapist has to guard against becoming either rendered ineffective by the client’s prejudices or defenses, or else becoming a guru to whom the client subordinates his own judgement. Neither of these attitudes will support therapeutic progress. Many of our dysfunctional patterns make sense when seen as habits from an earlier time in our lives, which we developed because of who we were, where we were, and with whom we had to get along. Client and therapist try to identify the environmental influences that impacted and programmed the client’s personality, which we might call the “software,” as well as trying to understand what the client is really like in areas relevant to therapy, the instinct or “hard wiring” of his personality, so to speak. This is the “sculpture of impressions” that the client and therapist work at; a work that is never complete, but which the client will continue with after the therapy is over. III This leads to criteria for judging whether a therapist is good enough for a particular client, and whether a particular therapeutic relationship is working. Does the therapist intuit how the client is interfering with his personal evolution through ineffective ways of being himself in the world, and to what extent is that understanding explicit and grounded in a view of the client’s developmental history? Does that understanding, fed into the therapeutic relationship, lead to insights about how the client can move toward more healthy ways of being in the world? Therapists who merely rely on cookbook formulae--”take one visualization, two affirmations and three cognitive therapy sessions,” or, “the first task of therapy is to analyze the oral phase”--do not understand the essential role of mutual attunement in therapy. To see mutual attunement as the primary dynamic of healing and growth in therapy is to understand that, however valuable concepts and techniques may be, conceptual and technique-centered approaches to training psychotherapists fall short by failing to focus clearly enough on what is most central to therapeutic effectiveness. This happens when concepts and techniques become ends in themselves rather than means to help therapist and client become attuned to one another in their therapeutic partnership. The therapist isn’t just a technician with a box of tools; he is, himself, a therapeutic instrument. His experience of his client’s personality and existential “being-in-the-world” leads to the questions, encouragement, insights, humor, support, investigation, provocation and challenge that can help the client make the necessary adaptations to live more successfully. That is why I say that I am changed, in some ways, by every therapeutic relationship that I engage in. When you relate with people at this level, you can’t help but be changed by the experience, each time. This underlies a dichotomy that has long confounded the training and certification of therapists. Students can learn information about therapy, including theories, methods, history, and so on, in school, and that stock of information can be tested by paper-and-pen tests. But you can’t learn therapeutic relationship that way. Therapeutic relationship is learned by means of itself, through experience, apprenticeship, and interaction with other therapists; and you have to have a certain talent for it in the first place, like a mechanic needs a knack for seeing how parts of an engine fit together spatially in order to work. A further complication is that personal styles make a difference. Some clients need a more egalitarian therapist while others need a more authoritative one, some need a more distant and reserved therapist while others need a more interactive one. Not every therapist can work with every client, and vice versa. It all depends on how well they can connect in the ways that matter therapeutically. Understanding the central role of mutual attunement also illuminates how short-term therapy, so popular today, nearly always truncates, and often excludes from therapy, its most effective, if most subtle, dynamic. Short-term therapy has its place. It can be effective when the client is highly motivated, the change in attitude or behavior that he needs to make is limited and discrete, and the therapist and client can become quickly attuned to one another around those issues. But the kinds of problems that bring most people into psychotherapy, in my experience, involve complex issues within the client and between the client and others, which are not usually to be quickly understood or resolved. The process of study of the situation by the client and therapist is itself part of the solution, and that needs respect and time from both therapist and client. (Note: A colleague with whom I discussed this article told me that the term “mutual attunement” has been used in a different way by writers in the “self psychology” school of psychoanalysis. I haven’t read that literature.) Dr. Einhorn does not practice psychotherapy or diagnostic evaluation over the internet. Writers with questions that are specific to their situations are advised to consult a mental health professional in person. He welcomes questions that involve general issues that may be of interest to general readers. All questions may be answered in a column on “Psychologist At Large” or elsewhere, and submission of a question gives Dr. Einhorn permission to answer it publicly, in this or another forum.